Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What do you try in patients with IBD-related spondyloarthritis with predominantly axial symptoms who are refractory to TNF inhibitors?
Treating these patients is challenging. It's always good to circle back to first-line therapy recommendations for axial spondyloarthritis and ensure that patients are doing physical therapy or exercise daily. Patients whose IBD is in remission may be able to add a COX-2 selective NSAID (celecoxib), ...
What is your next step in patients with polymyositis without interstitial lung disease who are refractory to methotrexate?
In general, first-line treatment for myositis patients includes methotrexate, azathioprine or CellCept. The exact choice of agent depends on concomitant manifestations of the disease, like lung disease or arthritis, and can move on to the next one if they fail one of them. At the same time though, w...
What agent do you try next in patients with myositis-related interstitial lung disease who are refractory to mycophenolate mofetil and azathioprine?
In those refractory to MMF or AZA, tacrolimus would be the next good option. There is data to support the use of tacrolimus in those who are more refractory, especially those who are MDA5 or have an antisynthetase syndrome.
When do you use tacrolimus in patients with myositis-related interstitial lung disease?
Tacrolimus can be used as a first-line treatment for any myositis-related ILD; however, it does require more frequent monitoring than other agents. I usually use tacrolimus as a first-line treatment for MDA5-associated ILD given the published literature from Japan and China. In the majority of cases...
Do you continue hydroxychloroquine in lupus patients who develop cardiomyopathy?
The short answer is yes, in that most lupus patients with cardiomyopathy do not have hydroxychloroquine drug induced cardiac injury. That is to say most of these patients either have ischemic cardiomyopathy or non-drug NICM. With that said, antimalarials can produce adverse effects both on the cardi...
Would you re-challenge patients who have had a TNF-associated paradoxical adverse event (such as inflammatory bowel disease) with a different TNF inhibitor?
I honestly have not heard of IBD as a paradoxical event with TNF inhibitors (unless possibly in a patient with underlying IBD that was not being treated adequately with etanercept rather than a monoclonal anti-TNF antibody). On the other hand, I have seen paradoxical psoriasis with TNF inhibitor use...
Is it okay to use COX-2 selective NSAIDs in patients with IBD-associated arthritis when the IBD is in remission?
I do not feel comfortable prescribing COX-2 NSAIDS to patients with IBD in remission. If I have such a patient and an NSAID is the major therapeutic option, I will reach out to the treating gastroenterologist for an opinion on whether this is advisable.
Should patients be screened for hepatitis B/C prior to starting a conventional synthetic DMARD such as methotrexate?
If you are even thinking about it, YES!!!!AASLD suggests HBV screening when contemplating immunosuppression with HBsAg, anti-HBcore, and anti-HBs for immunization status (separate issue). HCV-Ab should be done at the same time as I have advocated for many years, but now, the practice is catching up ...
How do you manage patients who are Hepatitis B core antibody positive/surface antigen negative and starting a biologic DMARD (other than rituximab)?
According to the 2015 American College of Rheumatology Guidelines, a patient with natural immunity to Hepatitis B (Core & Surface Antibody-positive; Antigen-negative, normal liver function tests) can be treated as any other patient. However, monitoring of viral load is recommended "regularly" at 6-1...
Do you regularly do bone density testing to screen for osteoporosis in men with rheumatoid arthritis without any other risk factors?
An important comorbidity in RA is fragility fractures. These patients are at higher risk of OP because of increased pro-inflammatory cytokines and glucocorticoid treatment. OP screening strategies are both feasible and effective in RA patients and recommended by most specialty organizations. Both me...