Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you refer for autonomic testing or manage symptomatically when dysautonomia symptoms complicate chronic musculoskeletal pain?
Great question. Dysautonomia is very common in patients with chronic overlapping pain conditions (e.g., ME/CFS & post-acute infectious syndromes), and it can be disabling. This is more of a clinically salient phenomenon in pt w/ ME/CFS, in my experience, whereas rheumatic patients with RA/SS/SLE, et...
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 ...
How do you counsel families of pediatric patients on methotrexate about live vaccine schedules?
Recommendations on vaccinating children with rheumatic diseases vary and seem to be changing frequently. Many of the ACR's specific timing recommendations are categorized as "conditional recommendations" based on low-to-moderate certainty of evidence, and because of this, they must frequently update...
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...
Do you routinely check HLA-B*58:01 allele status in patients of Vietnamese descent before starting allopurinol?
Of Asian or African American descent
How would you treat active SLE with high level crithidia dsDNA abs and recurrent pleuritis with effusions still requiring corticosteroids despite combination therapy with full doses of mycophenolate, hydroxychloroquine, and Benlysta for over 6 months after no response to Saphnelo for 6 months?
There are no controlled trials of different therapies for treating refractory pleuritis in lupus as the primary manifestation. Due to refractory pleuritis being relatively uncommon, the trials of benlysta and anifrolumab did not have enough patients to assess response. In the literature, there are a...
Would you pursue a kidney biopsy in a patient with stable stage 1 AKI, bland urine sediment, and a positive MPO titer without systemic signs of vasculitis?
PR3-ANCA and MPO-ANCA are associated with substantially higher specificities and positive predictive values for ANCA-associated vasculitis (AAV) than the immunofluorescence patterns to which they usually correspond (C-ANCA and P-ANCA, respectively). However, false-positive results remain a concern. ...
Are there benefits to adding IL5/IL5 receptor blockade in patients with vasculitic manifestations of EGPA?
While IL-5/IL5 receptor blockade has been shown to be efficacious in treating "eosinophilic" manifestations of EGPA, including asthma and nasal polyps, there are real-world studies that demonstrate its effectiveness in what we consider "vasculitic" manifestations of the disease as well. I personally...
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 frequently do you monitor for hypocalcemia in patients on romosozumab?
I do not know the clinical safety data well. In my own practice, I never saw anybody get hypocalcemia. I assume the potential cause of hypocalcemia is the anti-resorptive effect of the drug. Before any osteoporosis drug. I get a good chemistry panel, PTH level, vitamin D level, and when appropriate ...