Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is in the differential diagnoses for isolated bilateral tarsometatarsal joint erosions in the absence of other clinical or serologic evidence of systemic inflammatory arthritis?
Isolated tarsometatarsal (TMT) joint erosions in the absence of other clinical or serologic evidence of an inflammatory arthritis are distinctly unusual. The usual culprits for erosions at the TMT joints include rheumatoid arthritis, spondylarthritis such as psoriatic arthritis, and erosive osteoart...
Do you recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...
In patients with a history of retinal vein occlusion, how should the risk of recurrent thromboembolic events influence the selection of osteoporosis therapies?
The FDA-approved prescribing information for raloxifene explicitly lists retinal vein thrombosis alongside deep vein thrombosis and pulmonary embolism as contraindications.
How should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...
What factors do you weigh most heavily when choosing between belimumab and voclosporin as part of a triple therapy regimen for newly diagnosed class IV LN?
When I would choose belimumab: If the urine protein creatinine ratio (UPCR) is < 3 gm/gm and if there are significant extra-renal manifestations. In patients with adherence problems with oral medications, especially noting the high pill burden of voclosporin. In patients with severe renal dysfuncti...
How would you escalate treatment for a pediatric patient with CNO with mandibular involvement and only partial response to biweekly TNFi?
If you are convinced of the correct diagnosis, then adding pamidronate to TNFi would be my suggestion. Additionally, you could maximize TNFi dose/interval (e.g., adalimumab 40 mg weekly).
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
Would you consider combination mycophenolate and JAKi in a patient with RA-ILD?
I have minimal experience combining a JAKi with mycophenolate. A patient with RA-ILD whose joints were well controlled with tofacitinib but whose ILD was progressing had MMF added to their regimen by their ILD pulmonologist. Unfortunately, after 4 months, the patient developed significant leukopenia...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...