Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
What management considerations do you keep in mind in the management of pregnant patients with autoimmune liver disease?
AIH should ideally be well-controlled for a year prior to pregnancy, as this duration is associated with a lower risk of gestational and postpartum flares and a lower risk of preterm birth. Steroids, azathioprine, and CNIs are safe for use in pregnancy (and lactation), so important to emphasize the ...
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...
What is your approach for treating mononeuritis multiplex in patients with ANCA vasculitis?
Mononeuritis multiplex related to ANCA associated vasculitis generally responds to treatment with rituximab, which would be my treatment of choice. Clinicians need to be aware that neurologic recovery can be very slow, and it is important to distinguish damage from ongoing active nerve inflammation....
When interpreting bone density reports, are T-scores adjusted for different age brackets?
T-scores are standardized to a "young normal" population, and do not change with age. Z-scores are standardized to an age and sex-matched population, and do change with age. When assessing BMD over time, one should compare the actual measurement, not the T-score or Z-score and related to the measure...
Would you start romosozumab in an active smoker?
This is not simple! But we are good at assessment of risk vs benefit (or benefit vs risk!)First I would reassess fracture risk, prior treatments, reason to consider romo. Then I would do a deep dive into risk assessment for cardiovascular disease: how much do they smoke, prior cardiovascular disease...
How do you decide on a steroid sparing agent for idiopathic orbital inflammation partially responsive to steroids?
Idiopathic orbital inflammation is a diagnosis of exclusion which is usually supported by orbital imaging and/or biopsy. It is important to exclude other causes of orbital inflammation which include thyroid eye disease, ANCA-associated vasculitis, sarcoidosis, histiocytosis, infection, or metastatic...
How do you choose between delgocitinib & ruxolitinib for patients with CHE?
Delgocitinib has broader inhibition (JAKs 1, 2, 3, and TYK2 pathways) compared to ruxolitinib and costs twice as much wholesale price, so I prefer to start with ruxolitinib. I view all dermatitis as some combination of irritant, allergic (Th1 and Th2), and microbial (Th17) factors. CHE usually invol...
Should patients starting cyclophosphamide be screened routinely for latent tuberculosis (TB)?
Yes, I think patients starting Cyclophosphamide should be screened routinely for latent TB since CYC is a strong immunosuppressant and increases the risk of TB reactivation. The issue is that CYC is often being considered for life or organ-threatening situations, for which it may not be ideal to wai...
Would you use TNF inhibitor therapy in a patient with seropositive RA who had optic neuritis as a child without relapse as an adult?
This is a really complex question that doesn’t have a simple yes-or-no answer. It involves interpreting a small and complex literature of immunologic and epidemiologic data, along with my own small experience and judgment. That said, I probably wouldn’t use a TNF inhibitor in a patient like this for...