Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you extrapolate from uveitis treatment pathways when managing other inflammatory eye conditions such as atypical serpiginous choroiditis?
I do tend to apply these principles. So these entities like serpiginous, relentless placoid, etc., I would consider posterior uveitis. While we definitely do not fully understand the full pathophysiology of all these diseases, there is good evidence of inflammatory activity, hence response to steroi...
What would be your differential for a wrist monoarthritis in an elderly female with erosions on MRI after less than 3 months of symptoms?
I would put CPPD arthritis high on the differential, as the wrist is a common site for CPPD arthropathy in the elderly. In the right context, septic arthritis is a possibility, particularly if the patient is immunosuppressed. Indolent infections such as fungal or mycobacterial are possibilities. Les...
What would you use to treat polymyositis refractory to high dose steroids, methotrexate, mycophenolate, IVIG, and cyclophosphamide?
Refractory polymyositis might be a red flag for an alternate diagnosis, like IBM or genetic muscle disease, especially in the absence of a myositis specific antibody, like SRP or HMGCR (the most common antibodies in PM/immune-mediated necrotizing myopathies). If IIM is confirmed, then a combination ...
Is it safe to treat checkpoint inhibitor-induced arthritis with methotrexate or biologics?
How the safety of methotrexate or biologics compares to long term steroid use to treated checkpoint-inhibitor inflammatory arthritis has not been determined. With that said, steroids can have deleterious effects on the tumor response in addition to all the other known side effects. Therefore, for pa...
What is your approach to bladder cancer surveillance in patients who have received cyclophosphamide?
Risk of bladder cancer following cyclophosphamide treatment can be associated with oral therapy and likely also related to cumulative dose (1). Risk of bladder cancer with intermittent IV cyclophosphamide has been reported in some observational studies, but has not been consistently reproduced (2). ...
Do you follow patients with elevated ESR/CRP if their work-up for rheumatologic etiology is unrevealing and no other cause is identified?
The short answer is yes for most cases. That said, there are many variables. Typically, elevations in acute phase reactants (ARPs) occur in response to different initiating events and can be observed to resolve on repeat testing. Persistent elevations in ARPs in the absence of clinical signs and sym...
How do you screen dermatomyositis patients for malignancy if they have a high risk antibody profile (NXP-2/TIF1gamma positive) and their initial screen is negative?
If an initial screen is negative, including age-appropriate malignancy screening, the need for additional testing in an NXP2 or TIF1 gamma patient would be driven by the clinical presentation and risk factors. An older patient with severe disease (including dysphagia, ulcerations, vasculitis), refr...
What do you use to treat uveitis refractory to conventional synthetic DMARDs and TNF inhibitors?
I would add support to a trial of intravenous tocilizumab, particularly if macular edema is a feature of the uveitis. The STOP-Uveitis trial demonstrated reasonable efficacy in intermediate, posterior, and panuveitis (STOP-Uveitis) and I have used this within my own practice with success in patients...
What are the most effective therapies for CPPD with a "pseudo-RA" pattern?
That is a great question! The short answer is that we really don't know. There are no good quality RCTs for CPPD. In my experience, these patients are quite difficult to manage. I will often start with low dose prednisone (which almost always works) and then search for a steroid-sparing agent. I sta...
What is the safest approach to treating refractory RA in the setting of an active solid organ malignancy?
In order to best treat refractory RA in this patient with active solid malignancy who has failed rituximab, abatacept, and methotrexate, it is critical to understand their malignancy treatment options, prognosis as well as the patient’s goals of care. Traditional chemotherapy in certain types of sol...