Rheumatology
Questions discussed in this category
This question is part of our collaboration with ACR Convergence 2024 to Continue the Conversation from the meeeting. This question was inspired by the...
Patient with chronic urticaria and rheumatoid arthritis. What would be the safest biologic option for RA?
The patient was diagnosed on the basis of ANA 1:1,280, strongly positive Smith, Sm-RNP, dsDNA, pericarditis, inflammatory arthritis, and discoid lupus...
The last SHINGRIX was about 4 years ago and both doses were given.
The patient has tried conservative measures with compression stockings.
How do you decide to trial a patient off treatment? When do you consider spacing therapy and at what frequency?
This question is part of our collaboration with ACR Convergence 2024 to Continue the Conversation from the meeting. This question was inspired by the ...
Does the recommendation change based on the DMARD?
Does the presence of ILD change your approach?
No active joint disease, patient on Hydroxychloroquine and Cimzia. Normal ESR/CRP.
How do you view it relative to existing options like TNFi, IL-23, or IL-17s like ixekizumab?
For example, in patients with many swollen/tender joints, enthesitis, nail involvement do you expect particularly good response? Are there patients in...
This question is part of our collaboration with ACR Convergence 2024 to Continue the Conversation from the meeeting. This question was inspi...
Is there a target IgG level to aim for?
What should hematologists be aware of in monitoring these patients?
I'm uncertain why both individual parts can be so low/negative but together very positive. Is there an assay discrepancy, a false positive?
This question is part of our collaboration with ACR Convergence 2024 to Continue the Conversation from the meeeting. This question was inspi...
This question is part of our collaboration with ACR Convergence 2024 to Continue the Conversation from the meeting. This question was inspired by the ...
For example, baseline QT prolongation, elderly age group, or underlying heart disease?
Are there specific immunosuppressive agents effective for this manifestation?
Especially in an inpatient setting when EMG is not immediately available.
Pre-treatment troponin was mildly elevated, while ILR2 receptor, ACE, CRP, ESR were normal.
Do anabolic agents have a role?
How will you counsel patients about the risk and what strategies will you use to mitigate the increased risk of fungal infections see in the BE COMPLE...
Are you aware of any data regarding relative risk of molluscum contagiosum infection in reference to DMARDs/biologics?
Are there any clinical trials underway to study additional therapies?
SLE manifestations include arthralgias and cytopenias which are stable. Previously did well on methotrexate, but developed GI side effects. HCQ is on ...
Would you view this as a sign that disease is not adequately controlled despite labs and imaging suggesting no active vasculitis?
Do you use them sequentially or together?
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 ...
For example, is captopril dialyzable?
Do you monitor patients with CTAs or MRAs?
Patient previously trialed two anti-TNFi and Tocilizumab. Avoiding Rituximab due to positive JC virus testing.
What do adult rheumatologists need to understand about pediatric diseases?
Synovial fluid analysis: cell count >100,000, > 80% neutrophils. Gram stain, cultures (including fungal and mycobacterial), synovial biopsy, and...
Do you generally recommend anti-diarrheals, dietary modifications, or consider this an unacceptable side effect and move to other therapies?
UpToDate recommends Hydroxychloroquine for all SLE patients, but neutropenia is sometimes ascribed to HCQ rather than the underlying disease. What lev...
Patient has had previous failure of methotrexate. Would you switch to alternative (TNFi or Rituximab) or continue abatacept with regular dermatology...
The patient has ongoing inflammatory arthritis despite methotrexate, apremilast, and jak inhibitor trials.
The patient was treated with two doses of Rituximab and on MMF. Now with stable lung function and normalized CK.
Can nodular scleritis be a presenting manifestation of GCA?
What imaging do you use to monitor disease activity?
Imaging only shows chronic, fibrotic lesions making it hard to assess disease activity.
Caplacizumab is not FDA approved in pregnant patients, but has been used safely in isolated case reports.
What nuances do adult rheumatologists need to understand about pediatric diseases?
Do you use TNF-i or MMF?
The index question is: "neurosurgeons lately want to stop hydroxychloroquine prior to spinal surgery. Anyone allowing this for lupus patients and for ...
If a patient has received a kidney transplant for SLE-LN and is stable and doing well. Managed by their transplant team and on chronic immunosuppressi...
Would you continue corticosteroid therapy even with a normalized serum IgG4 concentration?
Is this managed as CTD-ILD with immunosuppressive +/- anti-fibrotic agents?
Would you be comfortable combining a TNFi with Rituxan in this patient?
The case prompting the question is a female in her late teens who was diagnosed with Class IV LN at her prepubescent age and was treated with HCQ and ...
Is there any concern for drug interactions of DMARDs and/or biologics with anti seizure medications?
If not, are there any serum or CSF tests you consider to be helpful?
What factors do you discuss when counseling the patient?
While remission rates after lowering or discontinuing therapy are lower, there is still a population of patients who do not require full-dose therapy ...
Which csDMARD do you taper in order, and is there a tapering strategy (duration/dose)?
Given the drug-drug interaction, do you monitor more closely for methotrexate toxicity, counsel on symptoms of methotrexate toxicity, or avoid the com...
E.g., a patient with newly diagnosed CIDP who is wheelchair-bound.
Is a biopsy or EMG helpful in confirming the etiology? What is the best treatment for sarcoid neuropathy?
Do you taper one DMARD as you uptitrate another versus do you stop the first DMARD and quickly uptitrate another one?
In patients with bone metastases and osteoarthritis, if it is unclear if the pain is from cancer or OA, how do you decide on the radiation dose/fracti...
What is your most and least preferred? In case of cancer in remission and in case of non-remission?
Cervical cancer FIGO stage IIIC2. Bloodwork shows elevated ESR and CRP.
Vasculitis involving aorta, subclavian, common carotid, SMA, IMA, renal artery, and celiac artery.
How do you counsel patients in this scenario?
Is the diagnosis of Sjogren's mostly clinical in a patient with a consistent history and physical with positive serologies?
I have a patient with recently diagnosed primary biliary cholangitis/cirrhosis (PBC) with SSc. Her laboratory values are within normal limits, but end...
Normal Vitamin D, bone scan showed osteoarthritis
How does the presence of extra-renal manifestations influence this decision?
Would you push for biopsy before deciding on treatment?
The patient is already on hydroxychloroquine.
And have you ever seen it occur in isolation without any other manifestations of SLE?
CT changes are subsolid and ground glass nodules.
Do you discontinue HCQ?
When do you switch to steroid-sparing medications? What steroid-sparing therapies do you prefer?
As immune checkpoint inhibitors have expanded into the neoadjuvant breast cancer setting, severe and unexpected autoimmune toxicities may cause delays...
Do treatments for osteoporosis have a large enough effect on tooth movement to make Invisalign less effective?
Given the lack of efficacy of most treatment options, do you generally try to treat calcinosis cutis that is not bothering the patient even if it is q...
When do you decide to hospitalize?
The patient has no extraocular features of a spondyloarthropathy and is on methotrexate. No active eye disease for past 1 year.
Arthritis did not respond to HCQ.
No evidence for acromegaly or Pagets.
Pt with active skin and joint disease. Previously on Cemiplimab (PD-1) for squamous cell carcinoma of the skin. Do you avoid traditional DMARDs due to...
Do you consider the appearance of a new rheumatoid nodule as a sign of RA activity?
This question is part of a collaboration with RheumMadness and is specifically in reference to: ULT During Gout Flare.
Is there any data on the use of anabolic agents in Paget's disease?
Are there certain surgeries (including orthopedic) that you recommend continuing biologic DMARDs?
The patient is actively breastfeeding.
In which situations or patient populations do you find this useful? How is it sterilized?
How do you monitor response and what do you consider a satisfactory response? Do you aim for a certain threshold of proteinuria?
Patient with active rheumatoid arthritis, on escalating dose of Rituxan and Methotrexate, also has antisynthetase syndrome and Hashimoto's thyroiditis...
The patient is a young African American female of reproductive age with positive Fibrillarin antibody and nucleolar antibody. No ILD.
Many patients are interested in romosozumab for "maximizing bone gain" and preventing future fractures. Some have had anabolic therapy with teriparati...
Does your choice of DMARD/biologics change due to increased risk of malignancy?
When a PCP calls with concern for GCA and is wondering whether to start empiric steroids what data do you prioritize to make that decision and do you ...
What side effects do you highlight in conversation with them? How do you approach toxicity monitoring?
Relatively newly diagnosed RNA Pol 3+ dcSSc with rapidly progressive skin involvement now on methotrexate 20mg/week and tocilizumab for concurrent inf...
Is there utility when classic inflammatory markers (ESR,CRP) or disease specific markers (C3, C4, dsDNA) do not correlate with patients disease activi...
Heritable autoinflammatory gene testing negative.
Is there a role for TNF inhibitor?
Patient is with past history of glomerulonephritis in remission after rituximab for the past 2 years. +MPO/P-ANCA
Do you ever start mycophenolate without steroids?
MRI with muscle edema but biopsy pending. Would you consider this overlap myositis even though muscle enzymes are normal?
Would it be safe to resume and if so, when?
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...
Thrombocytopenia is moderate (80-100,000 microL). No concomitant cytopenias present.
Specifically, do you check for any of these: ACE, Vitamin D 1,25, serum lysozyme, soluble IL2 or Adenosine deaminase levels?
Patient with alcoholism referred to rheumatology for elevated ACE level in the setting of new onset mild sensory peripheral neuropathy on nerve conduc...
If so, what dose-fractionation do you utilize? What other factors do you take into consideration?
This question is part of a collaboration with RheumMadness and is specifically in reference to: NORD-STAR (Østergaard et al., PMID 3742364...
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...
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 long has it been back on the market? What is the typical cost for patients? Are certain compounding pharmacies regularly carrying it?
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
And how would you monitor response?
After replacing Vitamin D, what will be your first treatment of choice? Labs including ALP and calcium levels are normal. T scores are -3 or above. Th...
How would you work up an elderly female with persistent anemia secondary to warm AIHA requiring almost monthly transfusion, with positive ANA,dsDNA (b...
Do you frequently order liver biopsies for these patients?This question is part of a collaboration with RheumMadness and is specifically in reference ...
CDC Healthcare Guidance
CDC Isolation and Work Restriction Guidance
CDC Immunocompromised Guidance
Do you refer all patients with suspected LN, patients with confirmed LN, or patients with specific features (not responding to usual therapy, certain ...
This question is part of a collaboration with RheumMadness and is specifically in reference to: Prevention of Autoimmune Disease: Vitamin D and O...
IgG4 manifestations include autoimmune pancreatitis and periaortic soft tissue mass.
This question is part of a collaboration with RheumMadness and is specifically in reference to: Allopurinol vs. Febuxostat
Do you plan to use sarilumab for all patients with relapsing or refractory PMR or are there certain features that will make you more or less likely to...
Have you found dose adjustments to be effective?
Will you still favor starting with steroids and traditional immunosuppressive agents, move IVIG earlier in your treatment strategy, or start with IVIG...
Do you advocate to taper the TNF-i or simply continue to monitor for long term adverse events? This question is part of a collaboration with Rheu...
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...
What disease activity index do you find more useful and most practical in a busy clinical setting? How often do you assess it?This question is part of...
Do you add low-dose mycophenolate to use in combination with Rituximab in these patients?
Would you obtain renal biopsy first or treat with additional immunosuppression for suspected renal involvement related to IgG4?
What formulation of topical nitroglycerin do you use?
How do you approach ongoing screening for TB in patients with history of treated latent TB, but have ongoing use of DMARDs and/or biologics given quan...
This question is part of a collaboration with RheumMadness and is specifically in reference to: Exercise in Knee OA
A male patient in his 30s with two lumbar compression fractures (non-traumatic) and a Z-score of -2.6 in the spine, Z-score -0.5 in hips. History of 3...
For example, when switching from MMF to azathioprine, do you overlap the treatments as you lower the dose of one and add the other?
Assuming follow-up IV bisphosphonate x2 infusions to prevent rebound fractures
Is it different between DMARDs (csDMARDs, biologic DMARDs, and target synthetic DMARDs)?
Patient with negative blood cultures, completed 6 weeks of IV antibiotics and vegetation persists. CT imaging without evidence of malignancy. No evide...
How has this impacted your counseling and management?
Are oral bisphosphonates contraindicated with all types of bariatric procedures?
Given poor pulmonary outcomes in people with anti-PL12 antibodies, would you recommend more aggressive therapy? The patient was diagnosed with onset o...
Does the type of autoimmune disease (ex IBD, rheumatoid arthritis, interstitial lung disease) matter?
Is the interaction considered severe?
If so, do you routinely recommend use of an additional form of contraception?
Is an MRI necessary to diagnose non-radiographic axial spondyloarthritis?
Would you still plan for lifelong anticoagulation in this scenario?
Is there a role in temporal artery biopsy?
Would you start with a baseline ultrasound and then pursue further workup such as fibroscan if fatty liver is present, or other?
Patient taken off methotrexate.
What imaging modality would be most helpful?
How much cumulative prednisone exposure do you tolerate and how many attempts at tapering will you pursue before considering addition of a steroid spa...
This question is part of a collaboration with RheumMadness and is specifically in reference to: Antibodies Before SLE.
Would you use with DMARDs/biologics or monitor?
What level or additional signs/symptoms trigger a workup? What does your workup typically consist of?
Would you consider alternative B cell depleting therapies such as ofatumumab or ocrelizumab?
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?
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...
Does it depend on location of radiation, length of radiation, and time since radiation?
For example, in patients who are HbSAg negative, anti-HBc positive and HbSAb negative, does vaccination reduce reactivation risk?
Low EF in the range of 30%
The patient is on mesalamine for Crohn’s and CellCept and HCQ for skin manifestations (currently on hold during workup). The infectious workup i...
This question is part of a collaboration with RheumMadness and is in reference to Pathogenic ANCA (RAVE Trial).
Would you consider belimumab over a TNF inhibitor for inflammatory arthritis? Which agent would be more beneficial for the lung disease?
PMID 35939577
Do you obtain serial cardiac PET scans?
Assuming no symptoms of TB, should patients be treated for latent TB prior to starting TNF inhibitors or other immunosuppressive agents?
How should IVIG and either biologic injections or infusions be spaced?
After what interval of sustained remission will you attempt to taper, and will you do so by first widening the dosing interval?
The patient has not responded/has contraindications to apremilast, colchicine, and adalimumab. When they were off azathioprine for 5 days in the past,...
And when do you consider (if ever) IGRT?
(Refractory to mycophenolate, azathioprine, and methotrexate. UpToDate suggests thalidomide or IVIG with mixed efficacy, while there are some case rep...
Will you initiate sarilumab as a first steroid sparing agent or will you still pursue a DMARD such as methotrexate before initiating sarilumab? To wha...
Do you universally perform baseline DEXA and Hgb A1C? How often are you obtaining routine labs?
Would you begin with DMARD therapy like MTX or would you consider starting with an IL-1 antagonist such as Acralyst?
If so, would you start immediately or wait for the second set of labs to confirm before initiating blood thinners?
Per 2021 GCA Vasculitis Guidelines: low evidence, but conditional recommendation for CTA neck, chest, abd/pelvis. Is anybody following this or do you ...
Patient has received treatment with Rituximab and is taking hydroxychloroquine.
For example, patients who have been maintained on 5mg of prednisone for years without previous tapering attempts and the rheumatic disease is not acti...
Additionally, is it correct to assume that IV therapies might be preferred vs oral treatment given alterations in GI absorption in PLE?
Patient became acutely flushed, developed severe and prolonged hypotension with brief loss of consciousness, dizziness, nausea, dry heaves and headach...
If so, when do you recommend timing for the cataract surgery?
Do you typically push for myocardial biopsy in this case?
While classically described as seen in seropositive patients, have they been reported in seronegative RA?
Significant history of autoimmune diseases and DVT in family, recent PE/DVT for a month
And if so, what is your approach to the diagnosis?
Patient is asymptomatic. Labs showed +P-ANCA 1:160. Negative MPO and PR3.
Vasculitis activity has been assessed with serial CTA of the chest and head/neck. She has existing right axillary artery disease and new areas of invo...
Do you treat with only an IV steroid pulse or do you use an oral steroid taper as well? How long of a taper do you typically use?
Lymph node biopsy with non-caseating granulomas and other etiologies (malignancy, infection, vasculitis) ruled out.
Female patient in her 20's with RA/SLE has been on steroids and methotrexate, currently on HCQ and Orencia. Failing Orencia with active disease. Want ...
What screening tests do you perform and at what intervals?
A specific example would be a clinically quiescent but serologically active patient.
Patient is on antibiotics for chronic spinal hardware infection.
How would you treat? Would you view tocilizumab as an option in the future?
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...
How would you treat a patient with necrotizing myopathy with positive anti-HMHCoR Ab (and low TIF1 gamma) that failed prednisone + Cellcept, IVIG + Ce...
Patient already on methotrexate and plaquenil.
Patient previously failed abatacept and Rituximab.
The patient is on a dose of 22 mg of methotrexate weekly for severe rheumatoid arthritis.
If you would discontinue the methotrexate, how long would y...
Nonreliable INR, given hepatic coagulopathy
ANC <500
Is there a certain disease duration or age beyond which you taper immunosuppressive treatments?
In patients with CKD, does urate lowering therapy have an effect (positive or negative) on progression of CKD?
Extrapolating from reactions with other sulfa medications potentially causes flares.
Patient with nephrotic range proteinuria, but there is no evidence of active TMA on renal biopsy.
Do you do blood work? Or do you rely on review of systems?
No evidence of malignancy on serial CT scans.
What doses of allopurinol do you use, and how frequently do you titrate the dose?
The patient was diagnosed with statin-induced necrotizing myopathy (HMGCR +) and received RTX and IVIG (one cycle over 3 days) but developed bra...
(C3 just below normal, C4 undetectable)
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...
Data is clear that we should hold methotrexate at least one week after COVID and flu vaccines. How do you approach methotrexate management around Shin...
The ADVOCATE trial only studied use for 52 weeks.
(Only associated with mild PAH(PAP 38) and with esophageal dysmotility as well.)
Also how would you manage this perioperatively?
In addition, what formula do you use to calculate the IgG index?
Patient with pulmonary hypertension (mixed group 1, 2, 3), COPD, HFpEF, Raynaud’s phenomenon, UCTD (ANA, PM-Scl, SSA-52kd), and recurrent severe...
Do you rechallenge with lower dose? What is your tolerance for mild persistent transaminitis?
Would you proceed with CABG procedure or treat the aortitis first?
Patient with dermatomyositis on rituximab with refractory inflammatory arthritis. Intolerant of traditional DMARDs such as methotrexate, leflunomide, ...
How is this entity distinct from other secondary HLH entities?
Do you typically start the patient on hydroxychloroquine?
What work-up do you perform?
It's been 5+ years after the first course. If you decide to re-irradiate what dosing schema would you use?
This question is part of a collaboration with RheumMadness and is specifically in reference to: Etanercept + Methotrexate.
Other manifestations improved (renal function has stabilized, fatigue, arthritis, and LCV have resolved). Ophthalmologist has controlled the uveitis u...
The patient has no known history of autoimmune disease.
A female in her 50s with iatrogenic Cushing's Syndrome presenting for management of SLE with low disease activity (but not remission) in the setting o...
Patient with history of toxoplasma chorioretinitis, currently on oral and topical prednisone.
Does your approach differ if treating more ILD versus cutaneous disease?
Apart from ruling out malignancy or infection?
How do you differentiate symptoms related to centralized pain syndrome from possible cognitive dysfunction?
Such as Leflunomide, Sulfasalazine, Mycophenolate or Azathioprine, since all of these medications have potential to cause liver enzyme elevation and i...
Do you base the decision on FEV1, 6MWD or symptoms at initial evaluation, or progression over time?
There are studies that show hydroxychloroquine inhibits autophagy (the orderly degradation and recycling of the contents of the cytoplasm for the cell...
(Patient with active RA despite hydroxychloroquine)
In what cases do you discontinue the medication?
When adding nintedanib what sort of treatment course do you counsel the patient on? Do you plan to continue it indefinitely as long as the patient tol...
Do you prefer to start with nintedanib and then add immunosuppressive agents, or give a trial of immunosuppressive medication first, then add nintedan...
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 ...
For example, a patient with a bone marrow biopsy that shows normocellular bone marrow. Prior management with leflunomide and HCQ with neutropenia attr...
Are there any instances where you would prefer a biosimilar rather than the reference product?
Patient with sacroiliitis on imaging, failure of two NSAIDs.
Do you attempt to taper fully or maintain at a low dose?
Are there ways to overcome barriers in insurance coverage of this combination of treatments?
Would you switch to a non TNFi biologic or continue current regimen with careful monitoring for evolution of lupus manifestations?
Is there a role for immunosuppressive medications such as TNF inhibitors in the management of IgA nephropathy in this setting?
Would the etiology of the thrombocytosis play a role in your decision-making?
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...
This question is part of a collaboration with RheumMadness and is specifically in reference to: Hydroxychloroquine Withdrawal.
This question is part of a collaboration with RheumMadness and is specifically in reference to:BeSt TrialMeasurement of Patient Outcomes in Arthritis
In a patient for whom rituximab is the best option for their disease management.
Is there a role of rituximab therapy over repeat cyclophosphamide? (Cyclophosphamide induction 2 years prior)
If a deficiency is present, do you consider IVIG to treat non-infectious symptoms such as skin rash, arthritis or hematological abnormalities?
In addition to the usual pharmcotherapy (CCBs, etc.)
There is no history of trauma or substance abuse.
Several speakers at ACR 2021 commented on the important role of drug levels in the management of these patients and cautioned against adding medicatio...
Patient has failed methotrexate and adalimumab.
Have you tried hyaluronidase?
ANA and ENA negative
4 cutaneous biopsies with no evidence of vasculitis. Sjogren’s diagnosis based prominent sicca symptoms and a significantly elevated SSA.
Patient failed topical ocular therapies, methotrexate, azathioprine.
Do you wait 12 weeks for confirmation to begin treatment if patient is declining?
What would you suggest to help address these disparities in our own practices?
This question is part of a collaboration with RheumMadness and is specifically in reference to: EMBRACE
Studies are now being pursued to ability the of implantable bioelectric device stimulation of the vagal nerve to attenuate disease activity in patient...
For example, in the setting of cirrhosis incidentally found on imaging.
Given the controversy in the literature regarding TNFi or MTX associated lymphoma in patients with RA.
Is SLE-related APLS managed differently in terms of anticoagulation?
When would you consider tapering? at one year? 18 months?
Although testing was not indicated, what do u do with these results?
Other hypercoagulability work up negative
Patients frequently mention diagnosis of SLE years ago but recent Sm, dsDNA (crithidia) and complements can be normal. Can treatment with medications ...
At what CD 19/20 level do you redose? Is this lab dependent?
Do you also use these levels to instruct patients when to get vaccinated?
Does it mirror the same approach as SSc without malignancy? Do patients with paraneoplastic SSc present atypically (without usual serologies or featur...
Would the answer differ if the index event was arterial vs venous?
When do you refer to genetics? Does your approach change if they have an additional finding such as mitral valve prolapse or a prolapsed bladder/uteru...
Significant impact on ADLs and no response to doxycycline, hydroxychloroquine, sulfasalazine or methotrexate.
And if so, are the target levels similar?
Continue MTX with monitoring of LFTs vs switching to another oral DMARD (aza, lef) vs GI for fibroscan?
MPO/PR3, P-ANCA negative. IgG4 normal.
When it seems fairly certain that this is a drug effect is it something that can just be monitored or requires a change in approach?
If work-up is sent and the patient is found to have a persistently positive antiphospholipid antibody, particularly lupus anticoagulant, would you con...
Tibial plateau insufficiency fxs are not discussed in the guidelines for dx or treatment.
Currently on nonwarfarin therapeutic anticoagulation
Is the approach different from uveitis immunosuppression?
Would you favor the use of any particular biologics over others?
Infection risk being primarily chronic venous stasis ulcers
Data is mixed based on the results of ORAL surveillance, STAR-RA and nationwide cohort studies.
If so, is there one type of antibody that is more likely to cause this false positive test?
How do you risk stratify and monitor such patient for disease progression or organ involvement?
Would the checkpoint inhibitor still work if blocking only that portion of the inflammatory cascade as opposed to more global blockade with steroids?
The patient has notable lip lesions from her discoid lupus erythematosus
What is the risk of pregnancy loss in absence of anticoagulation? What would you suggest if the patient had anticoagulation in prior pregnancies and r...
Such as patients with negative Hepatitis B surface antigen and negative viral load but with positive hepatitis b core antibody.
Do you just use antibiotic prophylaxis if therapy is started prior to meningococcal vaccination?
Are there any medications that surgeons like discontinued before their procedure?
Is there a role of immunosuppression or treating underlying malignancy will be enough?
What are your primary and secondary agents?
When would you de-escalate therapy?
When would you consider referral for lung transplant?
Is it time limited since it may have been triggered by the pregnancy or is it indefinite since it is APLS associated?
Any indications for triple therapy in the patients with subclinical ILD associated with MDA-5 dermatomyositis?
Would you obtain imaging? If so, what type of imaging?
I.e., what constitutes well-controlled cancer, IBD, nephrotic syndrome, etc. What other diseases do you put in this category (obesity, autoimmune dise...
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?
Is there a role for monitoring for relapse or increased disease activity as opposed to scheduled dosing?
In the absence of rhabdomyolysis is there still a need to protect the kidneys when patients with inflammatory myositis have CK over 5000 or 10000?
Would you consider EMG, muscle biopsy, repeat myositis panel? Would you consider starting immunosuppression?
In contrast to TNF inhibitors for psoriatic arthritis, which seem to peak and maintain response percentages, the DISCOVER-2 Trial (McInnes et al., PMI...
Does your evaluation hinge on nonresolution with warming? How extensive is your workup?
In clinical practice continued steroid dependence is often seen as a reason to switch therapy and providers can be especially hesitant to use systemic...
Based on the results of the DISCOVER-2 Trial (McInnes et al., PMID 34719872), should guselkumab be used prior to anti-TNF therapy in these patients?
In patients presenting with likely statin-induced myopathy versus statin-induced autoimmune necrotizing myopathy - how do you approach the decision re...
How do you counsel young adults with antibody-negative necrotizing myopathy on prognosis, risk of recurrence, and long-term monitoring/treatment?
Would you consider adding tacrolimus in this situation?
For patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance, what work up process do you typi...
Is there role for IVIG? Would you alter the dose or time course of steroid therapy?
(assuming that the malignancy evaluation has been completed and the lymphadenopathy is confirmed to be reactive)
How do you interpret elevations in antiphospholipid antibodies that are lower than Sapporo criteria?
(e.g. beta 2 glycoprotein IgM > 20 but <40)
Recent articles regarding the use of JAK-Inhibition in RA have suggested to avoid in patients with increased CV risk. However, RA itself is cons...
In your experience, are there specific disease manifestations in which HLAB51 is particularly helpful?
For example, would it be appropriate to consider JAK inhibitor therapy as preferable to TNF-alpha inhibitor in patients with heart failure with reduce...
Such as oral methylprednisolone, dexamethasone, prednisolone, etc.
Assuming other non CTD related causes for PAH have been excluded
How would the approach differ if the patient had a significant bleeding phenotype vs only minor bruising and mucosal bleeding?
If you avoid parathyroid hormone-related protein analog drugs in patients with prior external beam radiation, what data is this based on?
This type of etoposide sparing therapy has been previously described in a case series at https://pubmed.ncbi.nlm.nih.gov/32725881/
Other than inflammatory markers and following symptoms/exam, do you need any other specific monitoring for progression to systemic disease?
Hepatitis screening labs revealing Hep B ag and core positivity with positive PCR
If so, how long after diagnosis do you do so?
How does a diagnosis of active RA inform your treatment approach for patients with breast cancer, if at all?
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...
Does treatment with B-cell depletion and/or negative anti-spike antibody status despite COVID mRNA vaccination influence your decision?
Would you suggest switching to a viral vector vaccine, such as J&J?
Preference for low dose steroids vs attempting colchicine?
Do you routinely check IgA anticardiolipin and beta-2 glycoprotein antibody IgA in your practice? And how would a positive result change your manageme...
Would you hold these agents in the setting of invasive dental procedures?
e.g. DITP from eptifibatide after a cardiac intervention
How does this vary from continued disease monitoring?
For medical oncologists, would you offer a PD-1/L1 inhibitor? For other subspecialties, how would you counsel the oncologist regarding the risk of usi...
Since tocilizumab is known to normalize ESR/CRP, are there any markers/blood tests that may be helpful to check for PMR patients with question of exac...
i.e. obstretric APS without thrombosis or SLE
Would you change the treatment to rituxan or continue orencia with regular dermatology follow up?
Is there an increased drug induced lupus risk?
Additionally, what is the current role for temporal artery ultrasound in workup for GCA?
What immunosuppression and dosing do you typically use?
Specifically, how do you treat the delayed headache, not the headache that develops during the infusion where pre-hydration and slowing down the rate ...
Are there implications of reducing urate too much?
Without a discrete mass to biopsy, is there any utility of any blind biopsies to rule out IgG4 related disease, infectious or neoplastic process?
Is there a role for immunomodulatory therapy?
Is a liver biopsy ever helpful?
How do you decide if it may be safe to continue immunotherapy?
Would chemotherapy be preferred over RT?
Would you consider keeping the patient on denosumab or would switch to an anabolic agent?
Specifically in patients of Vietnamese background? An association has been shown between HLA-B*5801 and the risk of allopurinol hypersensitivity react...
Dr. Charles-Schoeman presented data at ACR 21 showing that, paradoxically, there is a U-shaped relationship between inflammation and LDL levels in pat...
Do you obtain vascular imaging routinely in these cases, and if so, do you use cross-sectional or invasive angiography?
Would you discontinue Methotrexate and TNF inhibitors even if previously no side effects from these medications, and would you consider Cyclophosphami...
Would you use immunosuppression in patients several years after curative treatment for melanoma?
Would your answer change for favorable vs unfavorable intermediate risk disease?
Would you consider this for patients on B-cell depleting therapies or more broadly for other immunosuppressive agents?
Does Quantiferon gold replace the need for baseline chest x-ray screen?
The ACR 2021 RA Guidelines suggest the gradual tapering approach is preferable.
Giving "rescue therapy" to patients in the combination group implies that there is room to escalate to the dose at enrollment.
Withdrawal of methotrexate may lead to more disease flares and lack of recoverability with other TNF inhibitors.
Usual clinical practice is to add TNFi once methotrexate monotherapy has failed. If this is the case in these patients, it would seem to increase the ...
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?
Myositis specific antibodies and pathology results often take weeks to result. In which cases do you start therapy before the diagnosis is solid...
What if the patient is triple-positive or has continued seropositivity on repeat lab testing? What is the appropriate interval of monitoring and does ...
Do you have a preferred initial immunosuppressive regimen?
Are there specific features that suggest drug-induced uveitis versus de novo uveitis?
Thoughts on sarilumab vs methotrexate, or just treat with steroids alone
Small study in pediatric PACNS have evaluated this as a potential marker (Cellucci et al., PMID 22740622)
While low-dose aspirin for primary thrombosis prevention in aPL without APS is not typically recommended outside cardiovascular prevention guidelines ...
Do you switch to SQ MTX, or is it best to add tx, such as a TNFi?
What factors go into choosing the right patient and determining length of therapy?
In other words, do we think of TNFi induced lupus and TNFi induced psoriasis as a drug effect or a class effect?
Do you avoid due to the increased risk of GI adverse events?
Do you use imaging (fibrosis vs. pneumonitis), PFTs, duration of prior immunosuppressive therapy?
There are multiple difficulties that could be seen: steroids can precipitate a sickle cell crisis, vasculitis and sickle cell can produce similar clin...
Does it depend on the DMARD type (biologic, targeted synthetic, or conventional synthetic)?
Is there a role for earlier use of anabolic agents to promote bone healing in patients that develop AFFs?
Would active vasculitis present a contraindication to therapy?
There is some emerging evidence that there is an inflammatory component.
Would you change rituximab maintenance dose or schedule?
Is there a risk of increased radioresistance or secondary malignancy (or conversely, toxicity) for patients on TNF inhibitors...
Specifically: starting dose, rapidity of up-titration, frequency of lab monitoring, frequency of office visits, and timing of assessment for treatment...
Specifically, do you reach for Rituximab or cyclophosphamide?
The case I am considering involves a patient with biopsy-proven fibrosing dacryoadenitis.
Do you follow the 2019 EULAR Guidelines that SLE patients with asymptomatic, positive aPL should be on low-dose ASA?
E.g., inflammatory polyarthritis or inflammatory myopathy with onset within 2 weeks of documented COVID infection
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
What non-pharmacological interventions do you recommend? Do you routinely prescribe prophylactic laxatives to patients initiating opioids? How do you ...
ADVOCATE trial
If so, how would positive levels guide your management?
Muscle disease is quiescent and no other manifestations such as ILD
How is your approach to treatment different than other ILD patterns such as NSIP? Does treatment response vary based on underlying CTD?
(Skin thickening in the absence of visceral disease)
In the ADVOCATE trial, patients were not re-dosed with rituximab.
E.g., MPO vs PR3, newly diagnosed vs relapsed, renal involvement. Acknowledge that the ADVOCATE study was not powered to detect these differences, but...
Especially in a triple-positive patient with an acute ischemic stroke who may have urgency for anticoagulation with high bleeding risk and severe thro...
Does denosumab effect knee replacement or hip replacement? Should replacement occur right before or after injection?
If so, do you take any additional precautions with planning?
For example, healthcare workers who require these vaccines for employment
Given the slow recovery of nerve damage, what would you expect to see on a repeat EMG after treatment? Continued denervation or just sequelae of past ...
What if the patient has MGUS?
Do patients with type 1 cryoglobulins need a bone marrow biopsy as part of the work up?
Are IL-17 or IL-23 inhibitors helpful?
Can axSpA affect the spine without affecting the sacroiliac joints?
How would you label such a patient?
Would you treat differently if they have poor functional status?
Do you stop methotrexate or adjust the dose?
Does your management change if there is renal involvement of the malignancy?
Patient was previously well controlled on methotrexate, which was discontinued during cancer treatment.
Cyclophosphamide/tacrolimus and Rituximab have been used in conjunction with steroids in case series.
Current guidelines do not support its use, but the EMPACTA trial suggests it may be effective in a subpopulation of patients.
If so, are there specific patient populations for which you would use this metric?
Does the type of cardiac involvement impact this choice?
Reduced requirements for documentation by CMS in 2021 with respect to billing and coding have raised new questions about what aspects of physician exa...
If so, what test do you use in clinical practice?
If so, what would be an ideal DMARD in this setting?
i.e., Troponin I, Troponin T, and CK-MB
If so, does this have clinical significance?
To my understanding, sm/RNP should also be positive in this situation (and one would assume a positive ANA as well)
Prior therapies include MTX, abatacept, rituximab
If so, would you adjust the dose?
How do you counsel these patients about hormonal agents?
Did the recently published BLISS-LN trial change your practice?
What if this was "triple-negative" antiphospholipid syndrome?
In patients refractory to NSAIDs and sulfasalazine
If you use both, how do you decide which to use for a particular patient?
Due to the shortage of rheumatologists, primary care physicians may need to manage some rheumatologic issues.
https://www.prismra.com
This question is part of a collaboration with RheumMadness and is specifically in reference to: ADIRA Diet
The SENSCIS trial was published in 2019 on efficacy of this agent. However, it's not clear where this should be in the treatment algorithm: Monot...
In a patient with early stage breast cancer that would otherwise require radiation, would you recommend treatment if the patient has active skin lupus...
Acknowledging that there is no time for good trials yet in this setting
Also, how would you handle immune modulators for rheumatoid arthritis during their treatment?
Do you re-challenge with nivolumab alone, change from nivo 1/ipi 3 to nivo 3/ipi 1 upon re-challenge, or stop immunotherapy altogether if grade 3?&nbs...
How about those with metastatic disease eager to maintain quality of life? Do you risk progression of disease if the TNF blocker is re-started?
Is there any literature on the safety of giving radiation to patients with scleroderma in H&N setting?
Would you require the rituxan to be held prior to radiation? Would this matter if it was in the post-prostatectomy setting?
Is IO related pneumonitis in the radiation field or more diffuse?
Are there any other medications, outside of anticoagulation, that would be considered absolute or relative contraindications?
Do you always stick with a conventional fracionation, or in some cases, are you comfortable hypofractionating? Do you ever use a wait and see approach...
Do you put more weight on specific CVDs such as scleroderma as contraindications for any RT?
Do you have any concern for increased toxicity when you treat a patient with radiation therapy who has an autoimmune disorder? (hypofractiationation v...
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