Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
In a patient with gout previously treated with pegloticase who then discontinued therapy, can pegloticase be safely and effectively restarted?
It depends on the reason for discontinuation of Pegloticase therapy in the first place, since efficacy and safety data varies with it.Pegloticase can be safely and effectively restarted if the initial discontinuation was not due to a loss of efficacy or a severe infusion reaction, and should be done...
How would you apprach a SLE patient who is planning pregnancy on hydroxychloroquine with a high titer dsDNA who cannot tolerate azathioprine and whose only symptom is arthralgia?
In an SLE patient planning pregnancy whose only clinical manifestation is arthralgia, hydroxychloroquine monotherapy is appropriate. During the pregnant and non-pregnant state, additional immunosuppression is not indicated for a high titer dsDNA; rather, monitoring for organ manifestations is approp...
How would you approach evaluation and management of a patient with chronic arthralgias and bilateral hand weakness who has a positive ANA (1:160) and low-titer anti-SSB positivity, in the setting of otherwise negative ENA panel, normal inflammatory markers, normal complement levels and immunoglobulins, and unrevealing EMG/NCS testing?
The low titer SSB/La antibody would only factor into the consideration of SjD if there were other suggestive features, like documented hypo salivation and/or high ocular staining score, neuropathy, etc. Would learn when they were totally well and what potential triggering events may have occurred. I...
Do you routinely check morning cortisol before discharging a patient who received more than 3 days of high-dose corticosteroids during a hospitalization for an acute illness?
No. In general, persistent HPA suppression does not occur when a single steroid treatment is shorter than 2 weeks.
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 is in the differential diagnoses for isolated bilateral tarsometatarsal joint erosions in the absence of other clinical or serologic evidence of systemic inflammatory arthritis?
Post-traumatic injury is the most common cause, especially mid-foot sprains and fractures, although not usually bilateral unless there is a predisposition such as high arches and osteoarthritis (OA) that can occur due to mechanical stress. Erosive OA can cause these findings, although more commonly ...
What factors do you consider when deciding to treat IgA nephropathy with immunosuppression in a patient with cirrhosis, given the possibility that IgA nephropathy could be secondary to cirrhosis?
Proteinuria is the most important factor here. If there is significant proteinuria (>1 g/d) and no other clear reason for it, I would treat the IgA nephropathy with immunosuppression. Secondary IgA due to cirrhosis is usually not associated with significant proteinuria.
For a patient with suspected post-streptococcal reactive arthritis who does not meet criteria for acute rheumatic fever and has a normal echocardiogram at presentation, do you prescribe 1 year of antibiotic prophylaxis?
This is a loaded question. Post-Streptococcal reactive arthritis (PSRA) plagued me during my fellowship (many moons ago). There is a fine line between PSRA and rheumatic fever (RF). We rarely see RF in the United States anymore. If I'm convinced it is PSRA and not RF (e.g., RF migratory arthritis qu...
What steroid regimen do you typically use for induction therapy in patients with lupus nephritis?
LN initial treatment requires at least three choices: First, initial steroids as pulse methylprednisolone vs. high-dose oral prednisone (e.g., 1 mg/kg/day). Second, if selecting pulse steroids, follow with 1 mg/kg vs. 0.5 mg/kg. And third, double vs. triple immunosuppression from the outset.LN treat...