Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In a patient with gout previously treated with pegloticase who then discontinued therapy, can pegloticase be safely and effectively restarted?
It depends on the reason for discontinuation of Pegloticase therapy in the first place, since efficacy and safety data varies with it.Pegloticase can be safely and effectively restarted if the initial discontinuation was not due to a loss of efficacy or a severe infusion reaction, and should be done...
What was the rationale for abrupt discontinuation of etanercept rather than gradual tapering in the SEAM-RA trial?
The main goal of this trial was to get RA patients off of therapy and to see whether they would flare or maintain remission. We didn’t expect that the ultimate likelihood of success or failure was going to be primarily related to how long it took to do that. While a gradual withdrawal of the drug ma...
Would you pursue cholestyramine washout in a patient on leflunomide for RA who is experiencing worsening necrotic dental infection secondary to pseudomonas?
I would pursue a BRIEF washout of leflunomide... a single day of cholestyramine, which will reduce blood levels 50%. This was used in the phase 3 trials with good results, e.g., a decrease in blood levels and rapid resolution of related adverse events. There is not a need for the 5 days of washout, ...
Do you think the benefits of performing a repeat kidney biopsy to assess histologic evidence of disease activity or chronic damage outweigh the risks in a patient with recently treated lupus nephritis and improving creatinine levels?
In patients with lupus nephritis who have recently undergone treatment and are demonstrating improved creatinine levels, performing a repeat kidney biopsy is generally unnecessary. The risks associated with the procedure do not justify its benefits unless there is persistent or worsening proteinuria...
What were your top takeaways in Myositis from ACR Convergence 2025?
ACR Convergence had an outstanding selection of myositis offerings, and the number of people attending the sessions reflects the increasing recognition of these heterogeneous diseases, coupled with the frequency that non-myositis specialist clinicians will encounter these entities. The convention pr...
What specific criteria or patient conditions would make you hesitant to use fluoroquinolones early in the treatment course for managing MSSA joint infections with oral antibiotics?
For MSSA joint infections, I have moved away from using FQ to using high-dose cephalosporins as a step-down therapy, particularly cefadroxil 1 g twice daily, given less frequent dosing/increased adherence. Considering the risk-benefit analysis, I prefer using FQ as an oral option in polymicrobial an...
How do you counsel patients with depression about the role exercise may play in alleviating depressive symptoms?
I’m a big fan of exercise for all of my patients, to the point where I have my 5th-degree black belt diploma on the wall of my office next to my undergrad, PhD, and MD diplomas. I tell patients, “That’s up there to say to try and fit in exercise as realistically as your schedule allows, in a way you...
How would you approach rituximab dosing in a patient with SLE-Myositis overlap with LN Class III, now with worsening UPCR and concern for worsening ILD 4 months post induction and incomplete B-Cell depletion on recent labs?
This is a challenging and concerning situation, as the patient is declining after rituximab. Without knowing which other medications have been tried, I would prioritize medications targeting life-threatening manifestations, i.e., the LN and ILD. In that case, I would start treatment with steroids, m...
How would you approach managing a patient with well-controlled RA on abatacept who develops a solid malignancy?
Ok- good question:I would switch to an IL6inhibiton and let oncology do their thing.Make sure they are on Plaquenil too. :)Also, if the patient is going to get traditional chemo - watch and wait, likely the RA will be controlled with blanket immunosuppression of chemotherapy.Petit et al., PMID 39241...
What strategies have you found most effective in improving long-term medication adherence in patients with SLE?
The most important long-term drug to have good adherence to is hydroxychloroquine.Soon after I began measuring HCQ drug levels in all my patients who were not in remission back in 2016, I was shocked at how many were not taking it very well (lived up to the low adherence numbers quoted in the litera...