Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you start low dose aspirin for preeclampsia prevention in patients with myositis planning pregnancy?
I generally favor low-dose aspirin for preeclampsia prophylaxis in pregnant patients with idiopathic inflammatory myopathy(IIM), barring contraindications and in collaboration with maternal–fetal medicine. I discuss the plan before conception but typically begin 81 mg daily at 12 weeks’ gestation, i...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
What is your approach to counseling patients regarding re-initiation of anti-TNF therapy after completion of treatment for non-disseminated pulmonary histoplasmosis?
We published a retrospective study on this topic in 2015 (Vergidis et al., PMID 25870331). We concluded that resumption of TNF-alpha antagonist therapy may be considered in individuals treated for histoplasmosis who have no evidence of residual disease and undetectable Histoplasma antigen levels. We...
Do you obtain mycophenolate levels before escalating therapy in patients with extrarenal SLE?
Similar to Dr. @Dr. First Last, I primarily check MPA levels to assess adherence to therapy. Not surprisingly, poor adherence is common due to the high pill burden of taking mycophenolic acid analogs (MPAA). Finding an unexpectedly low level can open that conversation about identifying barriers and ...
How would you approach treatment for a patient with positive C- ANCA/PR3 with sinus/nasal limited disease, but no renal or pulmonary involvement?
The treatment of non-severe GPA varies amongst practitioners because of limited trial data and different practice patterns. 2021 ACR/VF guidelines conditionally recommend methotrexate and glucocorticoids. Rituximab would also be a reasonable option; therefore, I typically favor shared decision-makin...
Would you initiate antifibrotic therapy in a patient with CTD-ILD experiencing worsening symptoms and declining lung function, despite no clear evidence of fibrosis on CT scans?
If the predominant findings on CT were ground glass opacities and/or nodules without any evidence of fibrosis on CT, I would not start with an antifibrotic and, instead, would start with immunosuppression as a first-line agent. Based on the American College of Rheumatology (ACR) and American Thoraci...
How would you approach management of asymptomatic hyperCKemia with + HMG-CoA reductase antibodies and biopsy findings suggestive of immune-mediated myopathy?
As anti-HMGCR antibody testing becomes more common, we are likely to see more false-positive results. Still, most patients with positive anti-HMGCR antibodies eventually require treatment. In the 2017 Johns Hopkins cohort (Tiniakou et al., PMID 28096458), only 4 of 104 anti-HMGCR-positive patients d...
Would you use febuxostat for an African-American patient with gout and previous cardiovascular events (stroke, MI) who tested positive for HLA-B*5801?
Well, I would certainly avoid using allopurinol. The initial CARES trial raised concerns about the safety of febuxostat, using a median dose of 40 mg. The subsequent study FAST did not show any signals of CV disease using a median dose of 80 mg. The internal validity of the study was greater in the ...
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 treatment options do you consider after TNF failure in intestinal Behcet's with ongoing steroid dependence?
Colonic Behcet’s does not necessarily respond the way that IBD does. The evidence base for alternative therapies includes anti-interleukin-1, -6 and anti CD20. Anti Il-12/23 have also been used. Would discuss with a rheumatologist about which options are reasonable, depending on where else there are...