Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you choose between delgocitinib & ruxolitinib for patients with CHE?
Delgocitinib has broader inhibition (JAKs 1, 2, 3, and TYK2 pathways) compared to ruxolitinib and costs twice as much wholesale price, so I prefer to start with ruxolitinib. I view all dermatitis as some combination of irritant, allergic (Th1 and Th2), and microbial (Th17) factors. CHE usually invol...
Should patients starting cyclophosphamide be screened routinely for latent tuberculosis (TB)?
Yes, I think patients starting Cyclophosphamide should be screened routinely for latent TB since CYC is a strong immunosuppressant and increases the risk of TB reactivation. The issue is that CYC is often being considered for life or organ-threatening situations, for which it may not be ideal to wai...
Is there any value in nonspecific inflammation seen on a salivary gland biopsy for making a clinical diagnosis of Sjogren’s disease in a seronegative patient with sicca symptoms (ie. chronic sialoadenitis with focus score 0)?
Unfortunately, nonspecific inflammation is unhelpful. In patients classified as having Sjogren's, the minor salivary gland biopsy will have a focus score of 0 in about 20% (Sharma et al., PMID 31092717). So you cannot rule out Sjogren's with a negative/non-specific biopsy. To meet the 2016 ACR/EULAR...
Would you use TNF inhibitor therapy in a patient with seropositive RA who had optic neuritis as a child without relapse as an adult?
This is a really complex question that doesn’t have a simple yes-or-no answer. It involves interpreting a small and complex literature of immunologic and epidemiologic data, along with my own small experience and judgment. That said, I probably wouldn’t use a TNF inhibitor in a patient like this for...
What studies do you find helpful to determine if an axial spondyloarthritis patient presenting late in the disease course with significant irreversible joint damage may benefit from immunosuppression?
I think this is a very clinically relevant question. While I do not know of any study that specifically examines this question, studies suggest that tumor necrosis factor inhibitors may inhibit long-term radiographic progression and improve functional status. Long-term extension of secukinumab trial...
How do you approach the concept of spondyloarthritis disease activity "burning out" and no longer requiring immunosuppression?
This is a difficult question to discuss academically, as we will have to accept a definition for “burning out,” which may or may not be synonymous with remission or a state that will support drug-free remission. That being stated, the possibility of spondyloarthritis going into remission (no “inflam...
Would you consider belimumab for an SLE patient who has generalized hair thinning, leukopenia (WBC <3), low C3, and markedly positive anti-dsDNA who is otherwise asymptomatic?
Absolutely (with important caveats), now hear me out (I'm sure this will be controversial): HOWEVER, 1st, I NEVER trust my own judgment on the cause of the nonscarring hair loss and automatically blame it on SLE. I've had too many patients who have had non-lupus causes, such as central centrifugal c...
How would you approach management of a patient with classic GCA symptoms, elevated ESR and improvement with steroids, but negative temporal artery biopsy and CTA imaging without evidence of vasculitis?
This is a difficult clinical situation, but one that comes up frequently. In the Olmsted County population-based cohort study, about 14% of patients had a clinical diagnosis of GCA (biopsy negative, imaging negative, or not done, Garvey et al., PMID 34644662).I would want to make sure that GCA mimic...
Does the presence of psoriatic arthritis affect your decision to use an anti-IL-17 or IL-23 drug in your psoriasis patients?
I tend to prefer IL-17s in patients with PsA as an indirect assessment of clinical trials suggests they are more effective than IL-23s (which fits my clinical experience) for PsA. IL-17s are also more effective for axial disease (IL-23s are not very effective in axial disease). If there is a history...
Would you give long term antistreptococcal antibiotic prophylaxis to a patient who presents with features of poststreptococcal reactive arthritis but who also meets criteria for Acute Rheumatic Fever?
Acute rheumatic fever should have prophylaxis. If no rheumatic heart disease, the recommendation is penicillin up to age 21 or for five years after the last episode. If heart disease is present, that recommendation is for life. In the setting of penicillin G benzathine shortage, the only option for ...