Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is elevated bone-specific alkaline phosphatase an absolute contraindication to teriparatide?
The original label for Forteo gave a warning against using teriparatide in patients with an “unexplained alkaline phosphatase”. This was clearly meant to avoid the use of teriparatide in individuals who may have Paget’s Disease of the bone. Since Paget’s disease has an independent increased risk for...
How would you approach a male in his 60s with bilateral optic perineuritis/neuritis on MRI, steroid-responsive bilateral jaw pain, normal ESR/CRP, negative temporal artery biopsy, and elevated IgG4?
This is a challenging case with a number of atypical features. When approaching such a scenario, I try to categorize the presenting clinical features by their specificity. In this case, optic perineuritis has a broad differential, including MOG, MS, sarcoidosis, SLE, systemic vasculitis, and infecti...
Do you recommend initiating zoledronic acid for osteoporosis at the time of hospitalization for a fracture?
I did not institute bisphosphonate therapy during hospitalization for a fracture. It would have been helpful to have known bone remodeling markers if the patient had been followed for osteoporosis. It is reasonable to institute antiresorptive therapy in patients with high bone turnover. However, I d...
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...
What biomarkers or patient characteristics do you feel best predict response to B cell depleting therapies in a patient with Sjogren's?
At present, it may depend on the Sjogren's phenotype being treated with B-cell depleting therapies. If it is vasculitis with or without cryo, cryoglobulins, rheumatoid factor, and complements are helpful, along with inflammatory markers (ESR/CRP). I also note the level of total IgG, if elevated, may...
What is your surveillance protocol for patients with common variable immunodeficiency receiving chronic IVIG therapy?
No target IgG level per se- dose/interval should be titrated to clinical condition. In general, trough IgG on treatment should be higher than 500 mg/dL, or 500 mg/dL higher than baseline. Most patients will not be in optimal clinical condition (minimal fatigue, arthralgias, absence of chronic cough,...
Has anyone incidentally diagnosed IgA deficiency in a patient who does not present with any recurrent infections?
Selective IgA deficiency is the most common primary immunodeficiency disorder. The majority of IgA deficiency patients are asymptomatic (often identified upon blood donation). It is thought that the other serum immunoglobulins compensate to provide enough protection in these asymptomatic patients. T...
How do you interpret small joint effusions seen on ultrasound without power doppler signal in the setting of compatible inflammatory symptoms (i.e morning stiffness)?
It certainly increases probability of Inflammatory arthritis, if aligns with clinical symptoms. I would check inflammatory markers, autoimmune serologies, infectious work up and all to determine type of arthritis and consider prednisone trial and likely consider immune suppressive regimen based on r...
For patients with SLE, is there an ANC level for which you would hold or adjust hydroxychloroquine in an asymptomatic patient?
Leukopenia most often as lymphocytopenia, of course, is not unusual in lupus. Total WBC less than 4000 is an ACR classification criteria for the disease as is ALC less than 1500 on two occasions. SLICC disease classification requires ALC less than 1000. Total WBC < 3000 generates SLEDAI points. On t...
Is there any benefit to checking serum viscosity in patients with autoimmune disease and headaches/migraines to see if aspirin or clopidogrel may be beneficial?
The serum viscosity test measures the time required for the serum to flow through a calibrated capillary tube under controlled pressure. Clinically significant elevations in viscosity (≥2.5 centipoise, normal range 1.4 - 1.8 cP) can cause symptoms and are most commonly seen in hyperviscosity syndrom...