General Rheumatology&nbsp;&nbsp;&nbsp;

How do you approach managing nausea and GI side effects when initiating methotrexate?

Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?

What are the current treatment options for progressive multifocal leukoencephalopathy in patients without HIV/AIDS?

Are there any clinical trials underway to study additional therapies?

How would you approach management of a patient with longstanding history of SLE, but having active psoriasis?

SLE manifestations include arthralgias and cytopenias which are stable. Previously did well on methotrexate, but developed GI side effects. HCQ is on ...

What are some important considerations for use of ACE inhibition in scleroderma renal crisis patients who require dialysis?

For example, is captopril dialyzable?

Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?

What is your approach to differentiating RA-ILD from medication toxicity (I.e. from methotrexate)?

How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?

Do you generally recommend anti-diarrheals, dietary modifications, or consider this an unacceptable side effect and move to other therapies?

Is it necessary to prescribe a steroid taper after two weeks of high-dose prednisone (60 mg daily)?

What is your workup and treatment approach for cranial neuropathies in patients with lupus?

For patients with SLE, is there an ANC level for which you would hold or adjust hydroxychloroquine in an asymptomatic patient?

UpToDate recommends Hydroxychloroquine for all SLE patients, but neutropenia is sometimes ascribed to HCQ rather than the underlying disease. What lev...

What would be the preferred treatment option for PMR if patient develops gastric perforation soon after initiation of steroids?

How would you approach management of nodular scleritis in the setting of suspected GCA?

Can nodular scleritis be a presenting manifestation of GCA?

How would you approach management of a patient with ESRD on the transplant list who is found to have high titer APS labs (ACL, B2GP1, LAC)?

In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?

How often do you see bony erosions in patients with Lyme arthritis?

How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?

7 Answers available

How do you approach use of DMARDs and/or biologics for inflammatory arthritis in patients with a history of seizure disorder on anti-epileptic medications?

Is there any concern for drug interactions of DMARDs and/or biologics with anti seizure medications?

When would you consider using G-CSF in patients with rheumatic disease who have received cyclophosphamide?

Do you perform genetic testing when patients have persistent hypogammaglobulinemia after rituximab therapy?

Are there any concerns with live vaccine innoculation and patients who are on denosumab?

What is your approach to DVT prophylaxis in patients who require IVIG but are at increased risk for thrombotic events?

E.g., a patient with newly diagnosed CIDP who is wheelchair-bound.

What is your approach to management of hyperlipidemia in patients taking JAK inhibitors?

How would you approach management of a young male patient with discoid lupus who has had minimal response to hydroxychloroquine (and subtherapeutic whole blood levels) who continues to use tobacco products?

How do you approach a patient with elevated bone specific ALP (>2X the normal limit), but no other evidence of Paget's disease?

Normal Vitamin D, bone scan showed osteoarthritis

Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?

What is the typical timeline for remission of autoimmune hypoglycemia?

How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?

Is there a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients?

Would you switch azathioprine to a different immunosuppressant if a controlled patient with SLE develops melanoma and/or non-melanoma skin cancer?

In a patient with isolated HLA B27+ anterior uveitis, how long would you continue immunosuppressive therapy?

The patient has no extraocular features of a spondyloarthropathy and is on methotrexate. No active eye disease for past 1 year.

Do you avoid hyaluronic acid injections in patients with chondrocalcinosis on imaging?

How do you approach the work up of pulmonary artery aneurysm in the absence of other clinical features of Behcet’s?

Do you find HZV titers useful in diagnosing shingles sine herpete?

What is your approach to differentiating tender spots (as in fibromyalgia) and enthesitis (as in axSpA)?

How do you approach work up for underlying rheumatologic disease in patients referred for chronic urticaria?

How are you utilizing vibratory devices for reducing pain associated with injection or procedures?

In which situations or patient populations do you find this useful? How is it sterilized?

How do you utilize cytokine panels in your clinical practice?

Is there utility when classic inflammatory markers (ESR,CRP) or disease specific markers (C3, C4, dsDNA) do not correlate with patients disease activi...

How do you decide when to obtain genetic testing for suspected autoinflammatory conditions in adults?

Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?

Do you recommend sending an autoimmune work up for patients with recurrent nephrolithiasis and 24 hour urine chemistries consistent with distal renal tubular acidosis?

Do you prefer celecoxib over a nonselective NSAID in patients with chronic kidney disease?

What is your approach to counseling patients regarding re-initiation of anti-TNF therapy after completion of treatment for non-disseminated pulmonary histoplasmosis?

Would it be safe to resume and if so, when?

For how long do you recommend treatment for latent tuberculosis prior to initiation of anti-TNF therapy?

6 Answers available

How do you monitor patients with incidentally found high titer anti-smooth muscle antibodies without stigmata of liver disease?

How do you approach evaluation for underlying rheumatologic disease in patients with chronic asymptomatic thrombocytopenia?

Thrombocytopenia is moderate (80-100,000 microL). No concomitant cytopenias present.

How do you approach management of adult patients with CVID and sarcoid-like syndrome?

Do you restrict topical diclofenac use in your patients with chronic kidney disease?

Does your institution have formal policies or work flows to reduce unnecessary IGRAs ordered for patients on biologics?

How do you approach biologic initiation in patients with inflammatory arthritis and repeatedly indeterminate Quantiferon?

5 Answers available

How do you approach ongoing screening for TB in patients with a history of treated latent TB, but who have ongoing use of DMARDs and/or biologics given Quantiferon testing and PPD can remain positive?

How do you approach ongoing screening for TB in patients with history of treated latent TB, but have ongoing use of DMARDs and/or biologics given quan...

What is your approach to working up diarrhea in an immunocompromised patient?

Do you avoid the use of hydroxychloroquine in patients with psoriasis and/or psoriatic arthritis?

Do you have concerns with the use of oral contraceptives in patients on JAK inhibitors given the black box warning for thromboembolic events?

How has this impacted your counseling and management?

What else do you consider in the differential diagnosis for pulmonary-renal syndromes if there is low clinical and serologic evidence of AAV, Goodpasture's or other rheumatologic disease (SLE, RA, APS, Scleroderma)?

Do you utilize post-vaccination IgG titers to detect common variable immunodeficiency in patients who are about to start or are actively on B cell depleting therapy?

How do you approach GI prophylaxis (e.g., PPIs, H2 blockers) in patients on long-term NSAIDs?

How do you approach follow up of young patients with isolated +ANA, but no current clinical signs or symptoms of SLE?

This question is part of a collaboration with RheumMadness and is specifically in reference to: Antibodies Before SLE.

6 Answers available

Do you consider anti-viral prophylaxis in patients taking JAK inhibitors who have recurrent uncomplicated Zoster infection, but would prefer not changing therapy?

Does hepatitis B vaccination reduce the risk of HBV reactivation associated with immunosuppressive therapy?

For example, in patients who are HbSAg negative, anti-HBc positive and HbSAb negative, does vaccination reduce reactivation risk?

How do you approach a negative ANA and positive dsDNA in patients with arthralgia, hair loss, or other UCTD features?

5 Answers available

How do you approach management of a patient with idiopathic PAH and +ANA, but no other current symptoms/signs of active rheumatologic disease?

Is it safe to combine mycophenolate and adalimumab for management of pulmonary sarcoidosis in a patient that could not tolerate methotrexate?

At what point would you consider anticoagulation in a pregnant patient with lupus nephritis and non-nephrotic range proteinuria?

Does IVIG or subcutaneous Ig interfere with monoclonal antibody therapy (i.e. dupilumab, infliximab, rituximab, etc)?

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

Do you have a preference between Quantiferon Gold and T-spot TB for screening in patients starting immunosuppressive agents?

What is your approach to evaluation in patients who present with erythromelalgia?

In patients taking biologics who are planning joint replacement and are known MRSA carriers do you perform decolonization prior to surgery?

0 Answers available

Can joint replacement surgery be performed in someone with active Paget’s disease elsewhere?

Do you stop TNF inhibitors during the third trimester of pregnancy?

How would approach the management of a patient with significantly positive anticardiolopin and beta 2 glycoprotein antibodies in the absence of any clotting (including obstetric) history but with significant thrombocytopenia (but no other features of active connective tissue disease)?

How do you approach evaluation and management of arthralgia in a patient after CAR-T cell therapy?

Have you seen drug induced SCLE from IL-17 inhibitors?

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

How would you approach management of incidentally identified unilateral retinal vasculitis with subsequent labs revealing +P-ANCA?

Patient is asymptomatic. Labs showed +P-ANCA 1:160. Negative MPO and PR3.

In a patient with active spondylarthritis and uveitis who cannot take TNF inhibitors, what is your next agent of choice?

What is your approach to continuing or altering therapy when inheriting a patient with combined biologic immunosuppression that is in excess of guidelines?

How do you approach de-escalation or justify therapy maintenance? Do you have tiers of medications that you attempt to de-escalate first? In one parti...

What is your approach to management of chronic neutropenia in a patient with Sjogren’s who was recently diagnosed with metastatic endometrial cancer and plans to start chemotherapy?

ANC <500

What is your approach to management of elevated liver enzymes in patients who recently started treatment with tocilizumab?

How do you approach dosing of anakinra in MAS?

What is your approach to evaluating a patient with known rheumatologic disease and elevated free kappa:lambda ratio, but no evidence of monoclonal immunoglobulins?

What is the optimal timing for Zoster vaccine administration for a patient who recently recovered from herpes zoster infection and is now planning to start B-cell depletion therapy?

How do you manage injection site reactions in patients on subcutaneous biologics such as TNF inhibitors?

In what cases do you discontinue the medication?

Do you generally recommend starting nintedanib prior to immunosuppressive therapy in a patient with CTD-ILD?

Do you prefer to start with nintedanib and then add immunosuppressive agents, or give a trial of immunosuppressive medication first, then add nintedan...

What would be the main indications for opting for biosimilars over an original biologic, outside of insurance barriers?

Are there any instances where you would prefer a biosimilar rather than the reference product?

Would you use TNF inhibitors in patients with features of SLE, but active peripheral and axial spondylarthritis?

Patient with sacroiliitis on imaging, failure of two NSAIDs.

How do you approach the workup for a patient with persistently elevated inflammatory markers (CRP and ESR) whose history and exam do not point to a clear cause?

Would you be comfortable using a JAK inhibitor in a patient with baseline thrombocytosis?

Would the etiology of the thrombocytosis play a role in your decision-making?

Would you consider re-challenging a patient with rituximab after they experienced delayed neutropenia?

In a patient for whom rituximab is the best option for their disease management.

How do you counsel patients about the malignancy risk associated with azathioprine?

Do you continue to utilize ESR and CRP in patients on tocilizumab?

Would you consider use of belimumab in a patient with SLE with recurrent anterior uveitis who failed other treatment options?

Patient failed topical ocular therapies, methotrexate, azathioprine.

In which clinical scenarios is relying on the urine protein-to-creatinine ratio as a measure of proteinuria unreliable, and interpretations should be made looking at urine protein and urine creatinine separately?

How do you manage a patient with progressive cerebellar ataxia and positive cardiolipin antibodies?

Do you wait 12 weeks for confirmation to begin treatment if patient is declining?

Do you typically see peripheral neuropathy in patients with castleman syndrome?

Is rituximab for refractory ITP contraindicated in the setting of an active COVID infection, particularly in a patient with asymptomatic COVID?

How do you interpret elevations in ESR and CRP in the setting of increased BMI?

Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?

When it seems fairly certain that this is a drug effect is it something that can just be monitored or requires a change in approach?

What is your approach to timing of medications like Rituximab and Cyclophosphamide around plasmapheresis in patients on daily PLEX?

What is the appropriate management of arthralgias associated with bosutinib?

How do you treat celiac disease associated inflammatory arthritis refractory to gluten free diet?

How do you approach the continued use of TNF inhibitors in a patient with inflammatory arthritis who develops a positive dsDNA without clinical evidence of drug-induced lupus?

Do you recommend continuous antibiotic prophylaxis for patients on complement inhibitors such as eculizumab?

Do you just use antibiotic prophylaxis if therapy is started prior to meningococcal vaccination?

What is your approach to using apremilast for psoriatic arthritis in patients with history of depression?

When considering the use of DOACs in APLS, does the number of positive APLS antibodies influence your decision?

What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?

When would you consider rituximab as induction therapy in IgG4-related disease?

Would you intensify therapy in IgG4 related disease based solely on a persistently significantly elevated IgG4 level when all disease manifestations and inflammatory markers have normalized?

In patients who develop a VTE, what conditions do you consider as persistent, provoking risk factors, and at what point are they controlled enough to stop anticoagulation?

I.e., what constitutes well-controlled cancer, IBD, nephrotic syndrome, etc. What other diseases do you put in this category (obesity, autoimmune dise...

What is your approach to the workup for an underlying systemic condition in a patient presenting with retinal vasculitis?

How do you evaluate livedo reticularis (not livideo racemosa)?

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

Which medications have the lowest risk of tuberculosis reactivation in patients with uncertain tuberculosis history and active rheumatologic disease?

Do you recommend routine use of Evusheld for pre-exposure prophylaxis for patients on immunosuppression?

Does treatment with B-cell depletion and/or negative anti-spike antibody status despite COVID mRNA vaccination influence your decision?

Is there a role for regular hepatitis and TB screening in patients on chronic immunosuppressive therapy in the absence of new risk factors or exposures?

How do you treat post-IVIG headache that is not responsive to Tylenol or NSAIDs?

Specifically, how do you treat the delayed headache, not the headache that develops during the infusion where pre-hydration and slowing down the rate ...

Is there a role for antibody testing to confirm vaccine response for patients on rituximab after COVID-19 vaccination?

When would you consider checking JC virus prior to initiating biologic therapy?

How are you timing the third dose of the COVID-19 mRNA vaccine in patients on rituximab?

What is your approach to monitoring lipids in patients with rheumatic diseases such as RA and SLE and do you have a lower threshold to start lipid lowering agents compared to the general population?

Are there any specific circumstances when you would consider the use of immunosuppression for DISH?

There is some emerging evidence that there is an inflammatory component.

How do you approach the evaluation of patients referred for chronic lyme disease and counsel patients regarding this entity?

How does a history of splenectomy alter how you counsel patients on the infection risk of TNF inhibitors or other biologics?

Are you recommending the mRNA COVID-19 vaccines to your patients with immune mediated inflammatory diseases?

5 Answers available

Do you recommend shingles vaccine to all immunosuppressed patients under the age of 50 y.o.?

Do you correct the synovial fluid white blood cell count for red blood cells, and if so, is there a rough approximation/equation you use?

How do you handle hypogammaglobulinemia detected in patients prior to maintenance rituximab infusion?

Would you hold all immunosuppressive medications for the first month of LTBI treatment, or just biologics?

How do you interpret a high positive RNP in the setting of a negative ANA and negative sm/RNP?

To my understanding, sm/RNP should also be positive in this situation (and one would assume a positive ANA as well)

Do you avoid any specific biologic therapies in HIV positive patients?

How do you manage patients who are Hepatitis B core antibody positive/surface antigen negative and starting a biologic DMARD (other than rituximab)?

Is there a role for tocilizumab in treatment of polymyalgia rheumatica in patients who do not have features of giant cell arteritis or rheumatoid arthritis?

Are there any clinical situations in which checking for anti-chromatin antibodies is helpful?