Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you counsel patients regarding alcohol intake when prescribing DMARDs other than methotrexate?
I always inquire about alcohol intake before starting any drug with a known issue of hepatotoxicoty, using the “Law of Two” I learned as an intern: alcohol abusers under-report their intake by a factor of two. Assuming there is no such red flag to avoid the drug, I tell my patients that alcohol is n...
How would you manage tubulointerstitial nephritis and renal tubular acidosis (RTA) in a patient with Sjogren's who is pregnant?
The most common form or renal disease in Sjogren's (SjD) is tubulointerstitial nephritis. This may result in tubular dysfunction leading to renal tubular acidosis (RTA), most commonly type I RTA leading to hypokalemia and a non-anion gap hyperchloremic acidosis. Over time, nephrocalcinosis can occur...
What is your approach to pharmacologic treatment options in a patient with both SLE and Crohn's disease?
When someone has another systemic inflammatory disease along with SLE, I always look at the drugs that can treat both. I'd want close communication between myself and GI so they can guide me regarding the Crohn's severity and activity. If the Crohn's is moderate or worse in severity, we have azathio...
Do you recommend starting aspirin for a patient with ESKD secondary to lupus nephritis with detected antiphospholipid antibodies on pretransplant workup but no history of a thrombotic event?
I agree. I tend to favor the use of Plaquenil in these APS patients although the data is not absolute either. I noticed that hematologists favor the use of the NOAC than Coumadin, and yet thus far, it appears that Coumadin, based on published data, prevents thrombosis better than other agents.
What is your approach towards initial regimen and tapering of mycophenolate in scleroderma?
I start low and go slow to avoid diarrhea and abdominal upset. I give the patient 250 mg tablets and tell them to increase as tolerated to 1000 mg PO BID. I write Cellcept 1000 mg PO BID to the pharmacy to avoid questions. I seldom increase beyond 1000 mg PO BID because it seems like pushing the dos...
How would you approach management of active bilateral pan uveitis in patients who have a history of prior infectious uveitis?
The first step in the approach to such a patient is information gathering. What type of infection caused uveitis in the past? How and for how long was it treated? What was the ocular disease phenotype in the past, what is it now (exceeding the definition of "panuveitis"), and what evidence exists to...
Which biologics are you comfortable combining with vedolizumab for spondyloarthritis or psoriatic arthritis patients in the setting of well-controlled inflammatory bowel disease?
Historically, rheumatologists have been hesitant to combine biologics in our patients, based largely on trials from 20 years ago that found an increased risk of serious infections when combining a TNF inhibitors and an IL1 inhibitor, or abatacept and another biologic. With the availability of newer ...
What is the optimal timing for Zoster vaccine administration for a patient who recently recovered from herpes zoster infection and is now planning to start B-cell depletion therapy?
This is a complicated question that must balance two competing factors. First, in general, most experts counsel waiting, approximately one year after zoster before vaccination in attempt to take advantage of endogenously boosted immunity and a low rate of recurrence within 12 months. On the other ha...
How would you approach persistent episcleritis/uveitis due to PR3+ GPA, which needs low dose prednisone to control, despite induction with Rituximab?
In patients who have refractory inflammatory eye disease despite rituximab, I have worked with ophthalmology to determine whether baseline escalation in immunosuppressive medication is indicated or if targeted organ therapy is an option. In general, there is more urgency when there is chronic active...
What is your approach to evaluating a patient with known rheumatologic disease and elevated free kappa:lambda ratio, but no evidence of monoclonal immunoglobulins?
The information given is a bit sketchy. But assuming a bone marrow biopsy has been done and there is no evidence of malignancy, I would adopt a watch-and-wait approach. If no bone marrow has been done, I would keep an eye on the appropriate blood tests and in collaboration with a hematologist do a b...