Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach a patient with newly diagnosed lupus/lupus nephritis receiving cyclophosphamide (euro lupus protocol) with active hemolysis not responding to steroids or IVIG?
Most importantly, the cause of the hemolysis must be figured out. I'd consider the following and order the following tests for each. The treatment varies depending on the cause: Autoimmune hemolytic anemia (AIHA) from SLE: assess the peripheral smear looking for spherocytes and measure direct Coomb...
How do you explain a very high positive ds-DNA antibody by Elisa but negative by IFA?
Different readouts using ELISA platforms vs Cell/organelle-based assay systems may arise due to target epitopes being more biophysically accessible in an ELISA platform than they are in whole cell/organelle preparations. As such, as outlined by Dr. @Dr. First Last, it is probably prudent to use a va...
Is there any role for administering another course of recombinant zoster vaccine (Shingrix) in a previously vaccinated patient with RA, who is in clinical remission on JAK inhibitor but has had a breakthrough shingles infection?
Dr. @Dr. First Last has provided a very complete and literate response. However, the critical word is “likely”. As with most vaccines, both the strength and the duration of response to the zoster vaccine decline with worsening levels of immunosuppression. We have increasingly adopted the practice of...
In what clinical situations do you consider azathioprine for treatment of inflammatory arthritis?
Azathioprine (AZA) is among the oldest pharmacologic immunosuppressive agents in use today. Initially developed as a long-lived prodrug of 6-mercaptopurine (6-MP), it was quickly found to have a more favorable therapeutic index. Gertrude B. Elion (Winner of 1988 Nobel Prize in Medicine for “importa...
Do you recommend getting a muscle biopsy in a patient with suspected IMNM with statin exposure, weakness, elevated CK, and positive HMGCR antibody?
A patient with a typical clinical presentation of IMNM (muscle weakness, high levels of CPK) and positive anti-HMGCR antibodies leaves no question regarding the diagnosis, and muscle biopsy would not change management. I would reserve muscle biopsy for atypical cases (for example, positive anti-HMGC...
How do you manage a patient with giant cell arteritis treated with weekly tocilizumab and low dose glucocorticoid who develops sudden vision loss?
Fortunately, this scenario is a rare event, as most patients treated with ongoing tocilizumab (TCZ) and prednisone are at a far lower risk for developing new visual loss due to giant cell arteritis (GCA). A recent paper by Amsler et al., PMID 33752737 reviewing the risk for visual loss in patients b...
In patients with suspected relapsing polychondritis, can pain, redness, and swelling occur only with sustained pressure on the ears or nose, rather than presenting spontaneously?
Hello, That is a common complaint for patients with a particular subtype of RP. Some patients can have similar symptoms in early disease. Marcela Ferrada
What is your approach for gout flare prophylaxis in patients with diabetes and advanced CKD?
Flare prophylaxis is an essential component of gout management when initiating treatment with uric acid lowering drugs (ULD). It is proven that with initiation of uric acid lowering therapy will induce gout flares, much to the chagrin of patients and doctors alike. Further that flare prophylaxis wit...
Do you use conventional DMARDs aside from methotrexate to prevent anti-drug antibody development for patients on infliximab?
Yes, I would consider using other DMARDs aside from methotrexate (MTX) if this drug cannot be used for whatever reason. In this scenario, for patients with inflammatory arthritis such as RA or PsA, leflunomide is a reasonable alternative to MTX. Azathioprine (AZA) is another option. LEF has the adva...
What is your approach to urate lowering therapy in patient with gout who is on azathioprine (for example, for transplant), where allopurinol and febuxostat are both contraindicated?
This is unfortunately not an uncommon scenario. As mentioned in the question, xanthine oxidase inhibitors such as allopurinol and febuxostat are contraindicated in patients on azathioprine or 6-MP and using them almost always leads to cytopenias due to azathioprine/6-MP toxicity (even in low doses)....