Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you always perform salivary gland biopsy to confirm the diagnosis In patients with suspected seronegative Sjogren's syndrome?
I often struggle with the decision of obtaining a biopsy in suspected Sjogren's in a person who is seronegative, when the main issue is dryness, and the main reason is that I wonder if it will make a difference in management. When I was a Rheumatology fellow, I was taught to give Hydroxychloroquine ...
Would you choose bimekizumab over other IL-17 inhibitors in patients with increased levels of disease related pain and poor functional status?
In the absence of head-to-head trials, I hesitate to make a recommendation regarding which IL 17 inhibitor is better in this situation. It is also very unlikely that the makers of the three IL 17 inhibitors would conduct such trials. Network meta analysis and matching-adjusted indirect comparison ar...
How do you approach the initial treatment for a patient presenting with MAS/HLH as the initial manifestation of SLE?
For rare manifestions of systemic lupus erythematosus (SLE) such as macrophage activation syndrome/hemophagocytic lymphohistiocytosis (MAS/HLH), I like to refer to the recent paper by the Members of the European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, th...
How would you approach escalation of therapy in an adult patient with refractory Still’s disease and associated MAS/HLH (ferritin >100,000, transaminitis, DIC) despite high-dose steroids, high-dose anakinra, tocilizumab, and ruxolitinib?
Emapalumab is an appropriate escalation in the described circumstance. I have no experience, and there is little published data as of yet with MAS825, but I would position this as an option to pursue before using etoposide. While there may be an indication of confounding, etoposide use nonetheless h...
Does your practice currently use low-dose radiation in the treatment of osteoarthritis?
Yes, we do. There is a long and storied history of utilizing LD-RT for benign inflammatory conditions in Germany. Much of the literature comes from there. I have had great success and truly believe it is a valuable tool to add to our toolbox. Pearls: At this time, I am limiting treatment to osteoar...
In patients with anti-PL7 antibody–associated antisynthetase syndrome, can sacroiliitis occur as part of the inflammatory arthritis spectrum, or should alternative causes be considered?
A review of the literature on large cohorts of antisynthetase syndrome does not report sacroiliitis as a feature, but rather, inflammatory arthritis similar to rheumatoid arthritis (with or without RF and CCP) is described. Therefore: It is important to confirm whether the PL-7 result is truly posi...
How do you counsel a patient with SLE who has labs suggesting active non-renal disease on the benefits of escalation of treatment if they aren't experiencing noticeable symptoms?
Non-renal disease is predominantly in the skin and joints. These are assessed by physical examination (not by laboratory tests). Yes, there are some patients with mild synovitis by exam who are NOT bothered by it, but most patients will have morning stiffness and require treatment. Patients who are ...
What do you feel are the potential barriers to widespread use of obinutuzumab in proliferative lupus nephritis?
1. Insurance Coverage: Oh, easy one! Since it is not FDA-approved yet for lupus nephritis (I bet it will be though... great data so far), insurance will unlikely cover it, except for a few (like Tricare, which is sometimes easier to get off-label drugs). I am fortunate to have the NIH Lupus Center c...
In postmenopausal osteoporosis, would you switch to romosozumab (rather than a PTH/PTHrP analog) if a patient fractures while on denosumab?
This is an interesting question because it raises the subject of how one defines "treatment failure" among patients who are using bone-strengthening medications. I remind patients that our drugs are most effective at preventing spinal fractures with efficacy that can exceed 70% relative risk reducti...
Have you seen synovitis (even if subtle) with aromatase inhibitor musculoskeletal syndrome?
Aromatase inhibitor (AI) drugs have been associated with the onset of arthralgias and myalgias. These have been reported to occur in as many as half the women prescribed this class of drug. The onset of an inflammatory arthritis is far less common. There are selected case reports documenting the ons...