Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What strategies have you found most helpful to improve adherence to hydroxychloroquine among patients with lupus?
In my practice, three approaches have been most useful: Make adherence measurable. I routinely check whole-blood hydroxychloroquine levels and review the trend with patients in a nonjudgmental way. This creates accountability and turns an otherwise “invisible” treatment into something concrete that ...
Can sIL2-R differentiate between active sarcoidosis affecting small airways vs uncontrolled asthma and guide treatment with methotrexte vs biologics?
This is an interesting question. Just to provide a little context, I used to have a sarcoidosis-focused clinic where one day each week I would see only sarcoidosis patients. I also had a day of seeing only neurosarcoidosis patients once per month, together with neuroimmunology. To be honest, since I...
How do you approach management in patients with adult-onset Still’s disease presenting with active polyarthritis (without macrophage activation syndrome) who remain symptomatic despite prednisone 15 mg/day and methotrexate 25 mg/week?
Biologics, especially IL-1 but also IL-6 blockers, have been shown to be beneficial for patients with Still's disease. In fact, there seems to be a window of opportunity whereby patients that are started early on cytokine blockade are more likely to achieve drug-free remission in the future. Anakinr...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
Do you obtain mycophenolate levels before escalating therapy in patients with extrarenal SLE?
I do not check them routinely unless I am concerned about compliance or potential side effects. It is reasonable to do so now that checking levels is readily available. It is not routine for lupus, as it is for transplant patients. In searching the literature, there is no controlled trial in lupus r...
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...
How has the ADVISE trial changed your approach to steroid sparing agents for non-infectious uveitis?
The ADVISE trial was a well-designed, multinational trial that compared adalimumab therapy for non-infectious intermediate, posterior, or panuveitis versus conventional immunosuppressive therapy or CID. Two hundred twenty-seven subjects were enrolled over four years, and a fifth year was required to...
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 would you approach immunosuppression in a patient with well-controlled HIV and RF+ rheumatoid arthritis breaking through hydroxychloroquine with ongoing inflammation confirmed on ultrasound?
The Infectious Disease Society of America (IDSA) defines HIV viral suppression as a viral load that is persistently below the level of quantification or detection of the assay used to measure the viral load. Prevention of sexual transmission is thought to occur at levels less than 200 copies of viru...
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Here is a recent expert consensus by Joel Block on the use of low-dose radiation therapy in OA: Some highlights: "Placebo-controlled randomized clinical trials have now been reported using LDRT for OA of the knees and of the hands. Taken together, they do not show benefit beyond placebo... While a d...