Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you favor obinutuzumab over voclosporin for patients with lupus nephritis and significant proteinuria and a history of non-adherence to medications?
Non-adherence to medications is a common issue in lupus patients, but this can be even more of a concern in lupus nephritis, where the pill burden for patients can be so high. I usually prefer to use intravenous medications for patients who have had difficulty adhering to oral medications in the pas...
What is the clinical significance of elevated serum complement (C3 and/or C4) levels?
I have always considered elevated complement levels to be an acute phase reaction and an indication of inflammation, be it infection or cancer, similar to the ESR and CRP. Recent data have linked these elevated levels with obesity and metabolic syndrome. We have known for years that levels of C3 and...
Assuming lab accuracy, what are some of the hallmarks and symptoms that would lead to a diagnosis of ANA-negative lupus as opposed to any other autoimmune condition?
I would not make an initial diagnosis of ANA-negative systemic lupus erythematosus (SLE) lightly, especially since there are so many mimics of SLE. However, it does occur, even in early, untreated patients. Even some of the best lupus centers in the world (SLICC) have a 6% prevalence of ANA-negative...
In patients with SLE do you have concerns about using trimethoprim-sulfamethoxazole (Bactrim) because of a potential risk of lupus flare?
I agree with Dr. @Dr. First Last . I have had too many SLE patients over the years show up in my office with a severe flare from TMP/SMX. We have too many alternative antibiotics these days, including for PJP prophylaxis, so sulfonamide antibiotics should be avoided in SLE patients. The typical scen...
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Here is a recent expert consensus by Joel Block on the use of low-dose radiation therapy in OA: Some highlights: "Placebo-controlled randomized clinical trials have now been reported using LDRT for OA of the knees and of the hands. Taken together, they do not show benefit beyond placebo... While a d...
What is the role of inebilizumab in the maintenance treatment of IgG4-related disease?
Inebilizumab may play an important role in the maintenance treatment of IgG4-related disease (IgG4-RD), particularly in patients at high risk for relapse. These are typically patients with multi-organ involvement and elevated serum IgG4 levels who initially respond well to corticosteroids but tend t...
What dose of methotrexate do you typically continue to prevent antibody formation when adding infliximab for sarcoidosis?
Infliximab is a chimeric molecule that contains approximately 25% murine protein, so it can be immunogenic in some individuals.Development of anti-infliximab antibodies (ATI) has been reported in various autoimmune diseases treated with infliximab.Around 10 to 50% of individuals with rheumatoid arth...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
How often are you performing CT screening in CVID patients to screen for ILD?
CT once every 1-2 years, depending on symptoms and PFTs. PFTs, including DLCO, are annually performed.
How long after initiation of steroids and immunosuppressive therapy does muscle biopsy remain reliably informative in the setting of suspected inflammatory myopathy?
I don't think there is any definitive, well-validated answer here. Certainly, obtaining a biopsy within ~2 weeks of initiating therapy, in my experience, has clearly not affected the histopathologic findings that would be characteristic of dermatomyositis, necrotizing myopathy, or autoantibody-assoc...