Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you screen for cardiac disease in patients with dermatomyositis in the absence of symptoms?
I don't typically evaluate for cardiac disease in patients with dermatomyositis who are not symptomatic. There are subtypes of myositis patients where cardiac involvement is more common (such as those with antimitochondrial antibodies and anti-SRP antibodies), and there it may make sense to keep a c...
How would you define failure of anabolic therapy for severe osteoporosis and when would you consider ordering a second round of Evenity or PTH analogue therapy?
“Failure” of any therapy is often in the eyes of the beholder. The most efficient way to determine if there is anabolic activity is to measure a serum PINP (does not need fasting) and, for the PTH anabolic recheck, the PINP 2-3 months later. IF the delta is >10, you can be confident there is more pr...
How do you approach anticoagulation in a woman with SLE who is planning pregnancy, has persistently positive isolated anticardiolipin IgA and anti-β2 glycoprotein I IgA antibodies and a prior history of a provoked DVT after prolonged air travel?
I consider persistently positive IgA anticardiolipin and anti-β2 glycoprotein antibodies just as relevant as IgG/IgM subclasses. Moreover, phosphatidylserine antibodies are also relevant, if this patient could be tested for that as well.
Do you start bisphosphonates after tapering off menopausal hormone therapy to prevent the rapid decline of bone mineral density?
Women lose one T-score unit (10-12%) of bone mass on average during menopause. Estrogen, as a part of menopausal hormone therapy (MHT), is approved by the FDA to prevent osteoporosis, but not for its treatment. Upon MHT discontinuation, women will experience a period of rapid bone loss, for which st...
How long after initiation of steroids and immunosuppressive therapy does muscle biopsy remain reliably informative in the setting of suspected inflammatory myopathy?
I don't think there is any definitive, well-validated answer here. Certainly, obtaining a biopsy within ~2 weeks of initiating therapy, in my experience, has clearly not affected the histopathologic findings that would be characteristic of dermatomyositis, necrotizing myopathy or autoantibody-associ...
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...
Do you routinely perform muscle biopsies in patients presenting with the classic symptoms of Inclusion Body Myositis along with positive CN1A antibody?
YES. There are new consensus guidelines from ENMC about the diagnosis of IBM (Lilleker et al., PMID 38522330). They define the clinical presentation of IBM as typical (age >45, progression over >12 months, long finger flexor weakness > deltoid weakness, quadriceps weakness > hip flexors), or atypica...
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 your approach to refractory oral ulcers in SLE?
I echo @ Cuoghi Edens thoughts! Failure of HCQ does not mean refractory disease. Oral ulcers in SLE often correlate with underlying disease activity and their presence signals a better need for disease control. I would consider escalation to a systemic DMARD, such as MMF, MTX, anifrolumab, or bel...
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...