Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there a minimum work-up necessary in patients with an ANA greater than 1:160 and no clinical symptoms suggestive of lupus (i.e., specific antibodies, UA)?
My personal practice has been to get the "ANA subtypes" and a UA for prot/Cr ratio, but I do this with the idea of needing to have a complete picture. Clinical symptoms are still king.
What is your approach to evaluation in patients who present with erythromelalgia?
Erythromelalgia is a tough condition to treat. I usually break it down into diagnostic workup and treatment as follows: Diagnostic workup: I usually just get a CBC yearly to look for myeloproliferative disorders. Treatment: I have not had a lot of luck with topicals being too effective, so I usuall...
When do you begin antifibrotic therapy for a patient with newly diagnosed ILD that is not IPF?
The evidence behind starting anti-fibrotic therapy for non-IPF ILD is largely based on the results of the INBUILD trial where patients who have non-IPF ILD who demonstrate progression (based on at least a 10% decline in FVC or a 5% decline in FVC with worsening symptoms or radiologic progression) ha...
If you have clinical suspicion for a paraneoplastic process (e.g. dermatomyositis or pemphigus), what work-up do you pursue?
This continues to be a topic of high interest. The first-ever evidence and consensus-based recommendations were recently drafted by an expert international committee under the auspices of the International Myositis Assessment and Clinical Studies (IMACS) group (in preparation). These recommendations...
How would you approach potentially tapering maintenance mycophenolate mofetil in a patient with a history of class IV LN that has been in remission for >5 years?
I would tell her, absolutely, and I'm sorry I did not consider this 2 years ago after being in remission for 3 years. ;-) I then proceed to explain the options and make a shared decision-making process. CHOICE 1 (my recommendation): A significant enough lupus nephritis patients are not in true patho...
What is your approach to further workup, monitoring, and treatment of Sjogren's syndrome patients with positive cryoglobulins but no clear signs of vasculitis?
Sjogren's disease patients who have cryoglobulinemia should have a thorough examination including a neuro examination to evaluate for vasculitis. Laboratory evaluation should include urinalysis, creatinine, and urine protein to creatinine ratio to evaluate for renal involvement. Serum and urine immu...
When would you consider using G-CSF in patients with rheumatic disease who have received cyclophosphamide?
Our primary concern would be our patients with systemic lupus erythematosus. There are reports of severe flares in SLE patients treated with G-CSF (vasculitis and nephritis; Vasiliu et al, PMID 16832843) and even reports of cardiac arrest (Ragsdale & Hall Zimmerman, PMID 34748466).Of course, this ne...
Do you recommend uric acid lowering therapies for asymptomatic hyperuricemia in chronic kidney disease?
There is conflicting literature about what to do with elevated uric acid levels in CKD patients. In my practice, I do usually treat high uric acid level over 10 even if asymptomatic. I definitely give allopurinol earlier if elevated uric acid levels and history of kidney stones, even if they are not...
How do you approach hypocomplementemia in Sjogren’s without features of lymphoma?
Low C3 and/or C4 support immune activity. Therefore, I look at all domains that SjD can potentially affect for further clues. Low complements in SjD are associated with systemic disease activity (Ramos-Casals et al., PMID 24162151). Low C4 may suggest a more severe disease (Pavlakis et al., PMID 223...
How would you approach medication de-escalation in a patient with a history of rapidly progressive CTD-ILD who responded to and is currently on mycophenolate 3 grams daily and IVIG 2mg/kg monthly infusions and has been stable for two years?
This is an excellent question with the very little data to go by. We spend most of our time studying escalation of therapy and very little time discussing de-escalation. It has been my experience as a rheumatologist for almost 37 years that many autoimmune diseases initially can be quite immunologic...