Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What strategies have you found most helpful to improve adherence to hydroxychloroquine among patients with lupus?
In my practice, three approaches have been most useful: Make adherence measurable. I routinely check whole-blood hydroxychloroquine levels and review the trend with patients in a nonjudgmental way. This creates accountability and turns an otherwise “invisible” treatment into something concrete that ...
Do you favor obinutuzumab over voclosporin for patients with lupus nephritis and significant proteinuria and a history of non-adherence to medications?
Non-adherence to medications is a common issue in lupus patients, but this can be even more of a concern in lupus nephritis, where the pill burden for patients can be so high. I usually prefer to use intravenous medications for patients who have had difficulty adhering to oral medications in the pas...
What is the clinical significance of elevated serum complement (C3 and/or C4) levels?
I have always considered elevated complement levels to be an acute phase reaction and an indication of inflammation, be it infection or cancer, similar to the ESR and CRP. Recent data have linked these elevated levels with obesity and metabolic syndrome. We have known for years that levels of C3 and...
How do you evaluate and manage patients with lupus who are having issues with decreased libido?
Decreased libido is one of several factors contributing to sexual dysfunction for people with lupus and other rheumatology disorders. Although sexual dysfunction is common in our patients, it is rarely discussed during office visits. The first step towards evaluation and management of decreased libi...
Assuming lab accuracy, what are some of the hallmarks and symptoms that would lead to a diagnosis of ANA-negative lupus as opposed to any other autoimmune condition?
I would not make an initial diagnosis of ANA-negative systemic lupus erythematosus (SLE) lightly, especially since there are so many mimics of SLE. However, it does occur, even in early, untreated patients. Even some of the best lupus centers in the world (SLICC) have a 6% prevalence of ANA-negative...
Would you stop methotrexate or leflunomide if MCV increases after starting the medication with no other parameters of anemia or leukopenia?
I would take this as a sign that the patient is taking their medication. Pretty common and definitely wouldn’t withhold RA tx for this.
In patients with SLE do you have concerns about using trimethoprim-sulfamethoxazole (Bactrim) because of a potential risk of lupus flare?
I agree with Dr. @Dr. First Last . I have had too many SLE patients over the years show up in my office with a severe flare from TMP/SMX. We have too many alternative antibiotics these days, including for PJP prophylaxis, so sulfonamide antibiotics should be avoided in SLE patients. The typical scen...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
Are there particular subsets of AAV patients in which avacopan is more effective?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:Patients in the ADVOCATE trial were stratified at entry according to time of diagnosis (new/relapsing), diagnosis (GPA/MPA), ANCA serotype (PR3/MPO), and background immunosuppressive (cyclophosphamide/rituximab) with re...
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...