Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to managing sclerosing mesenteritis (mesenteric panniculitis)?
I have seen and followed dozens of patients with this diagnosis. As noted above, it is important foremost to be sure of the diagnosis. Mesenteric panniculitis can be part of the IgG4 associated spectrum and so a biopsy is useful if it can be done safely. The other disease in the differential is carc...
How do you monitor patients with incidentally found high titer anti-smooth muscle antibodies without stigmata of liver disease?
I have quite a few SLE patients with ASMA who do not have any signs of hepatic disease (though I did not do bxs in those with normal hepatic transaminases). They are very common in the general population. I have down in my notes a prevalence of 16%. However, there are studies showing prevalences as...
What treatments have you found most effective for cholestatic pruritus?
My experience is mainly in Sjogren's or Sjogren's with PBC, ursodiol has been effective. Occasionally, I have used hydroxyzine or H1+H2 blockers. In Sjogren's where the skin biopsy has shown significant lymphocytic infiltration, mycophenolate or a calcineurin inhibitor trial has lead to the resoluti...
How long would you wait to start another biologic agent after Rituximab administration in patients with dermatomyositis and refractory inflammatory arthritis (intolerant to traditional DMARDs)?
The time frame between rituximab infusion and initiation of a different biologic agent depends on the severity of the symptoms. In case of life-threatening complications (like RP-ILD), then rituximab could be given simultaneously with an agent like tofacitinib. If the main symptom though is arthriti...
Which other agent would you consider for a patient with VEXAS who has failed methotrexate, multiple TNF inhibitors, Tocilizumab, and Ruxolitinib?
I would strongly consider referring for hematopoietic stem cell transplant. The NIH/National Cancer Institute has a trial that is currently recruiting:Koster et al., PMID 36251488
In light of the RECITAL study, would rituximab be a reasonable choice in a patient with PL-12 antibodies, rapidly progressive pulmonary disease with organizing pneumonia on biopsy?
The findings from the RECITAL study have confirmed the validity of our clinical approach, advocating for rituximab as the primary treatment for CTD-ILD, considering the elevated risks associated with the use of cyclophosphamide. Therefore, it is entirely justifiable to opt for rituximab in cases of ...
How do you determine osteoporosis treatment response when patients have discrepant DEXA scan results during monitoring (eg improved BMD of the hip and spine but worsening BMD of the femoral neck)?
This is not all that uncommon. The first thing I do is ask if they have fractured since we started the therapy. If not, I relax a little. This is a nice scenario for using bone turnover markers as part of initial work up. If PINP goes up by >10 I am happy that an anabolic drug is working... more you...
Do you avoid ESA use in patients with anemia and chronic kidney disease who also have APLS and risk for thrombosis?
I normally don't. I would make sure the patient is getting anticoagulated if indicated. I don't believe making the hemoglobin closer to normal in the setting of being anticoagulated increases thrombosis risk that much. I would shoot for a hemoglobin goal of 10-11.
How do you approach GI prophylaxis (e.g., PPIs, H2 blockers) in patients on long-term NSAIDs?
Risk analysis is at the heart of all therapies that we prescribe for our patients. Patients on long-term daily NSAIDS are at higher risk for GI symptoms, bleeding, and perforations. These risks can be between 2-4%/per year, and vary based on risk factors such as age, general health, cigarettes, prop...
Does hepatitis B vaccination reduce the risk of HBV reactivation associated with immunosuppressive therapy?
Hepatitis B reactivation is a critical concern when patients are undergoing immunosuppressive therapy, often described as 'deadly but preventable.' Screening for HBV is strongly advised before initiating biologic therapies, targeted synthetic therapies, or high-dose immunosuppression, including HBsA...