Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Which other agent would you consider for a patient with VEXAS who has failed methotrexate, multiple TNF inhibitors, Tocilizumab, and Ruxolitinib?
I would strongly consider referring for hematopoietic stem cell transplant. The NIH/National Cancer Institute has a trial that is currently recruiting:Koster et al., PMID 36251488
In light of the RECITAL study, would rituximab be a reasonable choice in a patient with PL-12 antibodies, rapidly progressive pulmonary disease with organizing pneumonia on biopsy?
The findings from the RECITAL study have confirmed the validity of our clinical approach, advocating for rituximab as the primary treatment for CTD-ILD, considering the elevated risks associated with the use of cyclophosphamide. Therefore, it is entirely justifiable to opt for rituximab in cases of ...
How do you determine osteoporosis treatment response when patients have discrepant DEXA scan results during monitoring (eg improved BMD of the hip and spine but worsening BMD of the femoral neck)?
This is not all that uncommon. The first thing I do is ask if they have fractured since we started the therapy. If not, I relax a little. This is a nice scenario for using bone turnover markers as part of initial work up. If PINP goes up by >10 I am happy that an anabolic drug is working... more you...
Do you avoid ESA use in patients with anemia and chronic kidney disease who also have APLS and risk for thrombosis?
I normally don't. I would make sure the patient is getting anticoagulated if indicated. I don't believe making the hemoglobin closer to normal in the setting of being anticoagulated increases thrombosis risk that much. I would shoot for a hemoglobin goal of 10-11.
How do you approach GI prophylaxis (e.g., PPIs, H2 blockers) in patients on long-term NSAIDs?
Risk analysis is at the heart of all therapies that we prescribe for our patients. Patients on long-term daily NSAIDS are at higher risk for GI symptoms, bleeding, and perforations. These risks can be between 2-4%/per year, and vary based on risk factors such as age, general health, cigarettes, prop...
Does hepatitis B vaccination reduce the risk of HBV reactivation associated with immunosuppressive therapy?
Hepatitis B reactivation is a critical concern when patients are undergoing immunosuppressive therapy, often described as 'deadly but preventable.' Screening for HBV is strongly advised before initiating biologic therapies, targeted synthetic therapies, or high-dose immunosuppression, including HBsA...
What would be your next step in management of a dermatomyositis patient on hydroxychloroquine and methotrexate whose skin is still active?
There are many different options for this kind of scenario. Depending on the physician's preference, patient's lifestyle, and insurance coverage, one could switch to mycophenolate, which seems to be more effective for skin manifestations, or azathioprine. If the patient did have a partial response t...
What immunosuppressive agents would be available to patients with a history of melanoma?
Generally, we try to use conventional synthetic DMARDs when possible. However, studies in RA have not shown an increase in de novo melanoma or recurrence of cancers more generally with TNF-inhibitors. So this is an option for patients with RA and melanoma history who are not responding to csDMARDs. ...
Do you generally prefer to continue hydroxychloroquine in lupus patients who develop ESRD despite the low likelihood of clinically active disease in this patient population?
Yes, I do. In my experience, nephrologists tend to forget or neglect the use of HCQ. HCQ can prevent lupus flare-ups and progression of disease not to mention CV benefits as well as being helpful in addressing APS if present.
How do you treat idiopathic acute anterior uveitis that recurs immediately after a course of topical corticosteroids?
Anterior uveitis has many known causes that include HLA-B27-associated (often with ankylosing spondylitis); viral such as herpes simplex, CMV, or zoster; or as part of a syndrome that includes interstitial nephritis; or as a manifestation of juvenile arthritis. Labeling it acute means that it starts...