Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What are your vaccine recommendations while patients are on biologics?
Live vaccines are best completed at least a month before initiation of biologics when these are appropriate (e.g., MMR, chickenpox, yellow fever). The data on non-live vaccines is limited. I personally think that some degree of protection is better than none. I will not interrupt biological therapy ...
Do you manage a patient presenting with ICI-induced PMR-like syndrome using the same glucocorticoid dosing and tapering schedule you would apply to primary PMR, or do you treat it as a distinct entity requiring a lower steroid dose given evidence suggesting it tends to be milder?
Thank you for the excellent question. Since ICI-induced PMR-like syndrome is often milder than primary PMR, and because prolonged glucocorticoid exposure may attenuate the anti-tumor efficacy of ICIs, I generally aim to use the lowest effective steroid dose and taper more rapidly than I would for pr...
For what sort of SLE clinical profile do you favor anifrolumab beyond patients with prominent skin manifestations?
Skin disease is obviously the primary clinical manifestation. I will also prescribe it to patients with arthritis, pericarditis, mucosal disease, and hair loss. I await the results of the trial in lupus nephritis. I have an n of 1 experience with a patient with long-term high anti-dsDNA and low comp...
How would you advise a CKD patient who asks about oral NSAIDs for management of chronic pain if they have a contraindication to taking acetaminophen?
This depends on the severity of the CKD/eGFR, age, course of disease, available alternatives to NSAIDs, severity of pain and impact on QoL, frequency with which NSAIDs might be taken. I have advised patients whose QoL is adversely affected by pain to take occasionally if needed but to keep to minimu...
How do you approach tapering decisions for disease-modifying therapy for ICI-induced inflammatory arthritis after the patient's cancer treatment has been completed or the ICI has been discontinued?
This is a great question and, honestly, one that every rheumatologist struggles with. Similar to managing other inflammatory diseases, the challenge is determining when a patient is truly in remission and whether therapy can be safely reduced or discontinued.My approach is fairly practical: The pati...
When do you consider testing autoimmune antibodies for axonal polyneuropathies without clear etiology?
Dr. @Dr. First Last gave an excellent summary of the clinical red flags that should trigger antibody testing in polyneuropathies. I would like to highlight that not all antibodies are pathogenic or cause the same phenotypes/clinical syndromes; therefore, I would like to break it down by antibody gro...
When a patient with ICI-induced inflammatory arthritis requires biologic DMARD therapy, how do you balance need to treat with concern for faster cancer progression?
More data is needed to fully understand whether biologic therapy affects the risk of cancer progression in the setting of ICI therapy. We do know that higher doses of corticosteroids are associated with progression. If the patient cannot get down to a low dose of steroids, biologic therapy is likely...
Have you utilized denosumab in treatment of erosive hand osteoarthritis?
I have not prescribed denosumab for patients with erosive hand osteoarthritis. While the 2024 double-blind placebo-controlled trial suggested that this RANK ligand inhibitor may have structure-modifying effects by inducing remodeling and preventing new erosions, the phase 2a study of 100 patients di...
Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?
I do screen all newly diagnosed IIM patients with PFTs and chest CT. This has a double purpose: establishing a baseline of lung function and, screening for lung cancer. While the patient might not have lung symptoms on presentation, respiratory involvement can manifest later on the course of the d...
What was the rationale for abrupt discontinuation of etanercept rather than gradual tapering in the SEAM-RA trial?
The main goal of this trial was to get RA patients off of therapy and to see whether they would flare or maintain remission. We didn’t expect that the ultimate likelihood of success or failure was going to be primarily related to how long it took to do that. While a gradual withdrawal of the drug ma...