Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In patients with SLE and coexisting knee osteoarthritis, how useful is musculoskeletal ultrasound particularly power Doppler in distinguishing an SLE inflammatory arthritis flare from an OA flare when serologies and inflammatory markers may not be helpful?
Unfortunately you are correct. Ultrasound alone is not able to distinguish between an effusion or synovitis due to the patient's OA or SLE. You would have to assess clinically for other evidence of an SLE exacerbation, and/or aspirate and analyze the fluid (which may be easier using ultrasound guida...
What would be the minimum duration of IL-1 therapy you would recommend for chronic pericarditis?
There is no great data. In my experience, it depends on the reason for IL-1 initiation, the severity of cMRI findings, and how chronic the pericarditis was prior to initiation.. If this is used as a steroid-sparing strategy or steroid weaning, probably 1-2 years minimum. In Rhapsody, the majority fl...
How do you treat a patient with new class V lupus nephritis and recent hx of breast cancer on tamoxifen?
The 2024 ACR and Kidney Disease Improving Global Outcomes (KDIGO) lupus nephritis treatment recommendations are excellent, and I tend to treat my patients similarly to their recommendations.NOTE: The KDIGO guidelines are excellent! Consider downloading them.Regarding the history of breast cancer and...
How do you manage inflammatory back pain when X-rays and MRI show no evidence of sacroiliitis?
While a normal MRI makes the diagnosis of axial spondyloarthritis unlikely, it doesn’t completely rule it out. This is specifically true in patients with inflammatory back pain or other features of spondyloarthritis. While classification criteria definitely should not be used for diagnosis, it is he...
What is your approach to induction therapy and maintenance therapy for patients with autoimmune hepatitis?
Depending on the severity - if severe injury with jaundice, I admit for IV solumedrol. On an outpatient basis, will do prednisone 40mg daily - repeat labs in 1 week and if improved, start Imuran 2 mg/kg (up to 200 mg daily; TPMT testing has to be ok - otherwise will do MMF 500 mg daily and increase ...
How long do you continue IVIG for myositis patients in remission on that therapy?
Typical total duration of IVIG is about 1-2 years. If someone is in remission, I will decrease IVIG to 1 gm/kg monthly dose. If still in remission for 3 months, I decrease to 1 gm/kg every other month for 2 more cycles. If still in remission, you could either stop or do 1-2 doses every 3 months befo...
What parameters would you use to decide whether to stop hydroxychloroquine in a patient whose lupus is well controlled but is found to have a prolonged QT interval on routine EKG?
This is an excellent question for which there is no one-size-fits-all answer. The first question is how prolonged the QT is, and if there is another drug they are on that is contributing to the prolonged QT. Obviously, it is important to avoid prescribing other medications that prolong the QT. It is...
When would you consider checking JC virus prior to initiating biologic therapy?
JC is a ubiquitous virus with sero-prevalence in the adult population of 60-70% in most studies. The concern is that in those who harbor latent JC are vulnerable to reactivation and ultimately the development of Progressive Multifocal Leukoencephalopathy (PML). The drug natalizumab used to treat MS ...
How do you approach a patient with IgG4-related disease who has failed rituximab and mycophenolate and continues to rely on high-dose steroids?
Most cases of IgG4-RD respond to rituximab similar to the steroid treatment. When there is a lack of response to moderate dose steroid or rituximab, either the diagnosis is not IgG4-RD or the manifestation is not due to active IgG4-RD. In many cases, if treatment is delayed, fibrosis takes over the ...
Is there a maximum duration for raloxifene use?
There is relatively scant data on long-term raloxifene use in patients with osteoporosis, but generally, there are no recommendations for a drug holiday. The primary endpoint in the pivotal registration trial, MORE, was incidence of vertebral fracture, and the difference between the raloxifene and p...