Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
Do you stop TNF inhibitors during the third trimester of pregnancy?
TNF inhibitor use in pregnancy is a common topic I review with patients. I make sure I include family members in my medication safety talks as well as provide tangible information, because unfortunately in the US there is a harmful stereotype that medications taken in pregnancy are bad and pregnant ...
How would you approach management of a patient with ankylosing spondylitis who was doing well on tofacitinib, but experienced a STEMI while on therapy?
This is an excellent question and complex clinical scenario. The patient is HLA-B27 positive with sacroiliitis, peripheral arthritis, and uveitis, and has previously failed two TNF inhibitors but experienced STEMI while on JAKi.We have the option to switch to IL-17i but we know IL-17- do not prevent...
How do you approach “clearing” a patient with SLE and ESRD for renal transplant?
Prefer the term "optimizing" as opposed to "clearing" SLE patients for procedures such as renal transplants and issues here similar to identifying the preferred time to proceed with pregnancy, specifically in patients with a history of LN, with the goal in both scenarios of achieving desired outcome...
How would you manage autoimmune pancreatitis in a patient after Whipple's procedure?
There are two types of autoimmune pancreatitis (AIP): type 1 AIP, which is synonymous with IgG4-related disease (IgG4-RD) involving the pancreas and makes up a large majority of AIP cases, and type 2 AIP, which is largely associated with inflammatory bowel disease. I am assuming from the question th...
Is there a benefit to having a transition period in which a patient continues following with their previous pediatric rheumatologist while establishing care with a new adult rheumatologist?
Several pediatric to adult care models exist. Some models involve transition clinics in which adult and pediatric providers are both present and care may overlap between the two providers. Others are primarily focused on the pediatric side in preparing adolescents and young adults for care in the ad...
What is typical presentation and time course for belimumab infusion-related depression and/or hallucinations, and how do you approach management?
As the reported occurrence of severe depression AEs is rare (<0.5%), one can not really ascribe a 'typical' presentation to depression occurring in the context of treatment with belimumab infusions. The reasons/mechanisms underlying the consistently observed increased incidence of this AE in both th...
Should testing for genetic causes of HLH be performed in all patients with MAS or secondary HLH regardless of the patient's age?
Familial HLH (fHLH) is a pediatric disease. Therefore, there is no place for genetic testing to establish a diagnosis of fHLH in adults, and treatment for HLH should not be delayed while waiting for genetic testing. However, there are hypomorphic polymorphisms in the fHLH genes that may be a contrib...