Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What would be your next step in management of a dermatomyositis patient on hydroxychloroquine and methotrexate whose skin is still active?
There are many different options for this kind of scenario. Depending on the physician's preference, patient's lifestyle, and insurance coverage, one could switch to mycophenolate, which seems to be more effective for skin manifestations, or azathioprine. If the patient did have a partial response t...
What immunosuppressive agents would be available to patients with a history of melanoma?
Generally, we try to use conventional synthetic DMARDs when possible. However, studies in RA have not shown an increase in de novo melanoma or recurrence of cancers more generally with TNF-inhibitors. So this is an option for patients with RA and melanoma history who are not responding to csDMARDs. ...
Do you generally prefer to continue hydroxychloroquine in lupus patients who develop ESRD despite the low likelihood of clinically active disease in this patient population?
Yes, I do. In my experience, nephrologists tend to forget or neglect the use of HCQ. HCQ can prevent lupus flare-ups and progression of disease not to mention CV benefits as well as being helpful in addressing APS if present.
How do you treat idiopathic acute anterior uveitis that recurs immediately after a course of topical corticosteroids?
Anterior uveitis has many known causes that include HLA-B27-associated (often with ankylosing spondylitis); viral such as herpes simplex, CMV, or zoster; or as part of a syndrome that includes interstitial nephritis; or as a manifestation of juvenile arthritis. Labeling it acute means that it starts...
How long do you continue PJP prophylaxis in a patient with GPA who is able to wean steroids and remains only on rituximab for maintenance therapy?
Great question! For my ANCA patients and the OSU vasculitis clinic, we leave them all on Bactrim for the life of the disease. Less about PJP, and more about helping minimize infections due to the sinus and respiratory inflammation creating a nice environment for bacteria to live. Also, there is some...
Would you consider the use of doxycycline or minocycline in the management of RA?
When faced with an issue of a TNF side effect or an infectious complication, I have used minocycline for the management of RA. This is based on an observation of minocycline’s effectiveness in early RA. A patient of mine developed optic neuritis while administering adalimumab, and Opthalmology (appr...
What is your workup and treatment approach for cranial neuropathies in patients with lupus?
Pretty much the same as is done for SLE patients presenting with acute or chronic inflammatory peripheral neuropathies with the additional concern for leptomeningeal inflammation. Evaluation: Cranial MR, CSF studies (cell count, albumin, IgG level with accompanying serum levels to determine IgG Inde...
How would you manage a patient with CKD4 due to lupus nephritis of unknown class who develops AKI requiring hemodialysis and nephrotic range proteinuria and is found to have atrophic kidneys on imaging?
The decision to biopsy a kidney is not based just on size. The operator should look at the kidney size compared to the height of the patient and the echogenicity on ultrasound.If the patient is short with a normal/near-normal echogenicity, even a <9cm kidney can yield useful information. This is rel...
What is your approach to treatment of infection-triggered HLH that does not respond to treatment of the underlying infection?
The algorithm our center follows is to Recognize hyperinflammation (see answer to question above -- in addition to baseline labs, we obtain an infectious disease consult) Look for and treat the trigger. A concern, if the patient is responding, is that we are missing a trigger (HLH does not occur sp...
Is there a concern for the potential of future congenital malformations in offspring when preservation of eggs and sperm is done AFTER cyclophosphamide treatment given that it is an alkylating agent?
No, there is not a significant risk of congenital malformations in embryos created with cryopreserved gametes or unassisted pregnancies AFTER cyclophosphamide use. While alkylating agents lead to both male and female infertility, congenital malformations from cyclophosphamide occur when conception h...