Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is the role of x-ray of the cervical or lumbar spine in patients presenting with radicular symptoms?
I agree that X-rays are useless the vast majority of the time. You can of course pick up lytic lesions from metastasis or plasmacytoma, or other bone-based cancers. Sometimes flexion/extension films are helpful, since MRIs are almost always static and supine (until dynamic MRIs obtain more widespre...
Do you find IgA isotypes of anti-beta2-glycoprotein antibodies and anticardiolipin antibodies to be clinically useful in the evaluation for APS?
I would answer yes to this question. We believe an isolated IgA elevation of AcL or anti-B2GPI carries diagnostic relevance in the right clinical context. We routinely look for all Ig isotypes in our diagnostic evaluation of APS. In fact, our group published the first such article.Murthy et al., PMI...
What bDMARD would you choose for a patient with RA with high infection risk and inadequate response to cDMARDs?
This is an important question and a prime example of the "art of rheumatology" where we must balance the risk and benefit of targeted therapies of treating active RA and adverse events such as serious infection. Ideally, we would have many head-to-head trials of every agent adequately powered to ans...
In your experience, is there an association between interstitial cystitis and systemic lupus erythematosus?
In my experience the association of interstitial cystitis has been relatively frequently seen in patients with fibromyalgia. In lupus, it must be rare, as pointed out by Dr. Gilkeson. However, lupus patients are not exempt from having fibromyalgia though.
Would you advise a patient with quiescent vasculitis who flared with the first Covid mRNA vaccine to obtain an additional dose?
There is still much we don't know about mRNA vaccines, including the true risk of vasculitis relapse and the risk of relapses occurring with vaccine re-challenge. Relapses of vasculitis after COVID vaccination have only been reported in case report form to date. Therefore it's not possible to tell w...
Do you avoid dupilumab (IL-4 inhibition) for severe asthma in patients already taking a biologic agent for RA?
Dupixent (dupilumab) is a humanized monoclonal IgG4 antibody that works by blocking the signaling of interleukin-4 (IL-4) and interleukin-13 (IL-13). This is achieved by binding to the IL-4Rα subunit. When dupilumab occupies this subunit, it prevents IL-4 signaling via the Type I receptor and both I...
Is there any utility in checking HLA-B*5801 in our Black and Asian patients who are already tolerating allopurinol?
I don't believe there is any value in checking HLA0B*5801 once the patient has been on allopurinol therapy for several weeks or months as allergic reactions, particularly SJS and TENS, occur within the first few weeks of treatment. Further, a positive test, weeks to months after beginning allopurino...
What is your approach to treatment for a patient with progressive ILD (UIP pattern) with high titer RF but no articular symptoms?
Hello and thank you for this question. It is very important. But I need more facts to safely answer this question. My very first thought is that assessment (i.e., a thorough history and physical exam) is highly operator-dependent. In most cases, the historical and exam findings of systemic autoimmun...
How do you differentiate a lupus flare versus drug-induced lupus in patients with SLE on a drug associated with DILE?
In my experience, the most common problem is drug-induced subacute cutaneous lupus erythematosus (DI-SCLE). Many drugs can cause the new onset of SCLE or the worsening of pre-existing SCLE. The list of SCLE-causing medications is extensive, growing, and includes common medications such as proton pum...
Would you start a TNF-I for seronegative non-erosive RA in a patient with positive ANA and sun sensitivity without other SLE features?
A diagnosis of "seronegative non-erosive RA" can be a valid descriptor, but in some cases, the terminology may obscure the proper diagnosis. For example, RA patients who are seronegative with erosive disease are generally grouped together with seropositive patients when it comes to making most thera...