Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In patients with connective tissue disease-associated interstitial lung disease (CTD-ILD) who have achieved clinical and physiologic stability after successful discontinuation of prednisone while on mycophenolate mofetil, how do you typically approach tapering or discontinuing the mycophenolate?
Unfortunately, there are no high-quality, evidence-based guidelines that specifically address tapering or discontinuing mycophenolate mofetil (MMF) in CTD-ILD after achieving clinical stability. The available literature strongly favors prolonged maintenance therapy rather than early discontinuation,...
Was the methotrexate dose reduced over time in the combination therapy or methotrexate monotherapy groups in the SEAM-RA trial?
No, methotrexate dose was not adjusted. Our goal was basically to answer one question: whether it is better to stop etanercept, stop methotrexate, or continue both. We did not want to be adjusting methotrexate doses at the same time as stopping because this would make results more difficult to inter...
How do you counsel patients on use of creatine monohydrate supplementation during a hospitalization for acute rhabdomyolysis from intense physical training?
I was a primary care doctor for the military for a few years. We regularly saw patients presenting with rhabdomyolysis from intense physical training. A standard question for all that present with this is whether supplements are being used. While there isn't a direct linkage to say that the use of c...
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
How would you manage resuming successful abatacept therapy in a refractory RA patient undergoing resection of stage 1 lung adenocarcinoma?
You can restart the abatacept once the patient has recovered from surgery. There is no signal for increased new solid tumors on abatacept, and you would expect the patient to be cured after resection of a stage 1 tumor.
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 manage a patient with SLE with acute bilateral sensorineural hearing loss refractory to high dose systemic and intratympanic steroids, normal MRI brain and APL labs?
Interesting, as I just saw a case almost exactly like this one (except my patient was unilateral)! I question whether systemic lupus erythematosus is truly the cause of the hearing loss. If immunologically induced (ie, autoimmune hearing loss), I'd expect to see at least some objective improvement o...
Over what timeline do you typically try to escalate your LN patients to triple therapy?
The new recommendation is "Early Quadruple Therapy" per the 2025 EULAR Lupus Nephritis Guidelines announced during a presentation at EULAR 2025 by Dr. Dimitrios Boumpos.Kudos to EULAR! They recommend this to: increase remission rates reduce the need for steroids with these steroid-sparing agents red...
Would you consider using avacopan in PR3+ mononeuritis multiplex without other systemic involvement?
I would certainly consider using avacopan in AAV mononeuritis multiplex. While we don't know the outcomes of mononeuritis in avacopan-treated patients specifically, ~20% of patients in the ADVOCATE trial (Jayne et al., PMID 33596356) had neuropathy and the outcomes overall suggest a robust response ...
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...