Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is the role of the rheumatologist in recommending and providing GLP-1 medications to their patients given the benefits across many disease domains including osteoarthritis?
Obesity has long been discussed in the literature as the most modifiable risk factor for knee osteoarthritis pain and progression, with a reduction in knee OA attributed to the decrease in mechanical load. But for the last decade, there has been much attention placed on the impact of metabolic facto...
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...
How do you approach the management of a symptomatic Baker's cyst?
I have offered NSAIDs, PT, and ultrasound-guided aspiration and injection for management of a symptomatic Baker’s cyst in a patient with OA or mechanical pathology. I favor aspiration and injection of the knee joint as well as the cyst, though the literature does not necessitate injection of the joi...
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...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
Would you stop methotrexate or leflunomide if MCV increases after starting the medication with no other parameters of anemia or leukopenia?
I would take this as a sign that the patient is taking their medication. Pretty common and definitely wouldn’t withhold RA tx for this.
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...
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 will you approach tapering of therapy in a patient with PsA who has responded well to tirzepatide and ixekizumab and has maintained disease remission for several years?
This is a difficult question to answer based on current data. While tapering is a standard strategy for DMARD therapies in many rheumatic diseases, many studies show that successful tapering or therapy discontinuation is not possible for most patients. If we are evaluating ixekizumab alone, few pati...
Based on Together-PsA, would you favor starting all patients with PsA and comorbid obesity on combination therapy with tirzepatide + bDMARD or will you pursue initial bDMARD monotherapy with tirzepatide rescue in the event of bDMARD non-response?
In looking at the Together-PsA data, this was a challenging cohort to treat, and a reasonable increase in treatment response was seen with combination therapy. Multiple studies have shown that obese psoriatic arthritis (PsA) patients are less likely to achieve minimal disease activity (MDA) and have...