Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach treatment of suspected CNS vasculitis with a negative work up?
Suspected CNS vasculitis is, simply put, extremely challenging, most often because the diagnosis is difficult to make. Commonly, the diagnosis is suspected based upon non-invasive imaging showing an unusual distribution of infarcts and/or evidence of intracranial arteriopathy (CTA or formal DSA). I ...
Do you consider immunosuppression in patients with a history of Sjogren's disease and clinical features of inclusion body myositis?
My short answer is no. The phenotype and MRI findings described in this case suggest IBM and recently published consensus criteria for the diagnosis of IBM require only the presence of endomysial lymphocytic inflammation in muscle biopsy as a mandatory criterion, along with supportive clinical pheno...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
For patients with evidence of prior bilateral uveitis (PS, pupillary membranes, inactive KP, no view posteriorly) who reports no prior symptoms and who has had negative lab work-up, when do you consider repeat work-up and which labs would you repeat?
This is a difficult question to answer succinctly, as so much information is missing to provide a complete response. However, it does raise some important points that are worth mentioning:There is a prevailing tenet, which I was taught as a resident and hear often from residents today, that 1st epis...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
Would you start hydroxychloroquine (or another DMARD) in a mid-20s female patient with positive ANA, SSA, SSB, and dsDNA, whose only clinical manifestation is intermittent parotid gland swelling?
Hmm... I think the better question to ask is, do you code as Sjogren's lupus overlap to get way more medication options? Certainly, HCQ is a reasonable DMARD and a place to start for both diseases. I would code as lupus and Sjogren's to have more options for the future. Hope someone can weigh in on ...
Would you consider combination mycophenolate and JAKi in a patient with RA-ILD?
I have minimal experience combining a JAKi with mycophenolate. A patient with RA-ILD whose joints were well controlled with tofacitinib but whose ILD was progressing had MMF added to their regimen by their ILD pulmonologist. Unfortunately, after 4 months, the patient developed significant leukopenia...
What was the rationale for abrupt discontinuation of etanercept rather than gradual tapering in the SEAM-RA trial?
The main goal of this trial was to get RA patients off of therapy and to see whether they would flare or maintain remission. We didn’t expect that the ultimate likelihood of success or failure was going to be primarily related to how long it took to do that. While a gradual withdrawal of the drug ma...
What is the role of the rheumatologist in recommending and providing GLP-1 medications to their patients given the benefits across many disease domains including osteoarthritis?
Obesity has long been discussed in the literature as the most modifiable risk factor for knee osteoarthritis pain and progression, with a reduction in knee OA attributed to the decrease in mechanical load. But for the last decade, there has been much attention placed on the impact of metabolic facto...
Should HCQ be continued in an asymptomatic SLE patient who has received renal transplant?
As far as I know there is not a definitive answer to this question due to a lack of clinical trials. My approach is to continue it at a dose adjusted for renal failure. My thought process is that both lupus and chronic renal failure increase the risk of cardiovascular events significantly. Plaquenil...