Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach a young patient with a history of APLS and VTE, desiring hormone replacement therapy after oophorectomy?
I think the answer is not straightforward. What APLAs are positive and what was/is the titer? Were there other risk factors at the time of the clot (smoking, oral contraceptives, etc...) My general recommendation would be to avoid estrogens in patients with APLAs. I can imagine a scenario where the ...
Would you feel comfortable combining MMF and an IL-17 blocker in a patient with both limited scleroderma and psoriatic arthritis?
We combine medications all the time! So the question is what is the risk-benefit? How bad psoriatic arthritis? Otezla and orencia for scleroderma? Otezla and MMF? Why not IL-23? Vs IL-17? Why not just methotrexate? So many choices you have! Also, you can always start with both for 2-6months then w...
How would you approach a patient with incidentally noted infrarenal periaortitis with positive C-ANCA, normal inflammatory markers and no systemic symptoms?
Based on data we and others have published over the past 20 years, the specificity of testing for ANCA depends on testing for antibodies to the specific antigens proteinase 3 (PR3) and myeloperoxidase (MPO) by ELISA or other newer methods. Immunofluorescence (IF) testing alone for ANCA is not accept...
How do you approach low to moderate titer of APLS when working up unprovoked DVT if it is persistent on repeat testing?
I have a low threshold to recommend long term (indefinite) anticoagulation for unprovoked thrombosis, regardless of whether there is positive APLS testing. I do agree with Dr. @Dr. First Last, however, that shared decision-making is important when committing a patient to prolonged anticoagulation, a...
What is your approach to managing RA patients with history of organ transplant already on immunosuppressive therapy such as cyclosporine or cellcept?
In contrast to my esteemed colleague, @Dr. First Last, in 38+ years in clinical rheumatology practice (maybe those 3 years make a difference), I have seen RA occur in 3 patients with solid organ transplants. All 3 were renal transplants; all 3 were recurrent diseases that had been previously control...
How would you manage immune check point inhibitor induced capillary leak syndrome refractory to IVIG monotherapy?
There is no great evidence and only case reports. Diuretics and supportive management. Stopping the ICIs is likely essential at this point because we do not know how to safely rechallenge yet. There is a discussion of possible using anti IL-6 therapy for capillary leak if IVIG and corticosteroids do...
How do you approach the workup for a patient with persistently elevated inflammatory markers (CRP and ESR) whose history and exam do not point to a clear cause?
Our hematologist/oncologist referred just such a patient. No evidence of malignancy, but elevated CRP &ESR. I did an “internist’s” workup as I would for dermatomyositis, starting with the most important and therefore most thorough aspect: taking a full and very “invasive” history, followed by a comp...
What is your approach to the diagnosis and management of lupus cystitis?
Lupus cystitis is a rare complication of lupus but there does appear to be an association. I depend on the urologist to confirm the diagnosis of interstitial cystitis. If mild to moderate in activity, will use standard treatments for cystitis with bladder infusions, bladder relaxants in collaboratio...
How would you approach the treatment of a patient who, during a hospitalization, was initially diagnosed with TTP and treated with PLEX with good response, but renal biopsy then resulted class IV LN along with changes of thrombotic microangiopathy?
This is a challenging scenario; the literature consists of case reports and case series. In clinical practice, combining PLEX with cyclophosphamide or Rituximab is a possibility.I was recently involved in a case of an SLE patient with refractory TTP (no nephritis) where Caplacizumab (Scully et al.,P...
What is your approach to the use of NSAIDs in patients with a history of gastric sleeve/bypass?
The use of nonsteroidal anti-inflammatory drugs in someone with a history of gastric bypass and/or sleeve surgery is risk prohibitive. Not only is there a risk of gastrointestinal bleeding, but more importantly, there can be effects on the previous surgical, anastomosis, and other untoward effects. ...