Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What factors would encourage you to choose abatacept vs tocilizumab in a patient with RA-ILD with a UIP pattern of pulmonary fibrosis?
The available literature on abatacept and tocilizumab in RA-ILD does not provide a definitive answer and hopefully with the general increase in interest in ILD we will have more definitive data in the near future. My review of the current literature suggests that abatacept has a slightly higher perc...
Do you routinely recommend PJP prophylaxis for patients with GCA receiving high-dose steroids?
This is an important question with considerable practice variation in our field. I do not routinely use PJP ppx in GCA because the data suggest that the risk of PJP is relatively low. A recent claims data analysis in over 1,000 patients with GCA did not identify any cases of PJP and a systematic rev...
Do you recommend structured Tai Chi for patients with osteopenia and osteoporosis?
Tai Chi is an excellent modality for prevention of falls, but only has a modest effect in improving bone density directly. Therefore, I would strongly recommend this for individuals at high risk for falling. Benefits require at least several sessions a week for a minimum of 12 weeks (preferably 6 mo...
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...
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 would you approach management of a young woman referred for isolated anterior uveitis (now resolved), in the absence of systemic manifestations or end-organ involvement, but with serologies notable for strongly positive PR3 (negative c-ANCA)?
This is a challenging case. While up to 50% of anterior uveitis are idiopathic, and uveitis is relatively uncommon in GPA (<5-10%, episcleritis and scleritis are the most common ocular manifestations. The PR3 antibody is quite specific. Therefore, I would have a high index of suspicion that the uvei...
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 ...
Do you generally pursue a temporal artery biopsy in a patient who has a halo sign on ultrasound but has an atypical clinical presentation of GCA with normal inflammatory markers in the setting of persistent temporal headache?
This is an important question, and the answer would depend significantly on the details of the presentation. In general, with a highly atypical presentation such as this with normal inflammatory markers AND atypical symptoms, I would pursue TA biopsy and consider large vessel imaging if negative. Wh...
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...