Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach management of a patient with idiopathic PAH and +ANA, but no other current symptoms/signs of active rheumatologic disease?
(1) Of note, abnormal nail fold capillaroscopy is associated with PAH in several systemic immune diseases: This is famously true for systemic sclerosis, but there are also publications reporting this association for other diseases, notably those in the “lupus family“ like SLE and dermatomyositis. As...
How would you approach the management of a new SLE patient presenting with lupus podocytopathy with FSGS and severe proteinuria (Pr/Cr 18) without immune complex deposition?
Hopefully one of the nephrologists will chime in on this one. However, this reminds me very much of a similar SLE patient I started to take care of about 6 years ago (BX = podocytopathy and FSGS; had marked proteinuria and renal dysfunction). I treated her with high-dose steroids, hydroxychloroquine...
Do you consider the use of antifibrotics at presentation in patients with a radiographic UIP pattern of pulmonary fibrosis in the presence of positive serologies without any symptoms of CTD who have not yet demonstrated evidence of a progressive phenotype?
I really like this question, because it succinctly encapsulates several areas of clinical uncertainty that we are routinely forced to address in our ILD clinics! Let’s unravel some of the subtleties here. For starters, if the radiographic pattern is convincingly that of UIP, our patient will technic...
How would you approach a young patient with bilateral lower extremity muscle weakness and positive anti-Smith, dsDNA, RNP, Raynaud’s, and pericardial effusion but normal muscle enzymes?
The timeline of weakness may be helpful, but another possible cause of weakness in the setting of normal CK would be an inflammatory demyelinating polyneuropathy (can be acute or chronic). EMG and NCS would be helpful in evaluating this.
What is the risk of uveitis flare in patients with JIA and uveitis, who are in remission, when tapering medications?
The ADJUST Trial is in progress and is trying to answer precisely this question for those currently receiving adalimumab. I am not aware currently of a large database to provide a reliable answer to this question. My approach is to require no evidence for active uveitis for at least 12 months, and t...
What is your approach to management of hyperlipidemia in patients taking JAK inhibitors?
The ORAL Surveillance Study published in the NEJM in 2022 was a phase IIIb/IV open-label noninferiority study in RA patients over the age of 50 with at least one cardiovascular risk factor. The aim was to demonstrate that JAK inhibitors were non-inferior in terms of major adverse cardiovascular even...
Do you use the peri-operative management of biologics and DMARDs guidelines, which were mainly based on total hip and knee replacement surgeries, for all peri-operative surgical management?
The American College of Rheumatology Perioperative Guidelines focused on patients undergoing hip or knee arthroplasty. These guidelines can be a helpful starting place when thinking about medication management in patients undergoing other surgeries, but my recommendations for perioperative managemen...
How do you approach the timing of DMARD initiation in patients with active RA who are on treatment for latent TB?
As the patient is already treated for latent TB, if they have not initiated DMARD therapy for RA, I would follow the guidelines and start conventional DMARD therapy. If the patient requires additional therapy because of insufficient response, I would choose a non-TNF inhibitor as the risk for TB rea...
Do you recommend avoidance of vaginal estrogen in patients with SLE?
It depends on the age. The SELENA study demonstrated that BCPs in premenopausal women did not lead to flares or increased disease activity though the risk of increased clotting is an issue for APL+ folks. Post-menopausal women treated with HRT had an increase in mild flares compared to those not on ...
For how long do you recommend treatment for latent tuberculosis prior to initiation of anti-TNF therapy?
Some recommendations call for completing a course of treatment for latent TB prior to starting a biologic but I find most patients and referring specialists are intolerant of that strategy. This reference: Yeo et al., European Respiratory Journal 2014 is a good example of data supporting a shorter w...