Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you routinely apply the 2010/2011 ACR symptom-based diagnostic criteria for fibromyalgia in your practice, or do you continue to use the 1990 tender point examination to make the diagnosis?
Fibromyalgia diagnostic criteria have been a source of controversy and multiple revisions. Much of this confusion relates to failing to distinguish classification criteria, established to provide uniform criteria for clinical studies, from diagnostic criteria, which rely on expert opinion. Rheumatol...
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 factors lead you to recommend a JAK inhibitor as second-line therapy in a patient with radiographic axSpA who has had a primary non-response to a TNF inhibitor, before trying an IL-17 inhibitor?
This is an excellent question which requires not just a treatment plan but also a revelation of how we should be making patient management decisions in Spondyloarthritis (SpA). My initial reaction is that primary non-response to a TNFi is not the usual story; if this truly happens, I recommend re-ev...
In patients with a history of retinal vein occlusion, how should the risk of recurrent thromboembolic events influence the selection of osteoporosis therapies?
The FDA-approved prescribing information for raloxifene explicitly lists retinal vein thrombosis alongside deep vein thrombosis and pulmonary embolism as contraindications.
Can you use bisphosphonates in a patient with osteoporosis who has had prior avascular necrosis of TMJ due to steroid use?
Due to the rarity of MRONJ, and significantly high fracture risk from osteoporosis, prior history of osteonecrosis is not considered an absolute contraindication for bisphosphonate use. Clinical picture is important is weighing this decision. If the patient is very high risk, anabolic therapy is app...
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 long would you recommend that a patient continues guselkumab prior to deciding that the therapy is not effective?
Many trials have a placebo-controlled period of 12-24 weeks. Thereafter, all patients receive active treatment. Even if the original treatment allocation remains unknown to the patient and doctor, they know that from that moment on, everyone receives active treatment. This will have an influence on ...
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...
Is anifrolumab safe to use in patients with a history of malignancy?
Anifrolumab is not formally contraindicated in patients with a history of malignancy, but I would use it with individualized risk assessment.The United States Food and Drug Administration (FDA) label states that the effect of anifrolumab on malignancy development is unknown and recommends weighing t...
Would you avoid use of JAK inhibitors in patients with dermatomyositis with autoantibody subtypes with increased risk of malignancy (TIF1y, NXP2)?
This is a difficult question to answer with certainty. Most of the direct data on malignancy risk with JAK inhibitors come from rheumatoid arthritis studies, and primarily involve tofacitinib. It is therefore possible that the risk is not the same across all JAK inhibitors, especially since they dif...