Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is in the differential diagnoses for isolated bilateral tarsometatarsal joint erosions in the absence of other clinical or serologic evidence of systemic inflammatory arthritis?
Post-traumatic injury is the most common cause, especially mid-foot sprains and fractures, although not usually bilateral unless there is a predisposition such as high arches and osteoarthritis (OA) that can occur due to mechanical stress. Erosive OA can cause these findings, although more commonly ...
When stopping denosumab and transitioning to PO bisphosphonate, do you wait for 6 months after the last denosumab injection to start PO bisphosphonate?
Some background: In patients discontinuing denosumab without subsequent antiresorptive therapy, BMD rapidly reverts back to baseline with an elevation in vertebral fracture risk (with an enhanced risk of multiple vertebral fractures). Thus, sequential treatment regimens following denosumab have been...
What is your approach to escalating therapies for stiff person syndrome that is refractory to IVIG and steroids?
Step 1: Make sure the diagnosis is correct, especially if seronegative or very weakly positive for GAD65 antibodies.Misdiagnosis of SPS is common and diagnostic criteria have been recently proposed (Reference 1). Patients who complain of subjective stiffness/muscle spasms, but do not have objective ...
How has the new data regarding long-term follow-up of degenerative meniscal tears vs surgery changed your management approach in these patients?
Degenerative meniscus tears are a common finding on MRI in our older patients. A challenge lies in determining if that finding is the cause of the patient's symptoms. When deciding whether to send for surgical consultation, I query about mechanical symptoms (catching, locking, or giving way) and/or ...
Would you consider combination mycophenolate and JAKi in a patient with RA-ILD?
I have minimal experience combining a JAKi with mycophenolate. A patient with RA-ILD whose joints were well controlled with tofacitinib but whose ILD was progressing had MMF added to their regimen by their ILD pulmonologist. Unfortunately, after 4 months, the patient developed significant leukopenia...
What is your approach to a patient with RF+/CCP+ rheumatoid arthritis that was previously on TNFi now with high-titer ANA and dsDNA (crithida 1:2560), +chromatin, +histone?
This scenario reads like TNF inhibitor drug-induced serological lupus. The first clinical issue is: are there accompanying symptoms or signs of systemic lupus erythematosus (SLE) beyond the underlying inflammatory arthritis, which would be better attributed to the seropositive rheumatoid arthritis (...
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...
Would you favor the use of denosumab over bisphosphonate therapy for treatment of osteoporosis in patients who are at high risk for osteoarthritis given recent data suggesting reduced risk of developing knee OA?
Although the overall data to date concerning the impact of denosumab to reduce incident knee OA or lessen established disease remain limited, there are sufficient signals that warrant further investigation and support the need for an appropriately powered RCT with endpoints that include both patient...
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 ...
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 ...