Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How often are you repeating screening PFTs in patients with SARDs who have 3 or more years of normal or stable PFTs?
The answer to this question is complex and needs to be tailored to the individual patient’s risk for ILD and the particular SARD.Approximately 30-40% of patients with systemic sclerosis (SSc) will develop ILD, typically within the first 5 years after the first non-Raynaud’s manifestation and rarely ...
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.
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...
What treatment options would you consider for a patient with seronegative inflammatory arthritis in setting of history of liver transplant on mycophenolate mofetil and cyclosporine?
Some of this depends on how far out they are from transplant and the preference of their transplant team. For a patient with RA and a liver transplant, I was able to ask the transplant hepatologist to switch to azathioprine instead of mycophenolate, which was more helpful for the joints. Cyclosporin...
How do you manage a possible autoimmune sialadenitis arising from checkpoint inhibitor therapy?
This is a great question and a common clinical scenario in patients receiving immune checkpoint inhibitors. In my experience, severe sicca symptoms from immunotherapy are often not classic primary Sjögren's syndrome, despite some overlapping features. Rather, this appears to be an acute T-cell-media...
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...
Do you recommend structured Tai Chi for patients with osteopenia and osteoporosis?
While I am not an expert, I am very supportive of Tai Chi or similar disciplines that work to improve balance. I have read some well done clinical trials that show improved balance. I live in a community (Phoenix) with lots of active retired people. Nearly every community has a Tai Chi or balance cl...
Do you screen for cardiac disease in patients with dermatomyositis in the absence of symptoms?
I don't typically evaluate for cardiac disease in patients with dermatomyositis who are not symptomatic. There are subtypes of myositis patients where cardiac involvement is more common (such as those with antimitochondrial antibodies and anti-SRP antibodies), and there it may make sense to keep a c...
How do you assess the risk of developing demyelinating disease when initiating TNF inhibitors?
Demyelinating disease (DD) associated with TNF inhibitors is rare. Risk assessment is mostly clinical. TNF should be avoided if there is a personal history of established DD, especially MS. A strong family history in first-degree relatives or concerning neurological symptoms should warrant caution a...