Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What characteristics make a PMR patient a good candidate for sarilumab?
As rheumatologists, we are familiar with sarilumab, so we may already be comfortable using this medication. It has a role to play in managing patients with some of the following issues: Those who are struggling with early steroid tapers, i.e., not successfully tapering from 10 down to 5 mg/qd. Pati...
In a patient with neurosarcoidosis who required infliximab for initially refractory symptoms but is now stable, how do you decide on the optimal time to de-escalate therapy?
I typically base this decision on several factors: Severity of initial symptoms, tolerability or side effects of treatment, degree/timeline of radiographic improvement, and patient preferences. I begin to consider tapering off or de-escalating infliximab after around 12-24 months of clinical and rad...
What isolation policies are Rheumatology offices employing for both staff and patients diagnosed with COVID-19 given the new CDC guidelines?
Still the same: masking in all settings.
Would you start anticoagulation in a patient with a history of CVA 1 year ago and high risk APL profile who was never started on anticoagulation, but is now presenting for follow up and without recurrent thrombotic events?
This is a difficult question. The details here are important. Therapeutically, you can go either way in my opinion. Were the positive antiphospholipid antibodies checked again later? Did the patient have an infection when the APS labs were first done? Does the patient have diabetes or other CV risk ...
What is your approach to a patient with IgG4RD with past pulmonary involvement (biopsy proven) managed with steroids alone, now with new hematuria/proteinuria, but stable renal function?
Significant hematuria is not a typical feature of IgG4-related kidney disease. IgG4-RKD most commonly presents as tubulointerstitial nephritis (TIN), which presents as mild, non-nephrotic range proteinuria. In fact, urinalysis in the context of TIN is often normal, as the proteinuria is largely non-...
How do you manage nausea in the setting of hydroxychloroquine use?
My method for approaching hydroxychloroquine (HCQ)-induced nausea: Stop HCQ When nausea is gone, restart with just 1/2 tablet every night after food or milk(I recall a study suggesting that nocturnal use caused less side effects, but I cannot find it. If anyone has the source, please chime in). A we...
How do you approach treating patients with lupus profundus?
For lupus profundus/lupus panniculitis, I would first confirm the diagnosis with a deep punch biopsy or incisional biopsy. The differential for lupus profundus includes factitial panniculitis, traumatic panniculitis, morphea profundus, and subcutaneous panniculitis-like T-cell lymphoma.Once the diag...
How long can you treat dermatomyositis with IVIG?
Typically, in best-case scenarios, you can treat dermatomyositis with IVIG for 1 year, but some patients require it for 18-24 months, and the minority of patients continue to require it over several years. Some patients may only need it until you achieve improvement, especially in some countries whe...
How would you approach a patient with MPO-positive isolated peripheral nerve vasculitis?
AAV can present with a peripheral neuropathy as a first manifestation. The first question we're often facing is whether a biopsy is necessary. If the neuropathy pattern is one of mononeuritis multiplex and there are no atypical features or other atypical serologic findings, I sometimes forego nerve ...
How will you adjust your approach to steroid taper in patients with PMR also on sarilumab?
I would try to replicate the prednisone taper followed in the SAPHYR study that weaned patients off over 14 weeks, understanding that there may be patients that won’t be able to taper the prednisone so aggressively or may benefit, in the opinion of the treating physician, from longer tapers (e.g., 4...