Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to use of IL-17 inhibitors in patients with axial spondyloarthritis and a family history of inflammatory bowel disease?
I would have no hesitation in using an IL-17i in an axSpA patient with a family history of IBD as long as the patient themselves do not have active IBD. Clinical trials on Secukinumab, Ixekizumab, and Bimekizumab did not exclude patients with a history of IBD, and family H/O IBD was not recorded. Ac...
What would be your treatment approach for a patient with concomitant diagnoses of multiple myeloma and axial spondyloarthritis?
The treatment of multiple myeloma would take precedence in this situation. I would get in touch with the oncologist, ask them about their treatment plans, explain to them how we treat axSpA (NSAIDs, csDMARDs for peripheral manifestations, and biologics, small molecules for axial disease), and then c...
What factors lead you to recommend a JAK inhibitor as second-line therapy in a patient with radiographic axSpA who has had a primary non-response to a TNF inhibitor, before trying an IL-17 inhibitor?
This is an excellent question, which requires not just a treatment plan but also a revelation of how we should be making patient management decisions in Spondyloarthritis (SpA). My initial reaction is that primary non-response to a TNFi is not the usual story; if this truly happens, I recommend re-e...
What is your approach to long-term immunosuppression in patients with Adult Onset Stills Disease?
For persistent or recurring disease flares, IL-1 blockers (canakinumab or anakinra).
Is there an association between treatment with anti IL-5 agents for eosinophilic asthma and the development of RA?
Not seen in clinic but would like to know also.
What is your algorithm for transitioning a patient with chronic noninfectious posterior uveitis from corticosteroids to immunosuppressive therapy?
There are some forms of noninfectious posterior/panuveitis where it is known from the time of uveitis diagnosis that steroid-sparing immunosuppression (IMT) will be needed. For example, in birdshot retinochoroiditis or serpiginous choroidopathy, IMT is often initiated in concert with oral corticoste...
Do you always pursue biopsy confirmation before diagnosing IgA vasculitis?
Technically, yes (by definition), but practically, not necessarily: Biopsy for direct immunofluorescence (DIF) testing would be required to confirm the status of IgA in cutaneous vasculitis. However, the presence of lesional IgA correlates positively with the clinical presentation (e.g., Henoch Schö...
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
Do you consider metformin as a disease-modifying adjunct in the management of patients with OA, particularly in those with comorbid metabolic syndrome or type 2 diabetes?
Based on the Pan et al., PMID 40274279, and the broader literature, I would not yet formally classify metformin as a disease-modifying osteoarthritis drug (DMOAD), but the evidence is increasingly compelling, particularly in the metabolic osteoarthritis (OA) phenotype.This randomized controlled tria...
How do you approach the workup of pauci-immune glomerulonephritis?
When a kidney biopsy reveals a pauci-immune GN, the Ddx must extend well beyond classic AAV and infective endocarditis. For instance, anti-GBM disease should remain high on the list, as up to 25% of these patients present with a "dual-positive" ANCA, and the characteristic linear IgG staining on IF ...