Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to long term lab monitoring for Sjogren's disease activity?
I do routinely monitor my Sjögren disease (SjD) population with labs. The frequency usually ranges from 3-6 months and depends on risk for moderate-severe SjD and for lymphoproliferation. Generally, risk is higher for patients with higher ESSDAI (systemic disease activity scores) and those with high...
How would you treat a recurrent endometrial cancer at the vaginal cuff that was initially FIGO 1A with no adj treatment, in a patient with actively treated scleroderma?
I would favor brachytherapy alone using MRI based planning with either a multichannel or hybrid applicator. Dose 6 Gy x 6 to CTV and higher dose (hot spots) to GTV.
How do you manage a patient with cervical cancer who has FDG uptake in bilateral ischial tuberosities with lytic areas on CT correlate, and also has a history suspicious for untreated polymyalgia rheumatica with chronic symptoms in the same anatomic locations?
I would be very interested in the opinion of a rheumatologist regarding the etiology of the lytic disease in the ischial tuberosities. A decision should be made on whether to biopsy one of these lesions. My suspicion is that it is unrelated to cervical cancer, but that possibility needs to be consid...
Do you wait until serum anti-GBM antibody titers are undetectable before hospital discharge in a patient with anti-GBM antibody disease with renal involvement who is receiving daily plasmapheresis, cyclophosphamide, and steroids?
If such a patient is responding to treatment, titers are declining, is otherwise doing well, and does not have extra-renal issues that would require hospitalization, for example, an ongoing oxygen requirement for lung involvement, they could be managed as an outpatient if pheresis can be arranged. I...
What aspects on history and physical exam could help differentiate genetic muscular dystrophy from immune-mediated myopathy?
Great question, and one that comes up all the time in clinical practice. Unfortunately, the question gets a little bit complicated because of the heterogeneity of the musculodystrophies, metabolic myopathies, and neuropathies that can mimic myositis (not to mention the phenotypic variation between t...
How do you determine duration of therapy for patients who have responded well to voclosporin therapy?
Determining the duration of therapy for patients who have responded well to voclosporin therapy in lupus nephritis involves several considerations, including patient-specific factors, disease activity, and risk of relapse. Here is a suggested approach:The duration of therapy is determined by the ren...
Do you typically screen every patient with headaches after the age of 60 with ESR?
I would not. Many patients will have elevated ESR because of other conditions (for example, chronic kidney disease). The history is going to be key in determining which cases to send for lab testing.
How will you use tocilizumab in the treatment algorithm for SSc-ILD, given its recent FDA approval?
I am excited that we finally have evidence for an effective therapy to treat SSc- ILD. Scleroderma is among the most challenging diseases facing the rheumatologist and over the years we have failed in our efforts to identify potentially effective treatment options for patients, especially those with...
What is your preferred regimen for remission induction and maintenance in EGPA with cardiac involvement?
Cardiac involvement in EGPA is associated with a poor prognosis and is an independent predictor of mortality. Therefore, it needs to be treated aggressively. Depending on the study, between 15-30% of EGPA patients present with or develop cardiac manifestations. The manifestations are highly variable...
Do you continue biologics in sJIA patients who develop lung disease on anti IL-1 or anti IL-6 therapies?
It really does depend. If a child is otherwise doing well, stopping cytokine inhibitors can worsen the underlying disease precipitously, putting the child at risk. More often than not, in my experience, at the time that lung disease is discovered, the treatments are not controlling the underlying di...