Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Does serologic activity (e.g., high titer dsDNA, low complements) without clinical disease activity in a pregnant lupus patient affect maternal or fetal outcomes?
Not specifically. High titers of anti-dsDNA and low C3 and/or low C4, especially those that are adversely trending, are predictors of renal involvement which could adversely affect outcomes especially if the renal involvement mandates a change in therapy, but otherwise no. If these biomarkers are ab...
How do you interpret granulomatous features on a muscle biopsy?
The differential for granulomatous myopathies is quite wide and depends on the clinical scenario. The most common diagnosis would still be sarcoidosis, but can also be seen with Crohn's disease, myopathy associated with anti-mitochondrial antibodies, rheumatoid arthritis, GPA/EGPA, rheumatoid arthri...
Are subcutaneous RA therapies less effective in obese patients?
Subcutaneous therapies may be less effective for RA in obese patients in some cases. The literature is mixed: no effect with subcutaneous abatacept but worse response in people with higher BMI with subcutaneous methotrexate.From personal experience, some obese patients or men with higher body weight...
Would you avoid the use of a TNF inhibitors in patients with a remote history of melanoma, including those with ocular melanoma?
Clinical trials of TNF inhibitors have identified a small but increased risk of malignancy with the use of TNF inhibitors, and most, but not all, of the follow-up studies done with real-world registries have confirmed this. These registries are of course sometimes affected by the behavior of physici...
Would you consider an osteoporosis medication in a pre-menopausal/young patient with a low Z score and an ongoing risk factor for secondary osteoporosis such as chronic antiepileptic treatment?
Osteoporosis prevention is always difficult in young patients with risk factors. For young premenopausal women or men below 40, I extrapolate from glucocorticoid-induced osteoporosis (GIOP) guidelines. If Z scores are below -3 and/or there is a history of fragility fracture(s), then treatment with O...
Do you have any suggestions about how to improve rheumatology training in internal medicine residency programs?
As an academic rheumatologist and also an internal medicine program director, I have a strong vested interest in promoting rheumatology. Our clinics are set up so residents have the opportunity to work with varied preceptors to encounter a wide array of pathology as well as practice styles. We have ...
Would you consider starting IVIG as initial steroid-sparing agent instead of azathioprine/methotrexate in a patient with inflammatory myopathy, high Jo-1, weakness with severe dysphagia and without skin involvement or ILD?
Yes, that would be one approach especially given severe dysphagia. The best treatment for dysphagia is IVIG. However, steroid + MTX/AZA would be a reasonable approach for 2-3 months. If not seeing desirable results, going for IVIG early rather than late would be a good strategy as well.
What is your work up and management for patients who develop neuropathy on a TNF inhibitor?
The first issue to address is whether the neuropathy is truly related to the TNF blocker. This can be challenging as many of our patients who were prescribed these drugs may have an underlying neuropathy related to their disease. For example, we know that patients with RA are susceptible to developi...
Do you recommend on-demand versus fixed-schedule dosing for rituximab maintenance in ANCA vasculitis?
This is a fairly hot question in the field, and one that reflects the success we have had with advancing therapy for ANCA-associated vasculitis; it’s nice to have choices! Although there are data for both approaches, there are more data (larger numbers, etc.), in my opinion, for fixed-dosing. The tr...
What clinical factors do you use to determine timing of on-demand dosing of rituximab in ANCA vasculitis maintenance therapy?
I tend to use scheduled dosing (q 6 months) with RTX for maintenance in my GPA/MPA patients, but will occasionally use "on-demand" dosing in those who are eager to minimize their RTX, do not tolerate the infusions well, or occasionally those who have lower risks of flare (mild disease, no history of...