Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend structured Tai Chi for patients with osteopenia and osteoporosis?
While I am not an expert, I am very supportive of Tai Chi or similar disciplines that work to improve balance. I have read some well done clinical trials that show improved balance. I live in a community (Phoenix) with lots of active retired people. Nearly every community has a Tai Chi or balance cl...
With the increasing availability of biosimilars and their adoption onto payer formularies, how do you approach selection among available biosimilars in clinical practice?
Insurance payers consider FDA‑approved biosimilars to be clinically equivalent. In my experience, selection is ultimately driven by the insurance payer formulary - what you can get for the patient on the time. This can be fleeting and quickly changing at times. Cases can be made for patient experien...
In a young patient who was vaccinated against chickenpox as a child (no previous varicella infection), should the patient receive a shingles vaccine prior to starting Rinvoq?
Yes. The vaccines are different and current vaccine is to prevent zoster for patients who have been previously exposed to varicella or vaccinated for varicella.
Should we be less cautious with the use of GLP 1 R agonist therapy for patients with osteoporosis and obesity given recent data suggesting significantly lower fall and fracture risk?
The interaction of GLP-1 R agonist therapy and fracture risk is complicated, and I would not assume a decrease in the risk of fracture for most patients. However, there were three recent retrospective studies that all showed decreased fracture risk following use of either semaglutide or tirzepatide ...
Do you counsel patients differently about the risk of radiation induced malignancy when you are treating a proximal joint (hip) vs a distal joint (elbow) for benign conditions such as OA?
The mentality for this must change from radiation oncologist thinking to radiation medicine thinking. There have been no documented cases of malignancy from LDRT treatment of OA. Those who worry about the spine reference old studies giving 20 Gy in 5 fx with an open field pre-linac era. This is not ...
How would you treat tophaceous gout after a course of pegloticase infusions if the patient has contraindications or intolerance to allopurinol, febuxostat, and probenecid?
Difficult question. I think there are a number of issues to address. What is a "course of pegloticase?" What are the patient's contraindications to treatment? How did intolerance to prior oral uric acid-lowering therapies manifest Was pegltoicase started because of "unresponsiveness to oral ULT" an...
Would you expect to see severe arthralgias within the first few days of immune-therapy in a patient without history of autoimmune disease?
The short answer is: Absolutely!The long answer is:From a mechanistic standpoint, it is common to see severe arthralgias within days of initiating immune checkpoint inhibition, even in a patient without a prior autoimmune diagnosis.Checkpoint inhibitors rapidly release inhibitory signals on T-cell a...
How do you explain the concept of CAR-T therapy and why it may work to patients with autoimmune disease who are interested in pursuing a clinical trial?
In full transparency, I have not personally obtained informed consent from a patient immediately before CAR-T or a related cellular therapy. My center has a highly active immune therapeutics program, however, and I have spoken and written extensively about this area. I also serve on our health syste...
How do you approach laboratory evaluation in patients with fatigue?
First search for evidence by history and physical examination for any evidence of inflammation. If there is tailor the lab workup rather than ordering tests as screening tools. ESR and CRP to start with. Anything more without a reasonable a priori likelihood of the targeted diagnosis is just asking ...
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 ...