Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is it okay to use belimumab to treat SLE in a patient who has a history of lymphoma and is on a Bruton's tyrosine kinase inhibitor (such as ibrutinib)?
For patients with ongoing SLE clinical/serologic activity despite ongoing treatment for lymphoma with agents targeting B cell proliferation, it's probably safe to use belimumab if needed in this setting. Thus far, reported experiences and our own using belimumab in patients who have undergone B cell...
How do you manage post-menopausal osteoporosis in a patient with stable bone density and no fractures after three years of holiday after giving zoledronic acid?
If the BMD is stable at three years of a post-treatment holiday, I would simply continue the holiday for another 1-2 years. The majority of post-menopausal women were able to achieve 5 years of treatment holiday before BMD dropped to baseline. Repeat the bone density measurement each year or two and...
What are examples of rheumatology quality measures that are both clinically meaningful and can be captured accurately and efficiently?
I can think of the following quality measures that I would recommend to practicing rheumatologists: 1. Screen every new patient with rheumatoid arthritis (RA) for infection with the hepatitis C virus. There are at least a couple of reasons to do this: A) Hep C infection can mimic RA, often with a p...
Is it ever appropriate to initiate a higher initial dose of allopurinol (such as 300mg daily) than is typically recommended in gout patients at low risk of allopurinol hypersensitivity syndrome and severe hyperuricemia?
Usually, allopurinol is started at a dose lower than that and gradually titrated up. This is the best strategy. In a rare instance, allopurinol may be started at 300 mg initial dose - where the patient has tolerated it at this or higher dose previously and is currently non-adherent; or has severe hy...
Is there a role for the VECTRA or other multi-biomarker tests in evaluating rheumatoid arthritis disease activity?
Yes. I find VECTRA very reliable and helpful in my community rheumatology practice. The reliability of the test has increased since its modified version came into the market a few years ago. VECTRA is an objective measure of disease activity in patients who already carry a diagnosis of RA. It should...
For which subset(s) of APS patients do you recommend an INR of 3 or higher?
According to the EULAR 2019 recommendations for managing APL (Tektonidou et al., PMID 31092409) and according to the 2011 APL Task Force recommendations: For secondary venous thrombosis prophylaxis, it is recommended to keep INR between 2-3. Patients who fail warfarin therapy at INR 2-3 may benefit ...
What is your approach to a patient with positive antiphospholipid antibodies who otherwise do not meet clinical criteria for APS?
As antiphospholipid antibodies constitute a diagnostic criterion of SLE, such patients may need to be evaluated and monitored long term for both SLE and APS.
Do you avoid any specific biologic therapies in HIV positive patients?
At present, the most safety data on the use of biologics in HIV is TNF inhibitors. CD4 count should be > 200 and VL undetectable. Etanercept is most preferable, give lower incidence of serious infections as well as its efficacy as monotherapy (without methotrexate). Wangsiricharoen et al., PMID 2733...
Are there any therapeutic options for cauda equina syndrome secondary to dural ectasia in end-stage ankylosing spondylitis?
The cauda equina syndrome is a rare complication in patients with ankylosing spondylitis (AS). Patients with longstanding disease leading to significant ankylosis of the spine have the highest risk of developing it. The likely underlying mechanism is arachnoiditis leading to damage of the lumbosacra...
How do you treat RA in patients with pulmonary mycobacterium avium complex (MAC) infections?
This is a very complex situation and requires teamwork between rheumatology and infectious disease with close patient follow-up and treatment. In general, avoiding TNF inhibitors in these patients is preferred, in particular the monoclonals, with close monitoring. Methotrexate is an option, and in t...