Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you avoid combining JAK inhibitors with IVIG given the risk of thromboembolism?
The evidence for this is not very clear and limited. I think a honest discussion about the risk of JAKs and IVIG with the patient will be the most important; but as long as there is no clotting history or high risk of DVTs/PEs, and this is documented, and if a patient needs both medications to attai...
Do you always pursue testing for NOD2 mutations when you are suspecting a diagnosis of Blau syndrome?
Blau Syndrome is a rare, autosomal dominant disease caused by mutations in the NOD2 gene, which codes for an intracellular sensor for muramyl dipeptide which is present in bacterial cell walls. The classic triad is arthritis, uveitis, dermatitis, but other organs can be affected. I do think that any...
Do you always biopsy patients who present with classic skin findings of dermatomyositis?
I actually very rarely perform a skin biopsy to confirm dermatomyositis, much like I rarely biopsy classic psoriasis or classic eczema. Because I see dermatomyositis frequently enough in my practice, most times, I can confidently diagnose it by physical examination alone. I reserve performing skin b...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
How do you taper corticotropin injections (Acthar) in patients with rheumatologic disease?
All rheumatologists will at some point in their career have a patient or two or three who do not tolerate any of the usually available steroids (po prednisone, po methylprednisolone, triamcinolone IM, IM methylprednisolone/dexamethasone, IV methylprednisolone) and who have ongoing active inflammator...
How do you counsel patients on the risks and benefits of an IL-23 agent versus an IL-17A or IL-17A/F agent?
Both IL-17 and IL-23 agents have demonstrated excellent efficacy for psoriasis. Choosing between them often comes down to access and insurance coverage.With that being said, considerations include: Side effect profile: The side effect profile for both IL-23 and IL-17 agents is similar, with the exc...
For patients with VEXAS syndrome and good response to azacitidine, what duration of therapy do you consider?
The short answer: as long as azacitidine is controlling inflammation, reducing/eliminating steroid dependence, and/or improving cytopenias, keep using it. Don't stop (or if the patient is being bridged to alloSCT, continue until BMT).The long answer:VEXAS is an autoinflammatory disease wherein patie...
How would you manage a patient with severe Hurley Stage 3 active, draining, HS who is also currently requiring Rituxan for management of vasculitis?
This case might be best discussed through oral conversation rather than this format, but here it goes.I try hard NOT to combine a TNFi with Rituxan. The additive immunosuppression will significantly increase the risk of severe infection to a level that is uncomfortable for me. I have done similar co...
How do you assess the potential role of obesity in driving inflammatory joint symptoms?
Unlike psoriatic arthritis, obesity has not been observed to be a primary etiological factor in the pathogenesis of RA. Metabolic syndrome is not a risk factor for the development of RA. However, the data supporting a role for obesity as a driver of ongoing inflammation in patients with RA is mixed....
Can Xolair (omalizumab) be safely used in combination with biologics for patients with rheumatic disease?
Ghazanfar & Thomsen, PMID 30132352 The above article addresses combined Xolair and Enbrel. Keep in mind, if RA flares or worsens after starting Xolair, it could be SE as it is well known to have a polyarticular small joint pattern similar to RA. So, the timing of Xolair initiation to RA loss of cont...