Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach the management of a patient with strongly positive SSA antibodies and an extraglandular feature such as ILD or peripheral neuropathy, but without sicca symptoms or parotid abnormalities?
The ACR/EULAR 2016 criteria are clear that a patient with a +SSA antibody needs to also have some degree of measurable sicca in order to be clinically diagnosed with SjD. In my experience, many patients may not perceive that they are dry because they have been able to tolerate the symptoms over time...
What would be your treatment approach for a patient with concomitant diagnoses of multiple myeloma and axial spondyloarthritis?
The treatment of multiple myeloma would take precedence in this situation. I would get in touch with the oncologist, ask them about their treatment plans, explain to them how we treat axSpA (NSAIDs, csDMARDs for peripheral manifestations, and biologics, small molecules for axial disease), and then c...
How do you approach treating a patient with RA and cirrhosis who did not respond to csDMARDs?
While cirrhosis patients are considered high risk for infection and related acute-on-chronic liver failure, I would not consider it an absolute C/I for biologics if they have active RA and need escalation of treatment. Data on infection outcomes in cirrhosis patients on biologics is limited. I agree...
Is it safe to continue teriparatide beyond 3 years in a patient with severe osteoporosis and atypical fracture of the femur?
The original label for teriparatide limited its lifetime use to 2 years. Two years is as long as the Phase 3 trial in postmenopausal women had gone when a decision to terminate the trial voluntarily was made by Eli Lilly, due to the finding of osteosarcoma in rats. Thus, the safety data was limited ...
How would you manage active axial spondyloarthritis in a patient with recent (<5 years) solid malignancy who completed chemotherapy?
I wouldn't be too concerned about employing a TNF inhibitor, but the malignancy data for IL-17 inhibitors—and the lack of any black box malignancy warning—are more reassuring. I would probably choose the IL-17 inhibitor unless there is comorbid IBD.
Do you need to hold Humira (adalimumab) during radiation for breast cancer in a patient with psoriatic arthritis?
To my knowledge, there is not a lot of data on the interaction of adalimumab or other similar meds and radiation therapy. I am increasingly seeing this in my practice, however, for patients with psoriatic or rheumatoid arthritis. I discuss with patients that we have limited data on potential interac...
Do you consider immunosuppression in patients with a history of Sjogren's disease and clinical features of inclusion body myositis?
My short answer is no. The phenotype and MRI findings described in this case suggest IBM and recently published consensus criteria for the diagnosis of IBM require only the presence of endomysial lymphocytic inflammation in muscle biopsy as a mandatory criterion, along with supportive clinical pheno...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
Would you consider the use of low-dose naltrexone in patients with fibromyalgia and/or type 2 lupus symptoms?
Yes, I think it is worth trying low-dose naltrexone in fibromyalgia - seems safe and may be effective.
How do you approach management of a patient with a retroperitoneal soft tissue mass and elevated IgG4 level when tissue biopsy is not feasible?
The question of whether to biopsy in presumed retroperitoneal fibrosis is asked in almost every case. The reason for the biopsy is to primarily rule out other causes of retroperitoneal masses, such as lymphoma, infection, and other rare variants. The mildly elevated IgG4 is not very helpful due to t...