Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you manage a patient with highly active ankylosing spondylitis, iritis and Crohn’s, controlled with weekly adalimumab with co-morbid IgG4RD and intolerance of azathioprine due to elevated LFTs?
There is not a known association between IgG4-RD and IBD or spondyloarthritis. Given that these are rare diseases, it is important to ensure diagnostic accuracy, as the combination of these diseases would be unusual, though not impossible. There are two types of autoimmune pancreatitis: type 1 (IgG4...
In patients with diffuse scleroderma and symptomatic lower extremity venous insufficiency, would you recommend treatment with endovenous laser/ablation?
It all depends on the severity of scleroderma and the severity of the venous insufficiency. No one can give an answer to that without knowing those two things.
Would you feel comfortable adding benlysta to patient already taking both mycophenolate and tacrolimus (and hydroxychloroquine) who still has some evidence of active lupus nephritis?
ABSOLUTELY (if the mycophenolate + tacrolimus combination therapy had had positive benefits on decreasing proteinuria plus was well tolerated thus far)!1. Per the package insert label for indications, "BENLYSTA is indicated for patients aged ≥5 with active systemic lupus erythematosus (SLE) or activ...
How would you manage a patient with SLE that has a remote history of positive anti-phospholipid antibodies with a current DVT and now completely negative APLs?
Assuming the reliability of the lab report indicating negative antiphospholipid antibodies (APL) and the absence of any other manifestations as per the latest APLS guidelines, I generally would not factor a distant history of APL positivity when determining the management of this patient.While the f...
Would you continue Jak inhibitor therapy in a patient with long standing, previously refractory RA in their 60s who was found to have stenosis of the left common femoral artery and no other history of arteriosclerotic disease?
The concern for the use of Jak kinase inhibitors in RA patients over the age of 65 with at least one risk factor for cardiovascular disease comes from the Oral Surveillance Trial published in the NEJM in 2022. It is randomized, open-label non-inferiority study comparing cardiovascular safety (and ma...
Do you advise patients to hold DMARDs for conditions such as psoriasis or rheumatoid arthritis while actively undergoing radiation treatment?
Data in this setting is limited. I have usually not held DMARDs with RT unless treating with concurrent chemo RT or treating a site (pelvis) where myelosuppression caused by RT would further suppression immunity especially with biologics and methotrexate.
Would you intensify therapy in IgG4 related disease based solely on a persistently significantly elevated IgG4 level when all disease manifestations and inflammatory markers have normalized?
While a perfect biomarker does not exist in IgG4-related disease (IgG4-RD), patients who have elevated serum IgG4 concentrations at baseline typically demonstrate a significant reduction of IgG4 concentrations after treatment and with improved disease activity. In patients treated with rituximab, on...
How do you monitor patients with incidentally found high titer anti-smooth muscle antibodies without stigmata of liver disease?
I have quite a few SLE patients with ASMA who do not have any signs of hepatic disease (though I did not do bxs in those with normal hepatic transaminases). They are very common in the general population. I have down in my notes a prevalence of 16%. However, there are studies showing prevalences as...
What treatments have you found most effective for cholestatic pruritus?
My experience is mainly in Sjogren's or Sjogren's with PBC, ursodiol has been effective. Occasionally, I have used hydroxyzine or H1+H2 blockers. In Sjogren's where the skin biopsy has shown significant lymphocytic infiltration, mycophenolate or a calcineurin inhibitor trial has lead to the resoluti...
How long would you wait to start another biologic agent after Rituximab administration in patients with dermatomyositis and refractory inflammatory arthritis (intolerant to traditional DMARDs)?
The time frame between rituximab infusion and initiation of a different biologic agent depends on the severity of the symptoms. In case of life-threatening complications (like RP-ILD), then rituximab could be given simultaneously with an agent like tofacitinib. If the main symptom though is arthriti...