Rheumatology   

Questions discussed in this category



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

In patients presenting with likely statin-induced myopathy versus statin-induced autoimmune necrotizing myopathy - how do you approach the decision re...

Additionally, what is the current role for temporal artery ultrasound in workup for GCA?

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

Would you consider keeping the patient on denosumab or would switch to an anabolic agent?

Specifically in patients of Vietnamese background? An association has been shown between HLA-B*5801 and the risk of allopurinol hypersensitivity react...

Especially given the recent FDA approval of voclosporin, how should we think about the use of this medication for LN? 

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

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

Would you discontinue Methotrexate and TNF inhibitors even if previously no side effects from these medications, and would you consider Cyclophosphami...

Would you use immunosuppression in patients several years after curative treatment for melanoma?

Does Quantiferon gold replace the need for baseline chest x-ray screen? 

Giving "rescue therapy" to patients in the combination group implies that there is room to escalate to the dose at enrollment. 

Withdrawal of methotrexate may lead to more disease flares and lack of recoverability with other TNF inhibitors.

Usual clinical practice is to add TNFi once methotrexate monotherapy has failed. If this is the case in these patients, it would seem to increase the ...

While classically described as seen in seropositive patients, have they been reported in seronegative RA?

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?

Myositis specific antibodies and pathology results often take weeks to result.  In which cases do you start therapy before the diagnosis is solid...

What if the patient is triple-positive or has continued seropositivity on repeat lab testing? What is the appropriate interval of monitoring and does ...

Would you change the treatment to rituxan or continue orencia with regular dermatology follow up?

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

Small study in pediatric PACNS have evaluated this as a potential marker (Cellucci et al., PMID 22740622)

While low-dose aspirin for primary thrombosis prevention in aPL without APS is not typically recommended outside cardiovascular prevention guidelines ...

What factors go into choosing the right patient and determining length of therapy?

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

Do you avoid due to the increased risk of GI adverse events?

There are multiple difficulties that could be seen: steroids can precipitate a sickle cell crisis, vasculitis and sickle cell can produce similar clin...

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

Is there a risk of increased radioresistance or secondary malignancy (or conversely, toxicity) for patients on TNF inhibitors...

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

E.g., inflammatory polyarthritis or inflammatory myopathy with onset within 2 weeks of documented COVID infection

How is your approach to treatment different than other ILD patterns such as NSIP? Does treatment response vary based on underlying CTD?

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

Does denosumab effect knee replacement or hip replacement? Should replacement occur right before or after injection? 

Given the slow recovery of nerve damage, what would you expect to see on a repeat EMG after treatment? Continued denervation or just sequelae of past ...

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

How would you label such a patient?  Would you treat differently if they have poor functional status?

Patient was previously well controlled on methotrexate, which was discontinued during cancer treatment.

Cyclophosphamide/tacrolimus and Rituximab have been used in conjunction with steroids in case series.

Current guidelines do not support its use, but the EMPACTA trial suggests it may be effective in a subpopulation of patients.

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

Reduced requirements for documentation by CMS in 2021 with respect to billing and coding have raised new questions about what aspects of physician exa...

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

How do you counsel these patients about hormonal agents? 

Due to the shortage of rheumatologists, primary care physicians may need to manage some rheumatologic issues.

The SENSCIS trial was published in 2019 on efficacy of this agent. However, it's not clear where this should be in the treatment algorithm: Monot...

In a patient with early stage breast cancer that would otherwise require radiation, would you recommend treatment if the patient has active skin lupus...

Also, how would you handle immune modulators for rheumatoid arthritis during their treatment?

Do you re-challenge with nivolumab alone, change from nivo 1/ipi 3 to nivo 3/ipi 1 upon re-challenge, or stop immunotherapy altogether if grade 3?&nbs...

How about those with metastatic disease eager to maintain quality of life? Do you risk progression of disease if the TNF blocker is re-started?

Would you require the rituxan to be held prior to radiation?  Would this matter if it was in the post-prostatectomy setting?

Are there any other medications, outside of anticoagulation, that would be considered absolute or relative contraindications?

Do you always stick with a conventional fracionation, or in some cases, are you comfortable hypofractionating? Do you ever use a wait and see approach...

Does the type of autoimmune disease (ex IBD, rheumatoid arthritis, interstitial lung disease) matter?

Do you have any concern for increased toxicity when you treat a patient with radiation therapy who has an autoimmune disorder? (hypofractiationation v...


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