Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Which immunosuppressed patients with SLE would benefit from antibiotic prophylaxis to prevent pneumocystis pneumonia?
Starting PCP prophylaxis in patients with lupus is controversial. We typically start lupus patients on PCP prophylaxis if they have underlying ILD and are on doses of steroids of 20 mg or higher. I also consider starting PCP prophylaxis in lupus patients while they are receiving cyclophosphamide and...
In what situations do you consider platelet-rich plasma injections in patients with osteoarthritis?
The literature on this topic is sparse, largely confined to discussions of knee OA, and unconvincing of real benefit. I would like to see well-designed clinical trials dedicated to the benefit of PRP in OA. I honestly cannot think of a situation when I would consider PRP injections for osteoarthriti...
Do you recommend using IL-1/IL-6 inhibitors in COVID-19 multisystem inflammatory syndrome in adults (MIS-A)?
There are very few published reports on the COVID-19 multi-inflammatory syndrome in adults (MIS-A), so most of the evidence is extrapolated from the experience of multi-inflammatory syndrome in children (MIS-C). MIS-A seems to occur very infrequently, typically in young adults, despite COVID-19 seve...
Should venous thrombosis in a patient with Behcet syndrome be treated with both immunosuppression and anticoagulation?
They should be treated with immunosuppressive medications, however, the additional benefit of anticoagulation is much debated. Various studies and metaanalysis have shown that anticoagulation, on average, does not add any benefit. There may be exceptions to this in the early part of treatment for so...
Is it safe to use statins in IIM patients if HMGCR antibodies are negative?
Absolutely, yes. Statins are a very important drug for patients with cardiovascular disease and should be given to most patients with myositis except patients with known immune-mediated statin myopathy or HMGCR Positive antibody. I would monitor CK levels before and 3 and 6 months post statin, as we...
Is there a role for PCSK9 inhibitors in patients with statin-associated immune mediated necrotizing myopathy?
The majority of patients with statin-associated immune mediated necrotizing myopathy are in need of cholesterol-lowering medications. While one can try other strategies (like diet or ezetimibe), these are usually inadequate. Therefore, I would advocate for PCSK9 inhibitors as first-line treatment, w...
What is your approach to treating refractory thrombocytopenia in lupus?
Refractory thrombocytopenia is challenging to treat. It is important to evaluate for non-SLE causes including infection, medications, and malignancy. It is also important to differentiate ITP from TTP/atypical HUS. Once the ITP diagnosis is confirmed, I usually don't treat asymptomatic thrombocytop...
What do you use for treatment induction in pure class V lupus nephritis with nephrotic-range proteinuria when MMF is contraindicated?
I'll begin my response by commenting that other than an allergic reaction, which is very rare or pregnancy, there is really no absolute contraindication to MMF. On the other hand, there are patients who cannot tolerate MMF most often due to G.I. side effects in which case mycophenolic acid is an opt...
Are there particular concerns related to the use of B-cell depletion therapies such as rituximab for rheumatic disease during the COVID-19 pandemic?
The attendant depletion of CD20+ B cells associated with treatment with rituximab likely results in impaired development of host immunity to previously unrecognized microbial pathogens. This has, therefore, been of concern in the context of the Covid-19 pandemic due to potential greater adverse outc...
What is the biologic of choice in a patient with RA and history of non-melanoma skin cancer?
We have long known that patients treated with TNF inhibitors (TNFi) have a higher risk of developing non-melanoma skin cancers. For this reason, all patients prescribed these drugs should undergo annual full-body dermatology skin exams. If this recommendation is followed, there should be no contrain...