Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you consider metformin as a disease-modifying adjunct in the management of patients with OA, particularly in those with comorbid metabolic syndrome or type 2 diabetes?
Based on the Pan et al., PMID 40274279, and the broader literature, I would not yet formally classify metformin as a disease-modifying osteoarthritis drug (DMOAD), but the evidence is increasingly compelling, particularly in the metabolic osteoarthritis (OA) phenotype.This randomized controlled tria...
How do you approach the workup of pauci-immune glomerulonephritis?
When a kidney biopsy reveals a pauci-immune GN, the Ddx must extend well beyond classic AAV and infective endocarditis. For instance, anti-GBM disease should remain high on the list, as up to 25% of these patients present with a "dual-positive" ANCA, and the characteristic linear IgG staining on IF ...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
What clinical features would raise your suspicion for IgG-4 related disease?
IgG4-related disease can affect multiple organs, leading to varied presentations. In the abdomen, patients can have symptoms secondary to pancreatitis and or biliary obstruction. In the liver, patients can present with a PSC-like picture (jaundice, cholangitis, ductal strictures/dilatation) that, un...
What therapies have you found most effective for JAK-induced/associated acne (JAKcne)?
Doxy will work quickly and is pretty safe. If all goes well, you can taper the dose of the oral antibiotic and use topical agents.
In a young patient with relapsing polychondritis and aortitis which has led to severe aortic valve regurgitation, is there any preference for a mechanical versus bioprosthetic valve replacement?
There is no data specifically on valve replacement for RP. If the patient can be safely anticoagulated, a mechanical valve would be likely better since it is a young patient. Data from TAK regarding valve replacement suggest subsequent complications are less likely when the aortic root is also repla...
Does SI joint erosion on MRI pelvis push you to use TNF inhibitors over NSAIDs as first line for axial spondyloarthritis?
A decision to consider TNFi (or another targeted therapy) over initial NSAID therapy depends primarily on disease severity, symptom burden, and impact on quality of life, presence of significant peripheral disease (where csDMARDs have already failed or resulted in side effects), contraindications or...
How do you manage persistent hyperuricemia in a patient with CKD3 and type 2 diabetes who has had severe reactions to both allopurinol (SJS) and febuxostat (drug rash), but only a single prior gout flare?
I would just recommend conservative management in this scenario. Unclear if there is an overneed to initiate any uricosuric agents in this scenario, given just single gout flare. If there was a history of uric acid stones, then would consider an alternative but that would be challenging, given canno...
Is anifrolumab safe to use in patients with a history of malignancy?
Anifrolumab is not formally contraindicated in patients with a history of malignancy, but I would use it with individualized risk assessment.The United States Food and Drug Administration (FDA) label states that the effect of anifrolumab on malignancy development is unknown and recommends weighing t...
How do you decide on the next therapy for post-ICI triple M syndrome (myositis/myocarditis/myasthenia) after steroids, PLEX, and IVIG?
The short answer is that there is no standard of care, and no way to reliably predict which of the third-line treatments will work best for each individual. As an introduction, 3M syndrome is a horrible combination of 3 immune-related adverse events (iRAEs) after ICI exposure for cancer, including m...