Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is the diagnostic utility of ordering an "Early Sjogren's Syndrome Profile", which tests novel autoantibodies, to support a diagnosis of Sjogren's syndrome in patients who test negative for SSA/SSB?
Currently, there is not much diagnostic utility to ordering these novel autoantibodies in patients who are negative for SSA/SSB as it is unclear how to interpret the results. In a mouse model for Sjogren's (Shen et al., PMID 23123440), these novel autoantibodies appeared earlier in the course of dis...
When do you consider discontinuing Pegloticase in a patient with tophaceous gout who has had excellent response to therapy?
This is an important question to clinicians who use pegloticase for their severely afflicted gout patients. There are no studies that provide guidance to answer this question but there is a good rational approach to knowing when to stop treatment.To recap, pegloticase therapy is indicated for patien...
Would you start anticoagulation in a patient with provoked blood clot in the past now with labs done for rheumatological reasons showing triple positive APLA?
The short answer is that I would probably not anticoagulate this patient as a history of prior thrombosis is hard to connect to the currently positive APL antibodies. I would certainly obtain a second set for future risk stratification. However, there are several variables that could influence the ...
Would you use belimumab in a breastfeeding patient with SLE who has persistent joint pain, leukopenia and elevated dsDNA despite HCQ and azathioprine?
While our understanding of the biologics safety in breastfeeding is still evolving and data is limited, based on my literature review, there are no signals that Belimumab is associated with an increased risk of adverse events in pregnancy/breastfeeding. Belimumab is a relatively large molecule, ther...
Have you seen drug induced SCLE from IL-17 inhibitors?
Fortunately, drug-induced subacute cutaneous lupus erythematosus (diSCLE) induced by IL-17 inhibitors is rare. I have never seen a case, but there are at least 3-4 cases in the medical literature (from brodalumab, ustekinumab, and secukinumab: Ang et al., PMID 33511692, Tierney et al., PMID 30891478...
How do you manage arthritis resulting from deferiprone in transfusion dependent thalassemia?
The precise pathophysiology of deferiprone associated arthropathy is not well understood but some reports have suggested that there may be some deposition of iron in the synovial membranes, and some subchondral bone damage. Unfortunately, there is no specific treatment for this arthritis, other than...
In patients undergoing MRI evaluation for inflammatory back pain, how long do you recommend they hold NSAIDs prior to imaging?
The other issue regarding NSAIDs and MRI is whether these agents will suppress the bone marrow edema signal which has been demonstrated in some patients. Therefore, it is recommended to hold NSAIDs for at least 3 days prior to the MRI.
When do you start bisphosphonates empirically, irrespective of DEXA results, in patients going on chronic glucocorticoids?
I think this is an important question. I personally got really interested in bone in large part because of all the glucocorticoids that I was using to treat serious inflammatory diseases. I was fortunate to spend time with Dr. Howard Polley from Mayo when I was a fellow. He was on the team that gave...
Can romosozumab be used in patients on dialysis?
This is an interesting question given the common finding of osteoporosis among patients undergoing hemodialysis. There have been several individual case reports suggesting that treatment with romosozumab in this patient population can be safe and effective. The largest study (no control group) of wh...
What is your approach to practical monitoring of lupus disease activity in clinical practice?
ANSWER TO QUESTION 1:I am so glad I am being asked this question!I use my clinical assessment (or physician global assessment).I generally love the 2023 EULAR SLE management update (Fanouriakis et al., PMID 37827694). However, I disagree with their recommendation that clinicians monitor the SLEDAI (...