Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
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...