Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients?
There is no good-quality evidence supporting a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients. The efficacy of nitazoxanide in viral gastroenteritis is supported by a small manufacturer-sponsored randomized, double-blind trial in non-immunocompromised ...
How will you approach tapering of therapy in a patient with PsA who has responded well to tirzepatide and ixekizumab and has maintained disease remission for several years?
This is a difficult question to answer based on current data. While tapering is a standard strategy for DMARD therapies in many rheumatic diseases, many studies show that successful tapering or therapy discontinuation is not possible for most patients. If we are evaluating ixekizumab alone, few pati...
Would you stop methotrexate or leflunomide if MCV increases after starting the medication with no other parameters of anemia or leukopenia?
I would take this as a sign that the patient is taking their medication. Pretty common and definitely wouldn’t withhold RA tx for this.
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...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
How do you approach the management of a symptomatic Baker's cyst?
I have offered NSAIDs, PT, and ultrasound-guided aspiration and injection for management of a symptomatic Baker’s cyst in a patient with OA or mechanical pathology. I favor aspiration and injection of the knee joint as well as the cyst, though the literature does not necessitate injection of the joi...
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 ...
How do you interpret treatment response in the DISCOVER-2 Trial when patients were allowed to remain on up to 10mg of prednisone equivalent for disease control while on guselkumab?
The dependence on the use of systemic glucocorticoids may indeed be a good reason to change treatment. Especially in patients with psoriatic arthritis. So, if patients are unable to stop systemic glucocorticoids and there are still treatment options for the patient, this could be tried. It is diffic...
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 ...