Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In which Sjogren's patients do you prioritize systemic treatment strategies at time of diagnosis?
Answering this question would really depend on what exact type of patient you are dealing with. You may consider initiating oral DMARDs such as hydroxychloroquine, methotrexate, or azathioprine for patients with inflammatory arthropathy or significant autoimmune rashes. More aggressive therapy would...
Are there clinical, laboratory, or imaging features that can help distinguish primary Sjögren’s syndrome from secondary Sjögren’s in patients with overlapping inflammatory arthritis or positive rheumatoid factor?
Such a good query. I don't really know, as associated SjD has been understudied. In my experience, associated Sjogren's does not look that different from Sjogren's alone. We have seen high ocular staining scores and markedly reduced unstimulated salivary flow in associated SjD (SLE, RA). In SjD, the...
How do you approach the management of a patient with psoriasis and chronic anterior uveitis who is unable to take DMARDs and has tried TNF inhibitors and IL-17 inhibitors but has ongoing bilateral anterior uveitis?
Psoriasis is so common that it is possible that this is a chance association, but published studies do support the likelihood that there is a causal association between psoriasis and uveitis and a much stronger association between psoriatic arthritis and uveitis. The choice of therapy depends to a g...
How soon after starting treatment for Takayasu arteritis do you decide on the need for any vascular interventions to manage chronic damage?
To answer this question, several elements need to be considered. As a rule of thumb, in TAK and large vessel vasculitis in general, it is recommended to perform vascular surgery at the time of disease remission to prevent complications during the surgical procedure and in the immediate postoperative...
For which SLE manifestations or disease activity markers do you generally recommend escalation to a biologic in a patient who does not have apparent renal involvement?
For renal lupus, mycophenolate is no longer sufficient as induction therapy: either belimumab or calcineurin inhibitors should be added. For non-renal lupus, EULAR 2023 guidelines (Fanouriakis et al., PMID 37827694) state that immunosuppressives and/or biologics can be added. Gatto et al have shown ...
What is your approach to treatment of severe intestinal vasculopathy in patients with myositis (such as NXP2)?
Avoid NSAIDs and agents that can cause gastritis or GI ulcers. IVIG is the best treatment for such patients.
Is there a preferred JAK inhibitor for the treatment of alopecia associated with childhood-onset systemic lupus erythematosus?
Unfortunately, this question likely comes down to FDA and insurance approval and not scientific evidence. Since only one JAKi is approved for alopecia right now and and 2 for poly JIA and none for SLE currently in any age, it will come down to which diagnosis you are going to use to get coverage.
How would you approach managing a patient with well-controlled RA on abatacept who develops a solid malignancy?
Ok- good question:I would switch to an IL6inhibiton and let oncology do their thing.Make sure they are on Plaquenil too. :)Also, if the patient is going to get traditional chemo - watch and wait, likely the RA will be controlled with blanket immunosuppression of chemotherapy.Petit et al., PMID 39241...
What strategies have you found most effective in improving long-term medication adherence in patients with SLE?
The most important long-term drug to have good adherence to is hydroxychloroquine.Soon after I began measuring HCQ drug levels in all my patients who were not in remission back in 2016, I was shocked at how many were not taking it very well (lived up to the low adherence numbers quoted in the litera...
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...