Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What do you include in differential diagnosis when evaluating a patient with calcinosis cutis?
When evaluating the patient with calcinosis cutis, I first make sure that the patient indeed has calcinosis cutis. In general, there are two types of ectopic calcifications in soft tissues: metastatic and ectopic. Metastatic calcifications occur in the setting of abnormal. serum calcium and/or phosp...
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...
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 ...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
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...
How often are you repeating screening PFTs in patients with SARDs who have 3 or more years of normal or stable PFTs?
The answer to this question is complex and needs to be tailored to the individual patient’s risk for ILD and the particular SARD.Approximately 30-40% of patients with systemic sclerosis (SSc) will develop ILD, typically within the first 5 years after the first non-Raynaud’s manifestation and rarely ...
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...
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...
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, ...
How long do you maintain patients with anti-synthetase syndrome on Rituximab?
This is a challenging question to address, as there are no evidence-based guidelines, and multiple approaches may be attempted. My practice is that once the patient has been stable for at least 6–12 months, and after discussing the risk of flare with them, I attempt to reduce immunosuppression. For ...