Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
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 (...
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...
What is in the differential diagnoses for isolated bilateral tarsometatarsal joint erosions in the absence of other clinical or serologic evidence of systemic inflammatory arthritis?
Post-traumatic injury is the most common cause, especially mid-foot sprains and fractures, although not usually bilateral unless there is a predisposition such as high arches and osteoarthritis (OA) that can occur due to mechanical stress. Erosive OA can cause these findings, although more commonly ...
How has the new data regarding long-term follow-up of degenerative meniscal tears vs surgery changed your management approach in these patients?
Degenerative meniscus tears are a common finding on MRI in our older patients. A challenge lies in determining if that finding is the cause of the patient's symptoms. When deciding whether to send for surgical consultation, I query about mechanical symptoms (catching, locking, or giving way) and/or ...
How do you approach incidental NXP-2 antibody positivity in patients without current clinical evidence of myositis or systemic autoimmune disease?
A positive anti-NXP2 antibody in an asymptomatic patient may indicate either a false positive or a subclinical form of dermatomyositis. The initial step is to review the testing method (e.g., ELISA, immunoblot). If possible, confirm the result with a different assay, ideally immunoprecipitation, tho...
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...
What is your approach to a patient with generalized morphea, no systemic involvement but a positive RNA Polymerase III?
I would perform age-appropriate cancer screening given the link between RNA pol III and cancer. Otherwise, I would simply monitor for onset of systemic sclerosis or other autoimmune disease symptoms.
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 ...