Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach evaluation and management of arthralgia in a patient after CAR-T cell therapy?
This is a great question - part of cytokine release at syndrome includes joint pain. So my questions are: How far after? What was the reason for the CAR-T? These are vital questions to understand first. To that be said - the answers will determine if you give a one-and-done treatment or long-term....
What is your approach to working up diarrhea in an immunocompromised patient?
Tough question and very common in clinical and research management. The approach is going to mirror any new complaint and start with a history. Diarrhea means many things to many patients/clinical trial subjects, so characterizing duration, frequency in a day, nocturnal events (diarrhea that occurs ...
Is there a role for hydroxychloroquine for secondary prevention in patients with APS without SLE?
There are no prospective trials to answer this question. In one cross-sectional study (Erkan et al., PMID 12154210) there was a suggestion of a protective effect of hydroxychloroquine. However, patients were also on aspirin and it may be difficult to sort out which of these agents had the protective...
How would you manage a patient with stable axial spondyloarthritis who develops newly active IgA nephropathy?
Although the data are sparse, in general, the principles of treatment of IgAN in the setting of spondyloarthritis is similar to primary IgAN. BP targets <120/80 RAS inhibitors or sparsentan SGLT2 inhibitors If persistent proteinuria despite above, targeted-release budesonide or oral corticosteroids ...
What is your approach for an RA patient with lung cancer who is starting immunotherapy?
How to manage the patient depends on how well controlled their RA is at the start of therapy and what kind of medication regimen they are on for their RA. If they are on csDMARDs and are stable we usually continue the csDMARDs with immunotherapy unless there is an objection with the oncologist (or i...
Do you prefer to taper rituximab by extending the interval between doses or decreasing the actual dose administered for RA patients who have achieved longstanding remission?
My practice has generally been to extend the interval, albeit with careful observation of the patient's clinical status throughout the process. To begin with, my practice is to start with 2 doses of 1000 mg at initiation of therapy, and then a single dose of 1000 mg for subsequent courses of therapy...
What dose and duration of steroid therapy do you use in steroid responsive ILD?
This is an extremely challenging question to answer as "steroid-responsive lung disease" encompasses a variety of formal and informal diagnoses as well as a variety of different clinical scenarios. Additionally, the dose and duration of corticosteroids would depend on patient factors and comorbid co...
Do you find MRI helpful to differentiate early erosive OA from psoriatic arthritis when early X-ray changes in both conditions may be hard to distinguish?
This is a great question to discuss. I do not in general let imaging dictate my decision about a diagnosis but factor it into the entire evaluation. I find the examination in conjunction with radiographs of the hands AND the feet help me sort out many of these issues. Symmetry, distribution, and par...
Do you use apremilast in combination with biologic DMARDs for psoriatic arthritis and/or psoriasis?
I have used apremilast in combination with a biologic in my practice. Monotherapy with biologics is not always effective in relevant treatment domains in patients with psoriasis and psoriatic arthritis. Then the choices are to switch to a different biologic agent, add a traditional DMARD or consider...
How would you approach management of incidentally identified unilateral retinal vasculitis with subsequent labs revealing +P-ANCA?
This anecdote raises at least 3 fascinating questions. First, how do you approach asymptomatic retinal vasculitis? Often a retinal vasculitis is defined by the dye, fluorescein, leaking from a retinal vessel on a study called a fluorescein angiogram. By this definition, pedal edema would be a pedal ...