Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What do you recommend to patients when they are having an acute flare of fibromyalgia symptoms?
Great, this is a really important area and unmet need in the field of fibromyalgia management. Unlike other nociplastic disease states (e.g., migraine), there are no rigorously studied abortive therapies to rapidly treat a flare of centralized pain. Indeed, all the therapies we use for FM are intend...
In a young female with lupus cerebritis with seizures would you start induction therapy with Rituximab over cyclophosphamide?
I am not aware of a direct comparison of the efficacy of cyclophosphamide versus rituximab for treating lupus cerebritis with seizures. In cases of life-threatening progressive disease, giving both agents has been reported. Choosing between the two should involve in-depth patient education and invol...
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Here is a recent expert consensus by Joel Block on the use of low-dose radiation therapy in OA: Some highlights: "Placebo-controlled randomized clinical trials have now been reported using LDRT for OA of the knees and of the hands. Taken together, they do not show benefit beyond placebo... While a d...
How would you approach treatment for a patient with positive C- ANCA/PR3 with sinus/nasal limited disease, but no renal or pulmonary involvement?
The treatment of non-severe GPA varies amongst practitioners because of limited trial data and different practice patterns. 2021 ACR/VF guidelines conditionally recommend methotrexate and glucocorticoids. Rituximab would also be a reasonable option; therefore, I typically favor shared decision-makin...
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...
Would you start urate lowering therapy in a patient with recurrent flares of joint pain/swelling and urate deposition confirmed by dual energy CT, despite a serum uric acid of 5 mg/dL between flares?
Of course, with colchicine or NSAID co-prescription, but first examine dietary excesses and medication effects, which can produce flares.
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.
How would you approach the workup and management of a young patient with recurrent biannual non-scarring oral ulcers and new onset neurologic symptoms with associated CNS white matter lesions concerning for Behcet’s?
This is a challenging case. It should be noted that oral ulcers in Behcet's typically occur more than twice per year (by ISG criteria should occur at least 3x per year) and without other symptoms of BD it can be very challenging to make a probable diagnosis of BD in this scenario. A careful history ...
What is the difference between P155/140 and TIF1-γ antibodies on the ARUP myositis panel?
TIF1g is the name of the protein itself, whereas "p155/140" refers to the IP (immunoprecipitation) finding of 2 distinct bands at 155 kDa (TIF1g) and 140 kDa (TIF1a), indicative of an anti-TIF1g antibody response. Until recently, ARUP (like most commercial laboratories) used immunoblotting, as it is...
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 ...