Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 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...
How do you approach further treatment in patients with anti-HMG-COA myopathy who have residual disease activity (ongoing weakness, elevated CK) after >1 year of combination therapy, e.g. IVIG and methotrexate?
The most important question is if the patient still has active disease, or their symptoms of residual weakness are from fatty atrophy. In the latter case, the patient will not benefit from additional immunosuppression but would require aggressive physical therapy. In anti-HMGCR IMNM, good markers fo...
In a patient with isolated HLA B27+ anterior uveitis, how long would you continue immunosuppressive therapy?
Although the majority of patients with Human Leukocyte Antigen B27 (HLA B27)-associated recurrent, acute anterior uveitis have some evidence of spondyloarthropathy, this disease does occur sometimes with clinical disease only in the eye. The disease is not usually chronic (i.e., lasting longer than ...
Would you consider using a JAK inhibitor for a patient with RA associated scleritis?
Yes, I have used it before with success when with limited options. I recommend speaking to the MSL from one of the JAKi developers and they can provide the data to make an informed decision or to appeal to insurance if denied.
What would be your approach to a patient with new diagnosis of seropositive rheumatoid arthritis manifesting as a constrictive pericarditis with no joint pain complaints?
This is an interesting clinical scenario. It highlights some of the current issues we face as rheumatologists, namely an atypical presentation of one of our more common diseases. This patient is labeled as having seropositive rheumatoid arthritis yet lacks arthritis features. I suspect the diagnosis...