Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
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 ...
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 ...
If a patient is legally blind and on hydroxychloroquine, do you still recommend follow up with ophthalmology to monitor for hydroxychloroquine retinal toxicity?
A patient who is legally blind but taking hydroxychloroquine absolutely needs to be monitored by an ophthalmologist. The usual definition of legal blindness in the United States is vision no better than 20/200 in the better-seeing eye. But 20/200 is far better than say counting fingers (the ability ...
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?
Unfortunately, there is no sarcoidosis-specific evidence or guideline that sets how long to continue mycophenolate once orbital disease is in remission. Most of this data is extrapolated from other studies that indirectly measure disease flares. Alipour et al., PMID 40316030, published a study in Re...
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,...
In the setting of new onset severe Raynaud’s with digital ischemia (partial toe amputation), but negative initial rheumatologic evaluation, what additional rheumatologic or hematologic workup should be considered?
This is always a difficult situation. As Rheumatologists, we tend to lean hard on the laboratories, but in cases like this, it is the history and physical examination that tell the better story. The history is critical here, since a smoking/tobacco history gives a lot of information. Any history of ...
Do you recommend medical therapy for extensive atraumatic osteonecrosis of the femoral head to mitigate pain or prevent femoral head collapse?
This is a good question. Extensive atraumatic ON of the femoral head will probably not respond to any medical therapy; eventually, the patient will need a replacement. However, ON that is from a systemic insult (drugs, alcohol) is often bilateral so if the other hip is less affected or not affected,...
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 ...
How should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...