Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When do you consider genetic testing for autoinflammatory diseases in patients with recurrent pericarditis and fever, particularly when symptoms are highly responsive to IL-1 blockade?
Yesterday;-)About 10% of patients with recurrent pericarditis have genes that may increase their risk of pericarditis. If you're already managing the patient with IL-1 inhibition, I would strongly encourage you to conduct genetic testing. Just my 2 cents...Jon
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 ...
Would you offer re-irradiation LDRT for someone with osteoarthritis or tendinitis if symptoms recur?
I have not personally offered a patient a third round of LDRT and do not know of any data that shows efficacy. However, I might offer a third round if a particular patient got adequate results with the first two and there was some separation in time (perhaps >1 year) since the last round.
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.
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 ...
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...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
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 ...
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...
Has the MAJESTY trial changed your approach to the rituximab versus obinutuzumab choice in a patient with newly diagnosed primary membranous nephropathy and nephrotic syndrome?
The Bottom Line: Recent landmark trials—MENTOR and MAJESTY—confirm that anti-CD20 therapies are superior to calcineurin inhibitors (CNIs) for the treatment of MN.Key Trial DataMENTOR: Demonstrated that RTX was noninferior to cyclosporine at 12 months, and decisively superior by 24 months (60% vs. 20...