Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
In a patient with persistent symptoms of Lyme arthritis after initial treatment course with oral antibiotics, do you prefer a second course of oral antibiotics or do you frequently offer a course of IV ceftriaxone?
Patients diagnosed with Lyme arthritis should receive a 28-day course of oral antibiotics, preferably doxycycline. If patients achieve at least a partial response, a second course of oral antibiotics may be given. However, in patients with minimal to no response following the initial course of oral ...
Do you have safety concerns when prescribing GLP-1 medications in patients on corticosteroids or immunosuppressive therapy?
I think we need to be particularly careful when co-prescribing with systemic corticosteroids because of the risk of sarcopenia. We know that rapid weight loss is accompanied not only by a loss of fat tissue but also of muscle. Corticosteroids can also have myotoxicity and cause muscle atrophy. I the...
Do you think we can extrapolate the results of TOGETHER-PsA and expect similar results and safety when adding Tirzepatide to another IL-17 inhibitor or to a bDMARD with different mechanism of action?
Yes and no. We don't have hard randomized controlled trial (RCT) data with biologic disease-modifying antirheumatic drugs (bDMARDs) other than ixekizumab at present. However, if we extrapolate data from prior weight loss studies in psoriatic arthritis (PsA) and psoriasis (PsO), it would be reasonabl...
Will you give a trial of tirzepatide in patients with PsA and obesity who have a partial response to bDMARD rather than switching their immunosuppressive regimen?
I don't believe the data on the magnitude of the benefit of GLP-1 agonists in arthritis symptoms is sufficient to suggest that adding one of these agents would be preferable to changing DMARDs in a patient with inadequate response.
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?
This is a very important question, but it is challenging to address with the current data. In an obese PsA patient with very mild disease, it might not be unreasonable to start a GLP-1RA in combination with an NSAID first to determine whether weight loss alone, along with a mild anti-inflammatory, i...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
What treatment strategies would you utilize in a patient with newly diagnosed HLA-B27+ axial spondyloarthritis (with active and chronic sacroiliitis on MRI) and recent diagnosis of MS that is well-controlled MS ocrelizumab given the need to avoid TNF inhibitors?
This is a very challenging scenario. On one hand, TNFi are generally unsafe for MS due to demyelination risk, and on the other hand, anti-CD20 therapies for MS are linked to new AxSpA, but B-cell depletion might also benefit AxSpA. Thus, management requires specialized care in balancing both disease...
How do you approach a patient with idiopathic anterior uveitis who has ongoing disease despite adalimumab every two weeks?
This is a style question, I think. I thought it would be useful to note the choice here might depend on testing for anti-adalimumab antibodies as there is some suggestion that changing to once weekly adalimumab in the presence of anti-adalimumab antibodies might not be efficacious. (Ismayilova et al...