Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach ongoing screening for TB in patients with a history of treated latent TB, but who have ongoing use of DMARDs and/or biologics given Quantiferon testing and PPD can remain positive?
Interferon-release assays (such as Quantiferon) and PPD testing do not discriminate between infection, reinfection, and prior infection with TB. However, in most developed countries, the likelihood that a patient who has once been treated for LTBI becomes reinfected and develops LTBI again is low, i...
How do you approach discussing the pill burden of voclosporin with patients who already have to take a regimen such as MMF+HCQ+ACEi and possibly more?
Medication adherence and a chronic disease such as lupus is an issue regardless of the number of medications. For example, hydroxychloroquine is very effective, but studies often show poor adherence as measured blood levels may be undetectable or below the intended therapeutic target.For patients wi...
In what cases, if any, do you find the use of naltrexone to augment lifestyle interventions (i.e., cognitive behavioral therapy, graded exercise therapy) for chronic fatigue to be helpful?
Absolutely no.
What is your approach to managing pyoderma gangrenosum recalcitrant to oral steroids?
Pyoderma gangrenosum is notoriously difficult to treat. The first thing I'd recommend in a case refractory to steroids is to reconsider the diagnosis. Notably, a high percentage of PG is misdiagnosed, so lack of response may indicate that you are dealing with a mimicker (e.g., infection, neoplasm, v...
When would you consider a diagnosis of peritonitis in a patient with SLE?
As noted in the question, clinically significant peritonitis is unusual/rare in lupus patients. In 25 years, I have seen two patients I was convinced had lupus peritonitis. The common thread was that both of them had had at least one abdominal surgery for an acute abdomen. The patients were known to...
Do you feel comfortable using JAK inhibitors in patients with a strong family history of CAD, but no other risk factors?
I would say it is a reasonable option to consider, especially if they have failed anti-TNF agents and if they do not have other cardiac risk factors. The studies which showed the highest risk used higher doses of JAK inhibitors, and those patients had other cardiac risk factors, so would suggest to ...
What are some practical tips for tacrolimus management/monitoring in SLE nephritis?
Consider starting with 1 mg bid on an empty stomach: I have been adding tacrolimus (TAC) to mycophenolate mofetil (MMF) and mycophenolic acid (MPA, Myfortic) or cyclophosphamide (CYC) for many years with great success. I start with 1 mg bid on an empty stomach along with their MMF/MPA, or without w...
Would you switch to a TNFi if a patient developed squamous cell skin cancer on abatacept after failure of methotrexate for seropositive RA?
All biologics or immunosuppressants have been associated with various rates of skin cancers. The decision to change or continue biologics should be based on disease activity through shared decision-making with the patient. The need for frequent skin examinations and treatment through their dermatolo...
How would you manage a patient with RA on abatacept now experiencing recurrent pericarditis not responsive to colchicine?
Anakinra or rilonacept (both IL-1 antagonists) have been shown to be effective in idiopathic pericarditis. Their utility in RA-associated pericarditis is unknown. In this particular patient, abatacept has resulted in well-controlled RA but has not prevented pericarditis even with concurrent colchici...
How do you manage steroid-refractory immune checkpoint inhibitor induced pneumonitis?
Steroid-refractory immune checkpoint inhibitor (ICI)-induced pneumonitis is managed with high-dose steroids plus an additional immunosuppressive agent, like infliximab or intravenous immunoglobulin (IVIG) among others. I recommend early immunomodulatory escalation as multiple studies have shown that...