Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
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 ...
In a young female with lupus cerebritis with seizures would you start induction therapy with Rituximab over cyclophosphamide?
I am not aware of a direct comparison of the efficacy of cyclophosphamide versus rituximab for treating lupus cerebritis with seizures. In cases of life-threatening progressive disease, giving both agents has been reported. Choosing between the two should involve in-depth patient education and invol...
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Here is a recent expert consensus by Joel Block on the use of low-dose radiation therapy in OA: Some highlights: "Placebo-controlled randomized clinical trials have now been reported using LDRT for OA of the knees and of the hands. Taken together, they do not show benefit beyond placebo... While a d...
What are your practice recommendations regarding live vaccinations in infants/children of women who are currently on DMARDs and are breastfeeding?
This question needs some clarification to provide an exact answer. However, in regards to DMARDs in lactation, per the ACR 2020 Reproductive Health Guidelines and resources like LactMed and Mother to Baby (both free!), Methotrexate, Leflunomide, and Mycophenolate are not recommended in lactation. Th...
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...
How has the ADVISE trial changed your approach to steroid sparing agents for non-infectious uveitis?
The ADVISE trial was a well-designed, multinational trial that compared adalimumab therapy for non-infectious intermediate, posterior, or panuveitis versus conventional immunosuppressive therapy or CID. Two hundred twenty-seven subjects were enrolled over four years, and a fifth year was required to...
Would you start urate lowering therapy in a patient with recurrent flares of joint pain/swelling and urate deposition confirmed by dual energy CT, despite a serum uric acid of 5 mg/dL between flares?
Of course, with colchicine or NSAID co-prescription, but first examine dietary excesses and medication effects, which can produce flares.
Can sIL2-R differentiate between active sarcoidosis affecting small airways vs uncontrolled asthma and guide treatment with methotrexte vs biologics?
Not exactly, and probably not with enough compelling precision to use it clinically. sIL-2R cannot reliably differentiate active small-airway sarcoidosis from uncontrolled asthma, nor can it independently select methotrexate versus biologic therapy. It is a marker of systemic T-lymphocyte/granuloma ...
How do you approach management autoimmune lymphoproliferative syndrome (ALPS) complicated by HLH?
Excellent and tough question. There are no direct guidelines for this specific question. We will have to extrapolate from other evidence and clinical reasoning.Investigation of the trigger must occur in parallel with management. I will discuss how I approach investigation first and then management.I...