Questions discussed in this category
Pre-treatment troponin was mildly elevated, while ILR2 receptor, ACE, CRP, ESR were normal.
I'm uncertain why both individual parts can be so low/negative but together very positive. Is there an assay discrepancy, a false positive?
For example, baseline QT prolongation, elderly age group, or underlying heart disease?
Do anabolic agents have a role?
Are you aware of any data regarding relative risk of molluscum contagiosum infection in reference to DMARDs/biologics?
Are there any clinical trials underway to study additional therapies?
SLE manifestations include arthralgias and cytopenias which are stable. Previously did well on methotrexate, but developed GI side effects. HCQ is on ...
Would you view this as a sign that disease is not adequately controlled despite labs and imaging suggesting no active vasculitis?
Do you use them sequentially or together?
Labs with normal PT, but prolonged PTT (47 sec, ULN 40 sec) that does not correct on immediate mix. Lupus anticoagulant negative (DRVVT and hexagonal ...
For example, is captopril dialyzable?
Do you monitor patients with CTAs or MRAs?
Do you generally recommend anti-diarrheals, dietary modifications, or consider this an unacceptable side effect and move to other therapies?
UpToDate recommends Hydroxychloroquine for all SLE patients, but neutropenia is sometimes ascribed to HCQ rather than the underlying disease. What lev...
The patient has ongoing inflammatory arthritis despite methotrexate, apremilast, and jak inhibitor trials.
Can nodular scleritis be a presenting manifestation of GCA?
Caplacizumab is not FDA approved in pregnant patients, but has been used safely in isolated case reports.
Do you use TNF-i or MMF?
The index question is: "neurosurgeons lately want to stop hydroxychloroquine prior to spinal surgery. Anyone allowing this for lupus patients and for ...
If a patient has received a kidney transplant for SLE-LN and is stable and doing well. Managed by their transplant team and on chronic immunosuppressi...
Is this managed as CTD-ILD with immunosuppressive +/- anti-fibrotic agents?
Would you be comfortable combining a TNFi with Rituxan in this patient?
The case prompting the question is a female in her late teens who was diagnosed with Class IV LN at her prepubescent age and was treated with HCQ and ...
Is there any concern for drug interactions of DMARDs and/or biologics with anti seizure medications?
What factors do you discuss when counseling the patient?
E.g., a patient with newly diagnosed CIDP who is wheelchair-bound.
Is a biopsy or EMG helpful in confirming the etiology? What is the best treatment for sarcoid neuropathy?
Vasculitis involving aorta, subclavian, common carotid, SMA, IMA, renal artery, and celiac artery.
How do you counsel patients in this scenario?
Normal Vitamin D, bone scan showed osteoarthritis
How does the presence of extra-renal manifestations influence this decision?
Would you push for biopsy before deciding on treatment?
The patient is already on hydroxychloroquine.
And have you ever seen it occur in isolation without any other manifestations of SLE?
CT changes are subsolid and ground glass nodules.
Do you discontinue HCQ?
When do you switch to steroid-sparing medications? What steroid-sparing therapies do you prefer?
Do treatments for osteoporosis have a large enough effect on tooth movement to make Invisalign less effective?
When do you decide to hospitalize?
The patient has no extraocular features of a spondyloarthropathy and is on methotrexate. No active eye disease for past 1 year.
No evidence for acromegaly or Pagets.
This question is part of a collaboration with RheumMadness and is specifically in reference to: ULT During Gout Flare.
The patient is actively breastfeeding.
In which situations or patient populations do you find this useful? How is it sterilized?
How do you monitor response and what do you consider a satisfactory response? Do you aim for a certain threshold of proteinuria?
Many patients are interested in romosozumab for "maximizing bone gain" and preventing future fractures. Some have had anabolic therapy with teriparati...
What side effects do you highlight in conversation with them? How do you approach toxicity monitoring?
Is there utility when classic inflammatory markers (ESR,CRP) or disease specific markers (C3, C4, dsDNA) do not correlate with patients disease activi...
Patient is with past history of glomerulonephritis in remission after rituximab for the past 2 years. +MPO/P-ANCA
Do you ever start mycophenolate without steroids?
MRI with muscle edema but biopsy pending. Would you consider this overlap myositis even though muscle enzymes are normal?
Would it be safe to resume and if so, when?
For example, I have a patient who has frequent (monthly) large to medium joint flares (Knee, Ankle) with crystal proven disease. Did not tolerate colc...
Thrombocytopenia is moderate (80-100,000 microL). No concomitant cytopenias present.
Specifically, do you check for any of these: ACE, Vitamin D 1,25, serum lysozyme, soluble IL2 or Adenosine deaminase levels?
For example, the patient may have other findings such as an elevated CRP. Would you diagnose SLE, or would you want to see other serologies or finding...
Is a BM biopsy a must when there is skin involvement?
If tryptase level is mildly elevated but less than 20 would you recommend a BM biopsy?
How long has it been back on the market? What is the typical cost for patients? Are certain compounding pharmacies regularly carrying it?
And how would you monitor response?
After replacing Vitamin D, what will be your first treatment of choice? Labs including ALP and calcium levels are normal. T scores are -3 or above. Th...
How would you work up an elderly female with persistent anemia secondary to warm AIHA requiring almost monthly transfusion, with positive ANA,dsDNA (b...
Do you refer all patients with suspected LN, patients with confirmed LN, or patients with specific features (not responding to usual therapy, certain ...
IgG4 manifestations include autoimmune pancreatitis and periaortic soft tissue mass.
What disease activity index do you find more useful and most practical in a busy clinical setting? How often do you assess it?This question is part of...
Do you add low-dose mycophenolate to use in combination with Rituximab in these patients?
How do you approach ongoing screening for TB in patients with history of treated latent TB, but have ongoing use of DMARDs and/or biologics given quan...
A male patient in his 30s with two lumbar compression fractures (non-traumatic) and a Z-score of -2.6 in the spine, Z-score -0.5 in hips. History of 3...
For example, when switching from MMF to azathioprine, do you overlap the treatments as you lower the dose of one and add the other?
Patient with negative blood cultures, completed 6 weeks of IV antibiotics and vegetation persists. CT imaging without evidence of malignancy. No evide...
How has this impacted your counseling and management?
Given poor pulmonary outcomes in people with anti-PL12 antibodies, would you recommend more aggressive therapy? The patient was diagnosed with onset o...
Is an MRI necessary to diagnose non-radiographic axial spondyloarthritis?
Would you still plan for lifelong anticoagulation in this scenario?
Is there a role in temporal artery biopsy?
Would you start with a baseline ultrasound and then pursue further workup such as fibroscan if fatty liver is present, or other?
This question is part of a collaboration with RheumMadness and is specifically in reference to: Antibodies Before SLE.
Would you use with DMARDs/biologics or monitor?
Do you consider pulmonary hypertension related to sarcoidosis to be an indication to start steroids?
Do you use biomarkers or PET scanning to stratify patients who may benefit most from therapy?
ANA patients referred to rule out CTD is a work-intensive, costly referral type. If they are positive for Anti-Dense Fine Speckled Protein 70 kDa (DFS...
For example, in patients who are HbSAg negative, anti-HBc positive and HbSAb negative, does vaccination reduce reactivation risk?
Low EF in the range of 30%
The patient is on mesalamine for Crohn’s and CellCept and HCQ for skin manifestations (currently on hold during workup). The infectious workup i...
This question is part of a collaboration with RheumMadness and is in reference to Pathogenic ANCA (RAVE Trial).
PMID 35939577
Do you obtain serial cardiac PET scans?
How should IVIG and either biologic injections or infusions be spaced?
The patient has not responded/has contraindications to apremilast, colchicine, and adalimumab. When they were off azathioprine for 5 days in the past,...
And when do you consider (if ever) IGRT?
(Refractory to mycophenolate, azathioprine, and methotrexate. UpToDate suggests thalidomide or IVIG with mixed efficacy, while there are some case rep...
If so, would you start immediately or wait for the second set of labs to confirm before initiating blood thinners?
Per 2021 GCA Vasculitis Guidelines: low evidence, but conditional recommendation for CTA neck, chest, abd/pelvis. Is anybody following this or do you ...
Additionally, is it correct to assume that IV therapies might be preferred vs oral treatment given alterations in GI absorption in PLE?
Patient became acutely flushed, developed severe and prolonged hypotension with brief loss of consciousness, dizziness, nausea, dry heaves and headach...
Do you typically push for myocardial biopsy in this case?
Significant history of autoimmune diseases and DVT in family, recent PE/DVT for a month
And if so, what is your approach to the diagnosis?
Patient is asymptomatic. Labs showed +P-ANCA 1:160. Negative MPO and PR3.
Vasculitis activity has been assessed with serial CTA of the chest and head/neck. She has existing right axillary artery disease and new areas of invo...
Female patient in her 20's with RA/SLE has been on steroids and methotrexate, currently on HCQ and Orencia. Failing Orencia with active disease. Want ...
A specific example would be a clinically quiescent but serologically active patient.
How would you treat? Would you view tocilizumab as an option in the future?
How do you approach de-escalation or justify therapy maintenance? Do you have tiers of medications that you attempt to de-escalate first? In one parti...
Nonreliable INR, given hepatic coagulopathy
ANC <500
Is there a certain disease duration or age beyond which you taper immunosuppressive treatments?
In patients with CKD, does urate lowering therapy have an effect (positive or negative) on progression of CKD?
Extrapolating from reactions with other sulfa medications potentially causes flares.
Do you do blood work? Or do you rely on review of systems?
What doses of allopurinol do you use, and how frequently do you titrate the dose?
(C3 just below normal, C4 undetectable)
Patients on baseline mycophenolate and azathioprine were excluded from the INBUILD trial however many patients with CTD-ILD will be on some form of im...
The ADVOCATE trial only studied use for 52 weeks.
Also how would you manage this perioperatively?
In addition, what formula do you use to calculate the IgG index?
Do you rechallenge with lower dose? What is your tolerance for mild persistent transaminitis?
Would you proceed with CABG procedure or treat the aortitis first?
How is this entity distinct from other secondary HLH entities?
Do you typically start the patient on hydroxychloroquine?
What work-up do you perform?
Other manifestations improved (renal function has stabilized, fatigue, arthritis, and LCV have resolved). Ophthalmologist has controlled the uveitis u...
The patient has no known history of autoimmune disease.
A female in her 50s with iatrogenic Cushing's Syndrome presenting for management of SLE with low disease activity (but not remission) in the setting o...
Do you base the decision on FEV1, 6MWD or symptoms at initial evaluation, or progression over time?
There are studies that show hydroxychloroquine inhibits autophagy (the orderly degradation and recycling of the contents of the cytoplasm for the cell...
In what cases do you discontinue the medication?
When adding nintedanib what sort of treatment course do you counsel the patient on? Do you plan to continue it indefinitely as long as the patient tol...
Do you prefer to start with nintedanib and then add immunosuppressive agents, or give a trial of immunosuppressive medication first, then add nintedan...
Classically, lupus mouth ulcers are large non-painful blisters at the roof of the mouth. What do you do with small scattered blisters, painful or not ...
For example, a patient with a bone marrow biopsy that shows normocellular bone marrow. Prior management with leflunomide and HCQ with neutropenia attr...
Are there any instances where you would prefer a biosimilar rather than the reference product?
Patient with sacroiliitis on imaging, failure of two NSAIDs.
Are there ways to overcome barriers in insurance coverage of this combination of treatments?
Is there a role for immunosuppressive medications such as TNF inhibitors in the management of IgA nephropathy in this setting?
Would the etiology of the thrombocytosis play a role in your decision-making?
I get a lot of low false positive ds dna (sometimes high- 300) in quest and labcorp but their crithidia specific dsDNA labs when repeated are ne...
This question is part of a collaboration with RheumMadness and is specifically in reference to: Hydroxychloroquine Withdrawal.
In a patient for whom rituximab is the best option for their disease management.
Is there a role of rituximab therapy over repeat cyclophosphamide? (Cyclophosphamide induction 2 years prior)
If a deficiency is present, do you consider IVIG to treat non-infectious symptoms such as skin rash, arthritis or hematological abnormalities?
Several speakers at ACR 2021 commented on the important role of drug levels in the management of these patients and cautioned against adding medicatio...
Patient failed topical ocular therapies, methotrexate, azathioprine.
Do you wait 12 weeks for confirmation to begin treatment if patient is declining?
What would you suggest to help address these disparities in our own practices?
This question is part of a collaboration with RheumMadness and is specifically in reference to: EMBRACE
Is SLE-related APLS managed differently in terms of anticoagulation?
When would you consider tapering? at one year? 18 months?
Although testing was not indicated, what do u do with these results?
Other hypercoagulability work up negative
Patients frequently mention diagnosis of SLE years ago but recent Sm, dsDNA (crithidia) and complements can be normal. Can treatment with medications ...
At what CD 19/20 level do you redose? Is this lab dependent?
Do you also use these levels to instruct patients when to get vaccinated?
Would the answer differ if the index event was arterial vs venous?
And if so, are the target levels similar?
MPO/PR3, P-ANCA negative. IgG4 normal.
When it seems fairly certain that this is a drug effect is it something that can just be monitored or requires a change in approach?
If work-up is sent and the patient is found to have a persistently positive antiphospholipid antibody, particularly lupus anticoagulant, would you con...
Currently on nonwarfarin therapeutic anticoagulation
If so, is there one type of antibody that is more likely to cause this false positive test?
Would the checkpoint inhibitor still work if blocking only that portion of the inflammatory cascade as opposed to more global blockade with steroids?
What is the risk of pregnancy loss in absence of anticoagulation? What would you suggest if the patient had anticoagulation in prior pregnancies and r...
Such as patients with negative Hepatitis B surface antigen and negative viral load but with positive hepatitis b core antibody.
Do you just use antibiotic prophylaxis if therapy is started prior to meningococcal vaccination?
Are there any medications that surgeons like discontinued before their procedure?
What are your primary and secondary agents?
When would you de-escalate therapy?
When would you consider referral for lung transplant?
Is it time limited since it may have been triggered by the pregnancy or is it indefinite since it is APLS associated?
Would you obtain imaging? If so, what type of imaging?
I.e., what constitutes well-controlled cancer, IBD, nephrotic syndrome, etc. What other diseases do you put in this category (obesity, autoimmune dise...
Is there a role for monitoring for relapse or increased disease activity as opposed to scheduled dosing?
In contrast to TNF inhibitors for psoriatic arthritis, which seem to peak and maintain response percentages, the DISCOVER-2 Trial (McInnes et al., PMI...
Does your evaluation hinge on nonresolution with warming? How extensive is your workup?
In clinical practice continued steroid dependence is often seen as a reason to switch therapy and providers can be especially hesitant to use systemic...
Based on the results of the DISCOVER-2 Trial (McInnes et al., PMID 34719872), should guselkumab be used prior to anti-TNF therapy in these patients?
Is there role for IVIG? Would you alter the dose or time course of steroid therapy?
(assuming that the malignancy evaluation has been completed and the lymphadenopathy is confirmed to be reactive)
How do you interpret elevations in antiphospholipid antibodies that are lower than Sapporo criteria?
(e.g. beta 2 glycoprotein IgM > 20 but <40)
In your experience, are there specific disease manifestations in which HLAB51 is particularly helpful?
How would the approach differ if the patient had a significant bleeding phenotype vs only minor bruising and mucosal bleeding?
This type of etoposide sparing therapy has been previously described in a case series at https://pubmed.ncbi.nlm.nih.gov/32725881/
Other than inflammatory markers and following symptoms/exam, do you need any other specific monitoring for progression to systemic disease?
If so, how long after diagnosis do you do so?
Does treatment with B-cell depletion and/or negative anti-spike antibody status despite COVID mRNA vaccination influence your decision?
Would you suggest switching to a viral vector vaccine, such as J&J?
Preference for low dose steroids vs attempting colchicine?
Do you routinely check IgA anticardiolipin and beta-2 glycoprotein antibody IgA in your practice? And how would a positive result change your manageme...
e.g. DITP from eptifibatide after a cardiac intervention
How does this vary from continued disease monitoring?
i.e. obstretric APS without thrombosis or SLE
Additionally, what is the current role for temporal artery ultrasound in workup for GCA?
Specifically, how do you treat the delayed headache, not the headache that develops during the infusion where pre-hydration and slowing down the rate ...
Are there implications of reducing urate too much?
Would chemotherapy be preferred over RT?
Specifically in patients of Vietnamese background? An association has been shown between HLA-B*5801 and the risk of allopurinol hypersensitivity react...
Do you obtain vascular imaging routinely in these cases, and if so, do you use cross-sectional or invasive angiography?
What if the patient is triple-positive or has continued seropositivity on repeat lab testing? What is the appropriate interval of monitoring and does ...
Thoughts on sarilumab vs methotrexate, or just treat with steroids alone
Small study in pediatric PACNS have evaluated this as a potential marker (Cellucci et al., PMID 22740622)
While low-dose aspirin for primary thrombosis prevention in aPL without APS is not typically recommended outside cardiovascular prevention guidelines ...
In other words, do we think of TNFi induced lupus and TNFi induced psoriasis as a drug effect or a class effect?
Do you avoid due to the increased risk of GI adverse events?
Do you use imaging (fibrosis vs. pneumonitis), PFTs, duration of prior immunosuppressive therapy?
There are multiple difficulties that could be seen: steroids can precipitate a sickle cell crisis, vasculitis and sickle cell can produce similar clin...
There is some emerging evidence that there is an inflammatory component.
Would you change rituximab maintenance dose or schedule?
Specifically, do you reach for Rituximab or cyclophosphamide?
The case I am considering involves a patient with biopsy-proven fibrosing dacryoadenitis.
Do you follow the 2019 EULAR Guidelines that SLE patients with asymptomatic, positive aPL should be on low-dose ASA?
E.g., inflammatory polyarthritis or inflammatory myopathy with onset within 2 weeks of documented COVID infection
ADVOCATE trial
If so, how would positive levels guide your management?
How is your approach to treatment different than other ILD patterns such as NSIP? Does treatment response vary based on underlying CTD?
In the ADVOCATE trial, patients were not re-dosed with rituximab.
E.g., MPO vs PR3, newly diagnosed vs relapsed, renal involvement. Acknowledge that the ADVOCATE study was not powered to detect these differences, but...
Especially in a triple-positive patient with an acute ischemic stroke who may have urgency for anticoagulation with high bleeding risk and severe thro...
For example, healthcare workers who require these vaccines for employment
Given the slow recovery of nerve damage, what would you expect to see on a repeat EMG after treatment? Continued denervation or just sequelae of past ...
What if the patient has MGUS?
Do patients with type 1 cryoglobulins need a bone marrow biopsy as part of the work up?
Are IL-17 or IL-23 inhibitors helpful?
Can axSpA affect the spine without affecting the sacroiliac joints?
How would you label such a patient?
Would you treat differently if they have poor functional status?
Do you stop methotrexate or adjust the dose?
Cyclophosphamide/tacrolimus and Rituximab have been used in conjunction with steroids in case series.
If so, are there specific patient populations for which you would use this metric?
Does the type of cardiac involvement impact this choice?
If so, does this have clinical significance?
To my understanding, sm/RNP should also be positive in this situation (and one would assume a positive ANA as well)
How do you counsel these patients about hormonal agents?
Did the recently published BLISS-LN trial change your practice?
What if this was "triple-negative" antiphospholipid syndrome?
In patients refractory to NSAIDs and sulfasalazine
If you use both, how do you decide which to use for a particular patient?
This question is part of a collaboration with RheumMadness and is specifically in reference to: ADIRA Diet
The SENSCIS trial was published in 2019 on efficacy of this agent. However, it's not clear where this should be in the treatment algorithm: Monot...
Is IO related pneumonitis in the radiation field or more diffuse?
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