Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend checking anti-drug antibodies for patients on TNF inhibitors?
This is a very good question with direct clinical practice implications. I do not check or follow anti-drug antibodies when using TNF inhibitors for the treatment of rheumatoid arthritis or psoriatic arthritis. There are reports that suggest, on a group level, that these antibodies, if present, impa...
How do you approach treatment in a patient with +anti-CCP antibodies, negative RF and no current evidence of active inflammatory arthritis, but progression of NSIP?
In these cases, observing a positive CCP suggests some form of an immunologic or autoimmune driven porcess responsible for the NSIP. The result may justify the use of immunosuppressive therapies, including corticosteroids and other drugs, to treat the lung disease. Anecdotally, the CCP positivity co...
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...
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Almost any and all circumstances.
How do you approach tapering decisions for disease-modifying therapy for ICI-induced inflammatory arthritis after the patient's cancer treatment has been completed or the ICI has been discontinued?
This is a great question and, honestly, one that every rheumatologist struggles with. Similar to managing other inflammatory diseases, the challenge is determining when a patient is truly in remission and whether therapy can be safely reduced or discontinued.My approach is fairly practical: The pati...
In patients with isolated anti-Centromere antibody positivity and Raynaud's phenomenon without other features of systemic sclerosis, what is your approach to screening for pulmonary complications?
In patients with isolated anti-centromere antibody (ACA) positivity and Raynaud's phenomenon, even without overt systemic sclerosis, the primary concern is pulmonary arterial hypertension (PAH), which can develop at any point, including decades after initial presentation. Notably, ACA-positive patie...
How do you try to encourage interested medical students and residents to consider a career in rheumatology?
I try to expose them to the practice of Rheumatology and the depth and breadth of what we do, not merely musculoskeletal medicine but every organ system. The beauty of the immune system when it works properly and the many ways we try to control it when it does not behave. The chronic care of these d...
How do you envision incorporating CAR-T therapy into your clinical rheumatology practice?
This is an excellent question—one that, for now, might best be explored over a glass of white wine and some lively hand-waving. It’s a question I often find myself reflecting on every time I hear a presentation or read a new paper on the subject. Here’s a brief editorial response outlining how I env...
How long would you recommend that a patient continues guselkumab prior to deciding that the therapy is not effective?
Many trials have a placebo-controlled period of 12-24 weeks. Thereafter, all patients receive active treatment. Even if the original treatment allocation remains unknown to the patient and doctor, they know that from that moment on, everyone receives active treatment. This will have an influence on ...
What was the rationale for abrupt discontinuation of etanercept rather than gradual tapering in the SEAM-RA trial?
The main goal of this trial was to get RA patients off of therapy and to see whether they would flare or maintain remission. We didn’t expect that the ultimate likelihood of success or failure was going to be primarily related to how long it took to do that. While a gradual withdrawal of the drug ma...