Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach deciding how long to use Avacopan for ANCA-associated vasculitis?
This is such an interesting question and one that I hope we have more data to guide our management in the future.The ADVOCATE trial used a year of Avacopan, demonstrating that sustained remission was superior in the Avacopan group (66% vs 55%). HOWEVER, the control group received either cytoxan foll...
What biologics would you use in a patient with rheumatoid arthritis who developed multiple basal cell carcinomas requiring Mohs surgery while on a TNF-inhibitor and did not respond to rituximab?
It would be a discussion with the patient about risks and benefits if the RA is well controlled on a TNF-inhibitor. If the patient wanted to switch, I'd consider switching to an IL-6R inhibitor like tocilizumab or sarilumab.
What are your recommendations for perioperative management of DMARDs and biologics in patients undergoing bariatric surgery?
One of the goals of the ACR's perioperative guidelines (Goodman et al., PMID 35718887) was to avoid unnecessarily long interruptions in therapy in the perioperative setting, which increases the risk of disease flares, can lead to increased glucocorticoid use in the perioperative setting (which is as...
What considerations do you take when using prednisone in patients with systemic sclerosis?
We tend to have a very high threshold for using systemic steroids in patients with systemic sclerosis and when we do, we try to limit it to less than 15 mg/day of prednisone. There is no clear evidence that it improves or slows down disease activity/progression even in the very early inflammatory ("...
Would you consider using Evenity in an elderly patient with rate controlled atrial fibrillation without history of MI or CVA?
The cardiovascular safety profile of Evenity is complex and has been reviewed in several publications. The concern is myocardial infarction and stroke. In general, if there is a history of an MI or stroke I would personally avoid Evenity. Although I do not have access to the safety dataset, I am una...
Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?
In general, the risk of HCV flare with immunosuppression in general including rituximab must be viewed as minimal for those who have achieved a sustained virologic response (Undetectable HCV RNA ≥12 weeks after treatment completion) and does not influence my therapeutic decision-making if the patien...
When would you consider a kidney biopsy in a patient with longstanding diabetes and hypertension (baseline creatinine 4-5, 4+ proteinuria) who was recently found to have dsDNA positivity?
Only if something changed clinically, urine protein abrupt increase, hematuria microscopic, increase in trajectory of creatinine, or symptoms suggestive of SLE. I feel bad when I biopsy a diabetic only to find diabetic nephropathy, but if you never find diabetic nephropathy, you aren't doing enough...
What is your approach to screening patients with sJIA for associated lung disease?
There are simple screens for all children with sJIA, including history (e.g. chronic cough, SOB, etc.) and physical exam (e.g. pulmonary exam, clubbing, persistent rash). Basic labs (e.g. hypereosinophilia, hyperferrtinnemia) may also push toward a more thorough evaluation of lung disease (e.g. pulm...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...
How do you guide patients who seek online information about their disease to ensure it is accurate, supports their understanding, and minimizes unnecessary anxiety?
I refer them to reputable sources and away from random online sites. I encourage them to learn more, but caution them on the fact that some sites are extremely biased and may well give them false, skewed, and/or biased information. As I am never quite sure of the disease-specific sites, I use these ...