Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you manage osteoporosis treatment following parathyroidectomy for primary hyperparathyroidism?
Good question and I usually do this with input from an endocrinologist. I monitor serum and urine calcium and provide supplements and if the bone mass declines, I consult an endocrinologist on the next steps. As a rheumatologist, I am not an expert on this issue.
How do you approach the workup of clinically diagnosed cutaneous vasculitis in healthy young individuals without systemic symptoms?
As with all of medicine this answer depends on the presentation. A thorough review of systems and exam is needed to stratify workup. If we are talking about classic LCV below the knee in an otherwise healthy person, with no other concerning s/sx (as sounds like you are asking), I do generally confir...
How do you decide when to obtain genetic testing for suspected autoinflammatory conditions in adults?
We have identified an autoinflammatory disorder that occurs in people of the Southern Appalachian mountains known as "Melungeons." Several have been evaluated at NIH, and while they do not have any of the known markers the diagnosis of familial Mediterranean fever has been confirmed. Dr. Kastner tol...
What would be the preferred treatment option for PMR if patient develops gastric perforation soon after initiation of steroids?
Of course Kevzara.
How would you approach the workup and management of a young patient with recurrent biannual non-scarring oral ulcers and new onset neurologic symptoms with associated CNS white matter lesions concerning for Behcet’s?
This is a challenging case. It should be noted that oral ulcers in Behcet's typically occur more than twice per year (by ISG criteria should occur at least 3x per year) and without other symptoms of BD it can be very challenging to make a probable diagnosis of BD in this scenario. A careful history ...
Are there patients with granulomatosis with polyangiitis on maintenance rituximab therapy for whom you do not co-administer glucocorticoid therapy?
I think this is a great question. @Dr. First Last et al (NCT01933724) have conducted a study to answer that question (conveniently called TAPIR). In their analysis that was presented 1 week ago at the International Vasculitis Workshop, they found that patients on low-dose prednisone along with other...
Do you extend the duration of maintenance therapy past 24 months for patients with ANCA glomerulonephritis who have multiple organ involvement?
The duration of maintenance therapy in patients with AAV depends on many factors and should be individualized. Some factors that are associated with a higher risk of relapse include PR3 positivity, seroconversion from negative to positive, ENT disease, use of a tailored approach to RTX dosing, and u...
What is your approach for steroid dosing for patients with ANCA vasculitis on induction treatment with rituximab, avacopan, and glucocorticoid therapy?
I do not personally have a one-size-fits-all approach. Remember that ADVOCATE had a screening window of up to 2 weeks where many patients got steroids before they were randomized. At the time of randomization, patients had to be on less than 20mg of prednisone which was tapered over 4 weeks.In addit...
Would you offer lung SBRT to a medically inoperable patient with systemic lupus erythematosus or other connective tissue disorders if well controlled?
This is a very timely and clinically relevant question that had intrigued us for quite a while. Thus, we looked into our over 10 year experience at UCLA for 197 adult patients with collagen vascular disease. This work was recently published in JAMA Open Network: Yoon et al., PMID 33599771.The hypoth...
How do you treat CTD-associated organizing pneumonia?
The approach to CTD-associated organizing pneumonia is similar to that of CTD-associated NSIP and involves treatment with glucocorticoids and steroid-sparing agents. The evidence for the choice of steroid-sparing agents is extrapolated from clinical trial and observational data from systemic scleros...