Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you add voclosporin to mycophenolate for refractory proteinuria in a patient with low EF?
There are two major potential concerns in a lupus nephritis patient with systolic dysfunction and a left ventricular ejection fraction (LVEF) of only 30%: QTc prolongation potential worsening leading to acute cardiac death Exacerbation of hypertension leading to worse LVEF and CHF However, with prop...
How do you approach pre-conception counseling in males who are on medications for which there is limited or no data such as Jak inhibitors, apremilast, or belimumab?
I am transparent about the lack of data, but discuss the differences in mechanism of action between cyclophosphamide and thalidomide (the only medications we recommend against conception with a partner) and JAKi, Apremilast, and Benlysta. Prior data has demonstrated a clinically insignificant amount...
How do you differentiate active vasculitis from pregnancy complications such as pre-eclampsia and HELLP in a patient with AAV?
Differentiating preeclampsia from autoimmune kidney disease in patients with rheumatic disease is often challenging due to the obvious overlap in clinical and serologic features. While most discussions about preeclampsia versus flare focus on SLE patients given that SLE is more common in women of re...
How would you approach immunomodulatory treatment for systemic lupus associated protein losing enteropathy (PLE) in a patient whose clinical course has been complicated by significant infection?
Lupus protein-losing enteropathy (LPLE) is a rare manifestation of systemic lupus erythematosus (SLE). Therefore, the medical evidence for the "best treatment" of LPLE is only based on anecdotal reports, case series, and retrospective reviews.Although the easy way out would be to say that a SQ or IV...
How would you approach treating a patient with Rheumatoid arthritis/Psoriatic arthritis and alcoholic cirrhosis?
The liver plays a central role in the clearance of nearly all small molecule (e.g. non-biologic) drugs. Thus, cirrhosis perturbs the clearance of these agents. Moreover, there generally is a potential deleterious effect on hepatocyte health, making these drugs unattractive from a safety perspective....
How will you approach drug sequencing in patients with PMR given the SAPHYR data?
The SAPHYR study enrolled patients with PMR who relapsed while tapering prednisone at daily doses equal to or greater than 7.5 mg. One group of patients received sarilumab 200 mg every 2 weeks along with a 14-week prednisone taper and another group of patients received a placebo along with a 52-week...
At what point do you consider a patient to have relapsing PMR?
Relapses in PMR are quite common. It is not unusual for patients to do well initially and as steroids are tapered, they start to describe a recurrence of symptoms. My concern is when these relapses occur early. For example, if they are noted as a patient tapers down from 10 mg towards 5 mg/day and r...
What baseline and ongoing testing do you recommend for patients with PMR who are going to be on a prolonged steroid taper?
My answer below is specific to patients with a definite diagnosis of PMR and does not necessarily cover diagnostic testing such as evaluation for possible mimics, which is certainly important and should include infections and malignancy in main differential, or other rheumatic diseases (RA, GCA). Va...
How do you approach an obese patient on long-term methotrexate with normal liver tests in terms of workup for underlying fatty liver?
Screen with ultrasound.
How do you manage recurrent urticarial lesions in a patient with underlying connective tissue disease that is otherwise well-controlled?
Similar to other cases of chronic urticaria - skin-directed therapy with TCS + high dose daily antihistamines (e.g. fexofenadine 180 mg bid + doxepin 10 mg qhs). Then in recalcitrant cases, you can use urticaria drugs (can go for dapsone, MTX or MMF if you want to also target underlying CTD or can g...