Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
Do you always aspirate effusions in patients with knee osteoarthritis prior to injecting hyaluronic acid?
There is strong biologic plausibility that one should always aspirate an effusion before injecting hyaluronic acid. Even a mildly inflammatory effusion will have an excess of white cells. White cells produce hyaluronidase. Hyaluronidase catalyzes the degradation of hyaluronic acid and renders it ina...
How do you manage a patient with severe RA or SLE that worsens after stopping immunosuppressants due to having chronic foot ulceration?
Fear the foot ulcer! These portals of entry for microorganisms can wreak havoc in immune-compromised patients. Rheumatologists must ensure that these lesions are being properly managed. Since healing can often be prolonged in some of our patients, the decision of whether and when to resume immune su...
Do you consider new onset autoimmune disease (e.g. seronegative rheumatoid arthritis) a few months after completing immunotherapy for cancer to be an immune-related adverse effect to the immunotherapy?
Yes, if there is no other features that suggest there is another etiology for the event. Immune-related adverse events (irAEs) can present after immunotherapy is stopped for at least one year and potentially longer. Consensus guidance (Naidoo et al., PMID 37001909) discusses delayed onset irAEs. If ...
What is your treatment approach for patients with MDA5-positive amyopathic dermatomyositis, who also have anti-CCP positive rheumatoid arthritis but no clinical lung involvement?
What clinical symptom or sign being treated is the key? If MDA-5 autoantibodies are associated with rash but no ILD or myositis, treatment should generally be directed at the skin. This is an active area of study. The presence of anti-CCP+ RA without ILD might prompt the use of rituximab given its p...