Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you select bisphosphonate versus denosumab when initiating treatment prompted by opportunistic CT findings of low L1 attenuation and a prevalent vertebral fracture?
Actually, I prefer calcitonin. It has few side effects and does not have the jaw necrosis risk.
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 would you approach evaluation and management of a patient with chronic arthralgias and bilateral hand weakness who has a positive ANA (1:160) and low-titer anti-SSB positivity, in the setting of otherwise negative ENA panel, normal inflammatory markers, normal complement levels and immunoglobulins, and unrevealing EMG/NCS testing?
The low titer SSB/La antibody would only factor into the consideration of SjD if there were other suggestive features, like documented hypo salivation and/or high ocular staining score, neuropathy, etc. Would learn when they were totally well and what potential triggering events may have occurred. I...
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...
In patients with Sjogren’s disease, what is your approach to baseline ILD screening and subsequent monitoring?
My approach generally follows the Consensus Guidelines for Evaluation and Management of Pulmonary Disease in Sjögren’s published in Chest in 2021 (Lee et al., PMID 33075377). These guidelines specify different approaches for asymptomatic patients diagnosed with SjD versus SjD patients with pulmonary...
In a young patient who was vaccinated against chickenpox as a child (no previous varicella infection), should the patient receive a shingles vaccine prior to starting Rinvoq?
Yes. The vaccines are different and current vaccine is to prevent zoster for patients who have been previously exposed to varicella or vaccinated for varicella.
Would you favor oral bisphosphonates over intravenous formulations for patients with hormone sensitive prostate cancer and androgen deprivation therapy (ADT) related osteopenia?
If kidney function is normal, either would do. Therapy depends on the risk level. (See Cosman et al., PMID 39073912.)
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 ...
Would you expect to see severe arthralgias within the first few days of immune-therapy in a patient without history of autoimmune disease?
The short answer is: Absolutely!The long answer is:From a mechanistic standpoint, it is common to see severe arthralgias within days of initiating immune checkpoint inhibition, even in a patient without a prior autoimmune diagnosis.Checkpoint inhibitors rapidly release inhibitory signals on T-cell a...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...