Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is the risk of uveitis flare in patients with JIA and uveitis, who are in remission, when tapering medications?
The ADJUST Trial is in progress and is trying to answer precisely this question for those currently receiving adalimumab. I am not aware currently of a large database to provide a reliable answer to this question. My approach is to require no evidence for active uveitis for at least 12 months, and t...
What is your approach to management of hyperlipidemia in patients taking JAK inhibitors?
The ORAL Surveillance Study published in the NEJM in 2022 was a phase IIIb/IV open-label noninferiority study in RA patients over the age of 50 with at least one cardiovascular risk factor. The aim was to demonstrate that JAK inhibitors were non-inferior in terms of major adverse cardiovascular even...
Do you use the peri-operative management of biologics and DMARDs guidelines, which were mainly based on total hip and knee replacement surgeries, for all peri-operative surgical management?
The American College of Rheumatology Perioperative Guidelines focused on patients undergoing hip or knee arthroplasty. These guidelines can be a helpful starting place when thinking about medication management in patients undergoing other surgeries, but my recommendations for perioperative managemen...
How do you approach the timing of DMARD initiation in patients with active RA who are on treatment for latent TB?
As the patient is already treated for latent TB, if they have not initiated DMARD therapy for RA, I would follow the guidelines and start conventional DMARD therapy. If the patient requires additional therapy because of insufficient response, I would choose a non-TNF inhibitor as the risk for TB rea...
Do you recommend avoidance of vaginal estrogen in patients with SLE?
It depends on the age. The SELENA study demonstrated that BCPs in premenopausal women did not lead to flares or increased disease activity though the risk of increased clotting is an issue for APL+ folks. Post-menopausal women treated with HRT had an increase in mild flares compared to those not on ...
Do you recommend routine use of Evusheld for pre-exposure prophylaxis for patients on immunosuppression?
The use of monoclonal antibodies as passive immunity for pre-exposure prophylaxis is an exciting development for vulnerable patients, including immunosuppressed patients (either primary or through medications such as for autoimmune diseases), cancer patients, and organ transplant recipients. Evushel...
For how long do you recommend treatment for latent tuberculosis prior to initiation of anti-TNF therapy?
Some recommendations call for completing a course of treatment for latent TB prior to starting a biologic but I find most patients and referring specialists are intolerant of that strategy. This reference: Yeo et al., European Respiratory Journal 2014 is a good example of data supporting a shorter w...
When is a biopsy necessary to diagnose relapsing polychondritis?
Since there are no specific lab tests for Relapsing Polychondritis, the diagnosis is based on clinical manifestations. Criteria proposed by McAdam et al. PMID 775252 require three or more of the following clinical features to confirm the diagnosis: Bilateral auricular chondritis Non-erosive, seroneg...
Do you consider immunosuppressive agents in progressive interstitial pneumonias or pneumonitis without a clear driving etiology?
Although it's often helpful to have a clear diagnosis of an underlying connective tissue disease (CTD) or positive autoantibodies to guide therapy (or perhaps feel better about prescribing it), we more often find ourselves dealing with ambiguous cases. When pathology is available to suggest an infla...
Do you recommend treatment of worsening skin thickening with Limited Scleroderma +ANA+centromere and if so with what agent would you use?
There really have not been adequate trials in patients with limited cutaneous scleroderma as far as the effectiveness of medication for 'worsening' skin thickening. In this situation, it is not clear since the patient likely has a long-standing disease, really has worse skin thickening and where is ...