Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What treatment strategies would you utilize in a patient with newly diagnosed HLA-B27+ axial spondyloarthritis (with active and chronic sacroiliitis on MRI) and recent diagnosis of MS that is well-controlled MS ocrelizumab given the need to avoid TNF inhibitors?
This is a very challenging scenario. On one hand, TNFi are generally unsafe for MS due to demyelination risk, and on the other hand, anti-CD20 therapies for MS are linked to new AxSpA, but B-cell depletion might also benefit AxSpA. Thus, management requires specialized care in balancing both disease...
How do you approach a patient with idiopathic anterior uveitis who has ongoing disease despite adalimumab every two weeks?
This is a style question, I think. I thought it would be useful to note the choice here might depend on testing for anti-adalimumab antibodies as there is some suggestion that changing to once weekly adalimumab in the presence of anti-adalimumab antibodies might not be efficacious. (Ismayilova et al...
What is your approach towards continuing cancer screening in a young adult with Tif-1+ dermatomyositis, and negative initial CT chest/abd/pelvis?
Young TIF-1 is likely behave as juvenile DM with TIF-1, where the risk of cancer is much lower. I have many young TIF-1 that never developed cancer. I still think that careful ongoing monitoring is needed for 3 years from diagnosis. For cancer risk assessment and management, use the International gu...
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.
Do you routinely apply the 2010/2011 ACR symptom-based diagnostic criteria for fibromyalgia in your practice, or do you continue to use the 1990 tender point examination to make the diagnosis?
I don’t use tender point counts in my practice: they were discarded after the 1990 criteria for many reasons, including poor inter-rater reliability and the sort of nebulous nature of what was really being measured. The ACR 2016 criteria reference this very issue, noting that some have described ten...
How do you approach the treatment of eosinophilic fasciitis refractory to glucocorticoids and methotrexate?
As rheumatologists, we are accustomed to managing people with rare diseases. Eosinophilic fasciitis (EF) ranks among the rarest of the rare, so it is understandable that there are no carefully designed trials assessing the efficacy of the various immune-modulating drugs. Clearly, corticosteroids are...
In a patient with negative Hep B surface Ag, Hep B surface antibody+, and Hep B core antibody+ serologies, do you initiate antiviral prophylaxis (e.g. entecavir) prior to starting rituximab?
I would use entecavir for Hep B reactivation prophylaxis in this case - based on recommendations from AGA 2025 guidelines, which does classify b-cell depleting agents as higher risk for reactivation for both Hep B surface Ag-positive and Hep B surface Antigen neg/core positive patients. It should be...
How do you counsel patients on use of creatine monohydrate supplementation during a hospitalization for acute rhabdomyolysis from intense physical training?
I was a primary care doctor for the military for a few years. We regularly saw patients presenting with rhabdomyolysis from intense physical training. A standard question for all that present with this is whether supplements are being used. While there isn't a direct linkage to say that the use of c...
How do you counsel patients on the risks and benefits of strontium supplements for osteoporosis management?
No experts whom I know prescribe Strontium for osteoporosis. It has not been shown to be efficacious to reduce fractures, although bone density will rise substantially. Also, bear in mind of very serious toxicities that have been associated with this drug. I would never use it in any of my patients....
Are the results of the SEAM-RA trial generalizable to other TNF inhibitors given the differences in immunogenicity?
This is a great question, and an important one because different TNF inhibitors have different immunogenicity and patients can make anti-drug antibodies that can effectively neutralize the drug and render it a less effective treatment option. This tends to happen more with some molecular constructs ...