Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you continue belimumab throughout pregnancy?
@Dr. First Last: @Dr. First Last is absolutely correct regarding the limitations of our studies regarding using belimumab in pregnancy.However, how much more evidence do we need?No one is going to perform a prospective randomized controlled trial. I and some others I know are feeling more comfortabl...
How do you plan to use canakinumab for the treatment of gout?
I recently had this approved for a gentleman with severe tophaceous gout who does not want to be on allopurinol due to mobilization flares and had anaphylaxis to pegloticase. He has CKD and multiple cardiac comorbidities which limit colchicine as prophylactic agent and difficulty with controlling bl...
Do you avoid tocilizumab in patients with prior bariatric surgery given the risk of GI perforation?
This is an interesting question with no current data to answer it with certainty. However, I personally would feel comfortable prescribing tocilizumab in a patient with an uncomplicated bariatric surgery history for the following reasons. The vast majority of GI perforations in the setting of TCZ oc...
What is your threshold for pursuing bone marrow biopsy in a lupus patient with cytopenias?
I rarely do bone marrow biopsies in patients with SLE as cytopenias are caused primarily by the disease itself and/or medications, primarily Azathioprine and Cyclophosphamide. SLE patients routinely have profound lymphopenia, neutropenia, and thrombocytopenia. I consider bone marrow biopsy in patien...
How do you approach the workup of a patient with incidentally found pachymeningitis?
In general, when we think about the meninges, we consider the leptomeninges and the pachymeninges separately, though many of the disorders of one can also cause disease in the other. We also consider whether the pachymeningitis is focal and nodular or diffuse. Common causes of pachymeningitis are in...
What is the utility in repeating a temporal ultrasound (US) in a previously US diagnosed positive GCA patient who has received treatment and is presenting with recurrent GCA symptoms?
While TA ultrasound may have a role in the assessment of disease relapse, currently there is little evidence to understand its utility in this area. It is well known that the halo sign is steroid responsive and multiple studies have shown that the halo sign recedes within the first several weeks of ...
Do you always perform temporal artery biopsy in patients with positive inflammatory markers and high clinical suspicion of GCA?
As with most clinical scenarios, the short answer is 'it depends'. If a patient has cranial symptoms, elevated inflammatory markers, and suspicion for GCA is high, I do refer for temporal artery biopsy to help confirm the diagnosis. This is in line with guidelines from the American College of Rheuma...
How do you approach management of a patient with persistent EBV infection and MAS despite treatment with Rituximab, anakinra and canakinumab?
The (presumed) rationale for B cell depletion in EBV-associated MAS is to deplete infected B cells that are potential targets for cytotoxic T/NK cells that may have perforin pathway defects leading to excessive/prolonged cytokine release. Failure of the MAS to resolve with steroids/anakinra/rituxima...
Is either ESR or CRP more sensitive or specific for the diagnosis of GCA?
I typically obtain both an ESR and a CRP in the workup of new onset or relapsing GCA. The CRP may be slightly more sensitive than the ESR based on Kermani et al., PMID 22119103 which demonstrated a sensitivity of 86.9% and 84.1% respectively for CRP and ESR, for a positive TAB. There is discordance ...
How do you treat post-IVIG headache that is not responsive to Tylenol or NSAIDs?
In my opinion, there is no one simple treatment for such headaches. We try slowing the infusion rate, premedicate with steroids, low dose Lasix, or premedicate with Nurtec. Usually, one of these methods helps minimize or eliminate the headaches.