Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is it safe to use quinacrine in SLE patients with a history of hydroxychloroquine-associated retinopathy?
To my knowledge, quinacrine, an anti-malarial, is not FDA-approved for use in the US. It may be obtained from compounding pharmacies but the FDA makes no assertions regarding either its safety or its efficacy. For lupus, it has been used primarily as adjunctive therapy for cutaneous disease, e.g. ad...
Would you consider re-challenging a patient with rituximab after they experienced delayed neutropenia?
This is an important question as rituximab is a key treatment option across multiple rheumatic conditions. Probably the best study to inform this question comes from Zonozi et al., PMID 32892495 who retrospectively studied 738 RTX-treated patients at a single institution. They found that late-onset ...
What is your threshold to repeat a kidney biopsy in a patient with a history of lupus nephritis who is on maintenance therapy and develops subtle changes in urinary protein excretion or microscopic hematuria?
There have been a number of lupus biopsy and treatment questions here lately. The management of lupus nephritis is VERY difficult with innumerable permutations of past and present, biopsy nuances, symptoms, and treatment histories. The answer to this question depends on more than "subtle changes in...
What is your approach to treatment for MDA5 dermatomyositis patients with rapidly progressive ILD?
Rapidly progressive ILD is a temporal term, describing rapidly declining lung function within weeks (usually defined as 3 months). Therefore, we commonly use this term when the patient is already hospitalized with respiratory failure. The majority of the data stem from Japan and China, where they en...
In a patient with a Factor V Leiden heterozygous mutation but no prior thrombosis, would you consider using a JAK inhibitor for the treatment of spondyloarthritis or rheumatoid arthritis if other options have been ineffective?
1. I'd love to hear others' thoughts who are more versed in thrombotic diastheses and JAKi's.2. The only article I could find assessing this showed no differences between the JAKi arm and the tumor necrosis factor inhibitor arm regarding patients with thrombophilia mutations (Weitz, et al., PMID 363...
How do you approach patients referred for C1-2 pannus/erosions without clinical findings or serologies consistent with RA or CPPD arthropathy?
This is a most unusual clinical scenario. Rheumatologists are taught to image the C1-C2 area in patients with longstanding RA and persistent neck pain with or without accompanying myelopathic features. Therefore, a situation where the patient remains totally asymptomatic is quite uncommon. In addit...
In a patient with bisphosphonate induced bilateral atypical femur fractures, how would you approach timing of alternative osteoporosis treatments and surgical management?
Unfortunately, this is still a very common problem. Although the information that oral bisphosphonates should likely be limited to 5 years duration has been available for many years, my large orthopaedic practice continues to see 2-4 atypical femur fractures per month and often the patient has been ...
What are your management strategies for patients with biopsy proven IgA nephropathy with rapidly progressive glomerulonephritis?
In adults, I believe these patients should be treated similarly to other patients with RPGN. I would start out with high dose steroids, then move to possibly rituximab versus possibly cyclophosphamide shortly afterwards if no response to steroids alone.
What is your treatment approach for a young female who has an idiopathic small right elbow effusion with synovial thickening that has resulted in limitation in her range of motion?
I might aspirate the joint, send for gram staining, cell count, culture, and crystals, check serology to rule out autoimmune like RA or lupus, tick-born disease, and X-ray the joint. If all is negative, consider a short course of steroids, even synovectomy.
What is your preferred add-on for membranous lupus nephritis (2.2 grams of protein, normal creatinine) in a young woman who is currently on hydroxychloroquine and mycophenolate 1500 mg 2x daily?
Persistent proteinuria in patients with any ISN/RPS class of LN is problematic recognizing goal is to achieve EULAR targets of uPCR < 25% at 3 months, < 50% at 6 months, and < 0.5 - 0.7 at 12 months compared to baseline. Proteinuria is renal tubulointerstitium toxic inducing pro-inflammatory and fib...