General Rheumatology&nbsp;&nbsp;&nbsp;

Does synovial biopsy provide diagnostic value in undifferentiated inflammatory arthritis?

Apart from ruling out malignancy or infection?

Is there any clinical benefit in referring patients with SLE or Sjogren's with cognitive impairment for neuropsychological testing?

How do you differentiate symptoms related to centralized pain syndrome from possible cognitive dysfunction?

How do you counsel patients regarding alcohol intake when prescribing DMARDs other than methotrexate?

Such as Leflunomide, Sulfasalazine, Mycophenolate or Azathioprine, since all of these medications have potential to cause liver enzyme elevation and i...

How do you approach management of patients with active RA and recurrent non-severe C.diff?

(Patient with active RA despite hydroxychloroquine)

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

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

In what cases do you discontinue the medication?

How long do you expect gastrointestinal side effects of leflunomide to persist after stopping treatment?

How do you approach patients referred for C1-2 pannus/erosions without clinical findings or serologies consistent with RA or CPPD arthropathy?

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

When tapering moderate to high doses of long term steroids do you routinely monitor for adrenal insufficiency?

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

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?

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

Do you find MRI helpful to differentiate early erosive OA from psoriatic arthritis when early X-ray changes in both conditions may be hard to distinguish?

Do you combine oral and topical NSAIDs for pain relief?

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?

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

What target do you utilize in clinical practice for defining disease remission in RA?

This question is part of a collaboration with RheumMadness and is specifically in reference to:BeSt TrialMeasurement of Patient Outcomes in Arthritis

Do you recommend chlorhexidine mouth rinse for prophylaxis against oral complications in patients undergoing dental work who are immunosuppressed?

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 differentiate the normal feeding vessel to the lunate from an erosion or power doppler signal on ultrasound?

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

Do you recommend patients continue folic acid for a few weeks after methotrexate discontinuation?

How do you approach the usage of hydroxychloroquine in patients with rheumatologic conditions and baseline cardiomyopathy or heart failure?

Do you use conventional DMARDs aside from methotrexate to prevent anti-drug antibody development for patients on infliximab?

This question is part of a collaboration with RheumMadness and is specifically in reference to: Etanercept + Methotrexate.

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

How do you approach the use of hydroxychloroquine in patients with a history of visual field defect from another cause such as macular degeneration or diabetic retinopathy?

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

5 Answers available

Is there utility in obtaining pericardial fluid autoimmune labs such as ANA or RF in patients with recurrent idiopathic pericardial effusions, but no other clinical or serologic evidence of rheumatic disease?

How do you approach evaluation of hypocomplementemia in a patient with arthralgias and a history of Hodgkin's lymphoma treated in the past?

ANA and ENA negative

How do you manage severe Raynaud's phenomenon with ulceration in scleroderma patients that is refractory to oral agents (CCBs, PDEis, ARBs, and ERAs)?

Is there any role of sympathectomy in Raynaud’s disease?

How do you approach oral DMARD and/or biologic selection in patients with RA and a history of gastric bypass or whom are planning bariatric surgery?

How do you counsel patients regarding contraception use while taking mycophenolate/mycophenolic acid?

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?

What is your approach to patients who present with unilateral Raynaud's?

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

How do you manage a patient with giant cell arteritis treated with weekly tocilizumab and low dose glucocorticoid who develops sudden vision loss?

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

What is your approach to the use of NSAIDs in patients with a history of gastric sleeve/bypass?

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

When do you consider discontinuing Pegloticase in a patient with tophaceous gout who has had excellent response to therapy?

What is your approach to patients with PMR on steroids over a prolonged initial course who start to experience weakness concerning for steroid myopathy?

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 approach treatment of RA with methotrexate in a patient with treated Hepatitis C and normal liver function?

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

Would you consider continuing a biologic for difficult to control autoimmune disease in a patient with a recent diagnosis of a surgically curable solid malignancy?

Would you favor the use of any particular biologics over others?

Are there any concerns utilizing apremilast for psoriatic arthritis in patients who are also taking roflumilast for COPD?

What are your top takeaways from ACR 2022?

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?

What is your approach to tapering therapy in a patient with recurrent pericarditis now well-controlled on rilonacept?

How do you approach Covid vaccine counseling in patients with rheumatic disease and history of pericarditis/serositis?

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?

In a patient who is on oral DMARDs and has received 3 COVID boosters, but recently had COVID-19 infection, is bivalent booster still recommended 3 months later?

How do you approach the workup of a patient with incidentally found pachymeningitis?

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

How do you assess potential fetal harm in patients who have unplanned pregnancy while taking teratogenic medications?

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?

Do you avoid intra-articular and bursa/tendon sheath corticosteroid injections in patients with a history of avascular necrosis?

When would you consider utilizing bone scintigraphy in the assessment of inflammatory arthritis?

How do you manage nausea in the setting of hydroxychloroquine use?

Do you utilize ethyl chloride spray prior to steroid injections?

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...

How would you manage polymyalgia rheumatica refractory to prednisone, methotrexate and tocilizumab?

Patient has no current evidence of underlying vasculitis or malignancy.

How do you evaluate patients who have panuveitis without any systemic symptoms?

Do you refer all patients with a Beighton score over 5 to genetics for further assessment?

What is your approach to monitoring for hepatic fibrosis in chronic methotrexate use?

Do you frequently order liver biopsies for these patients?

Would you favor stopping hydralazine in a patient requiring it for refractory hypertension if they also have a high titer ANA in the absence of any SLE symptoms?

What is the role of synovectomy in the diagnosis and management of patients with inflammatory arthritis?

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?

When do you consider vascular imaging in patients with Raynaud's and what type of imaging modalities do you utilize?

How do you manage psoriatic arthritis in patients who are planning to start treatment with checkpoint inhibitors for underlying malignancy?

What is your approach to workup for an underlying disorder in a patient with bilateral hip avascular necrosis?

How do you approach CV risk assessment in RA patients when RA itself is associated with some degree of increased CV risk at baseline?

Recent articles regarding the use of JAK-Inhibition in RA have suggested to avoid in patients with increased CV risk. However, RA itself is cons...

What is the role of non-prednisone oral glucocorticoids in the management of systemic rheumatologic disease?

Such as oral methylprednisolone, dexamethasone, prednisolone, etc.

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

What is the difference between Multisystem Inflammatory Syndrome in Adults (MIS-A) and MAS/HLH?

Does calcinosis appear differently in patients with dermatomyositis compared to systemic sclerosis?

Do you treat fibromyalgia in your practice or do you refer back to PCP after ruling out autoimmune inflammatory pathology?

How do you utilize methotrexate and/or hydroxychloroquine in the setting of limited scleroderma/CREST?

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?

Are there any known contraindications for IL-23 use in patients with psoriatic arthritis and CKD or ESRD?

How do you think about biologic use in patients with underlying HIV infection?

Do you hold tocilizumab for patients who are diagnosed with Covid and are with mild to moderate symptoms or non-hospitalized?

What is your approach to evaluation of underlying autoimmune disease in patients with bilateral scleromalacia?

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 prednisolone over prednisone in rheumatic patients with hepatic impairment?

When a patient with a preexisting rheumatic disease and on immunotherapy begins to flare, how do you decide if this is an underlying rheumatic disease activity versus an immunotherapy related adverse event?

How do you decide if it may be safe to continue immunotherapy?

Given the "LDL Paradox", in which RA patients with the highest levels of inflammation can have ultra-low levels of LDL (<70), how do you approach initiation of statin therapy in these patients?

Dr. Charles-Schoeman presented data at ACR 21 showing that, paradoxically, there is a U-shaped relationship between inflammation and LDL levels in pat...

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 will you use REGEN-COV (casirivimab/imdevimab-monoclonal antibody treatment recently approved under EUA as post-exposure prophylaxis for Covid) in rheumatic patients on immunosuppressive therapy?

Would you consider this for patients on B-cell depleting therapies or more broadly for other immunosuppressive agents?

What is your management approach for patients with Adult Onset Still's who are planning pregnancy?

What are your recommendations regarding methotrexate usage in patients with persistent chest CT changes post COVID pneumonia?

Would you have a different opinion based on whether it is a new therapy or an existing and previously well-tolerated therapy for the patient?

How do you diagnose and treat patients who develop uveitis while on bisphosphonate therapy for osteoporosis?

Are there specific features that suggest drug-induced uveitis versus de novo uveitis?

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

What is your differential for a patient presenting with multiple digits affected by flexor tenosynovitis, dupuytren's, and no evidence of peripheral inflammatory arthritis?

How do you approach folate supplementation for methotrexate-related side effects?

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 would you counsel a patient who is interested in using supplements (such as fish oil or turmeric) as an adjunct to treatment of inflammatory arthritis?

How do you approach the treatment of eosinophilic fasciitis refractory to glucocorticoids and methotrexate?

Would you consider using a TNFi in a patient with a family history of demyelinating disease, in the absence of a personal history?

How do you approach management of patients with inflammatory arthritis who are asymptomatic but develop radiographic progression?

What is your threshold for number of alcoholic drinks per week before reconsidering prescribing methotrexate/leflunomide?

How do you approach the use of biologics in patients with a history of Guillain-Barre syndrome?

What is your approach to managing abnormal lipids in a patient on tocilizumab?

How do you approach the treatment of inflammatory polyarthritis in patients with myelodysplastic syndromes?

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

Do you extrapolate from uveitis treatment pathways when managing other inflammatory eye conditions such as atypical serpiginous choroiditis?

Do you switch to certolizumab in RA patients who are doing well on other TNFis and planning to become pregnant?

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 approach patients with overlapping features of PMR and seronegative RA?

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)

Is there an increased risk of COVID-19 in patients on immunosuppressants?

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

What is your inflammatory arthritis differential when a patient presents with unilateral TMJ synovitis?

What are examples of rheumatology quality measures that are both clinically meaningful and can be captured accurately and efficiently?

Which steroid-sparing agent do you prefer to treat multi-organ Sweet's syndrome?

Do you follow patients with elevated ESR/CRP if their work-up for rheumatologic etiology is unrevealing and no other cause is identified?

What would be your differential for a wrist monoarthritis in an elderly female with erosions on MRI after less than 3 months of symptoms?

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?