Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there an evidence-based consensus on CT-derived Hounsfield unit thresholds for opportunistic assessment of osteoporosis, and how should such measurements be applied when DXA results are inconclusive or do not meet diagnostic criteria?
Per the International Society for Clinical Densitometry's official positions: "Opportunistic CT-based attenuation using Hounsfield Units (HU) can be used to estimate the likelihood of osteoporosis (L1 HU < 100) and normal (L1 HU > 150) bone density to support decisions regarding bone health assessm...
What is your preferred initial treatment strategy for patient with new diagnosis of seropositive RA who has end-stage renal disease?
My initial response is to make sure that the diagnosis of RA is correct. Onset of arthritis in a patient with end-stage renal disease could be from other causes maybe even related to the renal disease itself such as gout or CPPD. If this is truly RA, then the safest approach for initial management w...
What are your thoughts on using abatacept for RA-associated ILD in a patient undergoing treatment for CLL with zanubrutinib, and how would you assess the potential increased risk of infection in this context?
Zanubrutinib is an inhibitor of Bruton tyrosine kinase which is part of an important signaling pathway for B cells. BTK inhibition prevents B cell activation, proliferation, and survival. It is useful for B cell malignancies such as CLL.I have two concerns about using abatacept and zanubrutinib toge...
How would you manage axial stiffness without pain in an elderly gentleman with a distant history of HLA-B27+ axial and peripheral spondyloarthritis, now with SI joint fusion, no peripheral arthritis, normal inflammatory markers, and no response to TNF inhibition?
Based on the history and lack of response to anti-TNF therapy, I suspect the patient does not currently have active inflammatory disease but likely sequalae of prior damage and degenerative spinal disease as a cause of his stiffness. A trial off of the biologic would help assess if the medication is...
Do you prefer allopurinol or febuxostat for patients with chronic kidney disease who are receiving treatment for asymptomatic hyperuricemia?
Allopurinol. For my Asian and sometimes African American patients, I consider HLA testing to make sure they are not at risk for allopurinol hypersensitivity. In which case, I will prescribe febuxostat. Most often, I find the insurance will not even cover febuxostat unless I have tried allopurinol fi...
How do you time concurrent therapy with rituximab and IVIG?
Rituximab has about the same half-life as regular IgG. If the regular IVIG treatment can be delayed, it will be less likely to increase the catabolism of Rituximab. If the regular IgG is given at 3-4 week intervals, I would give the Rituxan halfway between IVIG doses. Complement is needed for optima...
How do you approach new-onset idiopathic intracranial hypertension (IIH) with someone who has history of systemic lupus erythematosus?
Since there is not a clinical recurrence of lupus, let's assume the disease is quiescent. The patient may have a clotting tendency so extra care should be taken in MRV interpretation. Does the MRV show the smooth-walled flow-related stenoses of intracranial hypertension or is it more consistent with...
How would you approach management of a patient with seropositive RA and UIP-ILD, with concern for active lung disease?
There is a potential benefit of adding additional immunosuppression for an RA patient with a UIP pattern on HRCT. My go-to-drugs are either abatacept or rituximab. While MMF is a standard first-line medication for many forms of ARD-ILD, it was tried for RA joint disease many years ago and the study ...
In a patient with negative Hep B surface Ag, Hep B surface antibody+, and Hep B core antibody+ serologies, do you initiate antiviral prophylaxis (e.g. entecavir) prior to starting rituximab?
I would use entecavir for Hep B reactivation prophylaxis in this case - based on recommendations from AGA 2025 guidelines, which does classify b-cell depleting agents as higher risk for reactivation for both Hep B surface Ag-positive and Hep B surface Antigen neg/core positive patients. It should be...
What patient factors guide your selection of maintenance therapies for a patient with autoimmune hepatitis?
I have no deep insight here. The goal is to try to get labs as normal as possible - also realizing that once achieved normal labs do not per se imply normal liver. Histological control lags biochemical control by years, hence the need for prolonged therapy and biopsies prior to withdrawal of therapi...