Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
What drives you to initiate a csDMARD early rather than relying on prolonged corticosteroids alone in a patient with ICI-induced inflammatory arthritis who has moderate disease activity with polyarticular involvement and tenosynovitis at the time of rheumatology referral?
My approach differs somewhat from the traditional paradigm of early csDMARD initiation. In patients with immune checkpoint inhibitor-induced inflammatory arthritis (ICI-IA), particularly those with moderate disease activity, polyarticular involvement, and tenosynovitis, my primary goal is to avoid p...
How do you approach evaluation and management of a patient with recurrent monoarticular inflammatory arthritis of unclear etiology?
Routine testing will not identify Lyme disease, although the WBC count is higher than usual. If the antibiotic does not target B. burgdorferi, recurrence might mean inappropriate therapy previously. WBC count is WAAAY too high for mere trauma or internal derangement. Anything else to suggest psorias...
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- machine not calibrated correctly.
Are there particular subsets of AAV patients in which avacopan is more effective?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:Patients in the ADVOCATE trial were stratified at entry according to time of diagnosis (new/relapsing), diagnosis (GPA/MPA), ANCA serotype (PR3/MPO), and background immunosuppressive (cyclophosphamide/rituximab) with re...
When stopping denosumab and transitioning to PO bisphosphonate, do you wait for 6 months after the last denosumab injection to start PO bisphosphonate?
Some background: In patients discontinuing denosumab without subsequent antiresorptive therapy, BMD rapidly reverts back to baseline with an elevation in vertebral fracture risk (with an enhanced risk of multiple vertebral fractures). Thus, sequential treatment regimens following denosumab have been...
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 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 ...
Do you routinely check HLA-B*58:01 allele status in patients of Vietnamese descent before starting allopurinol?
If Asian or African American descent.
How do you decide when to discontinue immunotherapy for primary angiitis of the central nervous system (PACNS)?
I take a multidisciplinary approach with involvement of my neurobiology and rheumatology colleagues for the immunotherapy. PACNS can be relapsing or remitting. So needs close monitoring with radiologic (MRI and MRA high resolution vessel wall imaging or CTA/MRA with CSF studies 6 months and then 1 y...