Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you increase the hydroxychloroquine dose to more than 5 mg/kg/day in a compliant patient with active non-organ threatening lupus (skin+joints) if serum hydroxychloroquine is not at goal until you reach an acceptable concentration?
Absolutely! Thanks for asking as this should be the trend in dosing.However, let's call this "non-life threatening lupus" instead of "non-organ threatening".Cutaneous lupus is one of the top reasons for the poor quality of life in lupus patients (Klein et al., PMID 21397983), so remission is our goa...
When would you administer the next maintenance dose of rituximab in a patient with ANCA glomerulonephritis who last received an infusion six months ago and has low immunoglobulin levels and an undetectable CD-19 cell count?
If an ANCA vasculitis patient is in remission and has no infections, I usually in clinical practice do not check Immunoglobulin levels or CD19/20 levels either. They should only be done in patients with recurrent sinus infections or Pneumonia. If the patient with recurrent infections has low Immunog...
How do you approach restarting cDMARDS/bDMARDS in a patient with active RA after incidence of disseminated CNS VZV infection while on tofacitinib?
This is a complex problem for which any response clearly is not data-driven. Disseminated VZV is a profound illness and is linked to JAKi exposure. While the majority of VZV is 'mild' all complications are increased in this setting and dissemination is among the most serious and potentially fatal co...
After completing 12 months romosozumab, what is the next best treatment option for patients with severe osteoporosis, high risk for fracture, and normal kidney function?
Zoledronic acid is my clear-cut first choice in this setting.
What features on CTA/MRA are most helpful for differentiating large vessel vasculitis from atherosclerosis?
While calcified plaque is not typically mistaken for large vessel vasculitis, distinguishing non-calcified atherosclerotic lesions from large vessel vasculitis is challenging. An experienced vascular radiologist is an invaluable resource in such situations if available. The first step is to assess ...
How do you approach biologic initiation in patients with inflammatory arthritis and repeatedly indeterminate Quantiferon?
This is an unusual but anxiety-inducing situation. Remember that an "indeterminate" Quantiferon is not an "intermediate" Quantiferon. It's not half-positive, it's uninterpretable. The result provides absolutely no reason to be more or less concerned that the patient has lTB, latent or otherwise. I a...
How do you approach the treatment of indeterminate UIP on HRCT with grossly positive MPO antibody and no other features consistent with AAV?
We see these patients in our combined ILD/Rheumatology and would treat with immunosuppressive therapy. The indeterminant UIP is likely NSIP although UIP is not an uncommon pattern seen in these patients. ILD can be the presenting manifestation in ANCA-ILD in 14-85% of ANCA vasculitis patients depend...
What is your approach for disease activity monitoring in patients with sarcoidosis?
Disease activity monitoring is useful in managing therapy and prognostication in sarcoidosis. Since the disease activity can vary across different organ systems, it can be a challenge. Broadly, good bio-markers of overall disease activity are lacking in this disease.ACE level lacks the sensitivity b...
Is it safe to continue administering Prolia per schedule for osteoporosis treatment shortly after a patient has undergone extensive spinal surgery?
There is no evidence that spine surgery is a contraindication to receiving Prolia. If the bone was incised, Prolia could help healing.
What is your approach to maintenance treatment in a patient with Sjogren's who received rituximab for mononeuritis multiplex?
The data supporting the use of maintenance DMARDs, in this scenario, is limited. On the other hand, there is some evidence that relapse is common. Therefore, agents such as Azathioprine, MFM or maintenance Rituximab, should be considered, akin to the management approach for ANCA vasculitis. Managing...