Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you assess and manage cavitating pulmonary rheumatoid nodules?
Challenging and rare situation these days!So first, my goal is to confirm that these cavitary nodules are indeed rheumatoid nodules, meaning that there is minimal concern for malignancy, infection, or an alternative cause.There’s a study from Mayo that aims to help differentiate rheumatoid nodules a...
In a young patient who was vaccinated against chickenpox as a child (no previous varicella infection), should the patient receive a shingles vaccine prior to starting Rinvoq?
Yes. The vaccines are different and current vaccine is to prevent zoster for patients who have been previously exposed to varicella or vaccinated for varicella.
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
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 ...
Should we be less cautious with the use of GLP 1 R agonist therapy for patients with osteoporosis and obesity given recent data suggesting significantly lower fall and fracture risk?
The interaction of GLP-1 R agonist therapy and fracture risk is complicated, and I would not assume a decrease in the risk of fracture for most patients. However, there were three recent retrospective studies that all showed decreased fracture risk following use of either semaglutide or tirzepatide ...
If a patient is legally blind and on hydroxychloroquine, do you still recommend follow up with ophthalmology to monitor for hydroxychloroquine retinal toxicity?
A patient who is legally blind but taking hydroxychloroquine absolutely needs to be monitored by an ophthalmologist. The usual definition of legal blindness in the United States is vision no better than 20/200 in the better-seeing eye. But 20/200 is far better than say counting fingers (the ability ...
For a patient with orbital sarcoidosis who has achieved sustained clinical remission on adalimumab in combination with mycophenolate mofetil, how long would you recommend continuing mycophenolate before considering a gradual taper and discontinuation?
Unfortunately, there is no sarcoidosis-specific evidence or guideline that sets how long to continue mycophenolate once orbital disease is in remission. Most of this data is extrapolated from other studies that indirectly measure disease flares. Alipour et al., PMID 40316030, published a study in Re...
What strategies have you found most effective in improving long-term medication adherence in patients with SLE?
Patient education and buy-in are key for achieving long-term medication adherence. Medication adherence is the outcome of several factors, including but not limited to access to healthcare: appointments, laboratory visits, transportation, health literacy, medication fatigue, and response to therapy,...
In the setting of new onset severe Raynaud’s with digital ischemia (partial toe amputation), but negative initial rheumatologic evaluation, what additional rheumatologic or hematologic workup should be considered?
This is always a difficult situation. As Rheumatologists, we tend to lean hard on the laboratories, but in cases like this, it is the history and physical examination that tell the better story. The history is critical here, since a smoking/tobacco history gives a lot of information. Any history of ...