Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you switch to bimekizumab if a patient with psoriatic arthritis who is already on an IL-17 inhibitor has breakthrough skin or joint disease?
Yes. An abstract at this year's ACR Meeting (Sood et al., PMID 39182686) showed that patients who had failed secukinumab, ixekizumab, or brodalumab did respond to bimekizumab. Although the study included only 43 patients, it still provides solid evidence for a response.
For patients who do not have access to biologic therapies, what are some csDMARD combination pearls or tips that you have that have particular efficacy in different rheumatologic diseases?
I normally use MTX in RA. I initially aim for 15mg of MTX per week, then split the dose and maximize to 20-25mg/week. In some patients, I use SQ MTX if they have GI problems or are very obese. The addition of HCQ with MTX is better than MTX alone in some patients. I have rarely used SSZ+MTX+HCQ but ...
How would you approach treatment of active axial spondyloarthritis refractory to NSAID in a patient with concurrent autoinflammatory disease on long-term anti-IL-1 therapy?
This is a difficult situation indeed. I would certainly maximize the use of NSAIDs, physical therapy, sulfasalazine for peripheral arthritis/enthesitis, etc. Then I would discuss with the patient the pros and cons of the combination therapy of JAK inhibitor with IL-1 inhibitor. With shared decision ...
What is your approach to differentiating tender spots (as in fibromyalgia) and enthesitis (as in axSpA)?
The tender points in fibromyalgia are not limited to tendon insertion sites but are much more generalized, such as in the middle of the muscles of the neck, shoulders and back. Often tender points in fibromyalgia are found at the costochondral junction and at the lateral epicondyle or other tendons ...
Would you transition a patient with axial spondyloarthritis to a biologic if their axial symptoms were controlled with an NSAID, but they also required a PPI to control dyspepsia/GERD caused by the NSAID?
If the axial symptoms are controlled, I would continue the NSAID and not switch to a biologic agent but I would refer the patient to a gastroenterologist for further evaluation and consideration of alternative treatments for GERD.
Do you start immunosuppression for enlarging pulmonary nodules without symptoms, impaired pulmonary function, or extra-pulmonary disease in a patient with sarcoidosis?
First consider whether further diagnostic workup is necessary, to increase your confidence that enlarging nodules, changing pulmonary function, or extrapulmonary disease is due to sarcoidosis. Sarcoidosis patients have an increased risk of cancer in the early peri-diagnostic period, likely due to th...
How do you approach diagnosis in a patient with inflammatory joint symptoms and isolated bilateral CMC joint erosions on x-ray imaging?
This would be atypical for RA but not totally impossible. CPPD and psoriatic arthritis should be considered. In the absence of other joint involvement, erosive OA, although possible, seems unlikely. Is there a history of trauma or of peculiar activities? Is there evidence of psoriasis on either skin...
How do you interpret elevations in ESR and CRP in the setting of increased BMI?
Increases in BMI (overweight and obesity range) have been shown to be associated with elevated CRP and ESR, with stronger associations shown with CRP specifically. Interestingly, the association between elevated CRP and obesity seems to be stronger in female populations than in male patients.In the ...
How do you interpret a high positive RNP in the setting of a negative ANA and negative sm/RNP?
This is a challenging scenario that we often see in clinical practice with our current multiplex assays. A great reference is the following ACR abstract: Clinical Significance of RNP Antibodies in Diagnosis of Systemic Autoimmune Rheumatic Disease When Detected By Multiplex Immunoassay. As demonstra...
How would you interpret a positive dsDNA in a patient with a negative ANA performed via indirect immunofluorescence?
Another important consideration is the methodology by which the anti-dsDNA antibody was assessed. Most commercial labs use EIA, which is sensitive but not as specific as Farr or Crithidia assays. Many positive EIA results are negative when checked by these more specific methodologies.