Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach immunosuppression in a patient with well-controlled HIV and RF+ rheumatoid arthritis breaking through hydroxychloroquine with ongoing inflammation confirmed on ultrasound?
There is a reasonable amount of literature on this topic. The consensus is that if ongoing HAART therapy is effective at controlling viral load and maintained, Methotrexate and TNF antagonists are well tolerated; they do not seem to affect HIV viral load. The safety of JAK inhibitors, leflunomide, a...
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...
Do you prioritize aerobic exercise over pharmacotherapy as the first active intervention in a patient with newly diagnosed fibromyalgia who has no prior treatment?
I use both in parallel as first-line agents. No one will improve if they're not moving (I use the word "movement" or "activity," rather than "exercise," as this could sound excessive to some folks). I only avoid pharmacotherapy if the pt. feels strongly against taking medications, but most people ar...
What is your approach to nephrology referral for patients with lupus nephritis?
The answer to this question "depends" on many factors.I had the luxury of learning under some lupus nephritis greats in the 1990s (John "Jack" Klippel, H Austin, and J Balow... the high-dose NIH CYC regimen guys). Therefore, I am fortunate to feel confident in my abilities to care for LN better than...
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...
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 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 ...
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...
In what clinical situations would you favor IM methylprednisolone over a short oral prednisone taper for managing an RA flare?
I am not an RA expert; however, I am well-versed in the use of IM steroids for flares.After Dr. Petri's FLOAT study in SLE (Danowski et al., PMID 16395750), we have utilized IM steroids instead of daily PO prednisone as our "go-to" treatment of choice as much as we can over Medrol dose packs and QD ...
How do you approach the management of inflammatory arthritis in a patient with Sjogren’s disease who is unable to tolerate or take methotrexate, leflunomide, or hydroxychloroquine?
Would consider a B-cell targeted agent. Currently, rituximab which was included in the 2017 MSK and biologic guidelines (Carsons et al., PMID 27390247) for SjD inflammatory arthritis.Serum level of BAFF is elevated in SjD, so an anti-BAFF agent, like belimumab, could be considered.Have avoided use o...