Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach evaluation and management of a patient with chronic arthralgias and bilateral hand weakness who has a positive ANA (1:160) and low-titer anti-SSB positivity, in the setting of otherwise negative ENA panel, normal inflammatory markers, normal complement levels and immunoglobulins, and unrevealing EMG/NCS testing?
The low titer SSB/La antibody would only factor into the consideration of SjD if there were other suggestive features, like documented hypo salivation and/or high ocular staining score, neuropathy, etc. Would learn when they were totally well and what potential triggering events may have occurred. I...
Are the results of the SEAM-RA trial generalizable to other TNF inhibitors given the differences in immunogenicity?
This is a great question, and an important one because different TNF inhibitors have different immunogenicity and patients can make anti-drug antibodies that can effectively neutralize the drug and render it a less effective treatment option. This tends to happen more with some molecular constructs ...
Do you regularly recommend an immunological workup for patients with suspected immunodeficiency or defer to immunology?
I defer after a very preliminary work-up based on the type of immunodeficiency expected. I try to direct the consult to a provider most likely to have expertise in the problem I suspect. Often, I suggest consulting with a provider at NIH.
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
From a rheumatology perspective, I would be mindful that there is accumulating data that like other viral infections, but perhaps even more so, COVID-19 can be a significant "epigenetic hit" to immunologic homeostasis, with the triggering of nascent autoimmune disease not uncommon. Profound fatigue ...
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 ...
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 ...
In a patient with biopsy proven statin associated immune-mediated necrotizing myopathy who previously responded well to methotrexate but now presents with recurrent proximal leg weakness and rising CK/aldolase levels after several years of stability, what would be your preferred next-line treatment strategy?
That's an excellent question. I would approach this as a probable disease flare, after excluding potential triggers such as statin re-exposure, including over-the-counter supplements (e.g., "natural" cholesterol-lowering mushroom products that may contain statin-like compounds). In that setting, I w...
What patient factors are most important when considering who needs a broader workup for osteoporosis prior to starting therapy?
A workup to rule out secondary causes must be done prior to starting therapy for osteoporosis. A good history and exam are recommended to look for any clues for modifiable factors. At a minimum, one should do CMP, 25-OH vitamin D, TSH, and a 24-hour urinary calcium or calcium/creatinine ratio should...
In patients treated with infliximab, do rates of immunogenicity vary based on underlying disease (RA, IBD, sarcoidosis, etc) and/or baseline disease activity?
Yes, rates of infliximab immunogenicity appear to vary based on underlying disease, with evidence showing higher rates for RA than IBD and spondyloarthritis, and tend to increase with higher baseline disease activity. Most patients tend to develop anti-drug antibodies within the first year, but this...
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...