Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 a patient with biopsy proven statin associated immune-mediated necrotizing myopathy who previously responded well to methotrexate but now presents with recurrent proximal leg weakness and rising CK/aldolase levels after several years of stability, what would be your preferred next-line treatment strategy?
That's an excellent question. I would approach this as a probable disease flare, after excluding potential triggers such as statin re-exposure, including over-the-counter supplements (e.g., "natural" cholesterol-lowering mushroom products that may contain statin-like compounds). In that setting, I w...
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.
In a patient with high +SSA antibodies and distal renal tubular acidosis (RTA), but without sicca symptoms or other systemic features of Sjogren's, should immunomodulatory therapy with hydroxychloroquine or azathioprine be considered in an effort to reduce subclinical tubular inflammation and prevent progression of renal disease?
Renal disease can occur as an initial manifestation in the absence of sicca in SjÓ§gren’s disease (SjD) patients (Goules et al., PMID 31464673). This is important to realize for other systemic manifestations of SjD (e.g., cystic lung disease, tubulointerstitial nephritis, radiographic nephrocalcino...
How do you interpret treatment response in the DISCOVER-2 Trial when patients were allowed to remain on up to 10mg of prednisone equivalent for disease control while on guselkumab?
The dependence on the use of systemic glucocorticoids may indeed be a good reason to change treatment. Especially in patients with psoriatic arthritis. So, if patients are unable to stop systemic glucocorticoids and there are still treatment options for the patient, this could be tried. It is diffic...
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 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...
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. ...
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...