Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How has the ADVISE trial changed your approach to steroid sparing agents for non-infectious uveitis?
The ADVISE trial was a well-designed, multinational trial that compared adalimumab therapy for non-infectious intermediate, posterior, or panuveitis versus conventional immunosuppressive therapy or CID. Two hundred twenty-seven subjects were enrolled over four years, and a fifth year was required to...
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 the most appropriate next step in management for a patient with dermatomyositis who is maintained on methotrexate 25 mg weekly but develops disease flare when prednisone is tapered below 10 mg daily and is unable to receive IVIG?
The fact that the patient cannot taper prednisone below 10 mg indicates that methotrexate alone, while has some effect, is not sufficient to control the disease. There are several options, depending on the severity of each organ involvement. Since the joints are affected, I would favor an agent that...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
Is it ever safe to use a biologic DMARD in a patient with RA who is on suppressive antibiotics due to a history of septic prosthetic arthritis?
I have used Orencia and HCQ as more immunomodulating with suppressive M/W/F antibiotics in a patient with UTI/Bactrim.
How do you approach hypogammaglobulinemia monitoring when using obinutuzumab for refractory nonrenal SLE patients?
I would start with a baseline evaluation that includes quantitative IgG levels, HBV serologies, including HBsAg and anti-HBc, to assess reactivation risk even if HBsAg-negative, and a CBC with differential. Before treatment, I would make sure all non-live vaccines are completed, and I would avoid li...
In the treatment of osteoarthritis with low-dose radiation therapy is there data to support the claim that LDRT does not limit or preclude later orthopedic surgery?
At LDRT doses, the biological effects are anti-inflammatory and immunomodulatory rather than cytotoxic or fibrogenic, and there is no evidence of vascular injury, impaired cellular proliferation, or tissue destruction. Animal models and cellular studies provide robust evidence that LDRT at OA releva...
How do you counsel patients on the risks and benefits of strontium supplements for osteoporosis management?
No experts whom I know prescribe Strontium for osteoporosis. It has not been shown to be efficacious to reduce fractures, although bone density will rise substantially. Also, bear in mind of very serious toxicities that have been associated with this drug. I would never use it in any of my patients....
How do you manage worsening cutaneous dermatomyositis when muscle disease appears controlled?
The fact that the patient still has an active pruritic rash while tapering steroids suggests that the current regimen isn't fully controlling the disease, and it can affect quality of life. I would consider adjusting immunosuppression, either adding another agent or switching therapies. The specific...
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...