Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you consider caplacizumab in a pregnant patient with iTTP?
As noted, caplacizumab was not studied in pregnancy (was an exclusion criteria) and is not approved in this setting.With that being said, as noted, caplacizumab use in pregnancy has been described in case reports (1, 2, 3) and in the post-partum setting (4). I would consider the use of caplacizumab ...
What would be the main indications for opting for biosimilars over an original biologic, outside of insurance barriers?
A timely question, as we head to 2023! The only reason to use biosimilars is for the broad purpose of resource stewardship. There isn't a medical reason to prefer a biosimilar over a reference product (or vice versa), because if a product were found to have a significantly different therapeutic effe...
Do you require lupus patients with ESKD or advanced CKD to be on minimal immunosuppression around the time of kidney transplantation?
Patients with SLE needs to have overall clinically quiescent disease to be actively listed for kidney transplant. They can be on stable/reduced dose of immunosuppression medications to keep the disease clinically under control. They can still have low complement levels (serologically active).
How do you approach monitoring for lymphoproliferative disease in Sjogren's patients?
I have an increased index of suspicion for lymphoma, myeloma, and amyloid in Sjogren's. Increased age, longer disease duration, and greater disease activity increase the lymphoproliferative risk.Persistent unilateral parotid or other salivary gland enlargements, lymphadenopathy, vasculitis (purpura,...
Would you treat a patient aggressively for lupus nephritis if they have persistent proteinuria over 1 gram but cannot get a timely kidney biopsy?
It all depends. I would keep pushing for a biopsy and try to overcome the barriers ASAP. If it is the patient who is the barrier (not wanting the biopsy), I would educate them on how a biopsy ends up not even being due to SLE in some cases and immunosuppressant treatment therapy would be exposing t...
Is it safe to use quinacrine in SLE patients with a history of hydroxychloroquine-associated retinopathy?
To my knowledge, quinacrine, an anti-malarial, is not FDA-approved for use in the US. It may be obtained from compounding pharmacies but the FDA makes no assertions regarding either its safety or its efficacy. For lupus, it has been used primarily as adjunctive therapy for cutaneous disease, e.g. ad...
Would you consider re-challenging a patient with rituximab after they experienced delayed neutropenia?
This is an important question as rituximab is a key treatment option across multiple rheumatic conditions. Probably the best study to inform this question comes from Zonozi et al., PMID 32892495 who retrospectively studied 738 RTX-treated patients at a single institution. They found that late-onset ...
What is your threshold to repeat a kidney biopsy in a patient with a history of lupus nephritis who is on maintenance therapy and develops subtle changes in urinary protein excretion or microscopic hematuria?
There have been a number of lupus biopsy and treatment questions here lately. The management of lupus nephritis is VERY difficult with innumerable permutations of past and present, biopsy nuances, symptoms, and treatment histories. The answer to this question depends on more than "subtle changes in...
What is your approach to treatment for MDA5 dermatomyositis patients with rapidly progressive ILD?
Rapidly progressive ILD is a temporal term, describing rapidly declining lung function within weeks (usually defined as 3 months). Therefore, we commonly use this term when the patient is already hospitalized with respiratory failure. The majority of the data stem from Japan and China, where they en...
In a patient with a Factor V Leiden heterozygous mutation but no prior thrombosis, would you consider using a JAK inhibitor for the treatment of spondyloarthritis or rheumatoid arthritis if other options have been ineffective?
1. I'd love to hear others' thoughts who are more versed in thrombotic diastheses and JAKi's.2. The only article I could find assessing this showed no differences between the JAKi arm and the tumor necrosis factor inhibitor arm regarding patients with thrombophilia mutations (Weitz, et al., PMID 363...