Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you stop azathioprine in a patient with ANCA vasculitis who has been in long term remission on azathioprine, but has a new diagnosis of lung cancer requiring initiation of immunotherapy?
Data about the effect of immunosuppression on the efficacy of immune checkpoint inhibitors suggests that there is a negative of effect of being on immunosuppression at the time of ICI initiation on tumor response. So if the patient really has been clinically stable for a long time there are a few op...
Have the results of the ancillary study of the VITAL trial, demonstrating that Vitamin D3 supplementation did not reduce the incident rate of fractures in generally healthy midlife and older adults, changed how you prescribe Vitamin D?
It should be appreciated that the function of vitamin D is to maintain a serum calcium concentration in a normal range to maintain neuromuscular function and most metabolic functions. It can accomplish this by increasing intestinal calcium absorption. When there is inadequate calcium in the diet, th...
Would you consider teriparatide use in a patient with prior radiation therapy, given that the black box warning regarding osteosarcoma risk has been removed by the FDA?
The rat studies were unequivocal that both teriparatide and abaloparatide increased the risk of osteosarcoma in rats given high doses for essentially their entire lifespan. Upon approval of teriparatide, Lilly agreed to a post-marketing pharmacovigilance study that started out as a case-finding stud...
How do you manage a DOAC if interested in testing for lupus anticoagulant?
Testing for anti-phospholipid antibodies encompasses two broad categories of testing. One is an ELISA based (aka solid phase) set of tests that include anti-cardiolipin and anti-beta 2 glycoprotein I antibodies. ELISA assay are not affected by DOACs. For the second lupus anticoagulant (aka fluid pha...
What is the recommended approach for systemic therapy in a patient with metastatic cutaneous squamous cell carcinoma with active autoimmune disease (dermatomyositis)?
Dermatomyositis can occur with myositis/myasthenia gravis (overlap syndrome). At the Ohio State University Comprehensive Cancer Center, we have established an Immunotoxicity Clinic headed by a rheumatologist, Dr. @Dr. First Last. I would recommend engaging with a rheumatologist who is familiar with ...
How do you approach evaluation for underlying rheumatologic disease in patients with chronic asymptomatic thrombocytopenia?
APL testing as well as evaluation for SLE and Sjogrens with complement, urine, antibody testing, not just an ANA.
How do steroids and/or DMARDs affect biopsy results if a renal biopsy for suspected lupus nephritis is delayed?
In contrast to GCA/TA, where the Mayo clinic has published data that steroid treatment for as much as circa 2-4 weeks is unlikely to result in a false-negative biopsy, as long as accounts for the skip phenomenon and carefully examines multiple sections of the biopsy, I am unaware of similar informat...
How do you utilize methotrexate and/or hydroxychloroquine in the setting of limited scleroderma/CREST?
Thank you for this great question!The use of immune-suppression in systemic sclerosis is generally reserved for progressing skin sclerosis, progressive ILD, inflammatory arthritis, inflammatory myositis, and myocarditis. These manifestations have a significantly higher prevalence in diffuse cutaneou...
How often should you screen for lymphoma in patients with primary Sjogren's syndrome?
Depends on index of suspicion, I don't have a set schedule. In addition to assessing the initial "phenotype" and disease activity of SjD, I want to know baseline status of quantitative Ig's and if a monoclonal is present. I reassess based on clinical scenario over time. Some colleagues will recommen...
Do you delay pegloticase in a patient with an active gout flare?
I don’t. The patient should be on prophylactic colchicine (if their renal function allows), and part of their pre-treatment involves the systemic administration of corticosteroids anyway such as hydrocortisone (used in the initial drug trials) or methylprednisolone (Solu-Medrol). It is known that du...