Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you interpret treatment response in the DISCOVER-2 Trial when patients were allowed to remain on up to 10mg of prednisone equivalent for disease control while on guselkumab?
If patients were on less than or equal to prednisone 10 mg, they could continue that in the background during the trial, but note that only 20% of patients were on prednisone, a much lower figure than a typical rheumatoid arthritis trial, which is consistent with the point that rheumatologists shy a...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
Do you consider co-prescribing hormone therapy and anticoagulation in a patient with prior DVT and uncontrollable VSM uncontrolled by non-hormonal therapies?
While I agree that you need to be thoughtful about adding additional VTE risk to patients with a history of VTE, I am much less concerned when patients are already on full-dose anticoagulation. Especially when the medication is transdermal estrogen, which has the lowest effect on thrombotic risk. I ...
How do you approach screening for ILD in patients with a diagnosis of MCTD given the recommendation discrepancies between the most recent EULAR and ACR/CHEST guidelines?
Another excellent question! While the EULAR guidelines treat MCTD as SSc-equivalent and suggest universal screening, ACR/CHEST guidelines suggest risk-stratified screening with emphasis on symptoms, PFT abnormalities, and high-risk phenotypes.Prevalence of ILD in MCTD can be high, in the range of 30...
What drives you to initiate a csDMARD early rather than relying on prolonged corticosteroids alone in a patient with ICI-induced inflammatory arthritis who has moderate disease activity with polyarticular involvement and tenosynovitis at the time of rheumatology referral?
My approach differs somewhat from the traditional paradigm of early csDMARD initiation. In patients with immune checkpoint inhibitor-induced inflammatory arthritis (ICI-IA), particularly those with moderate disease activity, polyarticular involvement, and tenosynovitis, my primary goal is to avoid p...
Do you have safety concerns when prescribing GLP-1 medications in patients on corticosteroids or immunosuppressive therapy?
I think we need to be particularly careful when co-prescribing with systemic corticosteroids because of the risk of sarcopenia. We know that rapid weight loss is accompanied not only by a loss of fat tissue but also of muscle. Corticosteroids can also have myotoxicity and cause muscle atrophy. I the...
Do you offer low-dose radiation therapy for osteoarthritis of the spine?
DEGRO has published guidelines on this very topic, so I would respectfully disagree with a comment arguing a lack of data. Of course, if one is looking for level 1 data on irradiating benign diseases in general, there may be little to satisfy.That being said, there's no level 1 data espousing the be...
How would you approach the evaluation and management of a patient with rheumatoid arthritis receiving leflunomide who presents with progressive peripheral pulmonary cavitary nodules, with biopsy revealing necrotizing granulomatous inflammation?
Given the association between leflunomide and nodules with necrosis and giant cells (though quite rare), I would consider stopping leflunomide and moving to another agent. I would, of course, make sure that cultures are negative on those nodules, given it could be mycobacterial, fungal, or even GPA.
How do you manage patients with scleroderma who present with finger ulcerations without other signs of soft tissue infection and MRI demonstrates potential concern for osteomyelitis?
I think this is a tricky situation. Sometimes there is bone damage from acro-osteolysis from the ischemic injury of the scleroderma itself, which can sometimes be difficult to distinguish from osteomyelitis. I would consider watching closely for other signs of deeper infection. You could also consid...
What additional workup and steroid-sparing option would you choose in a patient with potential medium-vessel vasculitis (petechial rash, sensorimotor neuropathy, renal infarcts, renal artery micro-aneurysms and ischemic/ulcerative duodenitis), hypocomplementemia, ASO 1525, negative blood cultures and normal echo?
This is a challenging case. Generally, PAN should be confirmed histologically, particularly if there are atypical features. In this case, hypocomplementemia is atypical, as non-HBV-associated PAN is generally normocomplementemic. Further, PAN more commonly causes ulcers/nodules/reticular lesions tha...