Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you consider belimumab for an SLE patient who has generalized hair thinning, leukopenia (WBC <3), low C3, and markedly positive anti-dsDNA who is otherwise asymptomatic?
Absolutely (with important caveats), now hear me out (I'm sure this will be controversial): HOWEVER, 1st, I NEVER trust my own judgment on the cause of the nonscarring hair loss and automatically blame it on SLE. I've had too many patients who have had non-lupus causes, such as central centrifugal c...
How would you approach management of a patient with classic GCA symptoms, elevated ESR and improvement with steroids, but negative temporal artery biopsy and CTA imaging without evidence of vasculitis?
This is a difficult clinical situation, but one that comes up frequently. In the Olmsted County population-based cohort study, about 14% of patients had a clinical diagnosis of GCA (biopsy negative, imaging negative, or not done, Garvey et al., PMID 34644662).I would want to make sure that GCA mimic...
Does the presence of psoriatic arthritis affect your decision to use an anti-IL-17 or IL-23 drug in your psoriasis patients?
I tend to prefer IL-17s in patients with PsA as an indirect assessment of clinical trials suggests they are more effective than IL-23s (which fits my clinical experience) for PsA. IL-17s are also more effective for axial disease (IL-23s are not very effective in axial disease). If there is a history...
Would you give long term antistreptococcal antibiotic prophylaxis to a patient who presents with features of poststreptococcal reactive arthritis but who also meets criteria for Acute Rheumatic Fever?
Acute rheumatic fever should have prophylaxis. If no rheumatic heart disease, the recommendation is penicillin up to age 21 or for five years after the last episode. If heart disease is present, that recommendation is for life. In the setting of penicillin G benzathine shortage, the only option for ...
In which patients with SSc do you add anti-platelet therapy and/or statins for Raynaud's phenomenon?
We believe that platelet aggregation plays some role in the development of digital ulcers, but we don't have any trial data to support the use of antiplatelet agents. But for patients who have recurrent digital tip ulcerations despite vasodilators, I will consider the use of antiplatelet agents (81 ...
When would you consider use of emapalumab for HLH/MAS?
The FDA has approved emapalumab for familial HLH. For secondary HLH/MAS, I typically begin with anakinra (100 mg q 6 hrs for those 40 kg or more). If this is not enough and if CXCL9 (I send on day one to have the data available) is notably elevated, then consider adding emapalumab. Alternatively, a ...
Is there a role for monitoring serum ANCAs to assess ANCA associated vasculitis disease activity?
This is (and remains) a somewhat controversial question. ANCA titers do appear to rise in anticipation of disease flares and patients with persistent titers appear to have more flares. This is especially true for PR3 ANCAs. However, the proximity of flares to rising ANCA titers is not terribly close...
Do you use IL-1 inhibitors to prevent flares of gout or CPPD in patients who experience flares despite prophylaxis with colchicine, NSAIDs, and/or low-dose prednisone?
I have used IL-1 inhibitors to control gout flares or gout flare recurrences in patients who have been refractory to standard gout flare or gout flare prophylaxis management. Likewise, on extremely rare occasions, I have used an IL-1 inhibitor for recurrent CPPD flares, though with mixed results.The...
How do you incorporate smart phone microscopy into your clinical assessment of Raynaud's?
I don’t personally use smartphone microscopy in the clinic. I use a commercially available nailfold cap device, which has associated software for analyzing the images and formulating a report that is uploaded to the patient’s medical record.
For suspected IgG4-RD, what imaging modality do you use in your practice for initial diagnostic evaluation?
Imaging is an essential component of the workup of IgG4-related disease (IgG4-RD). This is because multiorgan involvement is common, and many sites of involvement (e.g., pancreas, kidneys, blood vessels) may be entirely asymptomatic even during active disease, despite still placing the patient at hi...