Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach a patient referred for esophageal aperistalsis with a longstanding history of Raynaud’s phenomenon, but without other clinical features or serologic findings suggestive of systemic sclerosis?
Scleroderma esophagus (distal aperistalsis/absent contractility + hypotensive LES) is a manometric finding, not a diagnosis. There are multiple causes of this finding, including other autoimmune diseases, neuropathic conditions, and metabolic causes.In addition, RP is seen in 3-8% of the population....
How soon after starting treatment would you repeat imaging in patients with Takayasu to monitor response and ensure you have the correct diagnosis?
The optimal imaging frequency and imaging modality with which to monitor disease activity in TAK are not well defined. I would highlight some general concepts that I find helpful in determining the best monitoring strategy for a given patient. 1. Imaging interval should generally be shorter in patie...
In which Sjogren's patients do you prioritize systemic treatment strategies at time of diagnosis?
Answering this question would really depend on what exact type of patient you are dealing with. You may consider initiating oral DMARDs such as hydroxychloroquine, methotrexate, or azathioprine for patients with inflammatory arthropathy or significant autoimmune rashes. More aggressive therapy would...
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 ...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
Are there adverse consequences of suppressing serum urate levels too much?
It's an interesting question. I personally do not have a lower limit that I have in mind per se, and frankly rarely see anything less than 3 in any of my patients. But I would consider 2-3 being a range which could be deemed low and potentially an issue long term in brain health and because of its n...
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: 1) Trial increasing 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 defined ...
How do you decide whether to continue hydroxychloroquine in a young patient who develops subretinal neovascularization with no other risk factors?
Hydroxychloroquine (HCQ), an anti-inflammatory and immunomodulatory agent, is used to treat autoimmune diseases (rheumatoid arthritis, lupus, Sjogren’s disease, etc.) and malarial prophylaxis. Vision problems can ensue resulting from these deleterious irreversible effects of HCQ on retina if the cum...
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...
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 ...