Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach the management of autonomic neuropathy in a patient with Sjogren's?
Early on in working with autoimmune patients, I had access to neurogastroenterology specialists and gained an appreciation for GI dysmotility disorders. In addition to Scleroderma, Sjogren's patients frequently had documented abnormalities on motility studies. Neuro and immune abnormalities can lead...
How do you optimize retinopathy screening schedules for patients on hydroxychloroquine while also prioritizing cost-effectiveness?
I'll approach this from the cost-effectiveness standpoint as I agree with Drs. @Dr. First Last and @Dr. First Last on their excellent points.Patients with SLE have remarkably high costs when you add up copays, medications, imaging studies, travel, missing work, etc. Anything we can do to help reduce...
How do you approach diagnosis and management of orbital myositis?
Orbital myositis is an umbrella diagnosis that includes a wide range of potential underlying conditions. Patients with this presentation are often first evaluated by neuro-ophthalmology to exclude causes such as isolated orbital myositis, myasthenia gravis, thyroid eye disease, infection, and diabet...
For patients with evidence of prior bilateral uveitis (PS, pupillary membranes, inactive KP, no view posteriorly) who reports no prior symptoms and who has had negative lab work-up, when do you consider repeat work-up and which labs would you repeat?
This is a difficult question to answer succinctly, as so much information is missing to provide a complete response. However, it does raise some important points that are worth mentioning:There is a prevailing tenet, which I was taught as a resident and hear often from residents today, that 1st epis...
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...
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...
For a pediatric patient with juvenile spondyloarthropathy with partial response, though ongoing axial disease, on a JAKi, would you increase the dose of JAKi, add methotrexate, or switch to alternate therapy like IL-17 inhibition?
Let me first disclose that I am not a pediatric rheumatologist and would defer to one. Have NSAIDs been tried and optimized? If not, that is the best first option. In general, optimizing the dose of a medication that seems to be working is a great choice. However, I do not know what current dosage i...
Is there any role for prophylactic DMARD therapy to prevent immune-related adverse events (irAEs) in patients receiving immune checkpoint inhibitors?
Excellent and timely question!There are no good studies-- but I truly believe this is where we are heading for cellular therapies and IO. I am unsure if it will be DMARDs, as lung cancer patients get premetrexed with IO and still develop irAEs-- it will more likely be bDMARDs.The reason, I believe, ...
What is your approach to management of recurrent Kikuchi-Fujimoto Disease?
My experience with recurrent Kikuchi–Fujimoto disease (KFD) is limited, as I have not managed many recurrences; however, this is the general framework I use in practice. At the time of a recurrence, I first reassess the diagnosis and consider potential mimics—particularly infection, lymphoma, and ev...
Do you reduce the dose of hydroxychloroquine in patients with skin graying if they are not particularly bothered by this side effect?
I wouldn't if they're not bothered, but I would think to look into their HCQ blood levels... we know that certain doses of HCQ are more effective in controlling disease activity than others, and that of course, higher levels may be associated with adverse effects, not just in the skin.