Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach restarting immunotherapy in a patient with metastatic melanoma who previously developed immune-mediated hepatitis (Grade 3), with liver enzymes now back to baseline levels?
I prefer to rechallenge when the irAE is back to grade 0. It depends on how long the hepatitis took to revert to a normal level. If it goes back to normal quickly (within 4 weeks), I keep patients on 8 mg methylprednisolone when rechallenging patients. If they do well, I wean them off at the second ...
What are some immunosuppression regimens to consider in a patient with refractory cardiac sarcoidosis?
Unfortunately, there is no high quality data at this point to directly answer this question but here are some options. For patients who have only been treated with oral steroids, I would first consider the addition of weekly methotrexate at a dose of between 10 - 20 mg WEEKLY with supplemental folic...
Do you utilize soluble IL-2 receptor or ACE levels as serum biomarkers to monitor disease activity in pulmonary sarcoidosis?
I use ACE levels to monitor disease activity in patients who demonstrate elevated ACE levels at diagnosis of confirmed sarcoidosis and for which there is no other explanation for elevation of ACE. ACE normalizes with treatment and will increase again if/when the disease relapses. The literature indi...
Would you stop denosumab in a patient with chronic kidney disease if they develop asymptomatic hypocalcemia after the injection?
No. Stopping denosumab leads to rebound bone resorption and loss of all gains. The hypocalcemia indicates insufficient calcium and/or calcitriol. Calcium intake should be 1,000-1,200 mg daily from food and/or supplements in divided doses with food.
Are there instances when you consider rituximab first line in a patient with class V LN?
No, I would not. I agree with the KDIGO and ACR lupus nephritis guidelines, which state that rituximab should be reserved for refractory cases and cases where the patient is intolerant of therapies that have stronger efficacy evidence (e.g., calcineurin inhibitors, cyclophosphamide, and mycophenolat...
How do you approach dyspnea in a patient with seropositive rheumatoid arthritis with normal imaging findings but abnormal PFT findings (restriction, reduced DLCO)?
Pulmonary pathophysiological abnormalities are common in individuals with rheumatoid arthritis (RA) and respiratory symptoms. In individuals without respiratory symptoms, abnormalities may even be detected by lung function testing or high-resolution CT imaging. Any compartment of the lungs may be in...
Are there certain disease domains in a patient with psoriatic arthritis that will make bimekizumab a particularly good option?
Bimekizumab has shown comparable efficacy in PsA patients who are TNFi naive and TNFi inadequate responders. Therefore, I would choose bimekizumab in bDMARD-IR patients. My second answer might surprise you - I would choose bimekizumab in a PsA patient with recurrent uveitis.
How would you approach a patient with high CRP, rising liver enzymes and new biopsy proven liver granulomas 6 months after starting methotrexate and Rituximab therapy for ANCA vasculitis?
What does the liver biopsy show in detail? I'd be far more worried about infection than AAV. Sarcoid could also present this way. How did they get the AAV diagnosis?
Do you use hydroxychloroquine for patients with asymptomatic primary Sjogren syndrome to treat hypergammaglobulinemia without other concerning features?
I routinely use hydroxychloroquine in a significant proportion of my patients. While the JOQUER trial (Gottenberg et al., PMID 25027140) did not meet its primary endpoint, defined by improvement of the common symptoms of pain, fatigue, and dryness, I think there is a broad consensus among experience...
What is your typical steroid taper regimen for managing RA flares?
I tend to avoid doing steroids to my patients with RA. When I do, I use low doses, 5 mg to 7.5 mg QAM for no more than 2 weeks or so. Generally, I tend to avoid the use of steroids in this population unless absolutely necessary, e.g., RA vasculitis, etc. However, there are patients who require more...