Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you treat a patient with active lupus nephritis (class 3/4) who requires PD-1 immunotherapy for refractory metastatic renal cell carcinoma?
This is a complex question and there is a paucity of data to address it. The critical issues are of timing (new onset or existing nephritis, disease activity) and treatment regimen. Given that oncologists will not use checkpoint inhibitors on patients requiring more than 10 mg of prednisone at base...
Where do you place romosozumab in your treatment sequence for osteoporosis management?
I agree. It is very effective as first-line therapy in patients at high risk for fracture. It can also be useful post bisphosphonate therapy. I have used it successfully multiple times to transition patients from long-term Prolia therapy without loss of bone mass.
What is your approach to steroid sparing therapy in patients with suspected CTD-ILD?
It depends on numerous factors: What's the underlying CTD? Has the patient been trialed on immunomodulatory agents before? What's the risk of therapy in this patient? And many others. It's a big topic. To delve into some of the above by bullet point: Most guidance for immune suppression is driven by...
Do you routinely advise patients waiting for a kidney transplant to seek referrals at multiple institutions to decrease waiting time?
If your center is in a region (e.g., California and New York) with long wait time of up to 8-10 years, we routinely advise patients to seek referral at multiple centers with a shorter wait time out of the region if the patient does not have any potential donors.
What is the appropriate management of severe myalgia during atezolizumab infusion?
Immune related adverse events involving the skeletal muscle following immune checkpoint inhibitor therapy include polymyalgia rheumatica (PMR) like syndrome and myositis. Referral to a rheumatologist is recommended for a severe musculoskeletal adverse event. Myocarditis is not addressed in this brie...
How do you typically treat aortitis associated with spondyloarthritis?
This is a complicated question - I typically think about combination therapy or CellCept/methotrexate plus TNFis. Depending on the severity, Cytoxan is always a good option to start. Typically IL-6 blockade does not help for the spondy patient - so I only use IL-6 when the spondy symptoms are not pr...
Would you consider thrombophilia testing in a pregnant patient with VTE?
I would not check antiphospholipid antibodies in a pregnant woman with thrombosis unless she had a history of autoimmune disease or other concerning findings. However, if it were checked, I would make sure that it is a true positive. DOACs often cause a false positive LAC. I have had patients with f...
Do you routinely obtain a sural nerve biopsy in patients with EMG evidence of mononeuritis multiplex and clinically suspected polyarteritis nodosa?
Sural nerve biopsy can be quite helpful in cases of mononeuritis multiplex, particularly in those with isolated peripheral nerve involvement or patients who are seronegative with systemic features that do not allow for differentiation between PAN and other types of systemic vasculitis, in particular...
For a patient who would benefit from an anabolic agent for osteoporosis, do you prefer romosuzumab over teriparatide in the absence of contraindications to either agent?
Both teriparatide and romozosumab are excellent drugs to treat osteoporosis with documented risk reduction in fractures. TPTD reduces spine fracture about 85% and romozosumab about 75%. Both are excellent. They have very different biologies with TPTD being a remodeling-based anabolic and romozosumab...
What is your approach to patients with PMR on steroids over a prolonged initial course who start to experience weakness concerning for steroid myopathy?
One of two approaches, similar to the case in inflammatory myopathy: either increase steroid dose (pain/weakness increase argues for steroid myopathy; decrease means there is need for higher dose/longer taper) or decrease steroid dose (increase in symptoms means there is need for more/longer steroid...