Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What drives you to choose voclospsorin over tacrolimus given the substantially higher cost?
In a discussion of comparing voclosporin versus tacrolimus to treat LN, I would first like to address the issue of cost. As far as any individual patient, out-of-pocket expenses may be similar for these two calcineurin inhibitors since it is often covered by insurance. Additionally, Aurinia has a ve...
Do you ever combine voclosporin and belimumab in the treatment of lupus nephritis?
The combination of these two therapies has not yet been formally tested. Having said that, the combination has an appealing rationale. Immunologically, modulating T cells and B cells in LN seems likely to be efficacious. Beyond the immunology, there are other reasons that favor this combination. Voc...
Should all patients with suspected giant cell arteritis get a PET scan to look for large vessel disease?
PET-CT and PET-MRI can be very useful diagnostic modalities in GCA, but I do not recommend universal screening with PET scanning. The upcoming ACR/VF sponsored vasculitis guidelines will likely recommend obtaining non-invasive vascular imaging to evaluate for large vessel involvement, but the recom...
How do you weigh the risks and benefits of GLP-1 RAs in patients over age 65 specifically in regards to loss of muscle mass and osteoporosis?
This is indeed a crucial question: rapid weight loss is accompanied not only by a loss of adipose tissue but also by a loss of lean mass, including muscle and bone tissue. This must therefore be taken into account when making decisions, particularly in patients with osteoporosis, frailty, sarcopenic...
How do you ensure that fibromyalgia is appropriately recognized in patients with Sjogrens?
I like Dr. Pisetsky et al's recent recommendation of naming this "nociplastic pain" rather than fibromyalgia. They were specifically talking about "lupus-associated nociplastic pain", but after reading their article, it should also apply to Sjogren's disease.I'd encourage everyone to read their very...
How does an incidental finding of low bone density on imaging done for another reason inform your screening approach for osteoporosis?
In patients with CKD, I would also look for changes on the plan radiographs of secondary hyperparathyroidism. For example, erosion of the distal tufts of the phalanges on hand films, erosion of the clavicle, and arterial calcification. If these findings are present, then it signifies hyperparathyroi...
How do you incorporate hyperbaric oxygen therapy into the care of patients with wounds related to ischemic ulcerations?
Hyperbaric oxygen therapy (HBOT) is intended to improve local tissue hypoxia in non-healing ulcers. Evidence for its use remains limited, primarily consisting of case reports and small case series. Most documented cases involve lower-extremity ulcers, often related to macrovascular disease. For digi...
How often do you perform nailfold capillaroscopy in your clinical practice in patients with CTD?
In an ideal world, I would perform nailfold cap on all patients (to gain prognostic information on the extent of disease progression), but this is not feasible, and nailfold cap is not always necessary from a diagnostic perspective if the diagnosis is already clear. It is most useful when the diagno...
How do you approach the diagnostic evaluation of osteoporosis in CKD when renal dysfunction limits use of certain tests or biomarkers?
DEXA is still appropriate, and if anything, would underestimate the actual bone loss. For serum biomarkers, only TRAP5B, bone-specific Alkaline phosphatase (BSAP), and PINP are not altered with renal impairment (i.e., not partially cleared by the kidneys, leading to circulating fragments that render...
What is the maximum dose (mg/kg) you will push an IV TNFi to for a patient with Takayasu arteritis who is adherent and does not have evidence of anti-drug antibodies before switching to an alternate class of therapy?
For uveitis, I have used infliximab at 20 mg/kg/dose every 2 weeks to save vision.