Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach treatment for a patient with positive C- ANCA/PR3 with sinus/nasal limited disease, but no renal or pulmonary involvement?
The treatment of non-severe GPA varies amongst practitioners because of limited trial data and different practice patterns. 2021 ACR/VF guidelines conditionally recommend methotrexate and glucocorticoids. Rituximab would also be a reasonable option; therefore, I typically favor shared decision-makin...
Do you start low dose aspirin for preeclampsia prevention in patients with myositis planning pregnancy?
I generally favor low-dose aspirin for preeclampsia prophylaxis in pregnant patients with idiopathic inflammatory myopathy (IIM), barring contraindications and in collaboration with maternal–fetal medicine. I discuss the plan before conception but typically begin 81 mg daily at 12 weeks’ gestation, ...
How long do you maintain patients with anti-synthetase syndrome on Rituximab?
This is a challenging question to address, as there are no evidence-based guidelines, and multiple approaches may be attempted. My practice is that once the patient has been stable for at least 6–12 months, and after discussing the risk of flare with them, I attempt to reduce immunosuppression. For ...
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Here is a recent expert consensus by Joel Block on the use of low-dose radiation therapy in OA: Some highlights: "Placebo-controlled randomized clinical trials have now been reported using LDRT for OA of the knees and of the hands. Taken together, they do not show benefit beyond placebo... While a d...
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 should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...
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...
What is your approach to counseling patients regarding re-initiation of anti-TNF therapy after completion of treatment for non-disseminated pulmonary histoplasmosis?
We published a retrospective study on this topic in 2015 (Vergidis et al., PMID 25870331). We concluded that resumption of TNF-alpha antagonist therapy may be considered in individuals treated for histoplasmosis who have no evidence of residual disease and undetectable Histoplasma antigen levels. We...
Do you obtain mycophenolate levels before escalating therapy in patients with extrarenal SLE?
Similar to Dr. @Dr. First Last, I primarily check MPA levels to assess adherence to therapy. Not surprisingly, poor adherence is common due to the high pill burden of taking mycophenolic acid analogs (MPAA). Finding an unexpectedly low level can open that conversation about identifying barriers and ...
Would you initiate antifibrotic therapy in a patient with CTD-ILD experiencing worsening symptoms and declining lung function, despite no clear evidence of fibrosis on CT scans?
If the predominant findings on CT were ground glass opacities and/or nodules without any evidence of fibrosis on CT, I would not start with an antifibrotic and, instead, would start with immunosuppression as a first-line agent. Based on the American College of Rheumatology (ACR) and American Thoraci...