Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there a role for antibody testing to confirm vaccine response for patients on rituximab after COVID-19 vaccination?
It's a great question, but I do not feel that routinely performing COVID antibody testing would help in the management of these patients: We don't know how well most commercial antibody testing correlates with neutralizing antibody/immune-status (esp. if qualitative testing is performed), and I have...
Does calcinosis appear differently in patients with dermatomyositis compared to systemic sclerosis?
Classically, calcinosis in dermatomyositis and scleroderma are different with dermatomyositis having more typical sheet-like calcinosis in the muscles whereas in scleroderma it is more typical on the fingers, extensor surfaces of the forearm, olecranon, knee, and shins. However, many sclerodermas al...
What is your methotrexate initiation strategy in DMARD-naive RA patients?
Best final dose is 20 to 25 mg per week, not 15 mg per week. D Furst
How do you approach monitoring of patients found to have a positive anti-dsDNA antibody without other clinical evidence of SLE?
Autoantibodies are typically present for several years before the diagnosis of SLE. The study by Arbuckle et. al of the U.S. Department of Defense Serum Repository showed that ANA was present 3.4 years, and anti-DsDNA antibodies were present 2.2 years before the diagnosis of SLE. These results indic...
Are there any specific circumstances when you would consider the use of immunosuppression for DISH?
DISH and SpA are two separate pathological entities that share involvement of the axial skeleton and peripheral entheses. Both diseases cause bone proliferation in the spine and extraspinal entheseal sites, particularly in the later phases of the disease.DISH is characterized by calcification and os...
In which clinical scenarios is relying on the urine protein-to-creatinine ratio as a measure of proteinuria unreliable, and interpretations should be made looking at urine protein and urine creatinine separately?
I typically only use spot UPCRs because (1) they are easy to obtain and thus trend (2) they account for BSA indirectly because it accounts for Cr excretion. The best role of urine protein measurements is really just to trend if your therapy is effective or to screen for disease. When looking at urin...
How do you choose between oral and IV cyclophosphamide for the treatment of ANCA-associated vasculitis?
When considering cyclophosphamide for induction in severe AAV, both oral and IV regimens are reasonable routes of administration. In the CYCLOPS trial (DeGroot, Ann Int Med, 2009), oral cyclophosphamide 2mg/kg/d was compared with IV CYC 15mg/kg q 2 weeks for the first three pulses, then every 3 week...
What is your approach to long-Covid/post-Covid syndrome in your practice?
Many academic medical centers, including ours, have opened post-COVID clinics, and they are not necessarily managed by rheumatologists nor perhaps they should be. I agree that the symptoms are quite similar to fibromyalgia although, true post-COVID-19 medical problems may well be inflammatory, and f...
How do you approach patients with ANCA vasculitis who had partial response, but continue to have disease activity on q 6 month maintenance rituximab and remain on steroids?
This question raises some fundamental issues about the management of patients with ANCA-associated vasculitis (as well as other vasculitides or chronic inflammatory disorders), including i) the need to consider the potential contribution of comorbidities to clinical signs or symptoms suggestive of v...
Does the presence of ANCA antibodies in patients with newly diagnosed lupus nephritis alter your approach to management?
I've never encountered this, to be honest, but I've always worried about what I would do, since a fair percentage of patients with lupus are reported to have ANCA antibodies thought to have no clinical relevance. The problem is the "pauci-immune" part of ANCA-associated GN, so that there is no "posi...