Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to counseling patients on the safety and side-effect profile of a biosimilar compared to its reference biologic?
Relevant question as insurance companies may require a biosimilar over the reference biologic. According to the FDA, the spin-off (my term) must be "highly similar" to the original in both efficacy and safety. Approval is based on review of clinical trial data. As for my approach: until proven other...
How do you optimize retinopathy screening schedules for patients on hydroxychloroquine while also prioritizing cost-effectiveness?
I'll approach this from the cost-effectiveness standpoint as I agree with Drs. @Dr. First Last and @Dr. First Last on their excellent points.Patients with SLE have remarkably high costs when you add up copays, medications, imaging studies, travel, missing work, etc. Anything we can do to help reduce...
What is the role of inebilizumab in the maintenance treatment of IgG4-related disease?
Inebilizumab may play an important role in the maintenance treatment of IgG4-related disease (IgG4-RD), particularly in patients at high risk for relapse. These are typically patients with multi-organ involvement and elevated serum IgG4 levels who initially respond well to corticosteroids but tend t...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
Would you biopsy calcified lung nodules and or lymphadenopathy that have shown stability over a 2-year period, in a bid to rule out sarcoidosis?
No. Certainly not without a comprehensive occupational and other exposure history. Follow "the rules" for the assessment of any sarcoidosis suspect. Do a physical exam to look for extrapulmonary signs of sarcoidosis. Order an eye exam to assess for ocular sarcoidosis. Obtain baseline MTB testing and...
What dose of methotrexate do you typically continue to prevent antibody formation when adding infliximab for sarcoidosis?
Infliximab is a chimeric molecule that contains approximately 25% murine protein, so it can be immunogenic in some individuals.Development of anti-infliximab antibodies (ATI) has been reported in various autoimmune diseases treated with infliximab.Around 10 to 50% of individuals with rheumatoid arth...
What steroid regimen do you typically use for induction therapy in patients with lupus nephritis?
LN initial treatment requires at least three choices: First, initial steroids as pulse methylprednisolone vs. high-dose oral prednisone (e.g., 1 mg/kg/day). Second, if selecting pulse steroids, follow with 1 mg/kg vs. 0.5 mg/kg. And third, double vs. triple immunosuppression from the outset.LN treat...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
Was the methotrexate dose reduced over time in the combination therapy or methotrexate monotherapy groups in the SEAM-RA trial?
No, methotrexate dose was not adjusted. Our goal was basically to answer one question: whether it is better to stop etanercept, stop methotrexate, or continue both. We did not want to be adjusting methotrexate doses at the same time as stopping because this would make results more difficult to inter...
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 ...