Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
When would you recommend uric acid-lowering therapy for a patient with asymptomatic hyperuricemia without comorbidities but with family history of gout?
I would not recommend treating asymptomatic hyperuricemia unless the patient has clinical gout or concern for proven urate nephropathy (such as with uric acid kidney stones). The family history component is important to acknowledge that the patient may be at greater risk in the future, however, it d...
For a patient with orbital sarcoidosis who has achieved sustained clinical remission on adalimumab in combination with mycophenolate mofetil, how long would you recommend continuing mycophenolate before considering a gradual taper and discontinuation?
In patients with sarcoidosis who achieve remission, I generally favor considering a gradual taper of immunosuppressive therapy after sustained disease control, rather than discontinuing treatment immediately once clinical remission is achieved.There is no universally accepted duration of remission o...
Do you counsel patients differently about the risk of radiation induced malignancy when you are treating a proximal joint (hip) vs a distal joint (elbow) for benign conditions such as OA?
The mentality for this must change from radiation oncologist thinking to radiation medicine thinking. There have been no documented cases of malignancy from LDRT treatment of OA. Those who worry about the spine reference old studies giving 20 Gy in 5 fx with an open field pre-linac era. This is not ...
Should we be less cautious with the use of GLP 1 R agonist therapy for patients with osteoporosis and obesity given recent data suggesting significantly lower fall and fracture risk?
The interaction of GLP-1 R agonist therapy and fracture risk is complicated, and I would not assume a decrease in the risk of fracture for most patients. However, there were three recent retrospective studies that all showed decreased fracture risk following use of either semaglutide or tirzepatide ...
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 ...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
In a postmenopausal woman who is an avid marathon runner with no prior history of fractures, how would you approach treatment if DEXA shows severe osteoporosis at the distal radius (T-score −4.1) but only osteopenia at the hip and lumbar spine?
I would also make sure there was no error. I had a patient who had similar results, and it was a machine error- the machine was not calibrated correctly.
What is your typical steroid taper regimen for managing RA flares?
I tend to avoid doing steroids to my patients with RA. When I do, I use low doses, 5 mg to 7.5 mg QAM for no more than 2 weeks or so. Generally, I tend to avoid the use of steroids in this population unless absolutely necessary, e.g., RA vasculitis, etc. However, there are patients who require more...
What strategies have you found most effective in improving long-term medication adherence in patients with SLE?
Patient education and buy-in are key for achieving long-term medication adherence. Medication adherence is the outcome of several factors, including but not limited to access to healthcare: appointments, laboratory visits, transportation, health literacy, medication fatigue, and response to therapy,...