Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you perform genetic testing when patients have persistent hypogammaglobulinemia after rituximab therapy?
I would not routinely perform genetic testing. Multicenter studies (Labrosse et al., PMID 33862010; and Otttaviano et al., PMID 35892275) show that genetic testing returns a low yield, <5%. Several authors suggest that the risk of persistent hypogammaglobulinemia due to PID is increased if there is ...
In what clinical situations would you favor IM methylprednisolone over a short oral prednisone taper for managing an RA flare?
Oral prednisone is a pro-drug - it needs to be activated by the liver into prednisolone to work. In addition, if the patient is challenged by GI absorption or has significantly low serum albumin, this reduces the effect of oral prednisone. Those situations would be my greatest concern for such a cho...
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 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...
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...
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...
Would you give a trial of immunosuppression in a patient with previously diagnosed IPF who now comes to you with moderate titer ANA and history of discoid lupus but no other clear systemic features or lab abnormalities suggestive of SLE?
No, I would not automatically RX immunosuppressants in this clinical scenario, which has numerous facets to it that do need to be addressed: The treatment for progressive idiopathic pulmonary fibrosis (IPF) is an antifibrotic, not an immunosuppressant. I ALWAYS manage my SLE-pulmonary patients with ...
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?
I would certainly treat the ITP with hematology involvement if necessary but would continue to monitor for lupus or similar CTDs. I have seen patients present with an ITP-like picture for years before lupus declared itself eventually. It may take years. I would also check a UA for proteinuria. This ...
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...