Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach for gout flare prophylaxis in patients with diabetes and advanced CKD?
Flare prophylaxis is an essential component of gout management when initiating treatment with uric acid lowering drugs (ULD). It is proven that with initiation of uric acid lowering therapy will induce gout flares, much to the chagrin of patients and doctors alike. Further that flare prophylaxis wit...
Do you use conventional DMARDs aside from methotrexate to prevent anti-drug antibody development for patients on infliximab?
Yes, I would consider using other DMARDs aside from methotrexate (MTX) if this drug cannot be used for whatever reason. In this scenario, for patients with inflammatory arthritis such as RA or PsA, leflunomide is a reasonable alternative to MTX. Azathioprine (AZA) is another option. LEF has the adva...
What is your approach to urate lowering therapy in patient with gout who is on azathioprine (for example, for transplant), where allopurinol and febuxostat are both contraindicated?
This is unfortunately not an uncommon scenario. As mentioned in the question, xanthine oxidase inhibitors such as allopurinol and febuxostat are contraindicated in patients on azathioprine or 6-MP and using them almost always leads to cytopenias due to azathioprine/6-MP toxicity (even in low doses)....
How do you approach the management of patients with suspected membranous lupus nephritis who are found to have positive PLA2R antibodies?
In a patient with known SLE with proteinuria > 500 mg/g and (+) PLA2R antibodies in the serum, a kidney biopsy would be warranted. PLA2R staining should be performed on the kidney biopsy. PLA2R staining must co-localize on the subepithelial aspect in a granular fashion similar to IgG in PLA2R posit...
How would you approach the treatment for patients with renal-limited ANCA vasculitis who have persistent proteinuria, hematuria, and ANCA titers and have completed a steroid taper and received three doses of rituximab?
Renal limited ANCA is usually MPO associated. Isolated PR-3 involvement of the kidneys are rare. Further information is needed in making a decision for this case. We need to know when the patient was diagnosed with ANCA vasculitis. What was the Serum creatinine at presentation? When was the kidney b...
How do you approach the management of a patient with non-tophaceous gout who relapses upon withdrawal of acute gout prophylaxis despite adequate uric acid suppression on allopurinol?
The decision to initiate oral uric acid lowering therapy (ULT) is usually made when my patient has established a pattern of recurrent gout flares. Our discussion occurs during the flare, and the flare is treated. Depending on circumstances, the flare may be managed with colchicine, an NSAID, oral st...
What approach do you use for monitoring renal response to LN therapy?
Early in treatment, I will check a urinalysis, Urine protein: creatinine, and serum creatinine every 4-6 weeks to make sure that the patient is responding. After a few months, I will check every 2-3 months. I usually will recommend a repeat biopsy if 1) there is no response to treatment in six month...
Should IVIG dosing in patients with autoimmune disease (i.e., dermatomyositis) who become pregnant continue to be based on actual weight at the time of each infusion, or should it be limited to pre-pregnancy weight?
This is a very interesting and incredibly pragmatic question, but not one with an easy answer.By way of background:The treatment of pregnant DM patients is understandably complicated by the need to balance adequately treating disease activity against the maternal/fetal toxicity of medications. In ad...
What is your approach to managing sicca symptoms in patients not responding or not tolerating conservative measures, pilocarpine, and cevimeline?
Try lower doses of pilocarpine with just 1/4 tablet at a time. Very slowly go up on the dose as tolerated. The patient's job is to find the maximum tolerated dose. I recommend this pill splitter: Mix capsule of cevimeline in water, just drink a tiny bit at a time tid and go up on dose as tolerated...
How do you evaluate livedo reticularis (not livideo racemosa)?
Livedo reticularis appears as an interrupted vascular network on the lower limbs. One does not need to warm up the affected area in order to make this diagnosis. The response to heat usually occurs in cutis marmorata that is found in children. Livedo reticularis when it is acquired in teenage and la...