Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to explaining the role of the microbiome to patients with inflammatory arthritis?
The gut microbiota play a central role in modulating the inflammatory response. This is especially relevant to inflammatory arthritis, where the pathogenesis is quite well understood, especially as it relates to arthritis associated with inflammatory bowel disease. We also know that the diet is the ...
How do you approach the decision to initiate or continue bisphosphonate therapy in an older patient with significant esophageal disease or swallowing dysfunction?
Unless there are indications to turn first to non-bisphosphonate therapies, I would first consider whether the patient would be a candidate for IV bisphosphonate therapy. Many patients, even those without esophageal disease or dysphagia, find the convenience of an annual outpatient infusion appealin...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
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 routinely evaluate patients with collagen disorders or Ehlers-Danlos for platelet defects?
Yes, I routinely carry out a full hemostasis evaluation, including platelet aggregation and release studies, in patients referred to me with easy bruising and hypermobility with an increased Beighton score suggesting EDS and in those already diagnosed genetically with EDS. EDS patients typically hav...
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...
When in the treatment of OA do you think it is optimal to offer LDRT?
Evidence reality check: Two well-conducted sham-controlled RCTs (hand and knee OA) were negative for clinically meaningful benefit at their primary endpoints. (Minten et al., PMID 30231990, Mahler et al., PMID 30366945). ArthroRad (multicenter randomized, single-blinded) compared standard-dose vs ve...
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 screen for colon cancer in patients with Behcet syndrome with colonic involvement?
Behcet syndrome, unlike some other rheumatologic conditions, for the most part, has not been shown to increase risk of malignancies in patients. This may in part be due to the fact that the disease tends to get milder/less severe with time and treatment. As such, colon cancer screening should follow...
What is your approach to choosing a particular advanced therapy based on patient or disease factors when initiating treatment for moderate-severe IBD?
The selection is based less on relative efficacy and safety (aside from JAKs) and more on the patient: Age, gender, family history, and co-morbidities. Younger males: more concern regarding lymphoma with thiopurines. Young women: If contemplating pregnancy would consider biologics vs small molecule...