Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you think there is a role for belimumab in treating lupus nephritis and if so, in which patients would you considering adding it on?
The results from BLISS-LN showed modest efficacy as an add-on therapy to standard of care. The improvement was significant only in the non-black patients receiving mycophenolate mofetil (MMF) as standard of care. The primary endpoint was changed in the midst of the trial but still, the complete rena...
What agents can you use for treatment induction besides rituximab in cryoglobulinemic vasculitis (without hepatitis)?
The choice of induction/immunosuppression depends on the severity and is very similar to small vessel vasculitis like ANCA-associated vasculitis. So in addition to rituximab, cyclophosphamide is a very good induction agent for severe forms. This is one condition where plasma exchange is highly recom...
What is your inflammatory arthritis differential when a patient presents with unilateral TMJ synovitis?
The differential of TMJ disease depends on the age group. In the younger population, JIA must be very high on the differential. In adults, the differential includes RA, dermatomyositis, systemic sclerosis, systemic lupus erythematosis, and spondyloarthropathies (Ankylosing spondylitis and psoriatic ...
What is your approach to screening for cardiac involvement in patients with myositis and how does the finding of cardiac involvement change your management?
Cardiac involvement in IIM can often be overlooked but reportedly occurs at a high rate (~up to 75%) in a subclinical fashion. This can run the gamut of myocarditis, arrhythmias, conduction defects, cardiomyopathy, heart failure, and atherosclerotic disease. Screening for this often starts with an E...
How does your treatment algorithm differ for drug-induced ANCA vasculitis compared to non drug-induced ANCA vasculitis in cases with severe/organ-threatening manifestations?
When end-organ manifestations are present, my initial treatment approach is similar for drug-induced and non-drug induced AAV and typically consists of glucocorticoids and rituximab, including pulse glucocorticoids with severe end-organ involvement. Common drug culprits such as PTU, hydralazine, min...
What is your approach to monitoring lipids in patients with rheumatic diseases such as RA and SLE and do you have a lower threshold to start lipid lowering agents compared to the general population?
In patients with SLE/RA, there is a higher risk of cardiovascular disease compared to age-matched controls. This is multifactorial from underlying traditional risk factors such as obesity, HTN, DM, HLD, but may also be increased due to side effects of steroids, biologics, and other medications, and ...
How long do you continue steroid-sparing agents such as tocilizumab for GCA once the disease is in remission off steroids?
This is an excellent question and one we confront regularly. This is another of what I call “happy problems” because it is a consequence of increasing options for effective therapy for our patients.Tocilizumab is clearly an effective agent for some patients with giant cell arteritis (GCA), and patie...
How would you attempt to determine the etiology of intracranial hemorrhage in a patient with newly diagnosed lupus and an active viral infection?
My typical evaluation of a case like this is as follows: 1. Evaluate their lupus disease activity: CBC, CMP, ESR, CRP, C3, C4, dsDNA, urinalysis, urine protein/creatinine ratio (latter two are more for eval of renal disease) 2. Evaluate the cause of ICH: a. MR to further evaluate for other non-ICH r...
Do you monitor RS3PE patients for GCA with the same vigilance that you do in PMR patients?
I don't think there has ever been a confirmed case of GCA in someone with RS3PE. In this way, RS3PE is more similar to seronegative RA than PMR. However, it is possible that some patients with RS3PE may have overlapping features with cases of PMR, such as describing shoulder and hip girdle stiffness...
Which patients may benefit from eculizumab in refractory APS?
I do not know of any scheme/plan/approach that ahead of time would determine accurately and unequivocally if eculizumab would work. Having a low C4 and/or C3 serum level would suggest that the APLS antibodies are fixing complement. In other words, complement activation may be contributing to the pat...