Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you recommend that a patient with stable coronary artery disease and well-controlled RA on a JAK inhibitor continue on their current therapy?
There is no simple answer for this. It is a difficult situation and I would consider a few things in making a decision about what to recommend. These include the course of the patient’s disease, e.g., duration and severity of disease, their current and previous medication history, and the severity o...
How would you manage a patient with diffuse Systemic Sclerosis who develops severe rapidly progressive calcinosis?
Unfortunately, calcinosis cutis is a very challenging and frustrating manifestation of Systemic sclerosis to tackle. When extensive, response to trial of interventions is further unlikely or poor. The primary goal of treatment is to minimize symptoms and alleviate functional limitations rather than ...
Do you consider Anti-carbamylated protein antibodies (anti-CarP) as having any significance in evaluation of patients if RF and ACPA negative and clinically no active synovitis yet widespread arthralgias and generalized osteoarthritis?
Anti-CarP has been touted as another biomarker for early RA with rates of positivity in ACPA and/or RF-negative patients ranging from 4.5 % in a recent study by Ricchiuti et al., PMID 35885566 to 23.6% in the French ESPOIR cohort. Ricchiuti described anti-CarP tracked the most closely with 14-3-3 et...
How will you approach tapering sarilumab in patients with PMR in remission?
Unfortunately, there is no data at the moment to inform decisions about the optimal duration of sarilumab treatment for PMR patients and how to discontinue this medication. The clinical trial that demonstrated efficacy was limited to 12 months and the drug was stopped altogether after that period. N...
Do you continue belimumab throughout pregnancy?
@Dr. First Last: @Dr. First Last is absolutely correct regarding the limitations of our studies regarding using belimumab in pregnancy.However, how much more evidence do we need?No one is going to perform a prospective randomized controlled trial. I and some others I know are feeling more comfortabl...
How do you plan to use canakinumab for the treatment of gout?
I recently had this approved for a gentleman with severe tophaceous gout who does not want to be on allopurinol due to mobilization flares and had anaphylaxis to pegloticase. He has CKD and multiple cardiac comorbidities which limit colchicine as prophylactic agent and difficulty with controlling bl...
Do you avoid tocilizumab in patients with prior bariatric surgery given the risk of GI perforation?
This is an interesting question with no current data to answer it with certainty. However, I personally would feel comfortable prescribing tocilizumab in a patient with an uncomplicated bariatric surgery history for the following reasons. The vast majority of GI perforations in the setting of TCZ oc...
What is your threshold for pursuing bone marrow biopsy in a lupus patient with cytopenias?
I rarely do bone marrow biopsies in patients with SLE as cytopenias are caused primarily by the disease itself and/or medications, primarily Azathioprine and Cyclophosphamide. SLE patients routinely have profound lymphopenia, neutropenia, and thrombocytopenia. I consider bone marrow biopsy in patien...
How do you approach the workup of a patient with incidentally found pachymeningitis?
In general, when we think about the meninges, we consider the leptomeninges and the pachymeninges separately, though many of the disorders of one can also cause disease in the other. We also consider whether the pachymeningitis is focal and nodular or diffuse. Common causes of pachymeningitis are in...
What is the utility in repeating a temporal ultrasound (US) in a previously US diagnosed positive GCA patient who has received treatment and is presenting with recurrent GCA symptoms?
While TA ultrasound may have a role in the assessment of disease relapse, currently there is little evidence to understand its utility in this area. It is well known that the halo sign is steroid responsive and multiple studies have shown that the halo sign recedes within the first several weeks of ...