Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What are the current recommendations for the management of pediatric non-infectious uveitis?
Agree with Dr. @Dr. First Last's answer. By the time these patients see pediatric rheumatology, they have had a number of labs drawn looking for infectious and non-infectious etiologies of uveitis and have also usually been trialed on topical steroid drops (predforte or otherwise) +/- oral prednison...
What is the preferred osteoporosis therapy after completing teriparatide in a young woman planning pregnancy within the next year?
It would be helpful to know the T-scores of the spine and femoral neck. I also like to have the bone remodeling markers. My recommendation would be adequate calcium intake of 1000 mg daily, preferably from diet, and 4000 IUs of vitamin D daily, not only to help preserve bone health, but vitamin D al...
What minimum clinical features or risk factors drive you to obtain a baseline HRCT in a patient with RA or Sjogren's disease?
Overall, about 10% of RA patients will develop clinically significant ILD, as will 20% of those with SjD. Those are a significant number of people, and ILD should be on our radar as clinicians. Knowledge of risk factors for ILD can help us focus on people most likely to be affected. Several risk fac...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
Would you start hydroxychloroquine (or another DMARD) in a mid-20s female patient with positive ANA, SSA, SSB, and dsDNA, whose only clinical manifestation is intermittent parotid gland swelling?
Hmm... I think the better question to ask is, do you code as Sjogren's lupus overlap to get way more medication options? Certainly, HCQ is a reasonable DMARD and a place to start for both diseases. I would code as lupus and Sjogren's to have more options for the future. Hope someone can weigh in on ...
Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?
I do screen all newly diagnosed IIM patients with PFTs and chest CT. This has a double purpose: establishing a baseline of lung function and, screening for lung cancer. While the patient might not have lung symptoms on presentation, respiratory involvement can manifest later on the course of the d...
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.
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 ...
What findings on routine monitoring PFTs prompt you to pursue HRCT in your patients with SARDs?
That’s an excellent question, and the strategy might vary somewhat by the specific SARD, but in general, in any SARD patient undergoing annual PFTs, the presence of any of these should prompt an HRCT to evaluate for the development of ILD. FVC drop ≥ 10% DLCO drop ≥ 15% Moderate decline in FVC (5-9...
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 ...