Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Was the methotrexate dose reduced over time in the combination therapy or methotrexate monotherapy groups in the SEAM-RA trial?
No, methotrexate dose was not adjusted. Our goal was basically to answer one question: whether it is better to stop etanercept, stop methotrexate, or continue both. We did not want to be adjusting methotrexate doses at the same time as stopping because this would make results more difficult to inter...
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?
Hi, there are no data specifically on valve replacement for RP. If the patient can be safely anticoagulated a mechanical valve would be likely better since is a young patient. Data from TAK regarding valve replacement suggest subsequent complications are less likely when the aortic root is also repl...
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...
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 ...
For a patient with suspected post-streptococcal reactive arthritis who does not meet criteria for acute rheumatic fever and has a normal echocardiogram at presentation, do you prescribe 1 year of antibiotic prophylaxis?
This is a loaded question. Post-Streptococcal reactive arthritis (PSRA) plagued me during my fellowship (many moons ago). There is a fine line between PSRA and rheumatic fever (RF). We rarely see RF in the United States anymore. If I'm convinced it is PSRA and not RF (e.g., RF migratory arthritis qu...
Do you utilize cytokine panels to guide treatment of patients with EGPA?
Whether biomarkers can guide treatment decisions or predict disease relapse is a critical area of study in ANCA associated vasculitis. However, efforts to identify biomarkers that are predictive in EGPA are at an early stage currently. There have been multiple negative studies of biomarkers being ab...
What is your approach to a patient with RF+/CCP+ rheumatoid arthritis that was previously on TNFi now with high-titer ANA and dsDNA (crithida 1:2560), +chromatin, +histone?
This scenario reads like TNF inhibitor drug-induced serological lupus. The first clinical issue is: are there accompanying symptoms or signs of systemic lupus erythematosus (SLE) beyond the underlying inflammatory arthritis, which would be better attributed to the seropositive rheumatoid arthritis (...
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 ...
How would you apprach a SLE patient who is planning pregnancy on hydroxychloroquine with a high titer dsDNA who cannot tolerate azathioprine and whose only symptom is arthralgia?
In an SLE patient planning pregnancy whose only clinical manifestation is arthralgia, hydroxychloroquine monotherapy is appropriate. During the pregnant and non-pregnant state, additional immunosuppression is not indicated for a high titer dsDNA; rather, monitoring for organ manifestations is approp...
Over what timeline do you typically try to escalate your LN patients to triple therapy?
The new recommendation is "Early Quadruple Therapy" per the 2025 EULAR Lupus Nephritis Guidelines announced during a presentation at EULAR 2025 by Dr. Dimitrios Boumpos.Kudos to EULAR! They recommend this to: increase remission rates reduce the need for steroids with these steroid-sparing agents red...