Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is the approach to use of ACE inhibitors for suspected scleroderma renal crisis in patients with only mildly elevated BP and renal artery stenosis?
I recommend using a short-acting ACEi, like captopril, to treat scleroderma renal crisis. You can start at 6.25mg TID and rapidly titrate up the dose to achieve blood pressure goals. The presence of renal artery stenosis (RAS) would not dissuade me from using an ACEi, if there is evidence of thrombo...
How do you approach transaminase elevations with use of allopurinol in gout?
This is quite rare in my practice of the use of allopurinol. That may be because I discourage NSAID concomitant use in people with gout, given their concomitant hypertension, and NSAID-associated GI, renal, and liver toxicity. 1. If mild transaminitis happens, I would approach it as I do for any pat...
What is your approach to management of persistent painless salivary gland swelling/sialadenitis in patients with Sjogren's?
This is a common problem in this patient population, and we had Rheumatologist send to worry about physical findings that we are having trouble explaining. In this particular situation, the printable concern would be for sites of damage. Unfortunately, there are no known immunologic interventions th...
How do you manage patients with systemic sclerosis and chronic thrombotic microangiopathy on renal biopsy, but no other evidence of scleroderma renal crisis?
Very good question. Disclaimer 1st - I am not a nephrologist or nephropathologist so this really requires putting many heads together! Thrombotic microangiopathies (TMA) are clinical syndromes defined by the presence of hemolytic anemia, thrombocytopenia, and organ damage from micro thrombosis in ca...
What is your approach to monitoring a patient with SLE who has persistent hypocomplementemia on hydroxychloroquine, but clinically has resolution of cutaneous symptoms and no other internal organ manifestations of disease?
Per the subtitle under your question, an undetectable C4 with low C3 makes me wonder about the possibility of a homozygous C4 deficiency, of whom 75-80% of patients have SLE with a high occurrence of lupus nephritis (Yang et al., PMID 15294999). You can consider genetic testing (primarily for geneti...
How do you approach management of patients with inflammatory arthritis who are asymptomatic but develop radiographic progression?
Radiographic disease progression remains the gold standard test for assessing disease activity in patients with RA. Therefore, any time one notes progression of radiographic change, this finding needs to be taken seriously. Since plain radiographs may take many months or years to demonstrate such ch...
Do you use immune checkpoint inhibitors in NSCLC patients with pre-existing, well-controlled autoimmune disease?
While there is limited data on the use of PD1 inhibitors in patients with pre-existing autoimmune conditions; in patients with metastatic NSCLC with limited options, it warrants consideration. This is obviously a high risk population to treat and close monitoring and co-ordinated care with specialis...
Do you consider it safe to continue adalimumab for spondyloarthritis in a patient who develops localized melanoma if the adalimumab has worked well?
This is a challenging question as there's a lack of data regarding the impact of anti-TNF agents on melanoma progression. While the safety record for TNFi in the context of malignancy is generally positive, melanoma progression remains unpredictable. In the described case of localized melanoma, my p...
How do you approach an older male with a chronic and persistent granulomatous cutaneous medium vessel vasculitis that has been unresponsive/worsened on high dose steroids, cyclophosphamide, and rituximab immunosuppressive agents with a thorough and unremarkable serologic, infectious, and imaging work-up?
These types of patients vex all rheumatologists at one time or another during the course of clinical practice. The primary concern that is usually raised by a rheumatic disorder unresponsive to therapy is a paraneoplastic disorder. When you say you have a “thorough imaging work-up,” what do you mean...
What kinds of dental work do you particularly worry about and try to avoid in patients on bisphosphonates?
Firstly, the incidence of BRONJ (bisphosphonate-related osteonecrosis of the jaw) is very low with all drugs of this class. However, many patients and dentists are concerned about the possibility of this problem. Generally, BRONJ occurs after an extraction and subsequent poor healing at the extracti...