Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When would you consider a diagnosis of peritonitis in a patient with SLE?
As noted in the question, clinically significant peritonitis is unusual/rare in lupus patients. In 25 years, I have seen two patients I was convinced had lupus peritonitis. The common thread was that both of them had had at least one abdominal surgery for an acute abdomen. The patients were known to...
Do you feel comfortable using JAK inhibitors in patients with a strong family history of CAD, but no other risk factors?
I would say it is a reasonable option to consider, especially if they have failed anti-TNF agents and if they do not have other cardiac risk factors. The studies which showed the highest risk used higher doses of JAK inhibitors, and those patients had other cardiac risk factors, so would suggest to ...
Is there any expanded diagnostic workup that you pursue for a young female patient with gout?
In 45 years of practice, and with a strong focus on gout, I can count the number of premenopausal women with gout I’ve seen (or, perhaps better stated, recognized) on one hand. Of the last two, one had chronic renal failure due to acute kidney injury incurred secondary to an alcoholic binge a few ye...
What are some practical tips for tacrolimus management/monitoring in SLE nephritis?
Consider starting with 1 mg bid on an empty stomach: I have been adding tacrolimus (TAC) to mycophenolate mofetil (MMF) and mycophenolic acid (MPA, Myfortic) or cyclophosphamide (CYC) for many years with great success. I start with 1 mg bid on an empty stomach along with their MMF/MPA, or without w...
Would you switch to a TNFi if a patient developed squamous cell skin cancer on abatacept after failure of methotrexate for seropositive RA?
All biologics or immunosuppressants have been associated with various rates of skin cancers. The decision to change or continue biologics should be based on disease activity through shared decision-making with the patient. The need for frequent skin examinations and treatment through their dermatolo...
How would you manage a patient with RA on abatacept now experiencing recurrent pericarditis not responsive to colchicine?
Anakinra or rilonacept (both IL-1 antagonists) have been shown to be effective in idiopathic pericarditis. Their utility in RA-associated pericarditis is unknown. In this particular patient, abatacept has resulted in well-controlled RA but has not prevented pericarditis even with concurrent colchici...
How do you manage steroid-refractory immune checkpoint inhibitor induced pneumonitis?
Steroid-refractory immune checkpoint inhibitor (ICI)-induced pneumonitis is managed with high-dose steroids plus an additional immunosuppressive agent, like infliximab or intravenous immunoglobulin (IVIG) among others. I recommend early immunomodulatory escalation as multiple studies have shown that...
How do you approach further treatment in patients with anti-HMG-COA myopathy who have residual disease activity (ongoing weakness, elevated CK) after >1 year of combination therapy, e.g. IVIG and methotrexate?
The most important question is if the patient still has active disease, or their symptoms of residual weakness are from fatty atrophy. In the latter case, the patient will not benefit from additional immunosuppression but would require aggressive physical therapy. In anti-HMGCR IMNM, good markers fo...
How do you evaluate and manage patients with lupus who are having issues with decreased libido?
Decreased libido is one of several factors contributing to sexual dysfunction for people with lupus and other rheumatology disorders. Although sexual dysfunction is common in our patients, it is rarely discussed during office visits. The first step towards evaluation and management of decreased libi...
How do you approach a patient with idiopathic anterior uveitis who has ongoing disease despite adalimumab every two weeks?
This is a style question, I think. I thought it would be useful to note the choice here might depend on testing for anti-adalimumab antibodies as there is some suggestion that changing to once weekly adalimumab in the presence of anti-adalimumab antibodies might not be efficacious. (Ismayilova et al...