Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What aspects on history and physical exam could help differentiate genetic muscular dystrophy from immune-mediated myopathy?
Great question, and one that comes up all the time in clinical practice. Unfortunately, the question gets a little bit complicated because of the heterogeneity of the musculodystrophies, metabolic myopathies, and neuropathies that can mimic myositis (not to mention the phenotypic variation between t...
How do you determine duration of therapy for patients who have responded well to voclosporin therapy?
Determining the duration of therapy for patients who have responded well to voclosporin therapy in lupus nephritis involves several considerations, including patient-specific factors, disease activity, and risk of relapse. Here is a suggested approach:The duration of therapy is determined by the ren...
Do you typically screen every patient with headaches after the age of 60 with ESR?
I would not. Many patients will have elevated ESR because of other conditions (for example, chronic kidney disease). The history is going to be key in determining which cases to send for lab testing.
How will you use tocilizumab in the treatment algorithm for SSc-ILD, given its recent FDA approval?
I am excited that we finally have evidence for an effective therapy to treat SSc- ILD. Scleroderma is among the most challenging diseases facing the rheumatologist and over the years we have failed in our efforts to identify potentially effective treatment options for patients, especially those with...
In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?
When someone with ILD has an isolated biomarker without other clinical features associated with that biomarker, I have to ask myself these questions: first, is the biomarker simply a false positive because I have tested a plethora of biomarkers and second, is ILD the initial or only manifestation as...
What is your preferred regimen for remission induction and maintenance in EGPA with cardiac involvement?
Cardiac involvement in EGPA is associated with a poor prognosis and is an independent predictor of mortality. Therefore, it needs to be treated aggressively. Depending on the study, between 15-30% of EGPA patients present with or develop cardiac manifestations. The manifestations are highly variable...
Do you continue biologics in sJIA patients who develop lung disease on anti IL-1 or anti IL-6 therapies?
It really does depend. If a child is otherwise doing well, stopping cytokine inhibitors can worsen the underlying disease precipitously, putting the child at risk. More often than not, in my experience, at the time that lung disease is discovered, the treatments are not controlling the underlying di...
How do you treat MAS in patients with systemic JIA or AOSD with HLA-DRB1*15 alleles given risk for DRESS hypersensitivity to IL1 or IL6 inhibitor therapy?
Tough question. HLA-DRB1*15 is pretty common, and it may be a risk allele for lung disease. I, and many others, are not convinced, however, the lung disease represents DRESS, nor that a range of biologics are the etiology of the lung disease. One of my most recent sJIA patients presented with high e...
Would you consider combination belimumab and anakinra for a patient who has SLE and MAS?
I have used the combination of belimumab and IL-1 inhibition in a patient with SLE to treat recurrent pericarditis. It would not be unreasonable to use anakinra for MAS and add this to their belimumab. Managing MAS requires treatment of the underlying driver of the MAS, which in this case seems to b...
How do you utilize anifrolumab for SLE in your practice?
The answer to this SLE question involves a complex decision-making process. It is such an important question! I apologize in advance for the long answer. I am in the camp of achieving remission in my SLE patients and getting them off prednisone in the safest ways possible (Fanouriakis et al., PMID 3...