Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What treatment regimen would you recommend for a patient with biopsy-proven giant cell arteritis and diffuse cutaneous systemic sclerosis?
This is a challenging situation in which you must weigh the well-known high risk of irreversible blindness in untreated GCA with the known increased risk (but not necessarily 100% risk) of scleroderma renal crisis with steroid exposure >=15mg (Steen and Medsger, PMID 9751093). It is important to und...
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 ...
What is your approach to treatment for MDA5 dermatomyositis patients with rapidly progressive ILD?
Rapidly progressive ILD is a temporal term, describing rapidly declining lung function within weeks (usually defined as 3 months). Therefore, we commonly use this term when the patient is already hospitalized with respiratory failure. The majority of the data stem from Japan and China, where they en...
What are some practical tips for eliciting an accurate history of Raynaud's phenomenon in patients being assessed for CTD?
I use this approach. I first ask patients if they feel generally sensitive to the cold. All patients with Raynaud's should respond yes to this, but this is not specific, as there are many cold-sensitive patients who don't have Raynaud's. I will then ask if their fingers turn any colors in response t...
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 approach laboratory evaluation in patients with fatigue?
First search for evidence by history and physical examination for any evidence of inflammation. If there is tailor the lab workup rather than ordering tests as screening tools. ESR and CRP to start with. Anything more without a reasonable a priori likelihood of the targeted diagnosis is just asking ...
What is the role of skin biopsy for evaluating small fiber neuropathy in patients with rheumatic disease who have treatment recalcitrant pain?
I have a shared decision-making discussion with the patient, especially alluding to the fact that the result would not change my therapy (i.e., use neuropathic analgesics for treatment) for small fiber neuropathy (SFN). Where I find it especially useful is in a patient with systemic lupus (SLE) or S...
Is a history of Zoster ophthalmicus a contraindication to starting upadacitinib?
A history of HZO (herpes zoster ophthalmicus) or herpes zoster in any dermatome is a relative contraindication to the use of upadacitinib or any JAK inhibitor. HZO is often a very unpleasant disease with pain, ocular discomfort, and vision loss, so the chance of reactivation should be minimized. The...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
Is it better to give dose 2 of the mRNA 2024-2025 Covid-19 vaccine at month 2 or month 6 after dose 1 in moderately immunocompromised patients?
This is a complicated question and unfortunately, we have no clear answer for it based upon clinical outcome data. The COVID-19 pandemic has changed dramatically since its inception over 4 years ago. Based on a combination of favorable viral evolution of diminishing pathogenic potential continuing t...