Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When would you use tocilizumab to treat Takayasu's?
Currently, systemic steroids are the mainstay of Takayasu treatment. Because of the chronic nature of TAK and steroid related side effects, I favor treatment with an additional immunosuppressive agent early on in the disease course. In the majority of patients, methotrexate is prescribed as the firs...
How would you manage a middle-aged patient with Paget's disease who received one dose of zolendronic acid 2 years ago, currently suppressed CTX, normal bone-specific Alkaline phos, and a recent hairline fracture in the thoracic spine?
Parathyroid hormone analogs are, of course, contraindicated in patients with Paget's disease and I am not aware of any data regarding the use of romosozumab in patients with this condition. Paget's disease is primarily considered to be an osteoclast-related disorder and bisphosphonates, particularly...
How would you approach treating a patient with active rheumatoid arthritis and a history of treated lymphoma that is currently in remission?
I would individualize treatment in each patient depending on degree of RA activity, type of lymphoma and length of time of remission with shared decision-making between myself, patient and oncologist. For moderate to high degree of activity of RA, in general, rituximab in keeping with the ACR 2021 g...
How do you approach patients with RA and severe bronchiectasis with associated findings of UIP?
Usual Interstitial Pneumonia or UIP is among the most serious forms of RA-associated lung disease. Clinical studies have demonstrated that its prognosis is similar to idiopathic pulmonary fibrosis (IPF). UIP is extremely challenging to treat and we have learned from experience that our DMARDs and bi...
When do you consider immunosuppression in patients with Sjogren's neuropathy?
Only when disease activity is moderate-severe, impairing QoL, or rapidly progressive, ie mononeuritis multiplex/vasculitis, with significant risk of end-organ/tissue damage. Occasionally, autonomic neuropathy in SjD can be so debilitating to patient, and all other supportive treatments have failed, ...
What is your approach to a patient with incidental radiographic findings of sacroiliitis without clinical inflammatory back pain?
I agree. As mentioned, often, the radiology report going back to orthopedics, for example, may say "spondyloarthropathy" whereas, in fact, the radiologist is just describing osteoarthritis and/or spondylosis (the combination of OA and degenerative disc disease). Then, a rheumatology referral is init...
How do you monitor patients with cutaneous lupus for progression to SLE?
I think it is prudent to check patients with a new diagnosis of cutaneous lupus for any signs of SLE, typically with CBC, CMP, UA, complement levels, and ANA by IFA. If negative, I just screen with review of systems and check labs if something comes up.
Can JAK inhibitors for established rheumatoid arthritis be continued when starting an immune checkpoint inhibitor?
The concern for Jak inhibitors is not whether JAK inhibitors treat immune-related adverse events (irAEs). The issue with JAK inhibitors is that it may allow the tumors to grow. Oncologists are split over this issue and the answer may change depending on the cancer. There are case reports on JAK inhi...
How do you approach management of Adult Onset Still's disease in a patient with ongoing fatigue and inflammatory joint pain despite methotrexate, colchicine, canakinumab and tocilizumab?
There are several considerations for ongoing inflammatory symptoms despite trials of canakinumab and tocilizumab in a patient with presumed AOSD: If the patient has ongoing CRP elevation, a trial of anakinra might be considered if not previously used. The required daily dosing is not as convenient,...
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...