Rheumatology   

When do you switch to steroid-sparing medications? What steroid-sparing therapies do you prefer?

If so, what dose-fractionation do you utilize? What other factors do you take into consideration?

Do you taper one DMARD as you uptitrate another versus do you stop the first DMARD and quickly uptitrate another one?

Is a BM biopsy a must when there is skin involvement? If tryptase level is mildly elevated but less than 20 would you recommend a BM biopsy?

Do you frequently order liver biopsies for these patients?This question is part of a collaboration with RheumMadness and is specifically in reference ...

Will you still favor starting with steroids and traditional immunosuppressive agents, move IVIG earlier in your treatment strategy, or start with IVIG...

How has this impacted your counseling and management?

The patient is a young African American female of reproductive age with positive Fibrillarin antibody and nucleolar antibody. No ILD.

This question is part of a collaboration with RheumMadness and is in reference to Pathogenic ANCA (RAVE Trial).

How should IVIG and either biologic injections or infusions be spaced?

(Refractory to mycophenolate, azathioprine, and methotrexate. UpToDate suggests thalidomide or IVIG with mixed efficacy, while there are some case rep...

And if so, what is your approach to the diagnosis?

Do you do blood work? Or do you rely on review of systems?

Do you typically start the patient on hydroxychloroquine?  What work-up do you perform?

In what cases do you discontinue the medication?

Do you attempt to taper fully or maintain at a low dose?

Are there ways to overcome barriers in insurance coverage of this combination of treatments?

Several speakers at ACR 2021 commented on the important role of drug levels in the management of these patients and cautioned against adding medicatio...

Have you tried hyaluronidase? 

4 cutaneous biopsies with no evidence of vasculitis. Sjogren’s diagnosis based prominent sicca symptoms and a significantly elevated SSA. 

For example, in the setting of cirrhosis incidentally found on imaging.

Are there any medications that surgeons like discontinued before their procedure?

When would you de-escalate therapy?

Any indications for triple therapy in the patients with subclinical ILD associated with MDA-5 dermatomyositis?

Does your evaluation hinge on nonresolution with warming? How extensive is your workup?

Other than inflammatory markers and following symptoms/exam, do you need any other specific monitoring for progression to systemic disease? 

Do you obtain vascular imaging routinely in these cases, and if so, do you use cross-sectional or invasive angiography?

In other words, do we think of TNFi induced lupus and TNFi induced psoriasis as a drug effect or a class effect? 

Would you change rituximab maintenance dose or schedule?

Specifically: starting dose, rapidity of up-titration, frequency of lab monitoring, frequency of office visits, and timing of assessment for treatment...

ADVOCATE trial

Muscle disease is quiescent and no other manifestations such as ILD

In the ADVOCATE trial, patients were not re-dosed with rituximab.

E.g., MPO vs PR3, newly diagnosed vs relapsed, renal involvement. Acknowledge that the ADVOCATE study was not powered to detect these differences, but...

What if the patient has MGUS? Do patients with type 1 cryoglobulins need a bone marrow biopsy as part of the work up?

If so, are there specific patient populations for which you would use this metric?

 If you use both, how do you decide which to use for a particular patient?

This question is part of a collaboration with RheumMadness and is specifically in reference to: ADIRA Diet