Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach evaluation and management of a patient with recurrent monoarticular inflammatory arthritis of unclear etiology?
Routine testing will not identify Lyme disease although the WBC count is higher than usual. If the antibiotic does not target B burgdorferi recurrence might mean inappropriate therapy previously. WBC count WAAAY too high for mere trauma or internal derangement. Anything else to suggest psoriasis? Lo...
What is your approach to transitioning an SLE patient from a pregnancy incompatible regimen to pregnancy compatible regimen?
There are no clear data on how to do this. One study (Fischer-Betz et al., PMID 23382355) transitioned patients by reducing the MMF by 500mg/d dosing every four weeks and then stopping MMFo once the patient is down to MMF 500mg/d and adding azathioprine 2mg/kg. In my clinical practice, I taper faste...
What are some of the biggest challenges you run into when patients transition from pediatric to adult care?
Expectations – the pediatric health care system tends to have more resources readily available to assist patients (e.g., social work, child life, psychology, pharmacy) and appointment times tend to be longer. In the adult world, resources may be less readily available and appointment times shorter....
How would you manage a patient with ANCA associated vasculitis who has recurrent flare including pulmonary hemorrhage, persistent MPO antibody positivity while on maintenance rituximab and avacopan regimen even after induction rituximab therapy?
Probably cyclophosphamide but maybe mycophenolate or azathioprine.
Which ANCA vasculitis patients are better candidates for cyclophosphamide rather than rituximab?
Both can be used for induction in GPA/MPA vasculitis. I would use rituximab (RTX) if the patient has previously been treated with cyclophosphamide (CYC) and developed a relapse/flare and in patients who are young and with fertility concerns. In GPA/MPA, I tend to use RTX most of the time for inducti...
What is your approach to the workup for an underlying systemic condition in a patient presenting with retinal vasculitis?
Retinal vasculitis is a frequently misunderstood condition. My colleagues and I have written about it on several occasions such as in Current Opinion in Rheumatology, 2016. Retinal vasculitis is often diagnosed by an ophthalmologist on the basis of vascular leakage in a test called a fluorescein ang...
How do you manage occlusive bilateral retinal vasculitis with isolated lupus anticoagulant positivity?
Although I consider myself an expert on retinal vasculitis, I would often solicit help from a physician with expertise in coagulation, especially if that expertise is related specifically to the lupus anticoagulant. A tremendous part of the treatment strategy depends on the location and severity of ...
What lab markers are helpful for monitoring polymyalgia rheumatica patients on tocilizumab?
Based on the evidence supporting the use of tocilizumab (TOC) for the treatment of GCA, a number of small clinical trials have presented early data regarding its use for the treatment of PMR. Before we all jump on this bandwagon, we should carefully review the rationale for using TOC to treat PMR.Fi...
Would you consider using a TNFi in a patient with a family history of demyelinating disease, in the absence of a personal history?
No contraindication based on family history of MS that I am aware of. One could consider MRI head to rule out radiologically isolated syndrome, as a biomarker of risk.
How long do you maintain patients with anti-synthetase syndrome on Rituximab?
This is a challenging question to address, as there are no evidence-based guidelines, and multiple approaches may be attempted. My practice is that once the patient has been stable for at least 6–12 months, and after discussing the risk of flare with them, I attempt to reduce immunosuppression. For ...