Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach symptom control in a patient with diffuse cutaneous systemic sclerosis (dcSSc) and rapidly progressive skin disease?
This patient clearly seems to be on the uphill trajectory for skin involvement in RNA Pol III+ dcSSc which can progress quite rapidly over 6-12 months. Pain, burning, tightness and pruritus are quite intense during this period, and can be very difficult to treat. It does improve somewhat with time, ...
How do you determine which patients with ANCA associated vasculitis may be good candidates for reduced dose glucocorticoid tapering?
This is an important question. Currently there are several groups of patients that benefit from reduced dose glucocorticoids: The largest group are patients who are receiving avacopan for remission induction. The ADVOCATE trial demonstrated that avacopan can markedly reduce the dose of glucocorticoi...
Would you continue belimumab in high risk lupus patients with overlapping scleroderma features with ILD who become pregnant and who are already on HCQ and azathioprine?
If "high risk" means at high risk of flare or increased disease activity, then "yes." I always have a shared decision-making conversation with the patient first. This almost always occurs well before conception/pregnancy, as I strongly believe in contraception and pregnancy conversations early in th...
Do you recommend discontinuing IVIG for a newly diagnosed HMGCR+ statin induced necrotizing myopathy who developed a recent brachial DVT?
Really, the issue is if the DVT was provoked or not. If possibly not provoked then would decrease the dose of IVIG or give it over a long time frame. For example, if the patient is on 2 gm/kg over 2 days, I would do 2 gm/kg over 4 days. Or reduce the dose to 1 gm/kg over 2 days.
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
What is your approach to immunomodulatory treatment in patients with Sjogren's syndrome who have active serologies (i.e. elevated ESR, hypergammaglobulinemia, hypocomplementemia) but minimal symptoms?
Hypergammaglobulinemia and hypocomplementemia are risk factors for lymphoma in the setting of Sjogren's Disease (SjD), as well as cryo, IgM kappa, lymphopenia/neutropenia, RF+, asymmetric parotid swelling and disease activity (Nocturne et al., PMID 26606524). Therefore, even with "minimal symptoms" ...
How would you approach management of a patient with ESRD on the transplant list who is found to have high titer APS labs (ACL, B2GP1, LAC)?
This is an excellent but rather complex question. Management of patients with ESRD on the transplant list who are found to have high titer APS labs (ACL, B2GP1, LAC) depend on the renal histology, underlying autoimmune disease history, and comorbidities. Patients with thrombotic manifestations resul...
How do you approach weakly positive PL-7 antibody in a patient who initially presented with muscle weakness, rhabdomyolysis and non specific muscular edema on MRI that resolved with IV fluids?
During an episode of rhabdomyolysis, muscle MRI isn't reliable since it would be positive regardless of the underlying cause. So, monitoring the trajectory of CPK levels and serial muscle exams to evaluate for weakness would offer a more reliable assessment for true myositis. Positive antibody resul...
What dose and duration of steroid therapy do you employ while starting mycophenolate in an outpatient with relatively stable CTD-ILD?
This is a great question since it raises some important concepts about treatment response in this patient population. Providers often talk about the presence or absence of a steroid-responsive process, and if so, whether a steroid-sparing agent would be beneficial. My bias is to avoid steroids in an...
Do you check the Duffy-null phenotype before starting azathioprine and in which patients?
I personally do not check the Duffy antigen prior to starting azathioprine. I do check TMPT levels on all patients prior to starting it to help determine initial dosing.