Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Should we recommend the COVID-19 booster vaccine to patients who had a DVT or any other complications such as hemolytic anemia or thrombocytopenia from prior vaccine doses?
There are a few case reports of VTE following COVID-19 vaccinations (approximately 10 based on my PubMed review today). However, VTE has a high incidence of 0.1% in the general population and much higher after age 45 (Mary Cushman, PMID 17433897), so determining a causal relationship between the vac...
Is there a role for immunosuppression in patients with triple positive antiphospholipid antibodies who do not meet the clinical criteria for APS?
Currently, there are no “clinical” nor “diagnostic” criteria for antiphospholipid syndrome (APS). I suspect your question refers to patients not meeting the Sapporo APS “classification criteria.”There are two primary ways that patients with triple-positive antiphospholipid antibodies (aPLs: anticard...
Do you screen for HLA-B*5801 prior to starting allopurinol in patients of backgrounds other than Asian or African-American?
The guidelines now recommend checking for the presence of the HLA-B*5801 gene only in Asians and African-Americans. However, in our clinic, we are checking for the presence of this gene on everybody who becomes a candidate to receive allopurinol, partly due to the fact that we are doing a study. Int...
How do you diagnose and treat patients who develop uveitis while on bisphosphonate therapy for osteoporosis?
Ocular inflammation, usually anterior uveitis, can occur as a consequence of bisphosphonate therapy. Virtually always, the bisphosphonate is one that is given intravenously and the ocular inflammation begins a day or two after the treatment. Furthermore, the inflammation is generally self-limited; i...
What is your steroid-sparing agent of choice to treat GCA given the current tocilizumab shortage?
If at all possible, I continue to use tocilizumab as a glucocorticoid sparing agent for patients with giant cell arteritis. Given the results of the GIACTA trial, the Villiger trial, and lots of observational data, it is clear that tocilizumab provides efficacy in terms of reducing risk of relapse a...
What are your recommendations regarding methotrexate usage in patients with persistent chest CT changes post COVID pneumonia?
With the raging pandemic and the steady stream of post-COVID inflammatory/fibrotic patients, we are bound to encounter patients with such abnormalities who are on potentially pneumotoxic drugs (or need initiation).With minimal concrete data, any recommendation is purely based on experience.Methotrex...
What particular pre-operative considerations should we consider for SLE patients undergoing elective surgery?
Our guidance in the perioperative management of systemic lupus erythematosus (SLE) patients is essential. A 2016 study showed they are at a much higher risk for falls, thrombosis, acute kidney injury, and infections compared to patients with osteoarthritis (Roberts). This increased risk is even pres...
Do you recommend COVID vaccination in patients with antiphospholipid antibody positivity or other prothrombotic states not on anti-coagulation?
There are hypothetical reasons that the COVID-19 vaccine might increase thrombophilia in individuals with APS/APLAs. However, the only controlled study I could find, Absence of hypercoagulability after nCoV-19 vaccination: An observational pilot study by Campello et al., PMID 34246010 did not show a...
Do you send an antiphospholipid antibody panel routinely for all patients with an unprovoked thrombus?
Yes. My own practice is to perform testing for antiphospholipid antibodies in all patients with unprovoked VTE and also in patients with arterial thrombosis. Testing should include assays for lupus anticoagulant, anti-cardiolipin antibodies (IgG and IgM), and anti-beta 2 glycoprotein I antibodies (I...
How do you counsel patients regarding the cardiovascular risk of febuxostat?
We understand that gout is a very inflammatory state and in general that inflammatory states can be a risk factor for cardiovascular disease. Although studies such as this have shown an increased all cause and cardiovascular mortality in febuxostat group compared to allopurinol group, it is importan...