Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In patients with severe osteoporosis, history of retinal artery occlusion, and hypercalciuria, would you favor PTH analogue therapy or Evenity?
Assuming that PTH and vitamin D are normal, neither. Chlorthalidone is the treatment of choice in this scenario. Chlorthalidone is usually better than HCTZ, as HCTZ often must be given BID, whereas chlorthalidone can be given daily. I have seen very large improvements in BMD with thiazide therapy, o...
What factors do you weigh most heavily when choosing between belimumab and voclosporin as part of a triple therapy regimen for newly diagnosed class IV LN?
When I would choose belimumab: If the urine protein creatinine ratio (UPCR) is < 3 gm/gm and if there are significant extra-renal manifestations. In patients with adherence problems with oral medications, especially noting the high pill burden of voclosporin. In patients with severe renal dysfuncti...
How would you escalate treatment for a pediatric patient with CNO with mandibular involvement and only partial response to biweekly TNFi?
If you are convinced of the correct diagnosis, then adding pamidronate to TNFi would be my suggestion. Additionally, you could maximize TNFi dose/interval (e.g., adalimumab 40 mg weekly).
How would you approach evaluation and management of a patient with chronic arthralgias and bilateral hand weakness who has a positive ANA (1:160) and low-titer anti-SSB positivity, in the setting of otherwise negative ENA panel, normal inflammatory markers, normal complement levels and immunoglobulins, and unrevealing EMG/NCS testing?
The low titer SSB/La antibody would only factor into the consideration of SjD if there were other suggestive features, like documented hypo salivation and/or high ocular staining score, neuropathy, etc. Would learn when they were totally well and what potential triggering events may have occurred. I...
Do you routinely check morning cortisol before discharging a patient who received more than 3 days of high-dose corticosteroids during a hospitalization for an acute illness?
No. In general, persistent HPA suppression does not occur when a single steroid treatment is shorter than 2 weeks.
What factors do you consider when deciding to treat IgA nephropathy with immunosuppression in a patient with cirrhosis, given the possibility that IgA nephropathy could be secondary to cirrhosis?
Proteinuria is the most important factor here. If there is significant proteinuria (>1 g/d) and no other clear reason for it, I would treat the IgA nephropathy with immunosuppression. Secondary IgA due to cirrhosis is usually not associated with significant proteinuria.
What steroid regimen do you typically use for induction therapy in patients with lupus nephritis?
LN initial treatment requires at least three choices: First, initial steroids as pulse methylprednisolone vs. high-dose oral prednisone (e.g., 1 mg/kg/day). Second, if selecting pulse steroids, follow with 1 mg/kg vs. 0.5 mg/kg. And third, double vs. triple immunosuppression from the outset.LN treat...
What factors would encourage you to choose abatacept vs tocilizumab in a patient with RA-ILD with a UIP pattern of pulmonary fibrosis?
The available literature on abatacept and tocilizumab in RA-ILD does not provide a definitive answer and hopefully with the general increase in interest in ILD we will have more definitive data in the near future. My review of the current literature suggests that abatacept has a slightly higher perc...
Do you check mycophenolate levels in patients prescribed mycophenolate who present with a lupus nephritis flare?
In general, I tend to shoot for an induction dose (3 grams) if I am using Cellcept with steroids for a flare, unless I am doing multitarget therapy or there are side effects such as GI symptoms or cytopenias. In those cases, I lower the dose to 2 grams (1000 mg BID). If there is concern for unsatisf...
Do you favor obinutuzumab over voclosporin for patients with lupus nephritis and significant proteinuria and a history of non-adherence to medications?
Non-adherence to medications is a common issue in lupus patients, but this can be even more of a concern in lupus nephritis, where the pill burden for patients can be so high. I usually prefer to use intravenous medications for patients who have had difficulty adhering to oral medications in the pas...