Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach a patient with SLE and class II LN who has persistent lupus activity and incomplete B-cell depletion on rituximab therapy?
Great question! I would first make sure that their nephritis has not evolved/progressed by rebiopsying the patient if it has been a while since their last biopsy and/or they have developed new signs/symptoms of kidney involvement since their last biopsy (such as increasing UPC, decreasing complement...
What are your preferred alternative biologic agents for Blau Syndrome when anti-TNFα therapies are contraindicated?
As is true for most of us, I have limited direct clinical experience treating patients with Blau Syndrome. I have treated members of several families and am convinced that corticosteroids are effective and fraught with long-term toxicity. As the question implies, a TNF inhibitor (specifically a mono...
What tools or disease activity markers do you find most useful in tracking disease activity in Sjogren's patients?
The frequency of monitoring depends on the patient’s phenotype. For example, in patients with evidence of immunologic activity at baseline, such as B-cell hyperactivity, hypocomplementemia, or cryoglobulinemia, labs should generally be repeated every 3 to 6 months, particularly if they have active e...
Can Dupixent (dupliumab) be safely used in patients who are taking other biologics for rheumatic disease?
This is a really broad question given how many biologics exist now, but the answer is likely yes, given its outstanding safety profile. I have used it concurrently with other biologics on many occasions without any issues so far. As concurrent use increases, we may find out more if there are any "tw...
During treatment of severe osteoporosis with PTH analogs (abaloparatide), would a rise in alkaline phosphatase level >200 (in the setting of normal GGT) warrant discontinuation of medication?
During treatment with PTH analogs, it is not recommended to monitor the alkaline phosphatase but only Vitamin D and calcium every three months. The alkaline phosphatase, of course, increases with PTH analog therapy, but there is no upper limit, and the concerns about osteosarcoma have been removed f...
How would you approach a patient with newly diagnosed lupus/lupus nephritis receiving cyclophosphamide (euro lupus protocol) with active hemolysis not responding to steroids or IVIG?
Most importantly, the cause of the hemolysis must be figured out. I'd consider the following and order the following tests for each. The treatment varies depending on the cause: Autoimmune hemolytic anemia (AIHA) from SLE: assess the peripheral smear looking for spherocytes and measure direct Coomb...
How do you explain a very high positive ds-DNA antibody by Elisa but negative by IFA?
Different readouts using ELISA platforms vs Cell/organelle-based assay systems may arise due to target epitopes being more biophysically accessible in an ELISA platform than they are in whole cell/organelle preparations. As such, as outlined by Dr. @Dr. First Last, it is probably prudent to use a va...
Do you recommend getting a muscle biopsy in a patient with suspected IMNM with statin exposure, weakness, elevated CK, and positive HMGCR antibody?
A patient with a typical clinical presentation of IMNM (muscle weakness, high levels of CPK) and positive anti-HMGCR antibodies leaves no question regarding the diagnosis, and muscle biopsy would not change management. I would reserve muscle biopsy for atypical cases (for example, positive anti-HMGC...
How do you manage a patient with giant cell arteritis treated with weekly tocilizumab and low dose glucocorticoid who develops sudden vision loss?
Fortunately, this scenario is a rare event, as most patients treated with ongoing tocilizumab (TCZ) and prednisone are at a far lower risk for developing new visual loss due to giant cell arteritis (GCA). A recent paper by Amsler et al., PMID 33752737 reviewing the risk for visual loss in patients b...
In patients with suspected relapsing polychondritis, can pain, redness, and swelling occur only with sustained pressure on the ears or nose, rather than presenting spontaneously?
Hello, That is a common complaint for patients with a particular subtype of RP. Some patients can have similar symptoms in early disease. Marcela Ferrada