Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What are your thoughts on telitacicept use in SLE, and why has it not garnered more attention in US news cycle in rheumatology?
Telitacicept (a fully human TACI-Fc fusion protein that targets B lymphocyte stimulator (BLyS) and a proliferating-inducing ligand (APRIL) blocks the interaction of BLyS and APRIL, resulting in reduced B-cell proliferation and maturation. Theoretically, it makes sense that it should work in B-cell-d...
What would be your approach to managing severe ANCA-associated vasculitis in a patient who is also septic from a bacterial infection?
It is prudent to evaluate if the ANCA-associated vasculitis is being triggered by the underlying bacterial infection. Certain clues on the kidney biopsy including diffuse exudative as well as diffuse crescentic [of same age] pattern of injury on light microscopy, intense C3 staining on immunofluores...
How would you taper tocilizumab in a patient treated with the GIACTA 26 week steroid and tocilizumab protocol?
This is a very important question that should be high on the research agenda in GCA in the coming years. Several studies investigating the risk of relapse in GCA have yielded relapse rates ranging from the 30s-70s%. While these studies have significant limitations, it's reasonable to assume that the...
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
I am a radiation oncologist and palliative care physician.I teach: "the hand that writes the opioids, writes the laxatives - or else it does the disimpaction". Opioid induced constipation is very common, can cause physical and psychological discomfort, and have a major impact on quality of life. It ...
How do you approach the work up for patients with fibromyalgia and hypermobility?
I agree the folks that are hypermobile are very challenging and it can be difficult to feel confident in hypermobile EDS diagnosis, particularly with sort of nebulous criteria. I have also found that medical genetics referrals where I practice have over a year-long waitlist, and as there is no genet...
In older male patients with a history of underlying autoimmune disease, what clinical manifestations would prompt you to evaluate for VEXAS Syndrome?
Hello!!!Skin lesions, elevated MCV, elevated inflammatory markers.
What is your approach to patients with SLE who develop a rash after hydroxychloroquine initiation?
First, I diagnose the type of rash. If it is a severe cutaneous reaction, e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis (SJS/TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), or if it is a more persistent type of reaction like a lichenoid reaction, I stop hydroxychlor...
For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?
When deciding whether it is safe to re-challenge with rituximab after an infusion reaction, the most important consideration is the type of reaction that the patient experienced. This will help to risk stratify and determine whether same day or future infusions of RTX should be used. Importantly, th...
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
How do you approach inflammatory arthralgias without synovitis in a patient with psoriasis?
When a patient with psoriasis presents with inflammatory arthralgias, the approach should be centered on a prompt evaluation to differentiate psoriatic arthritis (PsA) from other causes of joint pain or non-inflammatory arthralgias. Clinical history and physical exam are the key. A good clinical his...