Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
How do you decide when to discontinue immunotherapy for primary angiitis of the central nervous system (PACNS)?
I take a multidisciplinary approach with involvement of my neurobiology and rheumatology colleagues for the immunotherapy. PACNS can be relapsing or remitting. So needs close monitoring with radiologic (MRI and MRA high resolution vessel wall imaging or CTA/MRA with CSF studies 6 months and then 1 y...
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...
Can you use leflunomide and rituximab in a patient with both multiple sclerosis and rheumatoid arthritis?
It is rare for a patient to have both diseases, but immunosuppressive therapy can be used for the management of both conditions. A study published in 2021 investigated the use of a combination of rituximab and leflunomide in rheumatoid arthritis (Behrens et al., PMID 33738492). Rituximab has previou...
For patients with eGFR <30 or who are on dialysis who are starting or continuing denosumab, how often do you monitor serum calcium?
For patients on denosumab, I’ve been checking CKD labs including magnesium, and phosphorus about 2 weeks after each dose and repleting with nephrology input when levels are low. What does everyone do in practice?
How do you manage pregnancy associated osteoporosis in post-partum patients with vertebral fractures?
I would make certain that the patient is getting adequate calcium and vitamin D and maintaining a serum 25-hydroxy vitamin D of at least 30 ng/mL. If the patient is breastfeeding, I would not give a bone active medication until breastfeeding has been halted. I would like a lot more information about...
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...
How do you explain the concept of CAR-T therapy and why it may work to patients with autoimmune disease who are interested in pursuing a clinical trial?
In full transparency, I have not personally obtained informed consent from a patient immediately before CAR-T or a related cellular therapy. My center has a highly active immune therapeutics program, however, and I have spoken and written extensively about this area. I also serve on our health syste...
In a young patient who was vaccinated to chickenpox as a child (no previous varicella infection) should the patient receive a shingles vaccine prior to starting Rinvoq?
Yes. The vaccines are different and current vaccine is to prevent zoster for patients who have been previously exposed to varicella or vaccinated for varicella.
In a patient with GCA and underlying cardiovascular risk factors, how do you approach antiplatelet therapy and statin use when starting tocilizumab as steroid sparing treatment?
I don't generally start ASA or other antiplatelet therapy for GCA without reviewing the need (if any) with a cardiologist. Neither the ACR nor the BSR guidelines for vasculitis recommend these drugs for GCA. On the other hand, managing lipids and blood pressure in all cases of GCA is essential. The ...