Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Will you give a trial of tirzepatide in patients with PsA and obesity who have a partial response to bDMARD rather than switching their immunosuppressive regimen?
I don't believe the data on the magnitude of the benefit of GLP-1 agonists in arthritis symptoms is sufficient to suggest that adding one of these agents would be preferable to changing DMARDs in a patient with inadequate response.
What biologic or conventional/synthetic DMARD would you use as a steroid sparing agent in a patient with GCA and a history of diverticulitis?
This is an important question. Both IL-6 inhibitors and JAK inhibitors have a risk of bowel perforation which is increased in patients with a history of diverticulitis, therefore, these agents must be used with great caution in such patients and alternative therapies are often preferred.First, it's ...
Can needle EMG or nerve conduction studies cause transient MRI abnormalities, such as apparent inflammation, edema, or enhancement of a nerve, that could be mistaken for neuritis on subsequent imaging?
Yes—needle EMG can create small, transient post-procedure MRI/MR-neurography abnormalities at needle insertion sites, including focal T2/STIR hyperintensity interpreted as edema and occasional small hematoma, which can potentially be mistaken for local pathology if the timing is not recognized. In a...
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...
How do you counsel a patient with Sjogren's and extremely dry mouth who is losing their ability to taste food?
Agree with Dr. @Dr. First Last, and we cannot overemphasize the candidiasis part. Have a very low threshold for treating candidiasis while at the same time maximizing salivary stimulation (pilocarpine, cevimeline, bethanechol). When severe xerostomia occurs, as in the question, atypical presentation...
What circumstances would drive you to consider using an oral IL-23 inhibitor over parenteral options for the management of psoriasis and/or psoriatic arthritis?
Psoriatic arthritis is a heterogeneous disease and the choice of therapy is driven by many factors.The most important factors in the decision tree are whether the patient has 1) axial disease and/or 2) severe psoriasis.Additional Considerations include: prior therapies, extramusculoskeletal manifest...
What is your approach to immunomodulatory treatment in patients with Sjogren's syndrome who have active serologies (i.e. elevated ESR, hypergammaglobulinemia, hypocomplementemia) but minimal symptoms?
Hypergammaglobulinemia and hypocomplementemia are risk factors for lymphoma in the setting of Sjogren's Disease (SjD), as well as cryo, IgM kappa, lymphopenia/neutropenia, RF+, asymmetric parotid swelling and disease activity (Nocturne et al., PMID 26606524). Therefore, even with "minimal symptoms" ...
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 ...
In patients with osteoporosis at high fracture risk, what factors most influence your decision to prescribe teriparatide versus abaloparatide?
Both abaloparatide and teriparatide are very effective anabolic agents to reduce vertebral and nonvertebral fracture risk in patients with osteoporosis (although clinical trials did not demonstrate reduction of hip fracture risk). The two agents are more similar than different and both induce an an...
How do you approach a patient with Paget’s disease of bone with elevated alkaline phosphatase and history of chronic kidney disease?
You can give Zol IV, which is clearly the optimal treatment for active Paget's. Those in the field that treat many such patients just administer this very slowly over 1-2 hours and assure good hydration concomitantly. I have treated a number of patients like this, with this scenario, without any pro...