Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
For patients with patellofemoral pain syndrome whose symptoms continue despite an adequate course of physical therapy, what adjunctive treatments (bracing, taping, injections, orthotics, or imaging) do you consider most helpful?
After an adequate course of physical therapy (under the guidance of a knowledgeable PT), I recommend imaging to determine if there is underlying pathology like chondromalacia, chondrosis/fissuring, an OCD lesion, or perhaps a tendinopathy or fat pad impingement. Starting with a plain film (AP, later...
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...
In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?
In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving...
Were the patients enrolled in the SEAM-RA trial prior methotrexate monotherapy non-responders?
Yes, presumably at one time, most of these patients were methotrexate non-responders because otherwise, it’s unlikely they would have required escalation to TNFi. Clinicians would typically not add TNFi therapy unless the patient had first failed DMARDs (i.e., methotrexate in this case). It is impor...
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 ...
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...
Is there any role for immunosuppressive therapy in patients with primary Sjogren's disease with severe pulmonary artery hypertension without ILD findings?
PAH (WHO Class I PH) in/and SJD is not a common relation, and as such would Rx as we Rx regarding PAH in PSS? The pathophysiology of PSS is, at least in part, a vasculopathy that SJD may not share. The question is, however, specific regarding Primary SJD and the assumption then is that this is not a...
Will you give a trial of tirzepatide in patients with PsA and obesity who have a partial response to bDMARD rather than switching their immunosuppressive regimen?
I don't believe the data on the magnitude of the benefit of GLP-1 agonists in arthritis symptoms is sufficient to suggest that adding one of these agents would be preferable to changing DMARDs in a patient with inadequate response.
Is there any expanded diagnostic workup that you pursue for a young female patient with gout?
In 45 years of practice, and with a strong focus on gout, I can count the number of premenopausal women with gout I’ve seen (or, perhaps better stated, recognized) on one hand. Of the last two, one had chronic renal failure due to acute kidney injury incurred secondary to an alcoholic binge a few ye...
How should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...