Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend continuous antibiotic prophylaxis for patients on complement inhibitors such as eculizumab?
This is an extremely important and timely question. There simply isn’t enough data or firm guidelines on this leading to different practices. The reality is that there have been a number of meningococcal breakthrough infections in those vaccinated against meningococcal disease. Complement therapies ...
How would you approach a patient incidentally found to have PET avid large vessel vasculitis on CT angiogram during pre CABG workup?
Observational data from cohorts of patients with Takayasu arteritis has shown that patients with active vasculitis undergoing surgical intervention are more likely to require re-operation (e.g. Fields et al., PMID 16414389).Based on such data, the ACR/VF guidelines for the management of large vessel...
How do you approach Covid vaccine counseling in patients with rheumatic disease and history of pericarditis/serositis?
This response would be more specific to those with idiopathic pericarditis. I encourage it as long as there is no temporal relationship between any prior pericarditis and covid-19 vaccine the pt experienced. For example, another abstract presented at AHA.2022 was incidence of complications in rilona...
How do you manage dermatomyositis related to underlying malignancy?
Treat underlying malignancy with urgency Steroid + IVIG is the best treatment for dermatomyositis with active malignancy.
How do you manage a case of dermatomyositis that is proven on skin biopsy and clinically has proximal muscle weakness but normal muscle enzymes, including CK, aldolase?
About 20-30% of Active Dermatomyositis patients may have normal muscle enzyme level. Also, sometimes muscle enzymes other than CK and aldolase are elevated such as LDH, AST and ALT. So check all 5 muscle enzymes. Can also do EMG or MRI or muscle biopsy to confirm muscle involvement. First line trea...
How do you use colchicine for gout in patients with chronic kidney disease or end-stage renal disease on hemodialysis?
As a last resort agent and with a lot of caution. For prophylaxis, half a 0.6 mg pill two times a week, carefully monitoring CBC and CK levels. If medication interactions are of concern, then do not use. For flares, a much better alternative would be glucocorticoids or even anakinra. NSAIDs could be...
How would you treat active rheumatoid arthritis in a patient in complete response on loralatinib for stage IV ALK positive NSCLC?
I would do my best to minimize immunosuppression. I would use IL-6 or Abatacept and possibly rituximab. Have done all to minimize DMARDs and have had success with all 3.
Do you recheck screening labs (ESR, BUN/Cr, urinalysis, ANA, etc) for patients with recurrent small vessel vasculitis of unknown origin with each flare?
If the recurrences occur 6 or more months apart, I would recheck the studies to exclude SLE. If the episodes are chronic, I would recheck at least once a year for the same reason or whenever there are new suggestive symptoms of LE.
Do you continue to utilize ESR and CRP in patients on tocilizumab?
Yes, it is still worthwhile getting these tests. Anti-Il-6 therapy will reduce CRP and ESR values to very low levels, so when a result returns higher than expected, it may imply limited compliance with the drug. In some patients with very high CRP values at baseline, the CRP may take some time to re...
Are whole blood hydroxychloroquine blood levels helpful in patients taking chloroquine?
I could not find anything in the literature, but a personal communication with Dr. Michelle Petri at the Johns Hopkins Lupus Center says that the answer is, "No."