Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In the treatment of lupus nephritis, which patients may benefit from the use of rituximab or other B-cell depleting agents during induction?
I agree with @Dr. @Dr. First Last's previous answer (posted July 2020). In addition, the 2024 ACR Lupus Nephritis guidelines (discussed at the 2024 ACR meeting) still recommend mycophenolate (MMF) or cyclophosphamide as first-line induction therapies for lupus nephritis (LN), rather than B-cell depl...
Do you prefer celecoxib over a nonselective NSAID in patients with chronic kidney disease?
There are many potential advantages of celecoxib, as a "selective" COX-2 inhibitor, over non-selective NSAIDs. Because of the lesser inhibition of platelet function, it has potential advantages in the peri-operative period, in patients with bleeding disorders or taking anti-thrombotic or anti-coagul...
Which steroid-sparing agent do you prefer to treat multi-organ Sweet's syndrome?
I have used methotrexate in combination with cyclosporine with some success but am most impressed with the effect of anakinra to control disease and allow discontinuation of corticosteroids. I would also recommend them in that order.
How do you approach management of adult patients with CVID and sarcoid-like syndrome?
Common variable immunodeficiency syndrome (CVID) is the most common primary immunodeficiency, and is of course, characterized by recurrent infections. This can lead to bronchiectasis due to structural damage from these recurrent infections. However, patients can also have non-infectious manifestatio...
How often do you see bony erosions in patients with Lyme arthritis?
There are three ways that Lyme disease can result in joint involvement. The most common is diffuse arthralgias (not a true arthritis) associated with the acute infection. This is self-limited and does not harm the joint. The second is an inflammatory arthritis that is similar to other infected joint...
What is your experience with using oral deucravacitinib off label for conditions such as recalcitrant facial discoid lupus or recalcitrant lichen planus?
This is an excellent question and importantly highlights the potential for newer therapies to help treat challenging diseases with few if any FDA approved options. In the case of DLE, I have found deucravacitinib to be a good option, sometimes as monotherapy or perhaps in conjunction with other topi...
What is your approach to counseling patients regarding re-initiation of anti-TNF therapy after completion of treatment for non-disseminated pulmonary histoplasmosis?
We published a retrospective study on this topic in 2015 (Vergidis et al., PMID 25870331). We concluded that resumption of TNF-alpha antagonist therapy may be considered in individuals treated for histoplasmosis who have no evidence of residual disease and undetectable Histoplasma antigen levels. We...
How do you approach treating and monitoring sarcoidosis manifested by maxillary bone/teeth loss without other symptoms?
I'm very curious how this was determined to be sarcoidosis. Has a PET been done to determine whether this is the only site? Other entities evaluated for like CRMO? Obviously, neoplasm and infection are also important to rule out before immunosuppressive treatment. Conversely, with our limited "tool ...
What is your approach to the management of shrinking lung syndrome in SLE?
No consensus exists on the best way to diagnose shrinking lung syndrome (SLS). Interestingly, I rarely see this anymore. Possibly due to better treatments and universal use of hydroxychloroquine (HCQ)? We are not even sure how and why it occurs. Could it be a myopathy of the diaphragms or a result o...
What steroid sparing agent do you use for treatment of cardiac sarcoidosis?
Recognizing that corticosteroids will be needed to acutely stabilize cardiac sarcoidosis, a steroid sparing agent is usually a reasonable choice early. My choice of secondary agents depends on the other manifestations of sarcoidosis present at the time of diagnosis. I have rarely seen cardiac sarcoi...