Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...
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 ...
How do you interpret treatment response in the DISCOVER-2 Trial when patients were allowed to remain on up to 10mg of prednisone equivalent for disease control while on guselkumab?
The dependence on the use of systemic glucocorticoids may indeed be a good reason to change treatment. Especially in patients with psoriatic arthritis. So, if patients are unable to stop systemic glucocorticoids and there are still treatment options for the patient, this could be tried. It is diffic...
How do you approach an isolated positive anti-Scl-70 antibody in a patient with no symptoms or exam findings suggestive of systemic sclerosis?
We see this often in the clinic, and it is usually a false-positive test. False-positive anti-topoisomerase I (Scl-70) results frequently occur with commercial immunoassays (ELISA/Multiplex), often leading to misdiagnosis of systemic sclerosis. In our practice, we repeat the test using immunodiffusi...
Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?
I do screen all newly diagnosed IIM patients with PFTs and chest CT. This has a double purpose: establishing a baseline of lung function and, screening for lung cancer. While the patient might not have lung symptoms on presentation, respiratory involvement can manifest later on the course of the d...
For a pediatric patient with juvenile spondyloarthropathy with partial response, though ongoing axial disease, on a JAKi, would you increase the dose of JAKi, add methotrexate, or switch to alternate therapy like IL-17 inhibition?
Let me first disclose that I am not a pediatric rheumatologist and would defer to one. Have NSAIDs been tried and optimized? If not, that is the best first option. In general, optimizing the dose of a medication that seems to be working is a great choice. However, I do not know what current dosage i...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
Do you provide empiric doxycycline for Lyme Disease to asymptomatic patients after a tick bite who haven't developed Erythema migrans or are not sure it was an Ixodes tick?
I would base post-exposure prophylaxis upon local prevalence (unless the patient has a recent notable travel history). For example, Lyme disease is very rare in California due to the Ixodes tick's intermediate host being the Western Fence Lizard (long story short, something in their blood kills the ...
How do you approach evaluation of a patient referred for mononeuritis multiplex and +SSB?
Step 1: A clinical syndrome of mononeuropathy multiplex always requires an EMG study. Is the primary mechanism of the MnM axonal or demyelinating? If it is demyelinating, there are only two possible diagnoses: multifocal CIDP (Lewis Sumner syndrome, which can occur in the context of Sjogren's syndro...