Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you interpret treatment response in the DISCOVER-2 Trial when patients were allowed to remain on up to 10mg of prednisone equivalent for disease control while on guselkumab?
The dependence on the use of systemic glucocorticoids may indeed be a good reason to change treatment. Especially in patients with psoriatic arthritis. So, if patients are unable to stop systemic glucocorticoids and there are still treatment options for the patient, this could be tried. It is diffic...
What is your approach to refractory oral ulcers in SLE?
I echo @Dr. First Last thoughts! Failure of HCQ does not mean refractory disease. Oral ulcers in SLE often correlate with underlying disease activity and their presence signals a better need for disease control. I would consider escalation to a systemic DMARD, such as MMF, MTX, anifrolumab, or belim...
Do you recommend patients hold folic acid on the day they take methotrexate?
The proposed mechanism of action (MOA) of methotrexate in rheumatic disease is not from the antimetabolite angle (given its oncologic MOA as a dihydrofolic acid reductase inhibitor), but rather as a potent anti-inflammatory and immunomodulatory medication through the MOA of extracellular adenosine a...
When should patients with diabetes mellitus be screened for osteoporosis?
Hip fracture risk is higher in patients with diabetes (T1DM almost 7 times and T2DM 38% higher than controls without diabetes) (Vestergaard, PMID 17068657), and BMD scores underestimate true risk. That has led the ADA to suggest considering treatment for bone densities with T-score <-2.0, rather tha...
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...
How would you approach using the new vagus nerve stimulator for patients with RA?
Vagus nerve stimulation (VNS) may be a consideration for treating those patients with RA who have disease that is either resistant to multiple DMARDs and biological therapies, or where the risk of immune suppression significantly outweighs the potential benefits of our standard approach to managing ...
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 ...
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...
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...
How do you use hydroxychloroquine in patients with lupus nephritis on hemodialysis or peritoneal dialysis?
After starting dialysis, other lupus manifestations frequently become clinically inactive. However, there is still a subset of patients who have clinical or serologic activity. Prior studies have shown that < 6% of lupus patients remain clinically active 5 years after starting dialysis, < 25% remain...