Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What patient factors guide your selection of maintenance therapies for a patient with autoimmune hepatitis?
I have no deep insight here. The goal is to try to get labs as normal as possible - also realizing that once achieved normal labs do not per se imply normal liver. Histological control lags biochemical control by years, hence the need for prolonged therapy and biopsies prior to withdrawal of therapi...
What management considerations do you keep in mind in the management of pregnant patients with autoimmune liver disease?
AIH should ideally be well-controlled for a year prior to pregnancy, as this duration is associated with a lower risk of gestational and postpartum flares and a lower risk of preterm birth. Steroids, azathioprine, and CNIs are safe for use in pregnancy (and lactation), so important to emphasize the ...
How do you balance infection risk in patients with immune-mediated liver disease on chronic immunosuppression (ex: prednisone, AZA, MMF, etc)?
The risk of infection depends on patient-related factors (some related to liver disease, others due to other conditions) as well as the degree of immunosuppression. Patient-related risk factors include the presence of cirrhosis, age, diabetes, CKD, and others, which can increase the risk of infectio...
What is your approach for treating mononeuritis multiplex in patients with ANCA vasculitis?
Mononeuritis multiplex related to ANCA associated vasculitis generally responds to treatment with rituximab, which would be my treatment of choice. Clinicians need to be aware that neurologic recovery can be very slow, and it is important to distinguish damage from ongoing active nerve inflammation....
When interpreting bone density reports, are T-scores adjusted for different age brackets?
T-scores are standardized to a "young normal" population, and do not change with age. Z-scores are standardized to an age and sex-matched population, and do change with age. When assessing BMD over time, one should compare the actual measurement, not the T-score or Z-score and related to the measure...
How do you decide on a steroid sparing agent for idiopathic orbital inflammation partially responsive to steroids?
Idiopathic orbital inflammation is a diagnosis of exclusion which is usually supported by orbital imaging and/or biopsy. It is important to exclude other causes of orbital inflammation which include thyroid eye disease, ANCA-associated vasculitis, sarcoidosis, histiocytosis, infection, or metastatic...
How do you choose between delgocitinib & ruxolitinib for patients with CHE?
Delgocitinib has broader inhibition (JAKs 1, 2, 3, and TYK2 pathways) compared to ruxolitinib and costs twice as much wholesale price, so I prefer to start with ruxolitinib. I view all dermatitis as some combination of irritant, allergic (Th1 and Th2), and microbial (Th17) factors. CHE usually invol...
Would you use TNF inhibitor therapy in a patient with seropositive RA who had optic neuritis as a child without relapse as an adult?
This is a really complex question that doesn’t have a simple yes-or-no answer. It involves interpreting a small and complex literature of immunologic and epidemiologic data, along with my own small experience and judgment. That said, I probably wouldn’t use a TNF inhibitor in a patient like this for...
What studies do you find helpful to determine if an axial spondyloarthritis patient presenting late in the disease course with significant irreversible joint damage may benefit from immunosuppression?
I think this is a very clinically relevant question. While I do not know of any study that specifically examines this question, studies suggest that tumor necrosis factor inhibitors may inhibit long-term radiographic progression and improve functional status. Long-term extension of secukinumab trial...
How do you approach the concept of spondyloarthritis disease activity "burning out" and no longer requiring immunosuppression?
This is a difficult question to discuss academically, as we will have to accept a definition for “burning out,” which may or may not be synonymous with remission or a state that will support drug-free remission. That being stated, the possibility of spondyloarthritis going into remission (no “inflam...