Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What treatment options do you recommend in a patient with idiopathic granulomatous mastitis that has not improved on steroids and methotrexate?
I have multiple cases of IGM that I have treated successfully and have gone into remission or at least not needing any prednisone with azathioprine monotherapy and combo methotrexate and adalimumab.
Do you recommend monitoring IgG level in patients with AAV receiving rituximab?
Yes! At the OSU Vasculitis clinic, we check IgG before every rituximab infusion. At a minimum, it must be done yearly to ensure no impending CVID or to change rituximab.
Is monitoring for fetal heart block recommended in pregnant patients with only slightly elevated SSA?
At this time, we don't have a consensus on the titer that causes heart block and how that changes across different labs. Dr. Buyon's group did present this at ACR. So I would recommend HCQ and monitoring for this patient.
What are your top takeaways from ACR Convergence 2023?
The great debate about whether to use biologics up front in people with GCA or PMR was fantastic. Based on the data presented, the approach of tapering prednisone more quickly in PMR (over 3-4 months instead of 1 year) and using a biologic if there is a flare seems like it may be a good approach in ...
How would you approach peri-operative immunosuppressive management of a patient with Behcet's, currently controlled on azathioprine, who needs genital surgery?
It might be helpful to know what kind of genital surgery is planned and why. Here are a few general thoughts: There are little data to guide a unified approach outside of BD patients who need vascular surgery. Standard rules of thumb are to 1) reduce surgeries to a necessary minimum and 2) regard mo...
What is your approach to monitoring patients with cardiac sarcoid while tapering immunosuppression?
Monitoring of patients with cardiac sarcoidosis (CS) is critical to optimizing therapy and improving outcomes. Once a decision has been made to institute immunosuppressive therapy, it is important that the efficacy of therapy is demonstrated and that the duration of therapy is guided by the response...
How would you approach treatment of active inflammatory arthritis in a patient with MCTD (+RNP/+Chromatin) and stable ILD who has failed MMF, azathioprine and methotrexate?
I'd think about Actemra to treat both ILD (with the scleroderma approval) and arthritis.
Is there a role for systemic therapy for a patient with scleroderma sine sclerosis, with esophageal strictures and Raynaud’s syndrome, but no pulmonary involvement?
We don't have any evidence that immunosuppression (assuming that is what you are referring to) would play a role in the treatment of the esophageal disease or the Raynaud phenomenon. Also, we don't have any data to suggest that this would have any overall long-term "disease-modifying" effects. So in...
How would you treat a young patient who presents with coronary vasculitis and aortitis with persistently positive MPO but no other features of AAV?
Once infectious causes such as syphilis have been excluded, the most common causes of the combination of aortitis and coronary vasculitis would be Takayasu arteritis and IgG4RD. However, AAV can cause both aortitis and coronary vasculitis (albeit infrequently). Therefore, if there are no features of...
How would you approach rheumatoid arthritis treatment for widespread large rheumatoid nodules but no active synovitis or subjective joint pain?
One needs also to consider drug-induced accelerated nodulosis. I used to see it more often in the 1990s from methotrexate, but since then, it has also been described with other drugs like TNF inhibitors and leflunomide (Patatanian & Thompson, PMID 12222551, Ahmed et al., PMID 11470988, Akiyama et al...