Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 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 anifrolumab safe to use in patients with a history of malignancy?
Anifrolumab is not formally contraindicated in patients with a history of malignancy, but I would use it with individualized risk assessment.The United States Food and Drug Administration (FDA) label states that the effect of anifrolumab on malignancy development is unknown and recommends weighing t...
Can you use bisphosphonates in a patient with osteoporosis who has had prior avascular necrosis of TMJ due to steroid use?
Due to the rarity of MRONJ, and significantly high fracture risk from osteoporosis, prior history of osteonecrosis is not considered an absolute contraindication for bisphosphonate use. Clinical picture is important is weighing this decision. If the patient is very high risk, anabolic therapy is app...
Would you avoid use of JAK inhibitors in patients with dermatomyositis with autoantibody subtypes with increased risk of malignancy (TIF1y, NXP2)?
This is a difficult question to answer with certainty. Most of the direct data on malignancy risk with JAK inhibitors come from rheumatoid arthritis studies, and primarily involve tofacitinib. It is therefore possible that the risk is not the same across all JAK inhibitors, especially since they dif...
Do you consider metformin as a disease-modifying adjunct in the management of patients with OA, particularly in those with comorbid metabolic syndrome or type 2 diabetes?
Based on the Pan et al., PMID 40274279, and the broader literature, I would not yet formally classify metformin as a disease-modifying osteoarthritis drug (DMOAD), but the evidence is increasingly compelling, particularly in the metabolic osteoarthritis (OA) phenotype.This randomized controlled tria...
Do you routinely screen for cardiovascular risk factors in a patient with moderate-to-severe psoriasis?
Review of systems. Depending on age, consider lipids and HbA1c if no data for the past year.
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 you use a parathyroid hormone analog for treatment of osteoporosis in a patient with mildly elevated AlkPhos of unclear etiology?
I would be hesitant to administer an anabolic in this setting without first delineating the reason for an elevated AlkPase. I would suggest starting with sorting out the source of the AlkPase (i.e., bone, liver, or gut with measuring bone-specific AlkPase, G-GGT levels, and possibly a liver ultrasou...
Do you routinely apply the 2010/2011 ACR symptom-based diagnostic criteria for fibromyalgia in your practice, or do you continue to use the 1990 tender point examination to make the diagnosis?
Fibromyalgia diagnostic criteria have been a source of controversy and multiple revisions. Much of this confusion relates to failing to distinguish classification criteria, established to provide uniform criteria for clinical studies, from diagnostic criteria, which rely on expert opinion. Rheumatol...