Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to discussing risk of adverse cardiovascular events in patients with RA whom you are considering starting a JAK inhibitor?
I would refer to the recommendations in the January 28, 2022, position statement by the American College of Rheumatology. This statement emphasizes the importance of shared decision making between the rheumatologist and the patient. There are many options available to treat RA that do not have a sim...
What is your approach to tapering therapy in a patient with recurrent pericarditis now well-controlled on rilonacept?
Good question, since rilonacept was only approved 1.5 years ago, a lot of this is gleaned (i.e. expert opinion) from those that participated in the Rhapsody clinical trial.In terms of actual data, the long-term follow-up from Rhapsody was just presented at AHA.2022. Of those in the extension that de...
Are there any concerns utilizing apremilast for psoriatic arthritis in patients who are also taking roflumilast for COPD?
This is an interesting question which I don't have a good answer for. In my experience, I have not used the combination and upon my review of the literature, I did not find any reported use of the combination. Roflumilast is currently being studied in and shows efficacy in psoriasis both in topical ...
What are your top takeaways from ACR 2022?
Risk stratification for cardiovascular risk with JAKi (Ytterberg et al., PMID 35081280 and more specifically subgroup analysis by Charles-Schoeman et al., PMID 36137735): heightened risk in patients with history of atherosclerotic CV disease-ASCVD (defined as CAD, stroke, PAD)-NNH only 16 over 5 ye...
What is your approach to immunosuppression in patients with recurrent peripheral ulcerative keratitis or marginal keratitis who have active disease despite steroid therapy and no current evidence of rheumatologic disease?
Drs. @Dr. First Last and @Dr. First Last provide some excellent insight in their responses. In this question, it's stated the patient has active disease despite steroids. I would agree with both Drs. @Dr. First Last and @Dr. First Last that non-infectious PUK typically requires high-dose steroid (1m...
Do you routinely screen for pulmonary artery aneurysm in patients with Behcet's?
I don't routinely screen Behcet syndrome patients for pulmonary artery aneurysms. They are a rare manifestation of Behcet syndrome; however, some clinical features increase the likelihood of pulmonary artery aneurysms. Behcet patients with thrombophlebitis are at increased risk of having pulmonary a...
How would you approach the use of JAK inhibitors in a patient with stable RA who is now starting treatment for pulmonary MAC infection?
Unfortunately, I would stop the JAK inhibitors, particularly in the induction antibiotic phase. Maybe treating the MAC may improve the inflammation overall and the arthritis. Once a month or 2 of antibiotics you can consider a trial of restart the JAK and see how the lungs do.
Do you ever consider using a higher dose of upadacitinib (30 mg daily) for rheumatoid arthritis in patients who fail to respond/partially respond to established dosing of 15 mg daily?
The FDA-approved dose of upadacitinib (UPA) for the treatment of RA is 15 mg per day. In other diseases, such as psoriatic arthritis (PsA), atopic dermatitis (AD) and ulcerative colitis (UC), higher doses (30mg and 45 mg per day) have been studied and shown to be efficacious and relatively safe when...
In patients with secondary Sjogren's how do you approach screening for lymphoproliferative malignancy?
1. Firstly, I do not discriminate between "secondary" and "primary" Sjogren's disease. There is currently a "Nomenclature Initiative" by the Sjogren's Foundation, led by Dr. Alan Baer, Director of the Sjögren’s Clinic at Johns Hopkins, and Dr. Manuel Ramos-Casals, a Sjogren's expert in Spain. Thus f...
Would you consider using a JAK inhibitor in combination with an IL 23 inhibitor in cases of severe psoriasis, psoriatic arthritis, or axial spondyloarthritis that is refractory to multiple biologic DMARDs?
Differential skin and joint responses in psoriasis, PsA and Axial SpA are not uncommon. Many PsA/PsO experts and scientists have postulated the potential benefit of using combination biologic (perhaps in serial fashion or lower doses of each) to treat these cases where there are suboptimal responses...