Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you consider antiphospholipid syndrome to be a contraindication for checkpoint inhibitor immunotherapy?
While there have been several cases of antiphospholipid antibody syndrome (APS) induced by immune checkpoint inhibitor therapy (Gupta et al., PMID 28099367, Tota et al., PMID 34411840, Mintjens-Jager et al., PMID 33224503), I am unaware of any evidence that pre-existing APS contributes to additional...
What treatment options do you recommend to patients with microstomia secondary to scleroderma?
Perioral and masseter botox 8U upper lip and 4U lower lip. 16U per masseter.
Do you offer anticoagulation to patients with prior antiphospholipid antibodies detected in pregnancy without a history of pregnancy loss or thrombosis?
I do not know what the risk of pregnancy loss is in a woman without a prior history of VTE or pregnancy loss. I am sure the risk is affected by whether the woman has an underlying rheumatological disease (SLE) and whether she has single positive vs. triple positive LAC. I recommend a baby aspirin on...
Do you recommend continuous antibiotic prophylaxis for patients on complement inhibitors such as eculizumab?
This is an extremely important and timely question. There simply isn’t enough data or firm guidelines on this leading to different practices. The reality is that there have been a number of meningococcal breakthrough infections in those vaccinated against meningococcal disease. Complement therapies ...
How would you approach a patient incidentally found to have PET avid large vessel vasculitis on CT angiogram during pre CABG workup?
Observational data from cohorts of patients with Takayasu arteritis has shown that patients with active vasculitis undergoing surgical intervention are more likely to require re-operation (e.g. Fields et al., PMID 16414389).Based on such data, the ACR/VF guidelines for the management of large vessel...
How do you approach Covid vaccine counseling in patients with rheumatic disease and history of pericarditis/serositis?
This response would be more specific to those with idiopathic pericarditis. I encourage it as long as there is no temporal relationship between any prior pericarditis and covid-19 vaccine the pt experienced. For example, another abstract presented at AHA.2022 was incidence of complications in rilona...
How do you manage dermatomyositis related to underlying malignancy?
Treat underlying malignancy with urgency Steroid + IVIG is the best treatment for dermatomyositis with active malignancy.
How do you manage a case of dermatomyositis that is proven on skin biopsy and clinically has proximal muscle weakness but normal muscle enzymes, including CK, aldolase?
About 20-30% of Active Dermatomyositis patients may have normal muscle enzyme level. Also, sometimes muscle enzymes other than CK and aldolase are elevated such as LDH, AST and ALT. So check all 5 muscle enzymes. Can also do EMG or MRI or muscle biopsy to confirm muscle involvement. First line trea...
How do you use colchicine for gout in patients with chronic kidney disease or end-stage renal disease on hemodialysis?
As a last resort agent and with a lot of caution. For prophylaxis, half a 0.6 mg pill two times a week, carefully monitoring CBC and CK levels. If medication interactions are of concern, then do not use. For flares, a much better alternative would be glucocorticoids or even anakinra. NSAIDs could be...
How would you treat active rheumatoid arthritis in a patient in complete response on loralatinib for stage IV ALK positive NSCLC?
I would do my best to minimize immunosuppression. I would use IL-6 or Abatacept and possibly rituximab. Have done all to minimize DMARDs and have had success with all 3.