Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is the difference between P155/140 and TIF1-γ antibodies on the ARUP myositis panel?
TIF1g is the name of the protein itself, whereas "p155/140" refers to the IP (immunoprecipitation) finding of 2 distinct bands at 155 kDa (TIF1g) and 140 kDa (TIF1a), indicative of an anti-TIF1g antibody response. Until recently, ARUP (like most commercial laboratories) used immunoblotting, as it is...
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 ...
How do you approach anticoagulation in a woman with SLE who is planning pregnancy, has persistently positive isolated anticardiolipin IgA and anti-β2 glycoprotein I IgA antibodies and a prior history of a provoked DVT after prolonged air travel?
Such a patient with IgA isotype APL antibodies would not meet EULAR – ACR classification criteria for antiphospholipid syndrome. However, there is evidence that IgA anti-Beta 2GP1 can be pathogenic. Therefore, this patient can meet less stringent disease classification and be considered a candidate ...
What dose of methotrexate do you typically continue to prevent antibody formation when adding infliximab for sarcoidosis?
Infliximab is a chimeric molecule that contains approximately 25% murine protein, so it can be immunogenic in some individuals.Development of anti-infliximab antibodies (ATI) has been reported in various autoimmune diseases treated with infliximab.Around 10 to 50% of individuals with rheumatoid arth...
How long would you recommend that a patient continues guselkumab prior to deciding that the therapy is not effective?
Many trials have a placebo-controlled period of 12-24 weeks. Thereafter, all patients receive active treatment. Even if the original treatment allocation remains unknown to the patient and doctor, they know that from that moment on, everyone receives active treatment. This will have an influence on ...
How do you decide whether to continue hydroxychloroquine in a young patient who develops subretinal neovascularization with no other risk factors?
Hydroxychloroquine (HCQ), an anti-inflammatory and immunomodulatory agent, is used to treat autoimmune diseases (rheumatoid arthritis, lupus, Sjogren’s disease, etc.) and malarial prophylaxis. Vision problems can ensue resulting from these deleterious irreversible effects of HCQ on retina if the cum...
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...
For patients <65 with significant intermittent steroid exposure who otherwise do not have risk factors for osteoporosis, when, if ever, do you recommend considering DEXA screening?
The FRAX guidelines recommend answering "Yes" for glucocorticoid use when a patient has received the equivalent of prednisone ≥5 mg daily for more than 3 months. However, many patients with rheumatoid arthritis have been treated with intermittent courses of corticosteroids over several years, which ...
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 ...
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...