Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When do you consider stopping denosumab when a patient with osteoporosis is otherwise tolerating it without issues?
This is a matter of "style" more than anything. I continue Prolia and have many patients now exceeding 10 years - up to12 years, without any apparent safety issues. I realize we are in a "data-free" zone after 10 years, but as rheumatologists, we are frequently giving monoclonal antibodies for perio...
When is the index of suspicion high for paraneoplastic systemic sclerosis in terms of clinical and serological presentation and how will you work it up?
This is a great question. Data on the risk for malignancy in newly diagnosed scleroderma patients has been emerging for the past 10 years or so. To date, it appears that the strongest risk factors may be autoantibody with RNA polymerase 3 antibodies showing consistent increase in risk amongst sclero...
What is your approach to patients who present with unilateral Raynaud's?
Thank you for that excellent question! Typically, Raynaud’s phenomenon impacts multiple digits of both hands (and often feet; sometimes tip of the nose, ears, nipples) and is often symmetric in the case of primary and can be asymmetric in Secondary Raynaud’s (often sparing the thumb). In some cases,...
What is your approach to maintenance rituximab in patients with IgG4-RD?
Since patients can go into a prolonged remission after rituximab induction therapy, I tend to monitor them for signs and symptoms of recurrence before retreating with rituximab. In patients with significant damage from IgG4-RD, such as damage to pancreatic endocrine or exocrine function, I will re-t...
How do you approach using CD 19/20 levels to redose Rituximab for ANCA associated vasculitis?
In the MAINRITSAN 2 trial, a tailored rituximab regimen adapted to ANCA-positivity or ANCA-titre change and/or circulating CD19+ B cell repopulation was compared with fixed-schedule rituximab infusions.There was no significant difference in relapse rates between the fixed-dose and tailored-dose arms...
How do you approach oral DMARD and/or biologic selection in patients with RA and a history of gastric bypass or whom are planning bariatric surgery?
Very interesting and important question. It is important to remember gastric bypass patients, depending on the type of intervention, can change the absorption of a host of medications, so it is a challenge to know if a lack of response is from poor efficacy or poor absorption, therefore poor bodily ...
How do you recommend tapering IVIG in patients whose inflammatory myositis has achieved remission?
This is a very good question without any right or wrong answer. My practice is to start tapering the IVIG 6 months after the patient has achieved clinical remission. I usually start decreasing the dose of the IVIG, but the other option is to extend the interval between the patient's infusions. The e...
How would you approach a low to moderate titer of one of the APLS antibodies in a patient with a strong family history but no personal history of thrombosis?
I do not do anything as there are no data to support intervention in this case.
How would you counsel a patient with active SLE on treatment, low to moderate level of one of the APLS antibodies, and remote history of provoked blood clot regarding perioperative anticoagulation?
Without knowing more specific details, my approach would be to repeat the full panel of antiphospholipid antibodies, institute treatment with HCQ if not there already, discontinue all estrogen products and counsel the patient against smoking. I would coordinate perioperative anticoagulation with a h...
Are there any major differences in clinical manifestations or autoantibody profiles in children with SLE based on ethnicity?
While there is some published data, including those from the Toronto pediatric lupus cohort (Hiraki et al., PMID 19833755), that suggest the prevalence of severe organ manifestations such as nephritis and central nervous system involvement may vary by race or ethnicity, it is difficult to know how d...