Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you routinely screen for pulmonary artery aneurysm in patients with Behcet's?
I don't routinely screen Behcet syndrome patients for pulmonary artery aneurysms. They are a rare manifestation of Behcet syndrome; however, some clinical features increase the likelihood of pulmonary artery aneurysms. Behcet patients with thrombophlebitis are at increased risk of having pulmonary a...
How would you approach the use of JAK inhibitors in a patient with stable RA who is now starting treatment for pulmonary MAC infection?
Unfortunately, I would stop the JAK inhibitors, particularly in the induction antibiotic phase. Maybe treating the MAC may improve the inflammation overall and the arthritis. Once a month or 2 of antibiotics you can consider a trial of restart the JAK and see how the lungs do.
Do you ever consider using a higher dose of upadacitinib (30 mg daily) for rheumatoid arthritis in patients who fail to respond/partially respond to established dosing of 15 mg daily?
The FDA-approved dose of upadacitinib (UPA) for the treatment of RA is 15 mg per day. In other diseases, such as psoriatic arthritis (PsA), atopic dermatitis (AD) and ulcerative colitis (UC), higher doses (30mg and 45 mg per day) have been studied and shown to be efficacious and relatively safe when...
In patients with secondary Sjogren's how do you approach screening for lymphoproliferative malignancy?
1. Firstly, I do not discriminate between "secondary" and "primary" Sjogren's disease. There is currently a "Nomenclature Initiative" by the Sjogren's Foundation, led by Dr. Alan Baer, Director of the Sjögren’s Clinic at Johns Hopkins, and Dr. Manuel Ramos-Casals, a Sjogren's expert in Spain. Thus f...
Would you consider using a JAK inhibitor in combination with an IL 23 inhibitor in cases of severe psoriasis, psoriatic arthritis, or axial spondyloarthritis that is refractory to multiple biologic DMARDs?
Differential skin and joint responses in psoriasis, PsA and Axial SpA are not uncommon. Many PsA/PsO experts and scientists have postulated the potential benefit of using combination biologic (perhaps in serial fashion or lower doses of each) to treat these cases where there are suboptimal responses...
How would you treat a patient with active lupus nephritis (class 3/4) who requires PD-1 immunotherapy for refractory metastatic renal cell carcinoma?
This is a complex question and there is a paucity of data to address it. The critical issues are of timing (new onset or existing nephritis, disease activity) and treatment regimen. Given that oncologists will not use checkpoint inhibitors on patients requiring more than 10 mg of prednisone at base...
Where do you place romosozumab in your treatment sequence for osteoporosis management?
I agree. It is very effective as first-line therapy in patients at high risk for fracture. It can also be useful post bisphosphonate therapy. I have used it successfully multiple times to transition patients from long-term Prolia therapy without loss of bone mass.
What is your approach to steroid sparing therapy in patients with suspected CTD-ILD?
It depends on numerous factors: What's the underlying CTD? Has the patient been trialed on immunomodulatory agents before? What's the risk of therapy in this patient? And many others. It's a big topic. To delve into some of the above by bullet point: Most guidance for immune suppression is driven by...
Do you routinely advise patients waiting for a kidney transplant to seek referrals at multiple institutions to decrease waiting time?
If your center is in a region (e.g., California and New York) with long wait time of up to 8-10 years, we routinely advise patients to seek referral at multiple centers with a shorter wait time out of the region if the patient does not have any potential donors.
What is the appropriate management of severe myalgia during atezolizumab infusion?
Immune related adverse events involving the skeletal muscle following immune checkpoint inhibitor therapy include polymyalgia rheumatica (PMR) like syndrome and myositis. Referral to a rheumatologist is recommended for a severe musculoskeletal adverse event. Myocarditis is not addressed in this brie...