Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What recommendations do you provide patients regarding immunization or boosters prior to initiating rituximab?
To my knowledge, there is no unified recommendation, although the majority of us recommend all age-appropriate immunizations plus strong consideration of younger-than-standard-age immunization for diseases such as pneumococcus and VZV prior to initiation of rituximab when medically feasible. Timing ...
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...
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...
How do you approach a patient with Paget’s disease of bone with elevated alkaline phosphatase and history of chronic kidney disease?
You can give Zol IV, which is clearly the optimal treatment for active Paget's. Those in the field that treat many such patients just administer this very slowly over 1-2 hours and assure good hydration concomitantly. I have treated a number of patients like this, with this scenario, without any pro...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
Do you taper glucocorticoids less aggressively when symptoms improve but serologies remain active in a patient with non-renal SLE?
Cautious tapering of glucocorticoids is a good idea in the setting of ongoing serologic activity. However, given there is clinical improvement in symptoms, one can go ahead and proceed with tapering steroids. It is important to recognize that a subset of patients with SLE may have persistent abnorma...
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...
How long after stopping prednisone do ESR and CRP become clinically reliable for reassessing disease activity?
As with most issues related to corticosteroids, the dose and duration of use matter. When steroids have been tapered slowly after a lengthy period of use, e.g., patients with PMR, it may take weeks (at the least) until we get a true reading of their ESR and CRP values. For shorter tapers, such as fo...
When do you consider genetic testing for autoinflammatory diseases in patients with recurrent pericarditis and fever, particularly when symptoms are highly responsive to IL-1 blockade?
Yesterday ;-). About 10% of patients with recurrent pericarditis have genes that may increase their risk of pericarditis. If you're already managing the patient with IL-1 inhibition, I would strongly encourage you to conduct genetic testing. Just my 2 cents...
What strategies have you found most helpful to improve adherence to hydroxychloroquine among patients with lupus?
In my practice, three approaches have been most useful: Make adherence measurable. I routinely check whole-blood hydroxychloroquine levels and review the trend with patients in a nonjudgmental way. This creates accountability and turns an otherwise “invisible” treatment into something concrete that ...