Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you manage a possible autoimmune sialadenitis arising from checkpoint inhibitor therapy?
This is a great question and a common clinical scenario in patients receiving immune checkpoint inhibitors. In my experience, severe sicca symptoms from immunotherapy are often not classic primary Sjögren's syndrome, despite some overlapping features. Rather, this appears to be an acute T-cell-media...
In the setting of new onset severe Raynaud’s with digital ischemia (partial toe amputation), but negative initial rheumatologic evaluation, what additional rheumatologic or hematologic workup should be considered?
This is always a difficult situation. As Rheumatologists, we tend to lean hard on the laboratories, but in cases like this it is the history and physical examination which tell the better story. The history is critical here, since a smoking / tobacco history gives a lot of information. Any history o...
As a primary care provider, how should I adjust cervical cancer screening for patients with different types and degrees of immunosuppression, such as solid organ transplant recipients on intensive regimens versus patients on biologics like Humira or Dupixent, or people with HIV and an undetectable viral load?
Dr. @Dr. First Last, I like this question a lot. We rheumatologists can tend to forget how complicated this topic can be.I. Hydroxychloroquine (Plaquenil), the #1 drug to treat SLE, is often mistaken as an immunosuppressant, but it is not. It is an immunomodulatory therapy without true immunosuppres...
In patients with Sjogren’s disease, what is your approach to baseline ILD screening and subsequent monitoring?
My approach generally follows the Consensus Guidelines for Evaluation and Management of Pulmonary Disease in Sjögren’s published in Chest in 2021. These guidelines specify different approaches for asymptomatic patients diagnosed with SjD versus SjD patients with pulmonary symptoms. For the former, a...
How do you envision incorporating CAR-T therapy into your clinical rheumatology practice?
This is an excellent question—one that, for now, might best be explored over a glass of white wine and some lively hand-waving. It’s a question I often find myself reflecting on every time I hear a presentation or read a new paper on the subject. Here’s a brief editorial response outlining how I env...
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...
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...
Do you ever consider tapering off steroid-sparing agents in patients with stable non-IPF ILD?
In short, the answer is YES—I always look for ways to reduce immunosuppression exposure over time and use the lowest effective dose required to keep a patient’s inflammatory ILD in check. I often remind myself that when these patients present with a mixture of fibrotic changes (e.g., traction bronch...
What do you include in differential diagnosis when evaluating a patient with calcinosis cutis?
When evaluating the patient with calcinosis cutis, I first make sure that the patient indeed has calcinosis cutis. In general, there are two types of ectopic calcifications in soft tissues: metastatic and ectopic. Metastatic calcifications occur in the setting of abnormal. serum calcium and/or phosp...
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 ...