Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How long do you continue rituximab in patients with ANCA associated vasculitis who have achieved remission?
My approach is to use rituximab every 6 months for remission maintenance for at least 2 years. Past that point, a lot depends on the individual patient circumstances. For patients who have already suffered substantial organ damage, for whom another flare could be catastrophic (e.g., a patient with s...
How do you approach prescribing analgesics for osteoarthritis related pain in patients with comorbidities, particularly given new evidence that even acetaminophen is associated with increased risk of GI complications (bleeding, peptic ulcer disease), heart failure and CKD?
Acetaminophen is still preferred, but at 3,000 mg or less per day. The next consideration is a COX-2 specific inhibitor, such as celebrex. Narcotics and steroids play no role in management of osteoarthritis.
Would you consider using avacopan in PR3+ mononeuritis multiplex without other systemic involvement?
I would certainly consider using avacopan in AAV mononeuritis multiplex. While we don't know the outcomes of mononeuritis in avacopan-treated patients specifically, ~20% of patients in the ADVOCATE trial (Jayne et al., PMID 33596356) had neuropathy and the outcomes overall suggest a robust response ...
What was the rationale for abrupt discontinuation of etanercept rather than gradual tapering in the SEAM-RA trial?
The main goal of this trial was to get RA patients off of therapy and to see whether they would flare or maintain remission. We didn’t expect that the ultimate likelihood of success or failure was going to be primarily related to how long it took to do that. While a gradual withdrawal of the drug ma...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
What is your approach to a patient with undetectable MMR titers checked prior to or during immunosuppression and a history of MMR vaccination in childhood?
MMR titers are good correlates of protection. If any titer is undetectable it could be one of these situations: Primary failure. The components of the MMR have different efficacy. Two doses of appropriately given MMR will have 96+% against measles, but only 88% for mumps. Thus 1 in 10 appropriately...
How do you approach hypogammaglobulinemia monitoring when using obinutuzumab for refractory nonrenal SLE patients?
I would start with a baseline evaluation that includes quantitative IgG levels, HBV serologies, including HBsAg and anti-HBc, to assess reactivation risk even if HBsAg-negative, and a CBC with differential. Before treatment, I would make sure all non-live vaccines are completed, and I would avoid li...
How would you approach rituximab dosing in a patient with SLE-Myositis overlap with LN Class III, now with worsening UPCR and concern for worsening ILD 4 months post induction and incomplete B-Cell depletion on recent labs?
This is a challenging and concerning situation, as the patient is declining after rituximab. Without knowing which other medications have been tried, I would prioritize medications targeting life-threatening manifestations, i.e., the LN and ILD. In that case, I would start treatment with steroids, m...
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...
How would you approach managing severe, functionally disabling steroid induced edema that is refractory to treatment with chlorthalidone or bumetanide?
This is a difficult issue - I'm assuming the patient is unable to taper steroids at this time. The edema results from the mineralocorticoid activity of the steroid, so attempting to change to a low or negligible mineralocorticoid corticosteroid may be helpful if possible - dexamethasone, betamethaso...