Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In which Sjogren's patients do you prioritize systemic treatment strategies at time of diagnosis?
Answering this question would really depend on what exact type of patient you are dealing with. You may consider initiating oral DMARDs such as hydroxychloroquine, methotrexate, or azathioprine for patients with inflammatory arthropathy or significant autoimmune rashes. More aggressive therapy would...
Are there clinical, laboratory, or imaging features that can help distinguish primary Sjögren’s syndrome from secondary Sjögren’s in patients with overlapping inflammatory arthritis or positive rheumatoid factor?
Such a good query. I don't really know, as associated SjD has been understudied. In my experience, associated Sjogren's does not look that different from Sjogren's alone. We have seen high ocular staining scores and markedly reduced unstimulated salivary flow in associated SjD (SLE, RA). In SjD, the...
In a patient with high +SSA antibodies and distal renal tubular acidosis (RTA), but without sicca symptoms or other systemic features of Sjogren's, should immunomodulatory therapy with hydroxychloroquine or azathioprine be considered in an effort to reduce subclinical tubular inflammation and prevent progression of renal disease?
Renal disease can occur as an initial manifestation in the absence of sicca in SjÓ§gren’s disease (SjD) patients (Goules et al., PMID 31464673). This is important to realize for other systemic manifestations of SjD (e.g., cystic lung disease, tubulointerstitial nephritis, radiographic nephrocalcino...
Do you view the difference between oral and sublingual cyclobenzaprine as clinically significant?
Yes. Oral cyclobenzaprine—a TCA analogue structurally identical to amitriptyline aside from a single double bond—has been used off-label for fibromyalgia for many years. Despite long-standing anecdotal benefit, a prospective placebo-controlled RCT showed only transient improvement at 4 weeks, with n...
How do you approach the management of a patient with psoriasis and chronic anterior uveitis who is unable to take DMARDs and has tried TNF inhibitors and IL-17 inhibitors but has ongoing bilateral anterior uveitis?
Psoriasis is so common that it is possible that this is a chance association, but published studies do support the likelihood that there is a causal association between psoriasis and uveitis and a much stronger association between psoriatic arthritis and uveitis. The choice of therapy depends to a g...
How often do you monitor urine protein levels for patients with membranous nephropathy for whom you initiate obinutuzumab?
Most studies of obinutuzumab in membranous nephropathy are retrospective, with remission rates of up to 83%. Would monitor UPCR every 1-3 months and check PLA2R every 3 months. Immunological remission (negative PLA2R) precedes clinical remission (one study with 76% at 3 mo and 80% at 6 mo), and clin...
How would you approach using the new vagus nerve stimulator for patients with RA?
Vagus nerve stimulation (VNS) may be a consideration for treating those patients with RA who have disease that is either resistant to multiple DMARDs and biological therapies, or where the risk of immune suppression significantly outweighs the potential benefits of our standard approach to managing ...
How do you approach management of rheumatoid vasculitis (in this era)?
We don't see rheumatoid vasculitis very often nowadays. When our drug options for RA were limited, most patients had smoldering ongoing disease, which predisposed them to the possible development of a rheumatoid arthritis related vasculitis, though even then, cases were uncommon. Nowadays, our abili...
How soon after starting treatment for Takayasu arteritis do you decide on the need for any vascular interventions to manage chronic damage?
To answer this question, several elements need to be considered. As a rule of thumb, in TAK and large vessel vasculitis in general, it is recommended to perform vascular surgery at the time of disease remission to prevent complications during the surgical procedure and in the immediate postoperative...
For which SLE manifestations or disease activity markers do you generally recommend escalation to a biologic in a patient who does not have apparent renal involvement?
For renal lupus, mycophenolate is no longer sufficient as induction therapy: either belimumab or calcineurin inhibitors should be added. For non-renal lupus, EULAR 2023 guidelines (Fanouriakis et al., PMID 37827694) state that immunosuppressives and/or biologics can be added. Gatto et al have shown ...