Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What drug class would you use to treat active psoriasis and psoriatic arthritis with axial involvement in patients on immunosuppression for other indications (e.g., tacrolimus for a liver transplant)?
Organ transplant recipients are immunocompromised due to their transplant rejection regimen and thus require a careful risk-benefit discussion prior to treatment with a biologic agent. I would consider two things prior to initiation of biologic therapy: how recent was the transplant and how active i...
What is your approach to treatment for patients with microscopic polyangiitis who have sustained remission at 6 months after induction rituximab?
This is an excellent and challenging question. Most studies of AAV used at least 12 months of maintenance therapy (Pagnoux et al., PMID 19109574), with most using longer regimens (e.g. 22 months in MAINRITSAN [Guillevin et al., PMID 25372085]). Further, studies suggest that longer maintenance therap...
How would you treat systemic polyarteritis nodosa with orchitis, mononeuritis and glomerulonephritis in a person who is being treated for HiV with low level viremia?
Difficult situation but there is a clear need to make decisions and balance somewhat unquantifiable risks. It is always good to remember that polyarteritis nodosa is quite rare. One should ensure the diagnosis is confirmed with, preferably, both a positive biopsy of one of the affected areas and neg...
How do you assess potential fetal harm in patients who have unplanned pregnancy while taking teratogenic medications?
This is a helpful reference that includes a table that summarises the evidence and the prevalence of maternal and fetal complications for many teratogenic medications. Götestam Skorpen et al. PMID 26888948 “The EULAR points to consider for use of anti-rheumatic drugs before pregnancy, and during pre...
How would you manage polymyalgia rheumatica refractory to prednisone, methotrexate and tocilizumab?
Interesting situation. With PMR, the first question I continue to ask myself is - do I have the right diagnosis? This disease is always rewarding to treat whether you get the thrill of starting steroids to be the hero or starting therapy and having to reassess. You report that there are no signs of ...
How do you evaluate patients who have panuveitis without any systemic symptoms?
Although many patients with panuveitis or another anatomic subset of uveitis might have a systemic disease such as sarcoidosis, Behcet's disease, ankylosing spondylitis, or inflammatory bowel disease, often a systemic disease is not diagnosable. A thorough history is the best way to suspect a system...
Do you initiate management of new onset diabetes in a patient on immunotherapy or refer immediately to endocrinology given the risk of rapid worsening?
New onset hyperglycemia during ICPi therapy warrants careful review of potential risk factors for type 2 diabetes mellitus (T2DM) and close monitoring of symptoms and lab results to distinguish from the rare and typically more threatening checkpoint inhibitor-associated diabetes mellitus (CIADM). Ne...
What is your preferred steroid sparing therapy in a patient experiencing a severe checkpoint inhibitor toxicity and not responding to high dose IV steroids?
There are likely two different questions here: 1) For patients who have responded to steroids, but are unable to taper off (or to a minimally acceptable chronic dose), I have favored mycophenolate as a steroid sparing agent. 2) For patients with severe pneumonitis that is refractory to steroid ther...
Do you counsel your RA patients to hold their methotrexate dose for simple infections such as UTIs?
I recommend that the default position is to hold methotrexate if currently exhibiting any signs or symptoms of infections. This includes asymptomatic as well as symptomatic simple UTI. Resumption of methotrexate can occur 1 week later if restored to good health with the clearing of sx. This emphasis...
Would you consider PLEX for patients with DAH from SLE-associated capillaritis?
DAH is a severe life-threatening manifestation of SLE. Usually, patients who present with DAH have multi-organ involvement. DAH could be triggered by an underlying infection. Evaluating other potential causes of hemoptysis and pulmonary infiltrates (heart failure, endocarditis, malignancy, medicatio...