Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What circumstances would drive you to consider using an oral IL-23 inhibitor over parenteral options for the management of psoriasis and/or psoriatic arthritis?
Psoriatic arthritis is a heterogeneous disease and the choice of therapy is driven by many factors.The most important factors in the decision tree are whether the patient has 1) axial disease and/or 2) severe psoriasis.Additional Considerations include: prior therapies, extramusculoskeletal manifest...
How often do you monitor urine protein levels for patients with membranous nephropathy for whom you initiate obinutuzumab?
Most studies of obinutuzumab in membranous nephropathy are retrospective, with remission rates of up to 83%. Would monitor UPCR every 1-3 months and check PLA2R every 3 months. Immunological remission (negative PLA2R) precedes clinical remission (one study with 76% at 3 mo and 80% at 6 mo), and clin...
Do you think the benefits of performing a repeat kidney biopsy to assess histologic evidence of disease activity or chronic damage outweigh the risks in a patient with recently treated lupus nephritis and improving creatinine levels?
In patients with lupus nephritis who have recently undergone treatment and are demonstrating improved creatinine levels, performing a repeat kidney biopsy is generally unnecessary. The risks associated with the procedure do not justify its benefits unless there is persistent or worsening proteinuria...
How do you approach the management of a symptomatic Baker's cyst?
I have offered NSAIDs, PT, and ultrasound-guided aspiration and injection for management of a symptomatic Baker’s cyst in a patient with OA or mechanical pathology. I favor aspiration and injection of the knee joint as well as the cyst, though the literature does not necessitate injection of the joi...
For those treating osteoarthritis with LDRT, is there any concern of adverse effects or decreased efficacy in patients with osteoporosis?
I’m not aware of any data specifically looking at the efficacy of LDRT for OA in patients with osteoporosis. The anti-inflammatory mechanism of LDRT should not be altered by the bone thickness/quality, but repetitive “injury” contributing to OA may be different if the cause is related to bone qualit...
How do you approach management of new onset ILD in a patient with RA who is otherwise well controlled on methotrexate or leflunomide?
We do not have any randomized controlled trials for DMARDs in RA-ILD. Most of the data is case series or retrospective analysis. Nonetheless, we can use current data to at least make clinical decisions until we receive more direction from high-quality clinical trials. We now know that in general met...
For a patient on appropriate treatment for invasive aspergillosis, how do you determine if and when it is acceptable to reintroduce a TNF inhibitor that likely contributed to their acquisition of the infection but is considered essential for control of their inflammatory condition?
There is no established answer to this question. The reintroduction of a TNF inhibitor must be individualized based on the clinical situation of the patient under consideration. There are two critical questions. First, how much does the patient need the inhibitor”? The more the patient is dependent ...
What is your approach to treatment of airway involvement, such as recurrent bronchial stenosis, in relapsing polychondritis?
Depending on the location of airway involvement from the subglottic area to the trachea and central airways, options include cryo-spray ablation, balloon dilation, APC/Laser ablation (less favored), Kenalog injection and airway stenting. Typically, combined modalities are more effective than single ...
How do you approach PJP prophylaxis in patients with rheumatic disease on corticosteroids?
Here is a graphic I made covering PJP Prophylaxis with Dr. @Dr. First Last if anyone is interested! As noted, one can check absolute lymphocyte count (ALC) or CD4 count as factors to further risk stratify as well.
What is a reasonable stepwise approach to diagnostic imaging when there is ongoing concern for cardiac amyloidosis?
Abnormalities on CMR are not diagnostic of cardiac Amyloidosis. Although LGE, abnormal ECV, and abnormal T1 are findings commonly seen in Cardiac amyloidosis, the absence of one or more does not rule out amyloid. In the setting of increased LV thickness and clinical suspicion of amyloid, I would hav...