Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you always pursue biopsy confirmation before diagnosing IgA vasculitis?
Technically yes (by definition), but practically, not necessarily: Biopsy for direct immunofluorescence (DIF) testing would be required to confirm the status of IgA in cutaneous vasculitis. However, the presence of lesional IgA correlates positively with the clinical presentation (e.g., Henoch Schön...
Do you counsel patients differently about the risk of radiation induced malignancy when you are treating a proximal joint (hip) vs a distal joint (elbow) for benign conditions such as OA?
The mentality for this must change from radiation oncologist thinking to radiation medicine thinking. There have been no documented cases of malignancy from LDRT treatment of OA. Those who worry about the spine reference old studies giving 20 Gy in 5 fx with an open field pre-linac era. This is not ...
For a pediatric patient with Takayasu arteritis with persistent enhancement and mild progression on imaging after recent transition to tocilizumab (2 months), would you continue tocilizumab therapy, increase to q2 week dosing, or transition to cyclophosphamide?
Would add to the methotrexate and Steroids-shortened interval of the tocalizamab -followed by moving to Cytoxan. There is less experience with B Cell targeted treatment such as Rituxan or obintuzamab for CD 19, or CD 20
In an infant whose mother resumes TNF inhibitor therapy (e.g., adalimumab, infliximab, certolizumab) after delivery and is breastfeeding, do you recommend delaying live vaccinations?
IgG-based biologic therapies - including TNF inhibitors - are all considered compatible with breastfeeding, since IgG passes only minimally into breast milk. Given these agents are proteins, the minimal drug that is transferred is unlikely to remain intact (or active) with passage through the infant...
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...
What factors lead you to recommend a JAK inhibitor as second-line therapy in a patient with radiographic axSpA who has had a primary non-response to a TNF inhibitor, before trying an IL-17 inhibitor?
This is an excellent question which requires not just a treatment plan but also a revelation of how we should be making patient management decisions in Spondyloarthritis (SpA). My initial reaction is that primary non-response to a TNFi is not the usual story; if this truly happens, I recommend re-ev...
What is a reasonable stepwise approach to diagnostic imaging when there is ongoing concern for cardiac amyloidosis?
Abnormalities on CMR are not diagnostic of cardiac Amyloidosis. Although LGE, abnormal ECV, and abnormal T1 are findings commonly seen in Cardiac amyloidosis, the absence of one or more does not rule out amyloid. In the setting of increased LV thickness and clinical suspicion of amyloid, I would hav...
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...
Is anifrolumab safe to use in patients with a history of malignancy?
Anifrolumab is not formally contraindicated in patients with a history of malignancy, but I would use it with individualized risk assessment.The United States Food and Drug Administration (FDA) label states that the effect of anifrolumab on malignancy development is unknown and recommends weighing t...
What treatment strategies would you utilize in a patient with newly diagnosed HLA-B27+ axial spondyloarthritis (with active and chronic sacroiliitis on MRI) and recent diagnosis of MS that is well-controlled MS ocrelizumab given the need to avoid TNF inhibitors?
This is a very challenging scenario. On one hand, TNFi are generally unsafe for MS due to demyelination risk, and on the other hand, anti-CD20 therapies for MS are linked to new AxSpA, but B-cell depletion might also benefit AxSpA. Thus, management requires specialized care in balancing both disease...