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 ...
How do you manage patients with severe hand OA (no synovitis on exam, negative serologies) who fail to respond to NSAIDs but respond very well to oral steroids?
I have used Hydroxychloroquine with some success and offer that to patients for a trial for 4 months if they are willing.
Is a history of Zoster ophthalmicus a contraindication to starting upadacitinib?
A history of HZO (herpes zoster ophthalmicus) or herpes zoster in any dermatome is a relative contraindication to the use of upadacitinib or any JAK inhibitor. HZO is often a very unpleasant disease with pain, ocular discomfort, and vision loss, so the chance of reactivation should be minimized. The...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
How would you approach the evaluation and management of a patient with rheumatoid arthritis receiving leflunomide who presents with progressive peripheral pulmonary cavitary nodules, with biopsy revealing necrotizing granulomatous inflammation?
Given the association between leflunomide and nodules with necrosis and giant cells (though quite rare), I would consider stopping leflunomide and moving to another agent. I would, of course, make sure that cultures are negative on those nodules, given it could be mycobacterial, fungal, or even GPA.
How do you try to encourage interested medical students and residents to consider a career in rheumatology?
I try to expose them to the practice of Rheumatology and the depth and breadth of what we do, not merely musculoskeletal medicine but every organ system. The beauty of the immune system when it works properly and the many ways we try to control it when it does not behave. The chronic care of these d...
When do you consider genetic testing for autoinflammatory diseases in patients with recurrent pericarditis and fever, particularly when symptoms are highly responsive to IL-1 blockade?
Yesterday ;-). About 10% of patients with recurrent pericarditis have genes that may increase their risk of pericarditis. If you're already managing the patient with IL-1 inhibition, I would strongly encourage you to conduct genetic testing. Just my 2 cents...
In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?
In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving...