Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are there particular subsets of AAV patients in which avacopan is more effective?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:Patients in the ADVOCATE trial were stratified at entry according to time of diagnosis (new/relapsing), diagnosis (GPA/MPA), ANCA serotype (PR3/MPO), and background immunosuppressive (cyclophosphamide/rituximab) with re...
Do you check mycophenolate levels in patients prescribed mycophenolate who present with a lupus nephritis flare?
In general, I tend to shoot for an induction dose (3 grams) if I am using Cellcept with steroids for a flare, unless I am doing multitarget therapy or there are side effects such as GI symptoms or cytopenias. In those cases, I lower the dose to 2 grams (1000 mg BID). If there is concern for unsatisf...
How do you counsel patients with osteoporosis and cervical spine osteoarthritis who are considering chiropractic cervical manipulation or traction?
I am concerned with the risks of actually causing a fracture or nerve impingement/damage. So, I would recommend against.
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 manage worsening cutaneous dermatomyositis when muscle disease appears controlled?
The fact that the patient still has an active pruritic rash while tapering steroids suggests that the current regimen isn't fully controlling the disease, and it can affect quality of life. I would consider adjusting immunosuppression, either adding another agent or switching therapies. The specific...
In patients with ILD who are started on nerandomilast on top of background nintedanib, what monitoring is most important early in therapy?
While it may seem initially that combining antifibrotics is a bad idea due to side effect profiles, it has, in fact, been done with some success. The INJOURNEY trial combined nintedanib AND perfenidone in patients with IPF, and during the study period (12 weeks), those on combined therapy lost only ...
In patients with inflammatory arthritis (RA, psoriatic arthritis) and a history of MGUS are there any concerns regarding use of biologics?
There is no absolute contraindication to any particular biologic used to manage active RA in a patient with MGUS. The literature does point out a small potential risk associated with tocilizumab in terms of development of myeloma influenced by the IL-6 pathway (and I would tend to extend that potent...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
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...
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?
There is not enough detail in the question to provide a clear answer. Usually, suppression of the hypothalamic-pituitary-adrenal (HPA) axis would take more than just a few days. If someone has been on high-dose glucocorticoids for longer (e.g., two weeks), we would usually discharge the patient on a...