Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you decide on the next therapy for post-ICI triple M syndrome (myositis/myocarditis/myasthenia) after steroids, PLEX, and IVIG?
The short answer is that there is no standard of care, and no way to reliably predict which of the third-line treatments will work best for each individual. As an introduction, 3M syndrome is a horrible combination of 3 immune-related adverse events (iRAEs) after ICI exposure for cancer, including m...
For a pediatric patient with Takayasu arteritis with persistent enhancement and mild progression on imaging after recent transition to tocilizumab (2 months), would you continue tocilizumab therapy, increase to q2 week dosing, or transition to cyclophosphamide?
Would add to the methotrexate and steroids, shortened interval of the tocilizumab, followed by moving to Cytoxan. There is less experience with B-cell-targeted treatment, such as Rituxan or obinutuzumab, for cluster of differentiation 19 (CD19) or CD20.
For a patient with suspected post-streptococcal reactive arthritis who does not meet criteria for acute rheumatic fever and has a normal echocardiogram at presentation, do you prescribe 1 year of antibiotic prophylaxis?
This is a loaded question. Post-Streptococcal reactive arthritis (PSRA) plagued me during my fellowship (many moons ago). There is a fine line between PSRA and rheumatic fever (RF). We rarely see RF in the United States anymore. If I'm convinced it is PSRA and not RF (e.g., RF migratory arthritis qu...
In patients with a history of retinal vein occlusion, how should the risk of recurrent thromboembolic events influence the selection of osteoporosis therapies?
The FDA-approved prescribing information for raloxifene explicitly lists retinal vein thrombosis alongside deep vein thrombosis and pulmonary embolism as contraindications.
Do you counsel patients differently about the risk of radiation induced malignancy when you are treating a proximal joint (hip) vs a distal joint (elbow) for benign conditions such as OA?
The mentality for this must change from radiation oncologist thinking to radiation medicine thinking. There have been no documented cases of malignancy from LDRT treatment of OA. Those who worry about the spine reference old studies giving 20 Gy in 5 fx with an open field pre-linac era. This is not ...
In an infant whose mother resumes TNF inhibitor therapy (e.g., adalimumab, infliximab, certolizumab) after delivery and is breastfeeding, do you recommend delaying live vaccinations?
IgG-based biologic therapies - including TNF inhibitors - are all considered compatible with breastfeeding, since IgG passes only minimally into breast milk. Given these agents are proteins, the minimal drug that is transferred is unlikely to remain intact (or active) with passage through the infant...
How often are you performing CT screening in CVID patients to screen for ILD?
CT once every 1-2 years, depending on symptoms and PFTs. PFTs, including DLCO, are annually performed.
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
Would you avoid use of JAK inhibitors in patients with dermatomyositis with autoantibody subtypes with increased risk of malignancy (TIF1y, NXP2)?
This is a difficult question to answer with certainty. Most of the direct data on malignancy risk with JAK inhibitors come from rheumatoid arthritis studies, and primarily involve tofacitinib. It is therefore possible that the risk is not the same across all JAK inhibitors, especially since they dif...
Do you routinely screen for cardiovascular risk factors in a patient with moderate-to-severe psoriasis?
Review of systems. Depending on age, consider lipids and HbA1c if no data for the past year.