Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
How do you manage worsening cutaneous dermatomyositis when muscle disease appears controlled?
The fact that the patient still has an active pruritic rash while tapering steroids suggests that the current regimen isn’t fully controlling the disease, and it can affect quality of life. I would consider adjusting immunosuppression, either adding another agent or switching therapies. The specific...
What is your approach to a patient with RF+/CCP+ rheumatoid arthritis that was previously on TNFi now with high-titer ANA and dsDNA (crithida 1:2560), +chromatin, +histone?
This scenario reads like TNF inhibitor drug-induced serological lupus. The first clinical issue is: are there accompanying symptoms or signs of systemic lupus erythematosus (SLE) beyond the underlying inflammatory arthritis, which would be better attributed to the seropositive rheumatoid arthritis (...
How do you approach management and monitoring of a patient with features suggestive of early or incomplete antisynthetase syndrome (mechanics hands and positive antisynthetase antibody) but no objective evidence of myositis, arthritis, or ILD at presentation?
Anti-Ha is a very rare antibody, and its positive predictive value is low, particularly when relying on line blot or multiplex bead assays. Especially in the setting of a high ANA titer, a low-level anti-Ha signal may represent cross-reactivity or a false positive, as anti-Ha antibodies are cytoplas...
How long would you recommend that a patient continues guselkumab prior to deciding that the therapy is not effective?
Many trials have a placebo-controlled period of 12-24 weeks. Thereafter, all patients receive active treatment. Even if the original treatment allocation remains unknown to the patient and doctor, they know that from that moment on, everyone receives active treatment. This will have an influence on ...
How do you interpret treatment response in the DISCOVER-2 Trial when patients were allowed to remain on up to 10mg of prednisone equivalent for disease control while on guselkumab?
The dependence on the use of systemic glucocorticoids may indeed be a good reason to change treatment. Especially in patients with psoriatic arthritis. So, if patients are unable to stop systemic glucocorticoids and there are still treatment options for the patient, this could be tried. It is diffic...
Do you check for JCV before starting belimumab?
No. The John Cunningham virus (JCV) is highly prevalent in adults (around 85% of us), and developing progressive multifocal leukoencephalopathy (PML) is incredibly rare in belimumab (BEL) patients. It would not change my patient management. Even if someone tested negative for JCV prior to starting ...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
In residency, we had to get patient permission to videotape sessions and allow our supervisors to watch sessions from behind a one-way mirror. If I were to use a scribe, especially an AI scribe, or if I were audio or video taping the sessions, I would definitely want to get a patient’s approval. I d...
If methotrexate is contraindicated or not tolerated, what systemic treatments do you use for generalized morphea?
I typically reach for mycophenolate as a second-line agent if methotrexate failed or is contraindicated. If the generalized morphea is actively progressing, I will add a steroid taper as a bridge until the DMARD has time to take effect. Whole body UVA1 is also a helpful adjunctive treatment to a DMA...
Which biologics for severe RA are safe in CKD4?
Most biologics, such as monoclonal antibodies, are large proteins that are not cleared by the kidneys, and thus, no dose adjustment is needed for renal impairment, and can be used in advanced stages of CKD. Keep in mind among tsDMARDs that the JAK inhibitors do have a renal dosing adjustment require...