Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach management of a patient with ESRD on the transplant list who is found to have high titer APS labs (ACL, B2GP1, LAC)?
This is an excellent but rather complex question. Management of patients with ESRD on the transplant list who are found to have high titer APS labs (ACL, B2GP1, LAC) depend on the renal histology, underlying autoimmune disease history, and comorbidities. Patients with thrombotic manifestations resul...
How do you approach weakly positive PL-7 antibody in a patient who initially presented with muscle weakness, rhabdomyolysis and non specific muscular edema on MRI that resolved with IV fluids?
During an episode of rhabdomyolysis, muscle MRI isn't reliable since it would be positive regardless of the underlying cause. So, monitoring the trajectory of CPK levels and serial muscle exams to evaluate for weakness would offer a more reliable assessment for true myositis. Positive antibody resul...
What dose and duration of steroid therapy do you employ while starting mycophenolate in an outpatient with relatively stable CTD-ILD?
This is a great question since it raises some important concepts about treatment response in this patient population. Providers often talk about the presence or absence of a steroid-responsive process, and if so, whether a steroid-sparing agent would be beneficial. My bias is to avoid steroids in an...
Do you check the Duffy-null phenotype before starting azathioprine and in which patients?
I personally do not check the Duffy antigen prior to starting azathioprine. I do check TMPT levels on all patients prior to starting it to help determine initial dosing.
How do you approach management of ILD in the presence of weakly positive RF and ANA but no other objective systemic findings of connective tissue disease?
This issue comes up frequently in our combined ILD/Rheumatology clinic and my pulmonary colleagues are typically looking at me for an answer as to whether I think the biomarkers are relevant to the patient's ILD. Low-level ANAs and RFs are not uncommon in the general population and can result in ove...
In a patient with SJIA who has been stable on Anakinra however is now planning to conceive or becomes pregnant, would you consider switching to Cimzia?
As a medpeds rheumatologist who specializes in pregnancy, would ask you to please not switch this patient's medication.Cimzia will not control the systemic aspects of the sJIA. Flaring is dangerous, particularly in pregnancy, can trigger MAS, and may lead to needing systemic steroids or even needing...
What role do you see for JAK inhibitors in RA treatment strategies given the data we now have regarding CV and cancer outcomes?
The outcomes of the ORAL Surveillance study (Ytterberg et al., PMID 35081280) will surely affect guideline recommendations as they have already led to changes to the FDA-approved labels of all JAK inhibitors approved for the treatment of RA, which now state that they are indicated for patients who h...
Would you uptitrate methotrexate dosing when a patient flares on a TNFi and methotrexate 15 mg weekly?
For mild to moderately low flare of disease, I would up-titrate methotrexate if no history of prior adverse effects at higher doses in the setting of normal renal function and no other medical comorbidities of concern. Many authors would still consider optimized dosing of methotrexate to be 20 to 25...
Would you recommend avoiding use of bimekizumab in patients at higher risk of fungal infections such as patients with diabetes who are on SGLT-2 inhibitors which also increase the risk of fungal infections?
At this point, I do not see this as an issue. The increased risk seen with IL17 inhibitors is overwhelmingly oral candidiasis and not candidiasis elsewhere, or other fungal infections. In the clinical trials, this risk seems to be higher with bimekizumab than with secukinumab or ixekizumab, which ma...
How do you approach interpreting a low titer dsDNA (such as crithidia 1:40 to 1:80) in the setting of a moderately elevated ANA without other specific features of SLE?
Serologies are not a diagnosis nor are they diagnostic. This patient does not NOW have lupus. Are there first-degree relatives with SLE? Does this patient have any other autoimmune disorders like Hashimoto thyroiditis? What to do? Follow-up and education. Routine follow-up and welcome phone calls to...