Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach immunosuppression in a patient with well-controlled HIV and RF+ rheumatoid arthritis breaking through hydroxychloroquine with ongoing inflammation confirmed on ultrasound?
The Infectious Disease Society of America (IDSA) defines HIV viral suppression as a viral load that is persistently below the level of quantification or detection of the assay used to measure the viral load. Prevention of sexual transmission is thought to occur at levels less than 200 copies of viru...
In patients with severe osteoporosis, history of retinal artery occlusion, and hypercalciuria, would you favor PTH analogue therapy or Evenity?
Assuming that PTH and vitamin D are normal, neither. Chlorthalidone is the treatment of choice in this scenario. Chlorthalidone is usually better than HCTZ, as HCTZ often must be given BID, whereas chlorthalidone can be given daily. I have seen very large improvements in BMD with thiazide therapy, o...
How do you treat nocturnal leg cramps?
Nocturnal leg cramps are similar to daytime leg cramps, but stretching may be less convenient to use as a remedy, as sleep can be further disrupted. Treating and preventing leg cramps typically utilizes some combination of hydration and electrolytes but sometimes, medications can help. Consider the ...
For patients with definite UIP and MPO-ANCA-associated vasculitis limited to the lungs (without systemic manifestations), what is the role of immunosuppression?
I think in these subjects (as opposed to UIP in RA), immune suppression would be my first agent. The data are limited; there is some suggestion on biopsy that they have significant inflammation (Arnold et al., PMID 38574743). I would start with immunosuppression and have a low threshold to add anti-...
How do you screen rheumatoid arthritis patients for lung disease (modality, frequency, patient selection)?
Theoretically, we are supposed to screen these patients obtaining a baseline chest X-ray before starting DMARD therapy. As I remember, these guidelines were formulated when MTX was still blamed for MTX lung disease although presently, even the presence of underlying ILD is not necessarily a contrain...
What factors would encourage you to choose abatacept vs tocilizumab in a patient with RA-ILD with a UIP pattern of pulmonary fibrosis?
The available literature on abatacept and tocilizumab in RA-ILD does not provide a definitive answer and hopefully with the general increase in interest in ILD we will have more definitive data in the near future. My review of the current literature suggests that abatacept has a slightly higher perc...
What would be the clinical role of SGLT-2 inhibitors for lupus nephritis given it has an indication for proteinuria related to CKD?
The benefit for SGLT-2 inhibitors at slowing the progression of kidney disease or death from cardiovascular causes had been well established in patients with diabetic nephropathy. Further studies continued to demonstrate benefit in non-diabetic, proteinuric kidney disease (HR, 0.72 (95% CI, 0.64-0.8...
Would you offer re-irradiation LDRT for someone with osteoarthritis or tendinitis if symptoms recur?
I have not personally offered a patient a third round of LDRT and do not know of any data that shows efficacy. However, I might offer a third round if a particular patient got adequate results with the first two and there was some separation in time (perhaps >1 year) since the last round.
Has the MAJESTY trial changed your approach to the rituximab versus obinutuzumab choice in a patient with newly diagnosed primary membranous nephropathy and nephrotic syndrome?
The Bottom Line: Recent landmark trials—MENTOR and MAJESTY—confirm that anti-CD20 therapies are superior to calcineurin inhibitors (CNIs) for the treatment of MN.Key Trial DataMENTOR: Demonstrated that RTX was noninferior to cyclosporine at 12 months, and decisively superior by 24 months (60% vs. 20...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...