Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is anifrolumab safe to use in patients with a history of malignancy?
Anifrolumab is not formally contraindicated in patients with a history of malignancy, but I would use it with individualized risk assessment.The FDA label states that the effect of anifrolumab on malignancy development is unknown and recommends weighing benefit-risk in patients with risk factors for...
How do you manage persistent hyperuricemia in a patient with CKD3 and type 2 diabetes who has had severe reactions to both allopurinol (SJS) and febuxostat (drug rash), but only a single prior gout flare?
I would just recommend conservative management in this scenario. Unclear if there is an overneed to initiate any uricosuric agents in this scenario, given just single gout flare. If there was a history of uric acid stones, then would consider an alternative but that would be challenging, given canno...
How do you manage worsening cutaneous dermatomyositis when muscle disease appears controlled?
The fact that the patient still has an active pruritic rash while tapering steroids suggests that the current regimen isn't fully controlling the disease, and it can affect quality of life. I would consider adjusting immunosuppression, either adding another agent or switching therapies. The specific...
What cosmetic options can you provide to patients with facial discoid lupus that seems stable?
Procedures such as botulinum toxin A, fillers, and autologous fat grafting can be considered in patients with discoid lupus if the disease has been clinically stable, typically meaning no new lesions or active inflammation for about a year. Light-based vascular treatments such as pulsed dye laser ca...
Would you avoid use of JAK inhibitors in patients with dermatomyositis with autoantibody subtypes with increased risk of malignancy (TIF1y, NXP2)?
This is a difficult question to answer with certainty. Most of the direct data on malignancy risk with JAK inhibitors come from rheumatoid arthritis studies, and primarily involve tofacitinib. It is therefore possible that the risk is not the same across all JAK inhibitors, especially since they dif...
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...
In patients with osteoporosis at high fracture risk, what factors most influence your decision to prescribe teriparatide versus abaloparatide?
Both abaloparatide and teriparatide are very effective anabolic agents to reduce vertebral and nonvertebral fracture risk in patients with osteoporosis (although clinical trials did not demonstrate reduction of hip fracture risk). The two agents are more similar than different and both induce an an...
In a young patient with relapsing polychondritis and aortitis which has led to severe aortic valve regurgitation, is there any preference for a mechanical versus bioprosthetic valve replacement?
There is no data specifically on valve replacement for RP. If the patient can be safely anticoagulated, a mechanical valve would be likely better since it is a young patient. Data from TAK regarding valve replacement suggest subsequent complications are less likely when the aortic root is also repla...
Does SI joint erosion on MRI pelvis push you to use TNF inhibitors over NSAIDs as first line for axial spondyloarthritis?
A decision to consider TNFi (or another targeted therapy) over initial NSAID therapy depends primarily on disease severity, symptom burden, and impact on quality of life, presence of significant peripheral disease (where csDMARDs have already failed or resulted in side effects), contraindications or...
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 ...