Rheumatology   

Questions discussed in this category



How does the presence of extra-renal manifestations influence this decision?

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

How do you monitor response and what do you consider a satisfactory response? Do you aim for a certain threshold of proteinuria?

Patient with active rheumatoid arthritis, on escalating dose of Rituxan and Methotrexate, also has antisynthetase syndrome and Hashimoto's thyroiditis...

Many patients are interested in romosozumab for "maximizing bone gain" and preventing future fractures. Some have had anabolic therapy with teriparati...

Does your choice of DMARD/biologics change due to increased risk of malignancy?

When a PCP calls with concern for GCA and is wondering whether to start empiric steroids what data do you prioritize to make that decision and do you ...

What side effects do you highlight in conversation with them? How do you approach toxicity monitoring?

Relatively newly diagnosed RNA Pol 3+ dcSSc with rapidly progressive skin involvement now on methotrexate 20mg/week and tocilizumab for concurrent inf...

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

While remission rates after lowering or discontinuing therapy are lower, there is still a population of patients who do not require full-dose therapy ...

For example, I have a patient who has frequent (monthly) large to medium joint flares (Knee, Ankle) with crystal proven disease. Did not tolerate colc...

Specifically, do you check for any of these: ACE, Vitamin D 1,25, serum lysozyme, soluble IL2 or Adenosine deaminase levels?

Patient with alcoholism referred to rheumatology for elevated ACE level in the setting of new onset mild sensory peripheral neuropathy on nerve conduc...

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?

This question is part of a collaboration with RheumMadness and is specifically in reference to: NORD-STAR (Østergaard et al., PMID 3742364...

For example, the patient may have other findings such as an elevated CRP. Would you diagnose SLE, or would you want to see other serologies or finding...

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?

How long has it been back on the market? What is the typical cost for patients? Are certain compounding pharmacies regularly carrying it? 

There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?

After replacing Vitamin D, what will be your first treatment of choice? Labs including ALP and calcium levels are normal. T scores are -3 or above. Th...

How would you work up an elderly female with persistent anemia secondary to warm AIHA requiring almost monthly transfusion, with positive ANA,dsDNA (b...

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

Do you refer all patients with suspected LN, patients with confirmed LN, or patients with specific features (not responding to usual therapy, certain ...

This question is part of a collaboration with RheumMadness and is specifically in reference to: Prevention of Autoimmune Disease: Vitamin D and O...

This question is part of a collaboration with RheumMadness and is specifically in reference to: Allopurinol vs. Febuxostat

Do you plan to use sarilumab for all patients with relapsing or refractory PMR or are there certain features that will make you more or less likely to...

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

Do you advocate to taper the TNF-i or simply continue to monitor for long term adverse events? This question is part of a collaboration with Rheu...

Given that antibody levels seem to fluctuate with disease activity in a subset of patients would you assume that prednisone therapy could turn an HMGC...

What disease activity index do you find more useful and most practical in a busy clinical setting? How often do you assess it?This question is part of...

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...

This question is part of a collaboration with RheumMadness and is specifically in reference to: Exercise in Knee OA

A male patient in his 30s with two lumbar compression fractures (non-traumatic) and a Z-score of -2.6 in the spine, Z-score -0.5 in hips. History of 3...

For example, when switching from MMF to azathioprine, do you overlap the treatments as you lower the dose of one and add the other?

Is it different between DMARDs (csDMARDs, biologic DMARDs, and target synthetic DMARDs)?

If not, are there any serum or CSF tests you consider to be helpful?

Patient with negative blood cultures, completed 6 weeks of IV antibiotics and vegetation persists. CT imaging without evidence of malignancy. No evide...

Is a biopsy or EMG helpful in confirming the etiology? What is the best treatment for sarcoid neuropathy?

Are oral bisphosphonates contraindicated with all types of bariatric procedures?

Given poor pulmonary outcomes in people with anti-PL12 antibodies, would you recommend more aggressive therapy? The patient was diagnosed with onset o...

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

Is an MRI necessary to diagnose non-radiographic axial spondyloarthritis?

Would you start with a baseline ultrasound and then pursue further workup such as fibroscan if fatty liver is present, or other?

How much cumulative prednisone exposure do you tolerate and how many attempts at tapering will you pursue before considering addition of a steroid spa...

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

What level or additional signs/symptoms trigger a workup? What does your workup typically consist of?

Do you use biomarkers or PET scanning to stratify patients who may benefit most from therapy?

ANA patients referred to rule out CTD is a work-intensive, costly referral type. If they are positive for Anti-Dense Fine Speckled Protein 70 kDa (DFS...

Does it depend on location of radiation, length of radiation, and time since radiation?

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

In patients with bone metastases and osteoarthritis, if it is unclear if the pain is from cancer or OA, how do you decide on the radiation dose/fracti...

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

Would you consider belimumab over a TNF inhibitor for inflammatory arthritis? Which agent would be more beneficial for the lung disease?

Assuming no symptoms of TB, should patients be treated for latent TB prior to starting TNF inhibitors or other immunosuppressive agents?

After what interval of sustained remission will you attempt to taper, and will you do so by first widening the dosing interval?

The patient has not responded/has contraindications to apremilast, colchicine, and adalimumab. When they were off azathioprine for 5 days in the past,...

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

Will you initiate sarilumab as a first steroid sparing agent or will you still pursue a DMARD such as methotrexate before initiating sarilumab? To wha...

Do you universally perform baseline DEXA and Hgb A1C? How often are you obtaining routine labs?

If so, would you start immediately or wait for the second set of labs to confirm before initiating blood thinners?

Per 2021 GCA Vasculitis Guidelines: low evidence, but conditional recommendation for CTA neck, chest, abd/pelvis. Is anybody following this or do you ...

Patient has received treatment with Rituximab and is taking hydroxychloroquine.

For example, patients who have been maintained on 5mg of prednisone for years without previous tapering attempts and the rheumatic disease is not acti...

Patient became acutely flushed, developed severe and prolonged hypotension with brief loss of consciousness, dizziness, nausea, dry heaves and headach...

If so, when do you recommend timing for the cataract surgery? 

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

Significant history of autoimmune diseases and DVT in family, recent PE/DVT for a month

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

Vasculitis activity has been assessed with serial CTA of the chest and head/neck. She has existing right axillary artery disease and new areas of invo...

Do you treat with only an IV steroid pulse or do you use an oral steroid taper as well? How long of a taper do you typically use?

Lymph node biopsy with non-caseating granulomas and other etiologies (malignancy, infection, vasculitis) ruled out. 

Female patient in her 20's with RA/SLE has been on steroids and methotrexate, currently on HCQ and Orencia. Failing Orencia with active disease. Want ...

A specific example would be a clinically quiescent but serologically active patient.

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...

How would you treat a patient with necrotizing myopathy with positive anti-HMHCoR Ab (and low TIF1 gamma) that failed prednisone + Cellcept, IVIG + Ce...

The patient is on a dose of 22 mg of methotrexate weekly for severe rheumatoid arthritis. If you would discontinue the methotrexate, how long would y...

Is there a certain disease duration or age beyond which you taper immunosuppressive treatments?

In patients with CKD, does urate lowering therapy have an effect (positive or negative) on progression of CKD?

Extrapolating from reactions with other sulfa medications potentially causes flares.

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

What doses of allopurinol do you use, and how frequently do you titrate the dose?

The patient was diagnosed with statin-induced necrotizing myopathy (HMGCR +) and received RTX  and IVIG (one cycle over 3 days) but developed bra...

Patients on baseline mycophenolate and azathioprine were excluded from the INBUILD trial however many patients with CTD-ILD will be on some form of im...

Data is clear that we should hold methotrexate at least one week after COVID and flu vaccines. How do you approach methotrexate management around Shin...

In addition, what formula do you use to calculate the IgG index?

Patient with pulmonary hypertension (mixed group 1, 2, 3), COPD, HFpEF, Raynaud’s phenomenon, UCTD (ANA, PM-Scl, SSA-52kd), and recurrent severe...

Do you rechallenge with lower dose? What is your tolerance for mild persistent transaminitis?

Patient with dermatomyositis on rituximab with refractory inflammatory arthritis. Intolerant of traditional DMARDs such as methotrexate, leflunomide, ...

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

It's been 5+ years after the first course. If you decide to re-irradiate what dosing schema would you use?

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

Other manifestations improved (renal function has stabilized, fatigue, arthritis, and LCV have resolved). Ophthalmologist has controlled the uveitis u...

A female in her 50s with iatrogenic Cushing's Syndrome presenting for management of SLE with low disease activity (but not remission) in the setting o...

Patient with history of toxoplasma chorioretinitis, currently on oral and topical prednisone. 

Does your approach differ if treating more ILD versus cutaneous disease?

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

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

Do you base the decision on FEV1, 6MWD or symptoms at initial evaluation, or progression over time?

There are studies that show hydroxychloroquine inhibits autophagy (the orderly degradation and recycling of the contents of the cytoplasm for the cell...

When adding nintedanib what sort of treatment course do you counsel the patient on? Do you plan to continue it indefinitely as long as the patient tol...

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

Classically, lupus mouth ulcers are large non-painful blisters at the roof of the mouth. What do you do with small scattered blisters, painful or not ...

For example, a patient with a bone marrow biopsy that shows normocellular bone marrow. Prior management with leflunomide and HCQ with neutropenia attr...

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

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

Would you switch to a non TNFi biologic or continue current regimen with careful monitoring for evolution of lupus manifestations?

Is there a role for immunosuppressive medications such as TNF inhibitors in the management of IgA nephropathy in this setting?

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

I get a lot of low false positive ds dna (sometimes high- 300) in quest and labcorp but their crithidia specific dsDNA  labs when repeated are ne...

This question is part of a collaboration with RheumMadness and is specifically in reference to: Hydroxychloroquine Withdrawal.

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

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

If a deficiency is present, do you consider IVIG to treat non-infectious symptoms such as skin rash, arthritis or hematological abnormalities? 

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

This question is part of a collaboration with RheumMadness and is specifically in reference to: ULT During Gout Flare.

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

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

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

Studies are now being pursued to ability the of implantable bioelectric device stimulation of the vagal nerve to attenuate disease activity in patient...

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

Given the controversy in the literature regarding TNFi or MTX associated lymphoma in patients with RA.

Patients frequently mention diagnosis of SLE years ago but recent Sm, dsDNA (crithidia) and complements can be normal. Can treatment with medications ...

At what CD 19/20 level do you redose? Is this lab dependent?  Do you also use these levels to instruct patients when to get vaccinated?

Does it mirror the same approach as SSc without malignancy? Do patients with paraneoplastic SSc present atypically (without usual serologies or featur...

When do you refer to genetics? Does your approach change if they have an additional finding such as mitral valve prolapse or a prolapsed bladder/uteru...

Significant impact on ADLs and no response to doxycycline, hydroxychloroquine, sulfasalazine or methotrexate.

Continue MTX with monitoring of LFTs vs switching to another oral DMARD (aza, lef) vs GI for fibroscan?

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?

If work-up is sent and the patient is found to have a persistently positive antiphospholipid antibody, particularly lupus anticoagulant, would you con...

Tibial plateau insufficiency fxs are not discussed in the guidelines for dx or treatment.

If so, is there one type of antibody that is more likely to cause this false positive test? 

How do you risk stratify and monitor such patient for disease progression or organ involvement?

Would the checkpoint inhibitor still work if blocking only that portion of the inflammatory cascade as opposed to more global blockade with steroids?

The patient has notable lip lesions from her discoid lupus erythematosus

What is the risk of pregnancy loss in absence of anticoagulation? What would you suggest if the patient had anticoagulation in prior pregnancies and r...

Such as patients with negative Hepatitis B surface antigen and negative viral load but with positive hepatitis b core antibody.

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

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

Is there a role of immunosuppression or treating underlying malignancy will be enough?

What are your primary and secondary agents?

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

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

Do you change therapy? If they are also on methotrexate, which medication would you potentially stop first?

In the absence of rhabdomyolysis is there still a need to protect the kidneys when patients with inflammatory myositis have CK over 5000 or 10000?

In contrast to TNF inhibitors for psoriatic arthritis, which seem to peak and maintain response percentages, the DISCOVER-2 Trial (McInnes et al., PMI...

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

In clinical practice continued steroid dependence is often seen as a reason to switch therapy and providers can be especially hesitant to use systemic...

Based on the results of the DISCOVER-2 Trial (McInnes et al., PMID 34719872), should guselkumab be used prior to anti-TNF therapy in these patients?

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

How do you counsel young adults with antibody-negative necrotizing myopathy on prognosis, risk of recurrence, and long-term monitoring/treatment?

For patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance, what work up process do you typi...

Is there role for IVIG? Would you alter the dose or time course of steroid therapy?

(assuming that the malignancy evaluation has been completed and the lymphadenopathy is confirmed to be reactive)

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...

In your experience, are there specific disease manifestations in which HLAB51 is particularly helpful?

For example, would it be appropriate to consider JAK inhibitor therapy as preferable to TNF-alpha inhibitor in patients with heart failure with reduce...

How would the approach differ if the patient had a significant bleeding phenotype vs only minor bruising and mucosal bleeding?

If you avoid parathyroid hormone-related protein analog drugs in patients with prior external beam radiation, what data is this based on?

This type of etoposide sparing therapy has been previously described in a case series at https://pubmed.ncbi.nlm.nih.gov/32725881/

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

Hepatitis screening labs revealing Hep B ag and core positivity with positive PCR

How does a diagnosis of active RA inform your treatment approach for patients with breast cancer, if at all? 

I teach my students/residents that they should hardly ever get routine X-rays in patients presenting with radicular symptoms. MRI far better for seein...

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

Do you routinely check IgA anticardiolipin and beta-2 glycoprotein antibody IgA in your practice? And how would a positive result change your manageme...

For medical oncologists, would you offer a PD-1/L1 inhibitor? For other subspecialties, how would you counsel the oncologist regarding the risk of usi...

Since tocilizumab is known to normalize ESR/CRP, are there any markers/blood tests that may be helpful to check for PMR patients with question of exac...

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

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

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

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...

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 ...

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 ...

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

What non-pharmacological interventions do you recommend? Do you routinely prescribe prophylactic laxatives to patients initiating opioids? How do you ...

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...

Especially in a triple-positive patient with an acute ischemic stroke who may have urgency for anticoagulation with high bleeding risk and severe thro...

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.

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

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...

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


Papers discussed in this category


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Cancer,

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Medicine (Baltimore),

The New England journal of medicine, 2010-07-15

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Arthritis Rheumatol, 2019 Oct

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N Engl J Med, 2022 Oct 06

RMD open, 2015

The New England journal of medicine, 2018-01-04

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Lupus,

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Ann. Intern. Med., 2019 Oct 15

Arthritis care & research, 2012-05

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Arthritis care & research, 2017-03

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Arthritis Rheum,

N Engl J Med,

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Clinical immunology (Orlando, Fla.), 2019-09

Seminars in arthritis and rheumatism, 2019-08

Clin Rheumatol, 2012 Nov 22

Ann Pharmacother,

Curr Rheumatol Rep, 2020 Oct 16

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Ann Rheum Dis, 2018 Oct 03

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The Journal of rheumatology, 2009-12

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J Am Heart Assoc, 2019 Sep 06

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The journal of allergy and clinical immunology. In practice, 2017

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Arthritis Rheumatol, 2016 Oct 26

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