Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to a patient with well-controlled seropositive RA on abatacept who develops melanoma?
There is evidence to suggest an association between the use of abatacept and melanoma. A recent multinational observational post-marketing study found that compared with other bDMARDs, exposure to abatacept in RA patients was only significantly associated with an increased risk of reporting melanoma...
How do you treat anti-HMGCoA myopathy?
IVIg is a great treatment for anti-HMGCoA antibody necrotizing myopathy. However, traditional treatments like methotrexate, azathioprine, as well as rituximab can be tried. We published a paper on IVIG results on refractory HMGCR and SRP positive patients with excellent results. Kocoloski et al., PM...
When is brain biopsy useful/warranted as part of the diagnostic work-up in patients with suspected primary CNS angiitis?
I have never diagnosed or seen a patient with primary angiitis of the CNS. First, I would ensure that the suspected diagnosis and findings are confined to the CNS and are not associated with a systemic inflammatory disease. If the condition is not confined to the CNS, other areas of the body may be ...
Do you refer all patients with a Beighton score over 5 to genetics for further assessment?
Our genetics clinic does not accept these patients for genetic testing anymore because they are inundated with such requests from patients with plain benign joint hypermobility syndrome. They reject these requests for genetic testing. They accept doing genetic testing only for patients with vascular...
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...