Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you treat active SLE with high level crithidia dsDNA abs and recurrent pleuritis with effusions still requiring corticosteroids despite combination therapy with full doses of mycophenolate, hydroxychloroquine, and Benlysta for over 6 months after no response to Saphnelo for 6 months?
There are no controlled trials of different therapies for treating refractory pleuritis in lupus as the primary manifestation. Due to refractory pleuritis being relatively uncommon, the trials of benlysta and anifrolumab did not have enough patients to assess response. In the literature, there are a...
Does IVIG or subcutaneous Ig interfere with monoclonal antibody therapy (i.e. dupilumab, infliximab, rituximab, etc)?
I definitely agree with Dr. @Dr. First Last concerns. For what it’s worth, I use a lot of IVIG in combination with monoclonal medications in my myositis clinic, and have anecdotally noted multiple instances in which I feel that the efficacy of one of those monoclonals seems to have been worse when t...
How would you manage a patient with Takayasu arteritis controlled on TNFi who develops erythema nodosum that is only partially responsive to NSAIDs?
Erythema nodosum and pyoderma gangrenosum (as well as erythema induratum) are well recognized as cutaneous manifestations of TAK. Unfortunately, we do not know how often cutaneous and the vascular disease are decoupled from each other due to a lack of available data. Most case series document associ...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
Would you try combination ketorolac and cortisone injections in a patient with severe knee OA who refuses surgery and had partial responses to injections of cortisone and ketorolac separately?
Clinical use of intraarticular injection of ketorolac has gained some popularity, especially in the orthopedic community, although the I.A. route is not an approved indication by the FDA. As such, its use is off-label, which may make reimbursement difficult in the U.S. Nonetheless, there have been s...
How would you approach the workup and management of isolated inflammatory subglottic stenosis in a young previously healthy patient that is steroid responsive with a completely negative serologic autoimmune workup?
This is a relatively unusual situation in that idiopathic subglottic stenosis is typically not managed with systemic immunosuppression. The typical therapies are endoscopic and include dilatation (+/- intralesional corticosteroids), endoscopic resection, and cricotracheal resection. A recent large t...
How do you approach folate supplementation for methotrexate-related side effects?
All MTX users should be taking some form of folate supplement. Either daily folic acid or weekly folinic acid are used and generally are effective. Tracking the RBC MCV is one way to ensure that patients are receiving adequate folate supplementation.The question has been raised whether folate supple...
Would you consider PTH analogue in a patient with mildly elevated PTH?
This is a complicated question because there is not any substantial literature. Almost all clinical trials with teriparatide and abaloparatide excluded patients with elevated PTH levels. However, there is considerable anecdotal experience. I have surveyed many colleagues with considerable experience...
How do you approach a patient with elevated bone specific ALP (>2X the normal limit), but no other evidence of Paget's disease?
There are other causes of elevated bone alkaline phosphatase e.g. osteomalacia. Check blood calcium, magnesium and phosphate, PTH and 25-OH-vitamin D. If PTH is elevated and no CKD, check 24-hour urinary calcium and creatinine.
How often should lupus anticoagulant be checked in patients with SLE if prior was negative or if prior was positive?
The key question when considering retesting for any laboratory test, including antiphospholipid antibodies (aPL), is: How would a positive or negative result change the patient's management or prognosis? This question helps guide the decision-making process by focusing on the potential clinical impl...