Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Have you seen microscopic polyangiitis associated with temporal artery involvement?
Temporal artery involvement or large vessel involvement in general can be seen in the anca vasculitides, though it is not common. A published series (Kaymakci et al., PMID 37672018) reported 17 patients with TA involvement in AAV patients. Another study of 101 patients with AAV reported the prevalen...
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...
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 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 ...
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 ...
How do you balance infection risk in patients with immune-mediated liver disease on chronic immunosuppression (ex: prednisone, AZA, MMF, etc)?
The risk of infection depends on patient-related factors (some related to liver disease, others due to other conditions) as well as the degree of immunosuppression. Patient-related risk factors include the presence of cirrhosis, age, diabetes, CKD, and others, which can increase the risk of infectio...
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....