Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you stop methotrexate or leflunomide if MCV increases after starting the medication with no other parameters of anemia or leukopenia?
I would take this as a sign that the patient is taking their medication. Pretty common and definitely wouldn’t withhold RA tx for this.
How do you optimize retinopathy screening schedules for patients on hydroxychloroquine while also prioritizing cost-effectiveness?
I'll approach this from the cost-effectiveness standpoint as I agree with Drs. @Dr. First Last and @Dr. First Last on their excellent points.Patients with SLE have remarkably high costs when you add up copays, medications, imaging studies, travel, missing work, etc. Anything we can do to help reduce...
With the increasing availability of biosimilars and their adoption onto payer formularies, how do you approach selection among available biosimilars in clinical practice?
Insurance payers consider FDA‑approved biosimilars to be clinically equivalent. In my experience, selection is ultimately driven by the insurance payer formulary - what you can get for the patient on the time. This can be fleeting and quickly changing at times. Cases can be made for patient experien...
Do you reduce the dose of hydroxychloroquine in patients with skin graying if they are not particularly bothered by this side effect?
1. I would check a trough whole blood HCQ level. Nathalie Costedoat-Chalumeau and her colleagues found higher levels in patients who developed skin pigmentation (Jallouli et al., PMID 23824340), but actual levels were not reported. Petri et al also showed that levels above 1200 ng/mL were associated...
How do you evaluate and manage patients with lupus who are having issues with decreased libido?
Decreased libido is one of several factors contributing to sexual dysfunction for people with lupus and other rheumatology disorders. Although sexual dysfunction is common in our patients, it is rarely discussed during office visits. The first step towards evaluation and management of decreased libi...
What steroid regimen do you typically use for induction therapy in patients with lupus nephritis?
LN initial treatment requires at least three choices: First, initial steroids as pulse methylprednisolone vs. high-dose oral prednisone (e.g., 1 mg/kg/day). Second, if selecting pulse steroids, follow with 1 mg/kg vs. 0.5 mg/kg. And third, double vs. triple immunosuppression from the outset.LN treat...
How would you approach immunosuppression in a patient with well-controlled HIV and RF+ rheumatoid arthritis breaking through hydroxychloroquine with ongoing inflammation confirmed on ultrasound?
There is a reasonable amount of literature on this topic. The consensus is that if ongoing HAART therapy is effective at controlling viral load and maintained, Methotrexate and TNF antagonists are well tolerated; they do not seem to affect HIV viral load. The safety of JAK inhibitors, leflunomide, a...
Are there particular subsets of AAV patients in which avacopan is more effective?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:Patients in the ADVOCATE trial were stratified at entry according to time of diagnosis (new/relapsing), diagnosis (GPA/MPA), ANCA serotype (PR3/MPO), and background immunosuppressive (cyclophosphamide/rituximab) with re...
What strategies have you found most helpful to improve adherence to hydroxychloroquine among patients with lupus?
In my practice, three approaches have been most useful: Make adherence measurable. I routinely check whole-blood hydroxychloroquine levels and review the trend with patients in a nonjudgmental way. This creates accountability and turns an otherwise “invisible” treatment into something concrete that ...
Do you favor obinutuzumab over voclosporin for patients with lupus nephritis and significant proteinuria and a history of non-adherence to medications?
Non-adherence to medications is a common issue in lupus patients, but this can be even more of a concern in lupus nephritis, where the pill burden for patients can be so high. I usually prefer to use intravenous medications for patients who have had difficulty adhering to oral medications in the pas...