Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach evaluation and management of a patient with recurrent monoarticular inflammatory arthritis of unclear etiology?
Routine testing will not identify Lyme disease, although the WBC count is higher than usual. If the antibiotic does not target B. burgdorferi, recurrence might mean inappropriate therapy previously. WBC count is WAAAY too high for mere trauma or internal derangement. Anything else to suggest psorias...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...
Would you switch to bimekizumab if a patient with psoriatic arthritis who is already on an IL-17 inhibitor has breakthrough skin or joint disease?
Yes. An abstract at this year's ACR Meeting (Sood et al., PMID 39182686) showed that patients who had failed secukinumab, ixekizumab, or brodalumab did respond to bimekizumab. Although the study included only 43 patients, it still provides solid evidence for a response.
Where do you anticipate using bimekizumab in your sequence of treatment options for a patient with psoriatic arthritis?
In the absence of head-to-head studies, the following answer is based on my own experience, and not data-driven. Bimekizumab is as good as IL-17A inhibitors (Secukinumab and Ixekizumab) on the skin and musculoskeletal (MSK) domains, better than TNFi on the skin, but equally efficacious on MSK sympto...
Do you generally pursue a temporal artery biopsy in a patient who has a halo sign on ultrasound but has an atypical clinical presentation of GCA with normal inflammatory markers in the setting of persistent temporal headache?
This is an important question, and the answer would depend significantly on the details of the presentation. In general, with a highly atypical presentation such as this with normal inflammatory markers AND atypical symptoms, I would pursue TA biopsy and consider large vessel imaging if negative. Wh...
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 assess the risk of developing demyelinating disease when initiating TNF inhibitors?
Demyelinating disease (DD) associated with TNF inhibitors is rare. Risk assessment is mostly clinical. TNF should be avoided if there is a personal history of established DD, especially MS. A strong family history in first-degree relatives or concerning neurological symptoms should warrant caution a...
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 ...
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...
What treatment options do you consider after TNF failure in intestinal Behcet's with ongoing steroid dependence?
Colonic Behcet’s does not necessarily respond the way that IBD does. The evidence base for alternative therapies includes anti-interleukin-1, -6 and anti CD20. Anti Il-12/23 have also been used. Would discuss with a rheumatologist about which options are reasonable, depending on where else there are...