Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Should JAK inhibitors and anti-IL6 medications be avoided in patients with known diverticulosis?
The development of diverticulitis, including complications such as bowel perforation, has been reported in patients taking JAK and IL-6 inhibitors (for example, see here and here). As a result, a history of diverticulitis is a relative contraindication for these agents (and carry a “use with caution...
How do you manage patients with SLE undergoing assisted reproductive therapy with estrogenic effects?
For patients undergoing any form of assisted reproductive technology (ART), it is important to assess their SLE disease activity. If a patient has moderate to severe SLE disease, I recommend delaying ART until we have better control of their disease. Once we plan to move forward with ART, I check an...
Do you continue methotrexate in patients with inflammatory arthritis who develop non-melanomatous skin cancer while on therapy?
Data on methotrexate use and the increased risk of non-melanomatous skin cancers has been conflicting, suggesting an increased risk or a neutral risk. A recent case-control study published in the British Journal of Cancer (Polesie et al., PMID 36739322) did suggest an increased risk of both squamous...
Do you utilize serial MRI imaging in patients with axial spondyloarthritis to ensure good disease control or do you rely on symptoms and physical exam to assess treatment response?
The ACR 2019 guidelines recommend that MRI could provide useful information in cases where the level of disease activity was unclear and where this information would influence treatment decisions. For patients with nr-axSpA, the imaging should focus on the sacroiliac joints. In interpreting MRI resu...
Does the presence of a connective tissue disorder such as lupus or scleroderma modify your radiation dose or technique for prostate cancer?
Here another article that may be of interest. It's actually a hometown favorite at VCU since the lead author is on our faculty. J Clin Oncol. 1997 Jul;15(7):2728-35.Irradiation in the setting of collagen vascular disease: acute and late complications. Morris MM1, Powell SN. PURPOSE: Based on repor...
Are there patients with gout in whom you would choose febuxostat first line over allopurinol for urate lowering therapy?
While both allopurinol and febuxostat have shown efficacy in reducing uric acid levels, in most cases allopurinol remains the first-line choice with and is considered safe. The main exception is for patients of Asian descent (especially Chinese, Korean or Thai) or who are Black, as they have a much ...
What is your approach to patients with severe sicca symptoms and history of B Cell lymphoma?
For your patient with SjD, B-cell lymphoma, and severe sicca; in addition to treating them with HCQ, I would also: Be diligent with treating the sicca sxs proactively to prevent dental loss and vision problems using the previous guidelines (Zero et al., PMID 26762707 and Foulks et al., PMID 25881996...
How do you interpret negative HMGCR antibody test results in a patient with necrotizing myopathy who has already been on treatment with steroids and whose CK has normalized?
HMGCR antibodies tend to remain present over time, even during periods of disease remission. Only recently have we began observing negative results in patients undergoing long-term treatment. Therefore, considering the patient received steroids for only a brief period, it's reasonable to suspect tha...
What is the diagnostic utility of ordering an "Early Sjogren's Syndrome Profile", which tests novel autoantibodies, to support a diagnosis of Sjogren's syndrome in patients who test negative for SSA/SSB?
Currently, there is not much diagnostic utility to ordering these novel autoantibodies in patients who are negative for SSA/SSB as it is unclear how to interpret the results. In a mouse model for Sjogren's (Shen et al., PMID 23123440), these novel autoantibodies appeared earlier in the course of dis...
When do you consider discontinuing Pegloticase in a patient with tophaceous gout who has had excellent response to therapy?
This is an important question to clinicians who use pegloticase for their severely afflicted gout patients. There are no studies that provide guidance to answer this question but there is a good rational approach to knowing when to stop treatment.To recap, pegloticase therapy is indicated for patien...