Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend adjusting the duration of a drug holiday based on the specific bisphosphonate used when treating osteoporosis?
If there has been a satisfactory response, the drug holiday for alendronate can be 2 years while zoledronic acid, which is more tightly bound to bone, can be stopped for three years.
Would you use an anti-IL 17 over an anti-TNFa as your first line biologic in psoriatic arthritis?
For the treatment of active psoriatic arthritis, I would use an IL17 inhibitor over a TNF inhibitor. Recent evidence supports this approach, and I review these data in the paragraphs below. Two studies of IL-17 inhibitors have now shown equivalent efficacy to TNF inhibitors for the psoriatic musculo...
What is your approach for severe SCLE in patients unable to tolerate HCQ?
30% of subacute cutaneous lupus erythematosus (SCLE) is worsened by or caused by drugs, especially PPIs, calcium channel blockers (CCBs), thiazides, minocycline, and anti-fungal meds. Very different from other drug-induced disorders, the culprit drug could have been started months to years (as long...
What is your approach to DVT prophylaxis in patients who require IVIG but are at increased risk for thrombotic events?
I am unaware of any published data to guide the decision-making for this topic. Empirically, I recommend low-dose aspirin in patients >50 who have to get long-term IVIG especially if there are a lot of underlying risk factors for thrombosis like diabetes, immobility, etc. Again, this is not an evide...
Where do you anticipate using bimekizumab in your sequence of treatment options for a patient with psoriatic arthritis?
In the absence of head-to-head studies, the following answer is based on my own experience, and not data-driven. Bimekizumab is as good as IL-17A inhibitors (Secukinumab and Ixekizumab) on the skin and musculoskeletal (MSK) domains, better than TNFi on the skin, but equally efficacious on MSK sympto...
How do you utilize cytokine panels in your clinical practice?
It's become easier to order cytokine panels that get processed locally in my hospital. However, I think we're still far from knowing how to interpret these or make clinical changes as a result. While it's tempting to think, "If TNF is elevated, I will give the patient a TNF inhibitor, which will mak...
Is it better to give dose 2 of the mRNA 2024-2025 Covid-19 vaccine at month 2 or month 6 after dose 1 in moderately immunocompromised patients?
This is a complicated question and unfortunately, we have no clear answer for it based upon clinical outcome data. The COVID-19 pandemic has changed dramatically since its inception over 4 years ago. Based on a combination of favorable viral evolution of diminishing pathogenic potential continuing t...
Would you increase the hydroxychloroquine dose to more than 5 mg/kg/day in a compliant patient with active non-organ threatening lupus (skin+joints) if serum hydroxychloroquine is not at goal until you reach an acceptable concentration?
Absolutely! Thanks for asking as this should be the trend in dosing.However, let's call this "non-life threatening lupus" instead of "non-organ threatening".Cutaneous lupus is one of the top reasons for the poor quality of life in lupus patients (Klein et al., PMID 21397983), so remission is our goa...
When would you administer the next maintenance dose of rituximab in a patient with ANCA glomerulonephritis who last received an infusion six months ago and has low immunoglobulin levels and an undetectable CD-19 cell count?
If an ANCA vasculitis patient is in remission and has no infections, I usually in clinical practice do not check Immunoglobulin levels or CD19/20 levels either. They should only be done in patients with recurrent sinus infections or Pneumonia. If the patient with recurrent infections has low Immunog...
What is your treatment approach for pregnant patients with IgA nephropathy who have worsening proteinuria during the first trimester?
Difficult question to answer without more details, but I would consider the following factors: One is whether it appears that the IgA is active. When was the last biopsy, and how much hematuria is present? Two would be if this is 'worsening proteinuria' is really just the first time proteinuria has ...