Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In a patient with strong serologic evidence of SLE presenting with isolated bilateral lower limb sensorimotor neuropathy, normal neuroimaging, and CSF, would you initiate cyclophosphamide with pulse-dose steroids upfront, or reserve escalation (e.g., plasma exchange or immunosuppressants) for cases refractory to steroids?
This has been a dilemma for me for over several decades.1. There is no good large data to guide us on this question. I do not think there is one correct answer.2. All sensorimotor neuropathies are not created equally. I assume all other causes of sensorimotor polyneuropathy have been ruled out. Howe...
How do you counsel patients about the potential malignancy risk associated with traditional DMARDs?
I discuss with them the slight increase of non-melanoma skin cancer in studies of methotrexate. Otherwise, there is not convincing data of associations between csDMARDs and cancer development.
Do you find 14.3.3 eta or vectra DA helpful in clinical practice?
These blood tests were developed to help diagnose and monitor rheumatoid arthritis.14-3-3 eta is an interesting protein that may have pro-inflammatory properties and could be helpful in diagnosing RA (Maksymowych et al., PMID 25128504), confirmed in a recent meta-analysis to have reasonable diagnost...
What serologic biomarkers do you send to assess for sarcoidosis at baseline and/or during flares, in patients where it may correlate with disease activity?
Elevated ACE, dihydroxy vitamin D, and soluble IL2r levels have been shown to correlate with disease activity, but it is important to keep in mind that the sensitivity and specificity are variable and they should never be used in isolation to diagnosis or assess disease activity in sarcoidosis. The ...
When transitioning from romosozumab to alendronate or teriparatide to alendronate, is there a minimum amount of time that alendronate needs to be continued to prevent loss of BMD gains?
My personal approach is that the transition to an anti-remodeling drug like alendronate should be done ASAP to reduce the risk of losing new bone that was made with the anabolic drug. The length of use of alendronate should be consistent with our typical use of oral alendronate. Generally, no more t...
How do you approach screening for occult cardiac or tracheal involvement in a patient with relapsing polychondritis?
Hello! Dynamic CT and echo, if you have suspicion of vasculitis (physical exam, sx), a CTA can help. Happy to discuss your case.
Is it safe to use one TNF inhibitor (e.g., infliximab) in a patient who has had a severe allergic reaction to a different TNF inhibitor (e.g., adalimumab)?
The short answer is yes - it is ok to proceed with a different TNFi. First, it is important to determine whether the reaction was truly allergic or a nonspecific infusion reaction instead. If possible, obtaining a serum tryptase level at the time of the reaction can help clarify. Realistically, this...
What is your approach to seronegative presumed pediatric autoimmune encephalitis?
My approach is to prove that the patient has that condition through objective testing (labs, imaging, tissue sampling) instead of having a "presumed" diagnosis as I do not treat patients based on presumptions...
Are there concerns with combining anti-IL5 biologics (mepolizumab or benralizumab) for severe asthma with other biologics for RA?
The question of combination biologic therapy is becoming increasingly important in our field. The main concern with combination biologic therapy is the risk of serious infections. This concern extends to IL-5 agents combined with biologics for RA. Unfortunately, there is a lack of data to guide our ...
What is your second line therapy for patients with EGPA with mainly pulmonary and sinonasal features who did not respond to mepolizumab 300 mg/month and still require high doses of steroid?
This is an important question. Benralizumab has recently been shown to have similar efficacy to mepolizumab with a suggestion of a greater number of patients being able to fully discontinue steroids when treated with benralizumab as compared to mepolizumab. On the basis of this study I would use ben...