Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend vitamin K2 supplements in patients with osteoporosis?
The answer, as with most vitamin supplementations, cannot be answered with high-level evidence to support a "yes or no". A bit of background and then a brief review of available evidence.Vitamin K is thought to be important for bone health because it activates several proteins involved in bone forma...
Do the results of FIBRONEER-ILD change your approach to antifibrotic treatment in patients with sarcoidosis related PPF?
It changes my thinking somewhat, but I would be careful not to overinterpret the sarcoidosis results. FIBRONEER-ILD supports the broader concept that once different non-IPF ILDs develop a progressive fibrotic phenotype, targeting fibrosis may be beneficial regardless of the original diagnostic label...
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
How would you manage a patient with non-tophaceous gout with renal insufficiency who previously failed allopurinol and now has a serum urate > 7 despite while on febuxostat 80 mg daily?
Provided the patient is compliant with the current Uloric dose of 80 mg daily and has ongoing flares (symptomatic), options are: Trial increasing the dose of Uloric to 120 mg daily, which is off-label in the US (approved in European and other countries, even in patients with moderate CKD; less defi...
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...
For a patient with ICI toxicity who is resistant to the use of high-dose steroids, are there scenarios where you would consider the use of first-line conventional synthetic DMARD in place of steroids?
Loaded question — I think we need a reframing of ICI-toxicity, much of the ICI side effects are just an autoimmune reaction in a specific organ. High doses of steroids are used if there is a true risk for organ damage (like when you have acute ANCA vasculitis, lupus nephritis, etc.). So if a patient...
How do you counsel patients on the potential benefits of nerandomilast for PPF?
Nerandomilast is an inhibitor of phosphodiesterase 4 (PDE4), which leads to elevated intracellular cAMP, which reduces the expression of profibrotic cytokines and growth factors. It has both antifibrotic and immunomodulatory activity and may be useful in active inflammatory ILD based on these charac...
In routine clinical practice, how do you operationally define ‘progression despite therapy’ in PPF to justify escalation to combination treatment?
ILD patients undergo regular monitoring with intervals based on concern for progression. In addition to symptom review, objective testing includes PFTs with spirometry and DLCO, 6-minute walk testing that provides information on distance walked, symptoms experienced, and whether or not the patient d...
Is it ever safe to use a biologic DMARD in a patient with RA who is on suppressive antibiotics due to a history of septic prosthetic arthritis?
I have used Orencia and HCQ as more immunomodulating with suppressive M/W/F antibiotics in a patient with UTI/Bactrim.
How do you approach management of recurrent idiopathic pleuropericarditis?
The first line is colchicine and NSAIDs until the pain resolves, CRP normalizes, etc… After this, if the CRP tracks with the symptoms, fluid reaccumulation, and/or cMRI evidence of the pericarditis, I find il-1 inhibitors work very well.