Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are there clinical, laboratory, or imaging features that can help distinguish primary Sjögren’s syndrome from secondary Sjögren’s in patients with overlapping inflammatory arthritis or positive rheumatoid factor?
Such a good query. I don't really know, as associated SjD has been understudied. In my experience, associated Sjogren's does not look that different from Sjogren's alone. We have seen high ocular staining scores and markedly reduced unstimulated salivary flow in associated SjD (SLE, RA). In SjD, the...
Can you use leflunomide and rituximab in a patient with both multiple sclerosis and rheumatoid arthritis?
It is rare for a patient to have both diseases, but immunosuppressive therapy can be used for the management of both conditions. A study published in 2021 investigated the use of a combination of rituximab and leflunomide in rheumatoid arthritis (Behrens et al., PMID 33738492). Rituximab has previou...
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 ...
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 ...
How often do you draw screening ANAs for discoid lupus?
Because a positive ANA is associated with an increased risk of progression to SLE in patients with discoid lupus, I routinely check an ANA at the initial visit in virtually all patients. If negative, I repeat it only if new symptoms concerning systemic involvement arise (e.g., joint pain, cytopenias...
How do you approach evaluation and management of a patient with recurrent monoarticular inflammatory arthritis of unclear etiology?
Routine testing will not identify Lyme disease, although the WBC count is higher than usual. If the antibiotic does not target B. burgdorferi, recurrence might mean inappropriate therapy previously. WBC count is WAAAY too high for mere trauma or internal derangement. Anything else to suggest psorias...
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...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...
What treatment options do you consider after TNF failure in intestinal Behcet's with ongoing steroid dependence?
Colonic Behcet’s does not necessarily respond the way that IBD does. The evidence base for alternative therapies includes anti-interleukin-1, -6 and anti CD20. Anti Il-12/23 have also been used. Would discuss with a rheumatologist about which options are reasonable, depending on where else there are...
How do you decide when to discontinue immunotherapy for primary angiitis of the central nervous system (PACNS)?
I take a multidisciplinary approach with involvement of my neurobiology and rheumatology colleagues for the immunotherapy. PACNS can be relapsing or remitting. So needs close monitoring with radiologic (MRI and MRA high resolution vessel wall imaging or CTA/MRA with CSF studies 6 months and then 1 y...