Rheumatology   

Questions discussed in this category



What are your primary and secondary agents?

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...

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

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?

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...

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

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?

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

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?

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

(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?

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

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

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...

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?

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

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

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 ...

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 ...

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...

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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