Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach management of a patient with longstanding history of SLE, but having active psoriasis?
Since methotrexate (MTX) worked well before, I'd revisit other possible ways to use it in ways that minimize GI issues. For example, splitting up oral MTX over 24 hours can help alleviate GI side effects (eg 2.5 mg q 12 hours for 3 doses), yet have greater efficacy due to a larger area under the cu...
How do you optimize retinopathy screening schedules for patients on hydroxychloroquine while also prioritizing cost-effectiveness?
I'll approach this from the cost-effectiveness standpoint as I agree with Drs. @Dr. First Last and @Dr. First Last on their excellent points.Patients with SLE have remarkably high costs when you add up copays, medications, imaging studies, travel, missing work, etc. Anything we can do to help reduce...
In what clinical situations would you favor IM methylprednisolone over a short oral prednisone taper for managing an RA flare?
I am not an RA expert; however, I am well-versed in the use of IM steroids for flares.After Dr. Petri's FLOAT study in SLE (Danowski et al., PMID 16395750), we have utilized IM steroids instead of daily PO prednisone as our "go-to" treatment of choice as much as we can over Medrol dose packs and QD ...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
How do you try to encourage interested medical students and residents to consider a career in rheumatology?
I try to expose them to the practice of Rheumatology and the depth and breadth of what we do, not merely musculoskeletal medicine but every organ system. The beauty of the immune system when it works properly and the many ways we try to control it when it does not behave. The chronic care of these d...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
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...
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 ...
Would you add romosozumab to denosumab for a year or switch to romosozumab for a year in a patient who fractures on long term denosumab therapy?
My preference, if insurance was not an obstacle, would be to add romo rather than switch. The data are limited and certainly this is "off label" but the rationale is reasonable. Denosumab treatment leads to increased sclerostin levels which would be targeted by the addition of Romo; furthermore thi...
Does significant eosinophilia (8-44%) in a patient with suspected granulomatosis with polyangiitis (GPA) based on sinusitis, pulmonary nodules and positive PR3 change your management approach?
This is an important question because at times the distinction between GPA and EGPA can be difficult to make. In general, I would rely on clinical symptoms as a key distinguisher. For example, sinusitis in GPA differs from that of EGPA, with the former often causing crusting, erosions/necrosis on EN...