Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you counsel a patient with SLE who has labs suggesting active non-renal disease on the benefits of escalation of treatment if they aren't experiencing noticeable symptoms?
Non-renal disease is predominantly in the skin and joints. These are assessed by physical examination (not by laboratory tests). Yes, there are some patients with mild synovitis by exam who are NOT bothered by it, but most patients will have morning stiffness and require treatment. Patients who are ...
What do you feel are the potential barriers to widespread use of obinutuzumab in proliferative lupus nephritis?
1. Insurance Coverage: Oh, easy one! Since it is not FDA-approved yet for lupus nephritis (I bet it will be though... great data so far), insurance will unlikely cover it, except for a few (like Tricare, which is sometimes easier to get off-label drugs). I am fortunate to have the NIH Lupus Center c...
Have you seen synovitis (even if subtle) with aromatase inhibitor musculoskeletal syndrome?
Aromatase inhibitor (AI) drugs have been associated with the onset of arthralgias and myalgias. These have been reported to occur in as many as half the women prescribed this class of drug. The onset of an inflammatory arthritis is far less common. There are selected case reports documenting the ons...
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...