Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
If a patient who has tolerated allopurinol for a prolonged period of time is subsequently found to be positive for the HLA-B*58:01 gene, how would you manage urate-lowering therapy thereafter?
There is a strong association between the presence of the HLA-B*58:01 allele and allopurinol-related severe cutaneous adverse reactions (SCAR* - Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis or Severe Hypersensitivity Syndrome). This association was demonstrated in a Taiwanese study by Hung e...
Can needle EMG or nerve conduction studies cause transient MRI abnormalities, such as apparent inflammation, edema, or enhancement of a nerve, that could be mistaken for neuritis on subsequent imaging?
Yes—needle EMG can create small, transient post-procedure MRI/MR-neurography abnormalities at needle insertion sites, including focal T2/STIR hyperintensity interpreted as edema and occasional small hematoma, which can potentially be mistaken for local pathology if the timing is not recognized. In a...
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 ...
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...
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...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
How do you approach the treatment of patients with Ehlers-Danlos hypermobile type with chronic muscle spasms with minimal exertion?
You accept that EDS is a genetic connective tissue disorder and not a rheumatological issue. You check hormones and vitamins to ensure they are in range: especially Mg with the cramps. Some EDS patients find working with an EDS physical therapist is beneficial: the goal being to learn how to exercis...
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...
In a patient with gout previously treated with pegloticase who then discontinued therapy, can pegloticase be safely and effectively restarted?
It depends on the reason for discontinuation of Pegloticase therapy in the first place, since efficacy and safety data varies with it.Pegloticase can be safely and effectively restarted if the initial discontinuation was not due to a loss of efficacy or a severe infusion reaction, and should be done...
How would you manage axial stiffness without pain in an elderly gentleman with a distant history of HLA-B27+ axial and peripheral spondyloarthritis, now with SI joint fusion, no peripheral arthritis, normal inflammatory markers, and no response to TNF inhibition?
Based on the history and lack of response to anti-TNF therapy, I suspect the patient does not currently have active inflammatory disease but likely sequalae of prior damage and degenerative spinal disease as a cause of his stiffness. A trial off of the biologic would help assess if the medication is...