Rheumatology&nbsp;&nbsp;&nbsp;

What is your approach to treatment of airway involvement, such as recurrent bronchial stenosis, in relapsing polychondritis?

Are there specific immunosuppressive agents effective for this manifestation?

How do you approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?

Do you use TNF-i or MMF?

Is there any benefit to checking serum viscosity in patients with autoimmune disease and headaches/migraines to see if aspirin or clopidogrel may be beneficial?

SLE, APLS, Sjogrens, and RA can sometimes have associated serum hyperviscosity. Is the standard viscosity test sensitive enough for these conditions a...

Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?

How would you approach management of a patient with seropositive RA and UIP-ILD, with concern for active lung disease?

Joint symptoms are stable on Hydroxychloroquine. Is there benefit of adding methotrexate or Rituximab for lung disease? CT of chest with predominately...

How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?

Renal perfusion scan shows 14 % perfusion on affected side.

How do you approach management of recurrent idiopathic pleuropericarditis?

How do you approach new onset idiopathic intracranial hypertension (IIH) with someone who has history of systemic lupus erythematosus? Would you consider this to be neuropsychiatric SLE (NPSLE) manifesting as IIH?

How do you approach someone with a history of SLE that has been well controlled for decades on CellCept and Plaquenil, who develops dizziness with a w...

How do you approach the significance of +RNP III antibody in a patient with positive ANA but no other signs or symptoms of systemic sclerosis?

No history of malignancy. No Raynauds.

How do you approach management of bone marrow involvement in sarcoidosis?

Patient with mild cytopenias, but not requiring transfusions and no infection issues. Non-caseating granulomas on bone marrow biopsy.

Is it safe to continue azathioprine in a patient with severe bilateral panuveitis (thought to be related to sarcoidosis) and benign ethnic neutropenia, given worsening neutropenia since starting the medication, or should an alternative immunosuppressive agent be considered?

Patient with a history of presumed benign ethnic neutropenia: PMN 1.5 prior to azathioprine and 1.2 after starting. The patient has an intolerance to ...

What is your treatment approach when managing patients with relapsing lupus nephritis who previously achieved remission with mycophenolate and steroids?

Would you initiate antifibrotic therapy in a patient with CTD-ILD experiencing worsening symptoms and declining lung function, despite no clear evidence of fibrosis on CT scans?

CT changes are subsolid and ground glass nodules.

How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?

Patient with +ANA 1:2560 for >10 years; rest of serologies are negative. Complements are normal. Negative dsDNA. Antiphospholipid labs are negative...

What are some immunosuppression regimens to consider in a patient with refractory cardiac sarcoidosis?

In a patient with sicca symptoms and SS-B antibodies only, can a minor salivary gland lip biopsy with lymphoid aggregates, but also scattered areas of acute neutrophilic inflammation be consistent with Sjogren's Disease?

Lymphoid aggregates consistent with Sjogren's Disease, but current criteria suggest that if the minor salivary gland lip biopsy has neutrophilic foci,...

What treatment options would you consider for a young patient with limited mobility, low bone mass and multiple vertebral compression fractures who is on dialysis for advanced kidney disease?

What is your approach to the management of shrinking lung syndrome in SLE?

Young woman (20s) with history of active lupus for 3-4 years. Serologies/Labs include +ANA, +dsDNA,+ RNP, + Smith, hypocomplementemiaManifestations i...

When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?

Is there any utility in ACE levels and/or IL-2 levels in the diagnostic work-up of cardiac sarcoidosis?

How do you interpret small joint effusions seen on ultrasound without power doppler signal in the setting of compatible inflammatory symptoms (i.e morning stiffness)?

What is your approach when surgeons want to stop hydroxychloroquine prior to surgery?

The index question is: "neurosurgeons lately want to stop hydroxychloroquine prior to spinal surgery. Anyone allowing this for lupus patients and for ...

Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?

For example, would you consider this method in an ESRD/HD patient with antiphospholipid syndrome who had a major bleed requiring reversal of warfarin ...

Would you consider the use of an anabolic agent to promote fracture healing?

Can anti-cardiolipin or anti-beta-2 glycoprotein antibodies cause prolonged PTT in the absence of a lupus anticoagulant?

Labs with normal PT, but prolonged PTT (47 sec, ULN 40 sec) that does not correct on immediate mix. Lupus anticoagulant negative (DRVVT and hexagonal ...

Do you continue TNF inhibitors in patients with a new diagnosis of CLL?

Patient with long standing history of HLAB27 associated uveitis on adalimumab and new diagnosis of CLL.

Do you recommend initiating immunosuppression and plasmapheresis in patients with dialysis dependent AKI in the setting of anti-GBM disease who do not have pulmonary involvement?

How do you screen rheumatoid arthritis patients for lung disease (modality, frequency, patient selection)?

This question is part of our collaboration with ACR Convergence 2024 to Continue the Conversation from the meeeting. This question was inspired by the...

What is the interpretation of an IGRA with positive TB wells and negative nil and negative mitogen wells?

A patient on meloxicam for LBP developed high, persistent fevers and no other symptoms. An IGRA, among many tests, was sent. The IGRA’s mitogen ...

Can lupus anticoagulant be positive despite a normal aPTT?

How often does this occur and does this lower your suspicion for a "true" or clinically significant lupus anticoagulant?

Is it ever safe to use a biologic DMARD in a patient with RA who is on suppressive antibiotics due to a history of septic prosthetic arthritis?

In patients with diffuse scleroderma and symptomatic lower extremity venous insufficiency, would you recommend treatment with endovenous laser/ablation?

The patient has tried conservative measures with compression stockings.

How would you approach the treatment for patients with renal-limited ANCA vasculitis who have persistent proteinuria, hematuria, and ANCA titers and have completed a steroid taper and received three doses of rituximab?

How would you treat an asymptomatic patient with a positive Blastomyces antibody, evidence of prior granulomatous lung disease on imaging, and who may require immunosuppression in the future?

Do you always perform salivary gland biopsy to confirm the diagnosis In patients with suspected seronegative Sjogren's syndrome?

What is the clinical significance of a low titer RNP, negative Sm, but Sm/RNP that is very high titer?

I'm uncertain why both individual parts can be so low/negative but together very positive. Is there an assay discrepancy, a false positive?

How do you determine which patients with ANCA associated vasculitis may be good candidates for reduced dose glucocorticoid tapering?

This question is part of our collaboration with ACR Convergence 2024 to Continue the Conversation from the meeeting. This question was inspi...

What specific criteria or patient conditions would make you hesitant to use fluoroquinolones early in the treatment course for managing MSSA joint infections with oral antibiotics?

For example, baseline QT prolongation, elderly age group, or underlying heart disease?

How soon after starting treatment for Takayasu arteritis do you decide on the need for any vascular interventions to manage chronic damage?

Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?

How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?

Pre-treatment troponin was mildly elevated, while ILR2 receptor, ACE, CRP, ESR were normal.

How would you manage a patient with Takayasu arteritis controlled on TNFi who develops erythema nodosum that is only partially responsive to NSAIDs?

Would you view this as a sign that disease is not adequately controlled despite labs and imaging suggesting no active vasculitis?

How do you approach the management of patients with suspected membranous lupus nephritis who are found to have positive PLA2R antibodies?

How soon after starting treatment would you repeat imaging in patients with Takayasu to monitor response and ensure you have the correct diagnosis?

Do you monitor patients with CTAs or MRAs?

Would you accept the diagnosis of SLE on the basis of an AVISE CTD panel where the results just showed a positive EC4d or BC4d, positive ANA>1/80 + one clinical criteria such as multiple tender joints but did otherwise not fulfill criteria for SLE?

What is your approach to differentiating RA-ILD from medication toxicity (I.e. from methotrexate)?

How do you approach evaluation and management of a patient with recurrent monoarticular inflammatory arthritis of unclear etiology?

Synovial fluid analysis: cell count >100,000, > 80% neutrophils. Gram stain, cultures (including fungal and mycobacterial), synovial biopsy, and...

Do you generally prefer to continue hydroxychloroquine in lupus patients who develop ESRD despite the low likelihood of clinically active disease in this patient population?

How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?

Do you generally recommend anti-diarrheals, dietary modifications, or consider this an unacceptable side effect and move to other therapies?

For patients with SLE, is there an ANC level for which you would hold or adjust hydroxychloroquine in an asymptomatic patient?

UpToDate recommends Hydroxychloroquine for all SLE patients, but neutropenia is sometimes ascribed to HCQ rather than the underlying disease. What lev...

How would you approach management of nodular scleritis in the setting of suspected GCA?

Can nodular scleritis be a presenting manifestation of GCA?

How long do you treat retroperitoneal fibrosis with immunosuppression?

What imaging do you use to monitor disease activity? Imaging only shows chronic, fibrotic lesions making it hard to assess disease activity.

What is your approach for steroid dosing for patients with ANCA vasculitis on induction treatment with rituximab, avacopan, and glucocorticoid therapy?

Should the age at which patients transition from pediatric to adult care differ depending on the disease diagnosis?

What nuances do adult rheumatologists need to understand about pediatric diseases?

How do you approach management of ILD in the presence of weakly positive RF and ANA but no other objective systemic findings of connective tissue disease?

Is this managed as CTD-ILD with immunosuppressive +/- anti-fibrotic agents?

In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?

How often do you see bony erosions in patients with Lyme arthritis?

How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?

7 Answers available

How would you approach the workup and management of a young patient with recurrent biannual non-scarring oral ulcers and new onset neurologic symptoms with associated CNS white matter lesions concerning for Behcet’s?

How do you approach use of DMARDs and/or biologics for inflammatory arthritis in patients with a history of seizure disorder on anti-epileptic medications?

Is there any concern for drug interactions of DMARDs and/or biologics with anti seizure medications?

Do you send CSF or serum ACE levels in the workup of neurosarcoidosis?

If not, are there any serum or CSF tests you consider to be helpful?

When would you consider using G-CSF in patients with rheumatic disease who have received cyclophosphamide?

Do you start immunosuppression for enlarging pulmonary nodules without symptoms, impaired pulmonary function, or extra-pulmonary disease in a patient with sarcoidosis?

What is your approach to DVT prophylaxis in patients who require IVIG but are at increased risk for thrombotic events?

E.g., a patient with newly diagnosed CIDP who is wheelchair-bound.

How do you workup patients with neuropathy suspected to be secondary to sarcoid?

Is a biopsy or EMG helpful in confirming the etiology? What is the best treatment for sarcoid neuropathy?

What would be your recommendation for treatment of worsening lung disease in a patient with long-standing scleroderma after long-term mycophenolate therapy which is no longer an option due to side effect/intolerance?

Which fracture sites outside of the classical spine and hip are considered to be osteoporotic fractures even in the absence of a bone density diagnosis?

Do you continue methotrexate in patients with inflammatory arthritis who develop non-melanomatous skin cancer while on therapy?

In patients with sicca symptoms and positive SSA/SSB how often do you perform other diagnostic testing such as salivary gland ultrasound, biopsy, Shirmers, ocular staining, stimulated salivary flow, etc?

Is the diagnosis of Sjogren's mostly clinical in a patient with a consistent history and physical with positive serologies?

How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?

How would you approach the workup and management of isolated inflammatory subglottic stenosis in a young previously healthy patient that is steroid responsive with a completely negative serologic autoimmune workup?

Would you push for biopsy before deciding on treatment?

How do you manage arthritis resulting from deferiprone in transfusion dependent thalassemia?

How do you approach management of new onset ILD in a patient with RA who is otherwise well controlled on methotrexate or leflunomide?

How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?

What is your threshold to repeat a kidney biopsy in a patient with a history of lupus nephritis who is on maintenance therapy and develops subtle changes in urinary protein excretion or microscopic hematuria?

What is your approach to managing pyoderma gangrenosum recalcitrant to oral steroids?

When do you switch to steroid-sparing medications? What steroid-sparing therapies do you prefer?

7 Answers available

Is there a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients?

Would you switch azathioprine to a different immunosuppressant if a controlled patient with SLE develops melanoma and/or non-melanoma skin cancer?

How do you approach the treatment of indeterminate UIP on HRCT with grossly positive MPO antibody and no other features consistent with AAV?

How do you approach the workup of clinically diagnosed cutaneous vasculitis in healthy young individuals without systemic symptoms?

How do you approach the work up of pulmonary artery aneurysm in the absence of other clinical features of Behcet’s?

Do you find HZV titers useful in diagnosing shingles sine herpete?

How would you approach a patient with anti-scl70 ab positive sine scleroderma complicated by ILD who also has seropositive RA with active arthritis?

Arthritis did not respond to HCQ.

What is your approach to progressive calvarial hyperostosis found in an elderly adult not caused by Pagets, acromegaly or hypercalcemia?

No evidence for acromegaly or Pagets.

Given the risk of hypocalcemia in dialysis dependent patients treated with denosumab, what is the best method of treatment for osteoporosis for these patients, and should we be transitioning to a different agent?

What features on CTA/MRA are most helpful for differentiating large vessel vasculitis from atherosclerosis?

What is your approach to differentiating tender spots (as in fibromyalgia) and enthesitis (as in axSpA)?

How do you approach work up for underlying rheumatologic disease in patients referred for chronic urticaria?

When would you consider utilizing bone scintigraphy in the assessment of inflammatory arthritis?

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?

Are there certain surgeries (including orthopedic) that you recommend continuing biologic DMARDs?

How would you approach management of a patient with rapidly progressive systemic sclerosis with worsening skin disease, myositis, arthritis, dysphagia and failure to thrive developing within 6 months?

The patient is a young African American female of reproductive age with positive Fibrillarin antibody and nucleolar antibody. No ILD.

How do you approach restarting cDMARDS/bDMARDS in a patient with active RA after incidence of disseminated CNS VZV infection while on tofacitinib?

How do you approach treatment of a patient with active RA and a history of Lynch Syndrome?

Does your choice of DMARD/biologics change due to increased risk of malignancy?

Do you consider Anti-carbamylated protein antibodies (anti-CarP) as having any significance in evaluation of patients if RF and ACPA negative and clinically no active synovitis yet widespread arthralgias and generalized osteoarthritis?

How do you utilize cytokine panels in your clinical practice?

Is there utility when classic inflammatory markers (ESR,CRP) or disease specific markers (C3, C4, dsDNA) do not correlate with patients disease activi...

How do you decide when to obtain genetic testing for suspected autoinflammatory conditions in adults?

What is your approach to management of pulmonary fibrosis in patients with a history of microscopic polyangiitis who do not have other active organ involvement?

Patient is with past history of glomerulonephritis in remission after rituximab for the past 2 years. +MPO/P-ANCA

How do you approach hypocomplementemia in Sjogren’s without features of lymphoma?

Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?

Can Milwaukee shoulder present with a large subacromial bursitis, or does it predominantly cause joint effusion/destruction?

How would you approach a young patient with bilateral lower extremity muscle weakness and positive anti-Smith, dsDNA, RNP, Raynaud’s, and pericardial effusion but normal muscle enzymes?

MRI with muscle edema but biopsy pending. Would you consider this overlap myositis even though muscle enzymes are normal?

Do you recommend sending an autoimmune work up for patients with recurrent nephrolithiasis and 24 hour urine chemistries consistent with distal renal tubular acidosis?

How would you treat a sarcoid patient whose only manifestations are B symptoms and generalized lymphadenopathy?

How do you approach using DMARDs for patients with CPP arthritis who have frequent flares?

For example, I have a patient who has frequent (monthly) large to medium joint flares (Knee, Ankle) with crystal proven disease. Did not tolerate colc...

How do you approach evaluation for underlying rheumatologic disease in patients with chronic asymptomatic thrombocytopenia?

Thrombocytopenia is moderate (80-100,000 microL). No concomitant cytopenias present.

What serologic biomarkers do you send to assess for sarcoidosis at baseline and/or during flares, in patients where it may correlate with disease activity?

Specifically, do you check for any of these: ACE, Vitamin D 1,25, serum lysozyme, soluble IL2 or Adenosine deaminase levels?

How would you approach evaluation of a patient with persistent elevated ACE (angiotensin converting enzyme) level without evidence of cutaneous, ocular, or pulmonary granulomatous disease?

Patient with alcoholism referred to rheumatology for elevated ACE level in the setting of new onset mild sensory peripheral neuropathy on nerve conduc...

How do you approach management of adult patients with CVID and sarcoid-like syndrome?

Are there patients with granulomatosis with polyangiitis on maintenance rituximab therapy for whom you do not co-administer glucocorticoid therapy?

Would you stop azathioprine in a patient with ANCA vasculitis who has been in long term remission on azathioprine, but has a new diagnosis of lung cancer requiring initiation of immunotherapy?

What is your approach to managing osteoporosis in patients with end stage kidney disease?

How do you approach weakly positive PL-7 antibody in a patient who initially presented with muscle weakness, rhabdomyolysis and non specific muscular edema on MRI that resolved with IV fluids?

Do you extend the duration of maintenance therapy past 24 months for patients with ANCA glomerulonephritis who have multiple organ involvement?

For patients with suspected complement-mediated TMA, are there specific clinical or laboratory parameters that can help guide the decision for starting empirical treatment (e.g., eculizumab) while awaiting the results of complement testing?

How do you manage diarrhea in a patient with CTD-ILD on MMF who was recently started on full dose nintedanib?

How do you approach interpreting a low titer dsDNA (such as crithidia 1:40 to 1:80) in the setting of a moderately elevated ANA without other specific features of SLE?

For example, the patient may have other findings such as an elevated CRP. Would you diagnose SLE, or would you want to see other serologies or finding...

How would you work up a patient with cutaneous mastocytosis?

Is a BM biopsy a must when there is skin involvement? If tryptase level is mildly elevated but less than 20 would you recommend a BM biopsy?

How would you approach a patient with axial spondyloarthritis who develops new-onset proteinuria?

How would you approach the work up of SLE in a patient over 80 years old?

How would you work up an elderly female with persistent anemia secondary to warm AIHA requiring almost monthly transfusion, with positive ANA,dsDNA (b...

Is there utility in monitoring IgE levels in patients with IgG4-RD?

How would you manage a patient with highly active ankylosing spondylitis, iritis and Crohn’s, controlled with weekly adalimumab with co-morbid IgG4RD and intolerance of azathioprine due to elevated LFTs?

IgG4 manifestations include autoimmune pancreatitis and periaortic soft tissue mass.

Do you pursue a malignancy workup beyond age-appropriate malignancy screening in patients with antibody negative necrotizing myopathy?

Is whole body PET scan sufficient to rule out cardiac involvement in sarcoidosis?

How would you manage a patient with diffuse Systemic Sclerosis who develops severe rapidly progressive calcinosis?

How would you approach the work up of a patient with nasal septal perforation, a negative infectious workup, and negative ANCA titers?

How do you interpret negative HMGCR antibody test results in a patient with necrotizing myopathy who has already been on treatment with steroids and whose CK has normalized?

Given that antibody levels seem to fluctuate with disease activity in a subset of patients would you assume that prednisone therapy could turn an HMGC...

Is a biopsy of either skin or muscle always indicated in the diagnosis of dermatomyositis?

What is your approach to a patient with IgG4RD with past pulmonary involvement (biopsy proven) managed with steroids alone, now with new hematuria/proteinuria, but stable renal function?

Would you obtain renal biopsy first or treat with additional immunosuppression for suspected renal involvement related to IgG4?

What is the approach to use of ACE inhibitors for suspected scleroderma renal crisis in patients with only mildly elevated BP and renal artery stenosis?

Should methotrexate be stopped prior to radiation therapy if a patient has rheumatoid arthritis?

In which patients with suspected IgA nephropathy and microalbuminuria would you recommend a kidney biopsy?

Can romosozumab be used in patients on dialysis?

How do you approach patients with RA and severe bronchiectasis with associated findings of UIP?

What is your approach to working up diarrhea in an immunocompromised patient?

How would you approach a patient with new temporal headache, temporal artery tenderness and TA biopsy with mild thickening, but normal inflammatory markers?

Do you typically adjust or hold immunosuppression in a well-controlled RA patient who is being treated for Mycobacterium avium-intracellulare (MAI)?

How do you approach the timing of DMARD initiation in patients with active RA who are on treatment for latent TB?

Is it different between DMARDs (csDMARDs, biologic DMARDs, and target synthetic DMARDs)?

What is your approach to diagnosis and evaluation of nonbacterial thrombotic endocarditis (Libman-Sacks)?

Patient with negative blood cultures, completed 6 weeks of IV antibiotics and vegetation persists. CT imaging without evidence of malignancy. No evide...

What else do you consider in the differential diagnosis for pulmonary-renal syndromes if there is low clinical and serologic evidence of AAV, Goodpasture's or other rheumatologic disease (SLE, RA, APS, Scleroderma)?

Do you utilize post-vaccination IgG titers to detect common variable immunodeficiency in patients who are about to start or are actively on B cell depleting therapy?

How would you manage autoimmune pancreatitis in a patient after Whipple's procedure?

Would you treat a patient aggressively for lupus nephritis if they have persistent proteinuria over 1 gram but cannot get a timely kidney biopsy?

What is your approach to further workup and treatment of abdominal aortitis found on imaging in asymptomatic individuals with elevated inflammatory markers?

Is there a role in temporal artery biopsy?

How do you approach tapering immunosuppression in a patient with a history of Susac Syndrome who has stabilized on MMF and IVIG?

How do you manage a patient with severe RA or SLE that worsens after stopping immunosuppressants due to having chronic foot ulceration?

Are there circumstances when you may consider imaging enthesitis in patients with psoriatic arthritis?

What imaging modality would be most helpful?

How would you treat a young patient who presents with coronary vasculitis and aortitis with persistently positive MPO but no other features of AAV?

Do you typically screen patients for antiphospholipid antibodies in autoimmune diseases besides lupus in the absence of a clotting event?

How would you manage asymptomatic osseous sarcoidosis of the lumbar spine without any other systemic involvement?

Would you use with DMARDs/biologics or monitor?

How do you screen dermatomyositis patients for malignancy if they have a high risk antibody profile (NXP-2/TIF1gamma positive) and their initial screen is negative?

Does phosphatidylserine antibody play a role in the diagnosis of antiphospholipid antibody syndrome?

What is your approach to a patient with a low alkaline phosphatase?

What level or additional signs/symptoms trigger a workup? What does your workup typically consist of?

Do you consider immunosuppressive agents in progressive interstitial pneumonias or pneumonitis without a clear driving etiology?

What is your approach for an RA patient with lung cancer who is starting immunotherapy?

How would you interpret a temporal artery biopsy demonstrating focal chronic inflammation in the adventitia associated with small adventitial vessels and nerves without inflammation of the intima and media and without giant cells?

Do you consider pulmonary hypertension related to sarcoidosis to be an indication to start steroids?

Do you use biomarkers or PET scanning to stratify patients who may benefit most from therapy?

Do you use anti-DFS70 Ab to help reduce the posttest probability of ANA-positive patients having a systemic autoimmune disease if other autoantibodies are negative?

ANA patients referred to rule out CTD is a work-intensive, costly referral type. If they are positive for Anti-Dense Fine Speckled Protein 70 kDa (DFS...

How would you approach medication de-escalation in a patient with a history of rapidly progressive CTD-ILD who responded to and is currently on mycophenolate 3 grams daily and IVIG 2mg/kg monthly infusions and has been stable for two years?

Do you avoid ESA use in patients with anemia and chronic kidney disease who also have APLS and risk for thrombosis?

How do you approach management of a patient with Sjogren's disease and lung mass biopsy revealing amyloidosis?

Is history of radiation an absolute contraindication to using parathyroid hormone (PTH) analogues?

Does it depend on location of radiation, length of radiation, and time since radiation?

Does hepatitis B vaccination reduce the risk of HBV reactivation associated with immunosuppressive therapy?

For example, in patients who are HbSAg negative, anti-HBc positive and HbSAb negative, does vaccination reduce reactivation risk?

How do you approach a negative ANA and positive dsDNA in patients with arthralgia, hair loss, or other UCTD features?

Would you continue Rituximab infusions in a patient with GPA and renal involvement who has been in remission on Avacopan and Rituximab, but had PRES post Rituximab infusion?

Would a surgical decompression be indicated in a patient with amyloidosis and severe median neuropathy at the wrist?

Would you add voclosporin to mycophenolate for refractory proteinuria in a patient with low EF?

Low EF in the range of 30%

How do you approach differentiating infectious vs inflammatory tenosynovitis?

How do you approach management of a patient with idiopathic PAH and +ANA, but no other current symptoms/signs of active rheumatologic disease?

How would you approach additional workup and management of a patient with active Crohn’s disease, who has multiple lung and brain nodules, with lung pathology demonstrating necrotizing granulomatous inflammation and brain biopsy with granulomatous inflammation and medium-large vessel vasculitis?

The patient is on mesalamine for Crohn’s and CellCept and HCQ for skin manifestations (currently on hold during workup). The infectious workup i...

What would be the clinical role of SGLT-2 inhibitors for lupus nephritis given it has an indication for proteinuria related to CKD?

Is there a role for monitoring serum ANCAs to assess ANCA associated vasculitis disease activity?

This question is part of a collaboration with RheumMadness and is in reference to Pathogenic ANCA (RAVE Trial).

Is it safe to combine mycophenolate and adalimumab for management of pulmonary sarcoidosis in a patient that could not tolerate methotrexate?

Is there a role for systemic therapy for a patient with scleroderma sine sclerosis, with esophageal strictures and Raynaud’s syndrome, but no pulmonary involvement?

When would you consider a kidney biopsy in a patient with longstanding diabetes and hypertension (baseline creatinine 4-5, 4+ proteinuria) who was recently found to have dsDNA positivity?

What is your approach to monitoring patients with cardiac sarcoid while tapering immunosuppression?

Do you obtain serial cardiac PET scans?

How do you approach immunosuppression in patients with a positive Interferon Gamma Release Assay and prior intravesicular BCG treatment for bladder cancer?

Assuming no symptoms of TB, should patients be treated for latent TB prior to starting TNF inhibitors or other immunosuppressive agents?

Would you check ANCA titers in a patient with a history of PR-3-ANCA glomerulonephritis in remission and a stable creatinine but with recurrent microscopic hematuria?

What treatment options do you recommend in a patient with idiopathic granulomatous mastitis that has not improved on steroids and methotrexate?

Does IVIG or subcutaneous Ig interfere with monoclonal antibody therapy (i.e. dupilumab, infliximab, rituximab, etc)?

How should IVIG and either biologic injections or infusions be spaced?

Is it safe to use quinacrine in SLE patients with a history of hydroxychloroquine-associated retinopathy?

Would you avoid combining JAK inhibitors with IVIG given the risk of thromboembolism?

How would you approach peri-operative immunosuppressive management of a patient with Behcet's, currently controlled on azathioprine, who needs genital surgery?

The patient has not responded/has contraindications to apremilast, colchicine, and adalimumab. When they were off azathioprine for 5 days in the past,...

How would you approach treating a patient with Rheumatoid arthritis/Psoriatic arthritis and alcoholic cirrhosis?

Do you recommend monitoring IgG level in patients with AAV receiving rituximab?

And when do you consider (if ever) IGRT?

Do you have a preference between Quantiferon Gold and T-spot TB for screening in patients starting immunosuppressive agents?

What is your approach to evaluation in patients who present with erythromelalgia?

What would be your approach to a patient with new diagnosis of seropositive rheumatoid arthritis manifesting as a constrictive pericarditis with no joint pain complaints?

Would you begin with DMARD therapy like MTX or would you consider starting with an IL-1 antagonist such as Acralyst?

In patients taking biologics who are planning joint replacement and are known MRSA carriers do you perform decolonization prior to surgery?

0 Answers available

What is your approach to using medications that can cause bone marrow suppression in SLE patients who have persistent leukopenia?

Can joint replacement surgery be performed in someone with active Paget’s disease elsewhere?

Do you routinely obtain baseline vascular imaging (CTA, MRA, PET) in patients with suspected GCA, but negative temporal artery biopsy?

Per 2021 GCA Vasculitis Guidelines: low evidence, but conditional recommendation for CTA neck, chest, abd/pelvis. Is anybody following this or do you ...

What is your approach to steroid sparing therapy in patients with suspected CTD-ILD?

How would you approach immunomodulatory treatment for systemic lupus associated protein losing enteropathy (PLE) in a patient whose clinical course has been complicated by significant infection?

Additionally, is it correct to assume that IV therapies might be preferred vs oral treatment given alterations in GI absorption in PLE?

What is your approach to a patient who has a cardiac PET scan suggestive of sarcoid but no other supporting evidence of a diagnosis of sarcoid?

Do you typically push for myocardial biopsy in this case?

How would approach the management of a patient with significantly positive anticardiolopin and beta 2 glycoprotein antibodies in the absence of any clotting (including obstetric) history but with significant thrombocytopenia (but no other features of active connective tissue disease)?

What is your approach in differentiating IPAF (interstitial pneumonia with autoimmune features) versus "CTD ILD" in patients with serologic abnormalities but do not fulfill criteria for autoimmune disease?

Have you seen rheumatoid nodules or RA-ILD in patients with seronegative RA?

While classically described as seen in seropositive patients, have they been reported in seronegative RA?

How do you manage a DOAC if interested in testing for lupus anticoagulant?

Significant history of autoimmune diseases and DVT in family, recent PE/DVT for a month

Have you seen drug induced SCLE from IL-17 inhibitors?

And if so, what is your approach to the diagnosis?

How would you approach management of incidentally identified unilateral retinal vasculitis with subsequent labs revealing +P-ANCA?

Patient is asymptomatic. Labs showed +P-ANCA 1:160. Negative MPO and PR3.

How do you recommend tapering IVIG in patients whose inflammatory myositis has achieved remission?

What is your approach to the management of patients with isolated cervical adenopathy related to sarcoidosis?

Lymph node biopsy with non-caseating granulomas and other etiologies (malignancy, infection, vasculitis) ruled out.

In patients with secondary Sjogren's how do you approach screening for lymphoproliferative malignancy?

What screening tests do you perform and at what intervals?

What is your approach to continuing or altering therapy when inheriting a patient with combined biologic immunosuppression that is in excess of guidelines?

How do you approach de-escalation or justify therapy maintenance? Do you have tiers of medications that you attempt to de-escalate first? In one parti...

What is your initial treatment of choice in patients with RA and associated interstitial lung disease?

How would you treat active rheumatoid arthritis in a patient in complete response on loralatinib for stage IV ALK positive NSCLC?

Patient already on methotrexate and plaquenil.

How would you manage warfarin in a patient with APLS and alcoholic cirrhosis?

Nonreliable INR, given hepatic coagulopathy

In a patient with history of scleroderma renal crisis resulting in ESRD, would you recommend using steroids for when needed?

What is your approach to treating crowned dens syndrome?

How long can you treat dermatomyositis with IVIG?

How do you approach the concept of spondyloarthritis disease activity "burning out" and no longer requiring immunosuppression?

Is there a certain disease duration or age beyond which you taper immunosuppressive treatments?

Is concomitant use of azathioprine and febuxostat safe from a bone marrow toxicity standpoint?

Are there concerns with using sulfasalazine in SLE?

Extrapolating from reactions with other sulfa medications potentially causes flares.

How do you manage patients with systemic sclerosis and chronic thrombotic microangiopathy on renal biopsy, but no other evidence of scleroderma renal crisis?

Patient with nephrotic range proteinuria, but there is no evidence of active TMA on renal biopsy.

Do you find MRI helpful to differentiate early erosive OA from psoriatic arthritis when early X-ray changes in both conditions may be hard to distinguish?

Is it safe to treat checkpoint inhibitor-induced arthritis with methotrexate or biologics?

What is your approach to management of elevated liver enzymes in patients who recently started treatment with tocilizumab?

Do you recommend discontinuing IVIG for a newly diagnosed HMGCR+ statin induced necrotizing myopathy who developed a recent brachial DVT?

The patient was diagnosed with statin-induced necrotizing myopathy (HMGCR +) and received RTX and IVIG (one cycle over 3 days) but developed bra...

What is your approach to using nintedanib in patients on baseline immunosuppression?

Patients on baseline mycophenolate and azathioprine were excluded from the INBUILD trial however many patients with CTD-ILD will be on some form of im...

How would you approach a patient with elevated CPK in the 500-1000 range with no weakness on exam or myositis on MRI but with positive HMGCoA ab?

What is your approach to urate lowering therapy in patient with gout who is on azathioprine (for example, for transplant), where allopurinol and febuxostat are both contraindicated?

In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?

Also how would you manage this perioperatively?

7 Answers available

How common are nasal telangiectasia in patients with systemic sclerosis?

Patient with pulmonary hypertension (mixed group 1, 2, 3), COPD, HFpEF, Raynaud’s phenomenon, UCTD (ANA, PM-Scl, SSA-52kd), and recurrent severe...

What is the role of kyphoplasty or vertebroplasty in patients with osteoporotic spinal fractures?

What is your approach to evaluating a patient with known rheumatologic disease and elevated free kappa:lambda ratio, but no evidence of monoclonal immunoglobulins?

How do you approach treating patients with lupus profundus?

Do you typically start the patient on hydroxychloroquine? What work-up do you perform?

Is there a reason to repeat HMGCR antibody level for monitoring disease activity once documented positive in patients with IMNM?

What is your approach to elevated CK in patients without clinical or serologic evidence of immune mediated myopathy?

Is there any clinical benefit in referring patients with SLE or Sjogren's with cognitive impairment for neuropsychological testing?

How do you differentiate symptoms related to centralized pain syndrome from possible cognitive dysfunction?

When do you begin antifibrotic therapy for a patient with newly diagnosed ILD that is not IPF?

Do you base the decision on FEV1, 6MWD or symptoms at initial evaluation, or progression over time?

When prescribing hydroxychloroquine, how do you explain the mechanism of action and how this translates into clinical benefit for the patient?

There are studies that show hydroxychloroquine inhibits autophagy (the orderly degradation and recycling of the contents of the cytoplasm for the cell...

What is your approach to assessing whether oral/nasal ulcerations are features of systemic lupus erythematosus versus from another etiology?

Classically, lupus mouth ulcers are large non-painful blisters at the roof of the mouth. What do you do with small scattered blisters, painful or not ...

Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?

What is your approach to further work-up and management of neutropenia in patients with SLE/RA overlap?

For example, a patient with a bone marrow biopsy that shows normocellular bone marrow. Prior management with leflunomide and HCQ with neutropenia attr...

What would be the main indications for opting for biosimilars over an original biologic, outside of insurance barriers?

Are there any instances where you would prefer a biosimilar rather than the reference product?

How do you treat sarcoidosis associated hypercalcemia in a patient with adenopathy and no other signs of systemic involvement?

How do you approach the workup for a patient with persistently elevated inflammatory markers (CRP and ESR) whose history and exam do not point to a clear cause?

Would you be comfortable using a JAK inhibitor in a patient with baseline thrombocytosis?

Would the etiology of the thrombocytosis play a role in your decision-making?

What is your approach to discordant dsDNA testing, such as positivity to dsDNA by crithidia but negativity to dsDNA by other modalities?

I get a lot of low false positive ds dna (sometimes high- 300) in quest and labcorp but their crithidia specific dsDNA labs when repeated are ne...

When is a kidney biopsy warranted in a patient with possible scleroderma renal crisis?

How would you interpret a positive dsDNA in a patient with a negative ANA performed via indirect immunofluorescence?

What dose and duration of steroid therapy do you use in steroid responsive ILD?

Do you recommend chlorhexidine mouth rinse for prophylaxis against oral complications in patients undergoing dental work who are immunosuppressed?

Is there utility of modifying DMARD treatment in a seropositive rheumatoid arthritis patient with recurrent pleural effusions and RA nodules without other signs of active disease?

In a patient with bisphosphonate induced bilateral atypical femur fractures, how would you approach timing of alternative osteoporosis treatments and surgical management?

How do you counsel patients about the malignancy risk associated with azathioprine?

How do you approach the usage of hydroxychloroquine in patients with rheumatologic conditions and baseline cardiomyopathy or heart failure?

What is your approach to checking IgG levels post vaccination to detect common variable immunodeficiency in patients with systemic lupus?

If a deficiency is present, do you consider IVIG to treat non-infectious symptoms such as skin rash, arthritis or hematological abnormalities?

Is there a role for hydroxychloroquine for secondary prevention in patients with APS without SLE?

How do you manage recurrent inflammatory pleural effusions in lupus pleuritis?

Do you continue to utilize ESR and CRP in patients on tocilizumab?

What is the differential for a patient with unilateral arm swelling, MRI with muscle edema, and markedly elevated CPK?

There is no history of trauma or substance abuse.

What is your approach to therapy for pulmonary sarcoidosis resistant to methotrexate?

Is there utility in obtaining pericardial fluid autoimmune labs such as ANA or RF in patients with recurrent idiopathic pericardial effusions, but no other clinical or serologic evidence of rheumatic disease?

How do you approach evaluation of hypocomplementemia in a patient with arthralgias and a history of Hodgkin's lymphoma treated in the past?

ANA and ENA negative

Do you typically get muscle MRI in patients with symptoms of myopathy?

How do you manage severe Raynaud's phenomenon with ulceration in scleroderma patients that is refractory to oral agents (CCBs, PDEis, ARBs, and ERAs)?

Is there any role of sympathectomy in Raynaud’s disease?

How do you approach low to moderate titer of APLS when working up unprovoked DVT if it is persistent on repeat testing?

Would you consider using DOACs in a young patient with SLE and Libman-Sacks endocarditis, who is negative for APS?

Do you routinely monitor the QTc when adding voclosporin to hydroxychloroquine in a patient with lupus nephritis?

How do you approach management of a patient with lower extremity ulcers from livedoid vasculopathy with a history Sjogren’s and Factor V Leiden?

4 cutaneous biopsies with no evidence of vasculitis. Sjogren’s diagnosis based prominent sicca symptoms and a significantly elevated SSA.

In which clinical scenarios is relying on the urine protein-to-creatinine ratio as a measure of proteinuria unreliable, and interpretations should be made looking at urine protein and urine creatinine separately?

How do you manage a patient with progressive cerebellar ataxia and positive cardiolipin antibodies?

Do you wait 12 weeks for confirmation to begin treatment if patient is declining?

Do you feel comfortable using azathioprine for dermatomyositis in patients with cirrhosis?

For example, in the setting of cirrhosis incidentally found on imaging.

What is your approach to patients who present with unilateral Raynaud's?

How would you approach treating a patient with active rheumatoid arthritis and a history of treated lymphoma that is currently in remission?

Given the controversy in the literature regarding TNFi or MTX associated lymphoma in patients with RA.

How would you counsel a patient with active SLE on treatment, low to moderate level of one of the APLS antibodies, and remote history of provoked blood clot regarding perioperative anticoagulation?

Is SLE-related APLS managed differently in terms of anticoagulation?

What are the reasons for SLE specific labs to turn negative?

Patients frequently mention diagnosis of SLE years ago but recent Sm, dsDNA (crithidia) and complements can be normal. Can treatment with medications ...

When is the index of suspicion high for paraneoplastic systemic sclerosis in terms of clinical and serological presentation and how will you work it up?

Does it mirror the same approach as SSc without malignancy? Do patients with paraneoplastic SSc present atypically (without usual serologies or featur...

Do you send an antiphospholipid antibody panel routinely for all patients with an unprovoked thrombus?

Is rituximab for refractory ITP contraindicated in the setting of an active COVID infection, particularly in a patient with asymptomatic COVID?

What is your approach to the diagnosis and management of lupus cystitis?

What is your approach to managing RA patients with history of organ transplant already on immunosuppressive therapy such as cyclosporine or cellcept?

Are there any risk factors for IO induced rhabdomyolysis and how do you approach and manage it?

How would you approach a patient with incidentally noted infrarenal periaortitis with positive C-ANCA, normal inflammatory markers and no systemic symptoms?

MPO/PR3, P-ANCA negative. IgG4 normal.

Do you routinely check G6PD level prior to initiation of hydroxychloroquine?

How would you approach an elderly patient with tibial plateau insufficiency fracture and normal DEXA?

Tibial plateau insufficiency fxs are not discussed in the guidelines for dx or treatment.

How do you typically treat aortitis associated with spondyloarthritis?

What is the appropriate management of arthralgias associated with bosutinib?

In patients with lupus nephritis on maintenance therapy, is there additional benefit in utilizing 2 grams vs 3 grams of mycophenolate mofetil (MMF) daily?

Do you initiate management of new onset diabetes in a patient on immunotherapy or refer immediately to endocrinology given the risk of rapid worsening?

Do you routinely screen for pulmonary artery aneurysm in patients with Behcet's?

Can APLS cause a false positive HIT ELISA?

If so, is there one type of antibody that is more likely to cause this false positive test?

In what circumstances do you pursue labial salivary gland biopsy in an asymptomatic patient with high titer ANA and positive SSA?

How do you risk stratify and monitor such patient for disease progression or organ involvement?

What is your approach to tapering therapy in a patient with recurrent pericarditis now well-controlled on rilonacept?

How would you approach initiating belimumab in a patient with serologic evidence of prior hepatitis B infection?

Such as patients with negative Hepatitis B surface antigen and negative viral load but with positive hepatitis b core antibody.

Do you recommend continuous antibiotic prophylaxis for patients on complement inhibitors such as eculizumab?

Do you just use antibiotic prophylaxis if therapy is started prior to meningococcal vaccination?

When do you consider immunosuppression in patients with Sjogren's neuropathy?

How do you approach the workup of a patient with incidentally found pachymeningitis?

How do you manage patients on biologics peri-operatively?

Are there any medications that surgeons like discontinued before their procedure?

When performing salivary gland ultrasound for Sjogren's, what else do you include in the differential diagnosis?

How do you manage a case of dermatomyositis that is proven on skin biopsy and clinically has proximal muscle weakness but normal muscle enzymes, including CK, aldolase?

How do you manage dermatomyositis related to underlying malignancy?

Is there a role of immunosuppression or treating underlying malignancy will be enough?

How do you approach RA management in a patient who develops a new solid tumor while on therapy?

Why do we not typically see features of rhabdomyolysis or acute kidney injury with idiopathic inflammatory myopathies?

When considering the use of DOACs in APLS, does the number of positive APLS antibodies influence your decision?

What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?

How do you approach treating idiopathic aortitis?

What are your primary and secondary agents?

Do you avoid intra-articular and bursa/tendon sheath corticosteroid injections in patients with a history of avascular necrosis?

How do you approach the workup for patients with hyperCKemia and positive NXP2 with no clinical symptoms?

What is the diagnostic utility of ordering an "Early Sjogren's Syndrome Profile", which tests novel autoantibodies, to support a diagnosis of Sjogren's syndrome in patients who test negative for SSA/SSB?

In your experience, is there an association between interstitial cystitis and systemic lupus erythematosus?

How would you approach a rising PR3 in a patient with limited GPA who is currently asymptomatic on methotrexate?

Would you obtain imaging? If so, what type of imaging?

What workup and initial treatment should be considered for suspected autoimmune myelofibrosis?

How would you manage polymyalgia rheumatica refractory to prednisone, methotrexate and tocilizumab?

Patient has no current evidence of underlying vasculitis or malignancy.

What is your approach in a patient who develops interstitial lung disease while on anti-TNF therapy?

Do you change therapy? If they are also on methotrexate, which medication would you potentially stop first?

How would you treat systemic polyarteritis nodosa with orchitis, mononeuritis and glomerulonephritis in a person who is being treated for HiV with low level viremia?

How much weight would you place on a low titer Ku antibody in a patient with mild CPK elevation but no weakness on exam and no other features of CTD overlap syndrome?

Would you consider EMG, muscle biopsy, repeat myositis panel? Would you consider starting immunosuppression?

How do you approach differentiating segmental arterial mediolysis from abdominal vasculitis?

Do you avoid PTH/PTHrP analogs in patients with recurrent/severe CPPD?

When do you consider tapering tocilizumab in patients with GCA in remission?

What is your approach to the workup for an underlying systemic condition in a patient presenting with retinal vasculitis?

How do you evaluate livedo reticularis (not livideo racemosa)?

Does your evaluation hinge on nonresolution with warming? How extensive is your workup?

How do you decide on initiation of treatment with steroids or immunomodulatory therapy in patients with statin-induced myopathy versus statin-induced autoimmune necrotizing myopathy?

In patients presenting with likely statin-induced myopathy versus statin-induced autoimmune necrotizing myopathy - how do you approach the decision re...

How would you approach a patient with refractory polymyositis (elevated CK, weakness) despite MMF, IVIG, and moderate dose prednisone?

Would you consider adding tacrolimus in this situation?

What workup do you do for patients who have PL-7 elevation when screening for myopathy?

How do you mitigate the risk of renal crisis from corticosteroids in a patient with UCTD?

How do you work up patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance?

For patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance, what work up process do you typi...

What is the negative predictive value of a negative extended myositis panel in dermatomyositis patients?

How do you manage psoriatic arthritis in patients who are planning to start treatment with checkpoint inhibitors for underlying malignancy?

What is your approach to workup for an underlying disorder in a patient with bilateral hip avascular necrosis?

If you have clinical suspicion for a paraneoplastic process (e.g. dermatomyositis or pemphigus), what work-up do you pursue?

How do you interpret elevations in antiphospholipid antibodies that are lower than Sapporo criteria?

(e.g. beta 2 glycoprotein IgM > 20 but <40)

At what point do you recommend muscle biopsy in the workup for myositis?

How important do you feel HLAB51 testing is in diagnosing Behcet's disease?

In your experience, are there specific disease manifestations in which HLAB51 is particularly helpful?

What is the role of non-prednisone oral glucocorticoids in the management of systemic rheumatologic disease?

Such as oral methylprednisolone, dexamethasone, prednisolone, etc.

How do you approach relapsing ANCA-associated vasculitis in a patient who has already undergone kidney transplant?

How do you clinically distinguish between group I and group III PH in patients with CTD-ILD?

Do you utilize soluble IL-2 receptor or ACE levels as serum biomarkers to monitor disease activity in pulmonary sarcoidosis?

How do you treat patients with sarcoid who have persistent symptoms after an initial 6 week course of corticosteroids?

Which medications have the lowest risk of tuberculosis reactivation in patients with uncertain tuberculosis history and active rheumatologic disease?

Do you consider the use of antifibrotics at presentation in patients with a radiographic UIP pattern of pulmonary fibrosis in the presence of positive serologies without any symptoms of CTD who have not yet demonstrated evidence of a progressive phenotype?

Can giant cell arteritis present with a partial cranial neuropathy?

What is the difference between Multisystem Inflammatory Syndrome in Adults (MIS-A) and MAS/HLH?

How do you approach treating cutaneous PAN?

Other than inflammatory markers and following symptoms/exam, do you need any other specific monitoring for progression to systemic disease?

Does calcinosis appear differently in patients with dermatomyositis compared to systemic sclerosis?

How do you approach DMARD therapy in patients with rheumatoid arthritis and chronic hepatitis B?

Hepatitis screening labs revealing Hep B ag and core positivity with positive PCR

When would you suspect metabolic myopathy and what is your approach to initial workup?

How do you differentiate a lupus flare versus drug-induced lupus in patients with SLE on a drug associated with DILE?

What is the role of x-ray of the cervical or lumbar spine in patients presenting with radicular symptoms?

I teach my students/residents that they should hardly ever get routine X-rays in patients presenting with radicular symptoms. MRI far better for seein...

Do you recommend routine use of Evusheld for pre-exposure prophylaxis for patients on immunosuppression?

Does treatment with B-cell depletion and/or negative anti-spike antibody status despite COVID mRNA vaccination influence your decision?

What is your approach to treatment for a patient with progressive ILD (UIP pattern) with high titer RF but no articular symptoms?

How do you treat lupus-associated small fiber neuropathy?

What is your approach to initial assessment of disease extent in patients with Behcet's disease?

How does this vary from continued disease monitoring?

How do you think about biologic use in patients with underlying HIV infection?

How would you approach evaluation and treatment of a patient on pembrolizumab therapy who presents with symmetric, proximal, upper extremity and lower extremity painful weakness without an elevated CK?

How would you approach new-onset large vessel vasculitis in a young patient with Crohn's disease?

At what point is a skin biopsy indicated in patients with neuropathy?

Do you always perform temporal artery biopsy in patients with positive inflammatory markers and high clinical suspicion of GCA?

Is either ESR or CRP more sensitive or specific for the diagnosis of GCA?

Additionally, what is the current role for temporal artery ultrasound in workup for GCA?

What is your approach to evaluation of underlying autoimmune disease in patients with bilateral scleromalacia?

How do you treat post-IVIG headache that is not responsive to Tylenol or NSAIDs?

Specifically, how do you treat the delayed headache, not the headache that develops during the infusion where pre-hydration and slowing down the rate ...

What is the utility in repeating a temporal ultrasound (US) in a previously US diagnosed positive GCA patient who has received treatment and is presenting with recurrent GCA symptoms?

How do you approach the management of immunosuppression in patients with lupus nephritis that go on to dialysis?

How would you approach asymptomatic hepatic sarcoid?

Multiple lesions on PET

Is there a role for immunosuppression in patients with triple positive antiphospholipid antibodies who do not meet the clinical criteria for APS?

What particular pre-operative considerations should we consider for SLE patients undergoing elective surgery?

How do you approach DMARD therapy in a patient with lupus and recurrent pericarditis?

How do you approach the use of commercial testing such as AVISE CTD in clinical practice?

Do you find 14.3.3 eta or vectra DA helpful in clinical practice?

In a patient with inflammatory orbital disease without a discrete mass to biopsy and recent bisphosphonate use, how much additional workup would you do if basic labs, urine studies, ANCA serologies, thyroid studies, chest imaging (to r/out sarcoid) are normal, before concluding that the process is likely secondary to bisphosphonate use?

Without a discrete mass to biopsy, is there any utility of any blind biopsies to rule out IgG4 related disease, infectious or neoplastic process?

How do you manage a patient with inclusion body myositis?

Is there a role for immunomodulatory therapy?

How do you approach immunosuppressive therapy in lupus-associated pulmonary arterial hypertension?

What is your approach to a patient with normal LFTS and high titer auto-antibodies suggestive of autoimmune hepatitis?

Is a liver biopsy ever helpful?

Is there any experience of using sarilumab instead of tocilizumab for steroid sparing effect in GCA during national tocilizumab shortage?

How do you clinically distinguish between cutaneous lupus with photosensitivity and polymorphic light eruption-like reactions?

What is the role for angiography in the workup of digital ischemia?

Do you obtain vascular imaging routinely in these cases, and if so, do you use cross-sectional or invasive angiography?

Is there a role for antibody testing to confirm vaccine response for patients on rituximab after COVID-19 vaccination?

When would you consider checking JC virus prior to initiating biologic therapy?

What immunosuppressive agents would be available to patients with a history of melanoma?

Would you use immunosuppression in patients several years after curative treatment for melanoma?

What is your preferred approach for patients with anti-phospholipid syndrome with recurrent thrombosis on coumadin and LMWH?

How will you use REGEN-COV (casirivimab/imdevimab-monoclonal antibody treatment recently approved under EUA as post-exposure prophylaxis for Covid) in rheumatic patients on immunosuppressive therapy?

Would you consider this for patients on B-cell depleting therapies or more broadly for other immunosuppressive agents?

Do you routinely obtain a chest x-ray prior to initiating anti-TNF or other biologic therapy?

Does Quantiferon gold replace the need for baseline chest x-ray screen?

What was the rationale for abrupt discontinuation of etanercept rather than gradual tapering in the SEAM-RA trial?

The ACR 2021 RA Guidelines suggest the gradual tapering approach is preferable.

What are your recommendations regarding methotrexate usage in patients with persistent chest CT changes post COVID pneumonia?

Would you have a different opinion based on whether it is a new therapy or an existing and previously well-tolerated therapy for the patient?

How do you approach the use of steroids for active muscle disease in patients with scleroderma-myositis overlap syndromes?

What suspected myositis manifestations drive you to start empiric therapy before the work-up is complete?

Myositis specific antibodies and pathology results often take weeks to result. In which cases do you start therapy before the diagnosis is solid...

What is your approach to managing sclerosing mesenteritis (mesenteric panniculitis)?

Do you have a preferred initial immunosuppressive regimen?

How do you diagnose and treat patients who develop uveitis while on bisphosphonate therapy for osteoporosis?

Are there specific features that suggest drug-induced uveitis versus de novo uveitis?

What is your steroid-sparing agent of choice to treat GCA given the current tocilizumab shortage?

Thoughts on sarilumab vs methotrexate, or just treat with steroids alone

Would you pursue temporal artery biopsy in patients with PMR who develop cranial GCA symptoms and have been on PMR dose steroids for one year?

What is your approach to differentiating SLE flare in pregnancy vs pre-eclampsia?

What criteria do you use on echocardiogram and PFT to determine who needs further evaluation for CTD-associated pulmonary hypertension?

What indicators do you use to identify patients with CTD-ILD who do not have potential to improve from continued immunosuppressive therapy?

Do you use imaging (fibrosis vs. pneumonitis), PFTs, duration of prior immunosuppressive therapy?

How do you approach treatment of vasculitis in a sickle cell disease patient?

There are multiple difficulties that could be seen: steroids can precipitate a sickle cell crisis, vasculitis and sickle cell can produce similar clin...

What is your differential for a patient presenting with multiple digits affected by flexor tenosynovitis, dupuytren's, and no evidence of peripheral inflammatory arthritis?

What studies do you find helpful to determine if an axial spondyloarthritis patient presenting late in the disease course with significant irreversible joint damage may benefit from immunosuppression?

Do you advise patients to hold DMARDs for conditions such as psoriasis or rheumatoid arthritis while actively undergoing radiation treatment?

Does it depend on the DMARD type (biologic, targeted synthetic, or conventional synthetic)?

What are your thoughts on use of 14-3-3 serum levels in rheumatoid arthritis in conjunction with RF and ACPA?

Are there any specific circumstances when you would consider the use of immunosuppression for DISH?

There is some emerging evidence that there is an inflammatory component.

How do you approach screening for inflammatory bowel disease prior to starting IL-17 inhibitors?

How do you approach the treatment of eosinophilic fasciitis refractory to glucocorticoids and methotrexate?

What immunosuppressive agents aside from steroids would you use to treat bronchiolitis obliterans in a patient with long-standing seropositive RA?

How do you approach treatment for arthritis associated with multicentric reticulohistiocytosis?

Would you start tocilizumab in a patient with temporal arteritis and cirrhosis?

Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?

ADVOCATE trial

Are there scenarios where you send additional antibodies beyond anti-centromere, Scl-70, and RNA polymerase III in suspected scleroderma patients?

How would you manage an active rheumatoid arthritis patient on suppressive antibiotic therapy for ocular HSV who has abnormal liver function tests?

Are there any concerns about using nintedanib in a patient with progressive fibrosing ILD on background mycophenolate?

Do you recommend checking anti-drug antibodies for patients on TNF inhibitors?

If so, how would positive levels guide your management?

When is it necessary to monitor the QTc interval in patients on hydroxychloroquine?

What aspects on history and physical exam could help differentiate genetic muscular dystrophy from immune-mediated myopathy?

How do you treat CTD-associated organizing pneumonia?

How is your approach to treatment different than other ILD patterns such as NSIP? Does treatment response vary based on underlying CTD?

How do you approach peri-operative management of anti-resorptive therapies such as denosumab in patients undergoing joint replacement?

Does denosumab effect knee replacement or hip replacement? Should replacement occur right before or after injection?

Is it okay to use medications associated with drug-induced lupus in patients with SLE?

How would you approach refractory gangrenous Raynaud's secondary to type one cryoglobulins?

What if the patient has MGUS? Do patients with type 1 cryoglobulins need a bone marrow biopsy as part of the work up?

Do you image the spine in addition to the sacroiliac joints when you suspect axial spondyloarthritis?

Can axSpA affect the spine without affecting the sacroiliac joints?

How do you treat RA in patients with pulmonary mycobacterium avium complex (MAC) infections?

How would you approach a patient with MPO-positive isolated peripheral nerve vasculitis?

How would you label such a patient? Would you treat differently if they have poor functional status?

Are there particular concerns related to the use of B-cell depletion therapies such as rituximab for rheumatic disease during the COVID-19 pandemic?

Should all patients with suspected giant cell arteritis get a PET scan to look for large vessel disease?

What is the utility of MRI for identifying disease activity in myositis patients when physical exam and labs are inconclusive?

Is there a role for G-CSF treatment for SLE patients with persistent neutropenia?

Do you escalate treatment in patients with myositis who achieve clinical remission but continue to have elevated CPK?

Is there a role for measuring hydroxychloroquine blood levels in clinical practice?

If so, are there specific patient populations for which you would use this metric?

What is your threshold for pursuing bone marrow biopsy in a lupus patient with cytopenias?

What is considered an adequate treatment period to assess response of AAV induction therapy with rituximab or cyclophosphamide?

How do you approach a patient found to have a coronary lesion suggestive of vasculitis on coronary CT?

How does a history of splenectomy alter how you counsel patients on the infection risk of TNF inhibitors or other biologics?

For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?

What are the benefits of sending HLA B27 genotype over HLA B27 antigen when evaluating for spondyloarthritis?

Do you correct the synovial fluid white blood cell count for red blood cells, and if so, is there a rough approximation/equation you use?

Should venous thrombosis in a patient with Behcet syndrome be treated with both immunosuppression and anticoagulation?

How do you handle hypogammaglobulinemia detected in patients prior to maintenance rituximab infusion?

How does the presence of myositis alter your interpretation of cardiac enzymes when evaluating acute chest pain?

i.e., Troponin I, Troponin T, and CK-MB

What is your approach to treating refractory thrombocytopenia in lupus?

In gout, do MSU crystals form only in tissue, or are there circulating microcrystals of MSU within blood vessels?

If so, does this have clinical significance?

At what point in GCA management do you typically introduce tocilizumab?

Is there a role for PCSK9 inhibitors in patients with statin-associated immune mediated necrotizing myopathy?

Do you recommend medical therapy for extensive atraumatic osteonecrosis of the femoral head to mitigate pain or prevent femoral head collapse?

Which immunosuppressed patients with SLE would benefit from antibiotic prophylaxis to prevent pneumocystis pneumonia?

Would you hold all immunosuppressive medications for the first month of LTBI treatment, or just biologics?

Do you recommend getting a muscle biopsy in a patient with suspected IMNM with statin exposure, weakness, elevated CK, and positive HMGCR antibody?

Is it ever appropriate to use hydroxychloroquine temporarily in higher doses (more than 5mg/kg) to control lupus activity such as skin manifestations?

How do you interpret a high positive RNP in the setting of a negative ANA and negative sm/RNP?

To my understanding, sm/RNP should also be positive in this situation (and one would assume a positive ANA as well)

Is there an increased risk of COVID-19 in patients on immunosuppressants?

How do you counsel Takayasu patients on their prognosis?

How would you attempt to determine the etiology of intracranial hemorrhage in a patient with newly diagnosed lupus and an active viral infection?

How does your treatment algorithm differ for drug-induced ANCA vasculitis compared to non drug-induced ANCA vasculitis in cases with severe/organ-threatening manifestations?

Do you avoid any specific biologic therapies in HIV positive patients?

What is your inflammatory arthritis differential when a patient presents with unilateral TMJ synovitis?

What is your approach to screening for cardiac involvement in patients with myositis and how does the finding of cardiac involvement change your management?

Are there certain subsets of ANCA vasculitis patients for whom you would consider life long maintenance therapy?

Which steroid-sparing agent do you prefer to treat multi-organ Sweet's syndrome?

Is there any role for direct oral anticoagulants in the treatment of antiphospholipid syndrome?

What if this was "triple-negative" antiphospholipid syndrome?

What is your first treatment of choice in patients with dermatomyositis sine myositis?

For which subset(s) of APS patients do you recommend an INR of 3 or higher?

How do you assess transaminitis in a patient with sarcoidosis with known liver involvement being treated with methotrexate?

How do you treat small fiber neuropathy associated with rheumatic conditions like Sjogren’s syndrome?

Do you continue hydroxychloroquine in lupus patients who develop cardiomyopathy?

When is a biopsy necessary to diagnose relapsing polychondritis?

What is your approach to bladder cancer surveillance in patients who have received cyclophosphamide?

In what situations do you check for HIV status in your workup for inflammatory arthritis?

What would be your differential for a wrist monoarthritis in an elderly female with erosions on MRI after less than 3 months of symptoms?

What do you use to treat a GCA patient refractory to methotrexate who responded but had adverse effects with both tocilizumab and sarilumab?

What is your work up and management for patients who develop neuropathy on a TNF inhibitor?

Do you have any suggestions about how to improve rheumatology training in internal medicine residency programs?

Due to the shortage of rheumatologists, primary care physicians may need to manage some rheumatologic issues.

How do steroids and/or DMARDs affect biopsy results if a renal biopsy for suspected lupus nephritis is delayed?

How do you interpret granulomatous features on a muscle biopsy?

How do you manage patients who are Hepatitis B core antibody positive/surface antigen negative and starting a biologic DMARD (other than rituximab)?

Would you avoid the use of a TNF inhibitors in patients with a remote history of melanoma, including those with ocular melanoma?

Are there any clinical situations in which checking for anti-chromatin antibodies is helpful?

Is there a minimum work-up necessary in patients with an ANA greater than 1:160 and no clinical symptoms suggestive of lupus (i.e., specific antibodies, UA)?

How do you differentiate between axial psoriatic arthritis and axial spondylitis with psoriasis, and is it important to distinguish between these two conditions from a prognostic and treatment perspective?

When do you use tacrolimus in patients with myositis-related interstitial lung disease?

When suspecting a diagnosis of complex regional pain syndrome (or reflex sympathetic dystrophy), what workup should be done to confirm or exclude it?

Would you re-challenge patients who have had a TNF-associated paradoxical adverse event (such as inflammatory bowel disease) with a different TNF inhibitor?

What is your treatment algorithm for RS3PE?

What baseline work-up or "staging" do you do in patients with a new diagnosis of Sjogren's (i.e., PFT, cryoglobulins, complement, RF, UA)?

When do you stop immunosuppressants in patients with GPA?

What is your next step in patients with polymyositis without interstitial lung disease who are refractory to methotrexate?

Is your approach to managing immune related adverse events altered at all in light of COVID-19?