Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
Has the MAJESTY trial changed your approach to the rituximab versus obinutuzumab choice in a patient with newly diagnosed primary membranous nephropathy and nephrotic syndrome?
The Bottom Line: Recent landmark trials—MENTOR and MAJESTY—confirm that anti-CD20 therapies are superior to calcineurin inhibitors (CNIs) for the treatment of MN.Key Trial DataMENTOR: Demonstrated that RTX was noninferior to cyclosporine at 12 months, and decisively superior by 24 months (60% vs. 20...
How would you work up a patient with cutaneous mastocytosis?
In adults, consider mastocytosis as being systemic until you prove it is not. A single normal or low-elevated tryptase does not eliminate the possibility of systemic mastocytosis. All patients should go to Heme/Onc for consideration of bone marrow biopsy and ideally high-sensitivity PCR to look for ...
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
How do you approach patients with fibromyalgia who are reluctant to consider a psychiatric component to their illness but present with clear mood or anxiety symptoms?
Since patients with fibromyalgia (FM) are often stigmatized and worried that clinicians think “it is all in my head,” it is important to discuss FM treatment and mental health referral from a biopsychosocial perspective. This might include introducing concepts such as the pain/depression dyad, centr...
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...
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.
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...
Is it still significant to denote the etiology of ILD in a patient with PPF?
Yes, absolutely! Infact, the most effective treatment in patients without IPF (PPF) is treatment of the cause. So if there is underlying autoimmune disease or exposure, primary treatment should be directed against that trigger and this has potential to stop progression and even improve lung function...
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...