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 ...
What is your approach to management of a patient with sarcoidosis who is asymptomatic, but demonstrates progressively enlarging mediastinal lymphadenopathy and rising soluble IL-2 receptor levels?
My concern here would be whether such a patient does not have 'asymptomatic sarcoidosis' but has CVID (often associated with multifocal non-caseating granulomas) with an associated B-cell lymphoma (for which such patients have a 30-fold Relative Risk) with developing mHLH (elevated sIL-2 being an as...
Do you start low dose aspirin for preeclampsia prevention in patients with myositis planning pregnancy?
I generally favor low-dose aspirin for preeclampsia prophylaxis in pregnant patients with idiopathic inflammatory myopathy (IIM), barring contraindications and in collaboration with maternal–fetal medicine. I discuss the plan before conception but typically begin 81 mg daily at 12 weeks’ gestation, ...
How do you determine osteoporosis treatment response when patients have discrepant DEXA scan results during monitoring (eg improved BMD of the hip and spine but worsening BMD of the femoral neck)?
This is not all that uncommon. The first thing I do is ask if they have fractured since we started the therapy. If not, I relax a little. This is a nice scenario for using bone turnover markers as part of initial work up. If PINP goes up by >10 I am happy that an anabolic drug is working... more you...
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 do you include in differential diagnosis when evaluating a patient with calcinosis cutis?
When evaluating the patient with calcinosis cutis, I first make sure that the patient indeed has calcinosis cutis. In general, there are two types of ectopic calcifications in soft tissues: metastatic and ectopic. Metastatic calcifications occur in the setting of abnormal. serum calcium and/or phosp...
How would you approach management of asymptomatic hyperCKemia with + HMG-CoA reductase antibodies and biopsy findings suggestive of immune-mediated myopathy?
As anti-HMGCR antibody testing becomes more common, we are likely to see more false-positive results. Still, most patients with positive anti-HMGCR antibodies eventually require treatment. In the 2017 Johns Hopkins cohort (Tiniakou et al., PMID 28096458), only 4 of 104 anti-HMGCR-positive patients d...
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...
Do you recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...
How often are you repeating screening PFTs in patients with SARDs who have 3 or more years of normal or stable PFTs?
The answer to this question is complex and needs to be tailored to the individual patient’s risk for ILD and the particular SARD.Approximately 30-40% of patients with systemic sclerosis (SSc) will develop ILD, typically within the first 5 years after the first non-Raynaud’s manifestation and rarely ...