Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you monitor patients with cutaneous lupus for progression to SLE?
I think it is prudent to check patients with a new diagnosis of cutaneous lupus for any signs of SLE, typically with CBC, CMP, UA, complement levels, and ANA by IFA. If negative, I just screen with review of systems and check labs if something comes up.
Can JAK inhibitors for established rheumatoid arthritis be continued when starting an immune checkpoint inhibitor?
The concern for Jak inhibitors is not whether JAK inhibitors treat immune-related adverse events (irAEs). The issue with JAK inhibitors is that it may allow the tumors to grow. Oncologists are split over this issue and the answer may change depending on the cancer. There are case reports on JAK inhi...
How do you approach management of Adult Onset Still's disease in a patient with ongoing fatigue and inflammatory joint pain despite methotrexate, colchicine, canakinumab and tocilizumab?
There are several considerations for ongoing inflammatory symptoms despite trials of canakinumab and tocilizumab in a patient with presumed AOSD: If the patient has ongoing CRP elevation, a trial of anakinra might be considered if not previously used. The required daily dosing is not as convenient,...
Would you recommend that a patient with stable coronary artery disease and well-controlled RA on a JAK inhibitor continue on their current therapy?
There is no simple answer for this. It is a difficult situation and I would consider a few things in making a decision about what to recommend. These include the course of the patient’s disease, e.g., duration and severity of disease, their current and previous medication history, and the severity o...
How would you manage a patient with diffuse Systemic Sclerosis who develops severe rapidly progressive calcinosis?
Unfortunately, calcinosis cutis is a very challenging and frustrating manifestation of Systemic sclerosis to tackle. When extensive, response to trial of interventions is further unlikely or poor. The primary goal of treatment is to minimize symptoms and alleviate functional limitations rather than ...
Do you consider Anti-carbamylated protein antibodies (anti-CarP) as having any significance in evaluation of patients if RF and ACPA negative and clinically no active synovitis yet widespread arthralgias and generalized osteoarthritis?
Anti-CarP has been touted as another biomarker for early RA with rates of positivity in ACPA and/or RF-negative patients ranging from 4.5 % in a recent study by Ricchiuti et al., PMID 35885566 to 23.6% in the French ESPOIR cohort. Ricchiuti described anti-CarP tracked the most closely with 14-3-3 et...
How will you approach tapering sarilumab in patients with PMR in remission?
Unfortunately, there is no data at the moment to inform decisions about the optimal duration of sarilumab treatment for PMR patients and how to discontinue this medication. The clinical trial that demonstrated efficacy was limited to 12 months and the drug was stopped altogether after that period. N...
Do you continue belimumab throughout pregnancy?
@Dr. First Last: @Dr. First Last is absolutely correct regarding the limitations of our studies regarding using belimumab in pregnancy.However, how much more evidence do we need?No one is going to perform a prospective randomized controlled trial. I and some others I know are feeling more comfortabl...
How do you plan to use canakinumab for the treatment of gout?
I recently had this approved for a gentleman with severe tophaceous gout who does not want to be on allopurinol due to mobilization flares and had anaphylaxis to pegloticase. He has CKD and multiple cardiac comorbidities which limit colchicine as prophylactic agent and difficulty with controlling bl...
Do you avoid tocilizumab in patients with prior bariatric surgery given the risk of GI perforation?
This is an interesting question with no current data to answer it with certainty. However, I personally would feel comfortable prescribing tocilizumab in a patient with an uncomplicated bariatric surgery history for the following reasons. The vast majority of GI perforations in the setting of TCZ oc...