Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there any clinical benefit in referring patients with SLE or Sjogren's with cognitive impairment for neuropsychological testing?
I have been grappling with this issue more often in fibromyalgia and chronic fatigue syndrome and more recently in patients with Post-acute COVID Syndrome. In FM and CFS I have not found neuropsychological testing helpful to distinguish true cognitive impairment from the confounding effects of sever...
How do you approach the use of commercial testing such as AVISE CTD in clinical practice?
Short story to start off with: A little over 20 years ago, I was a young rheumatologist sitting in a meeting room full of more experienced rheumatologists from the Washington DC area. Some of them were very well known in the field. The person in charge asked, "anti-CCP antibodies are now available t...
How do you approach tapering immunosuppression in a patient with a history of Susac Syndrome who has stabilized on MMF and IVIG?
Susac's is a rare disease characterized by an occlusive retinal vasculopathy, eighth nerve disease including hearing loss and balance issues, and CNS disease with a predilection for involvement of the corpus callosum. I am not aware of any randomized controlled data to guide treatment for Susac's, b...
What is your approach to a patient with well-controlled seropositive RA on abatacept who develops melanoma?
There is evidence to suggest an association between the use of abatacept and melanoma. A recent multinational observational post-marketing study found that compared with other bDMARDs, exposure to abatacept in RA patients was only significantly associated with an increased risk of reporting melanoma...
How do you treat anti-HMGCoA myopathy?
IVIg is a great treatment for anti-HMGCoA antibody necrotizing myopathy. However, traditional treatments like methotrexate, azathioprine, as well as rituximab can be tried. We published a paper on IVIG results on refractory HMGCR and SRP positive patients with excellent results. Kocoloski et al., PM...
When is brain biopsy useful/warranted as part of the diagnostic work-up in patients with suspected primary CNS angiitis?
I have never diagnosed or seen a patient with primary angiitis of the CNS. First, I would ensure that the suspected diagnosis and findings are confined to the CNS and are not associated with a systemic inflammatory disease. If the condition is not confined to the CNS, other areas of the body may be ...
Do you refer all patients with a Beighton score over 5 to genetics for further assessment?
Our genetics clinic does not accept these patients for genetic testing anymore because they are inundated with such requests from patients with plain benign joint hypermobility syndrome. They reject these requests for genetic testing. They accept doing genetic testing only for patients with vascular...
Would you switch a patient with glucocorticoid induced osteoporosis to romosozumab if a patient sustained a fragility fracture 1 year into treatment with teriparatide?
This is an interesting question for which there is no evidence-based medicine. It would be important to know what bone was broken. If it was a vertebral fracture I would likely suggest a change to romosozumab because vertebral fractures are usually not traumatic and are the purest osteoporotic fract...
Would you use voclosporin or belimumab as adjunctive therapy for treatment of lupus nephritis?
Yes, I would. However, this is not a uniformly accepted practice. Many clinicians believe the effect sizes were not sufficiently large to warrant drugs as initial therapy. The reasons for dual therapy (MMF and belimumab or MMF and voclosporin) go beyond the primary endpoint of the BLISS-LN and Auror...
How do you manage a pregnant patient with lupus who develops renal disease during pregnancy that is not due to pre-eclampsia?
As the question implies, the first order of operations, when a pregnant lupus patient develops clinical features of nephritis, is to distinguish between the two most common etiologies, pre-eclampsia and lupus nephritis. The former is due to an imbalance between SFLT (soluble FMS like tyrosine kinase...