Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?
When deciding whether it is safe to re-challenge with rituximab after an infusion reaction, the most important consideration is the type of reaction that the patient experienced. This will help to risk stratify and determine whether same day or future infusions of RTX should be used. Importantly, th...
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
How do you approach inflammatory arthralgias without synovitis in a patient with psoriasis?
When a patient with psoriasis presents with inflammatory arthralgias, the approach should be centered on a prompt evaluation to differentiate psoriatic arthritis (PsA) from other causes of joint pain or non-inflammatory arthralgias. Clinical history and physical exam are the key. A good clinical his...
Are there patients with SLE associated inflammatory arthritis in whom you recommend TNF inhibitors as a treatment option?
In patients who have inflammatory arthritis due to SLE and other causes have been excluded, such as infection, gout, and CPPD, I avoid TNFi therapy due to the concern of flaring lupus disease activity. Alternatively, I tend to add therapy for which there is evidence-based data to support their use, ...
How would you manage a patient with arthritis mutilans who has failed TNFi, IL-17i, and JAKi and now on bimekizumab and with worsening joint disease?
Difficult case of destructive joint disease without a lot of options. If this is truly an "active" disease, and not just pain from prior joint destruction, the addition of cs-DMARDs to current therapy or adding 2 targeted therapies could be tried. TYK-2 (deucravacitinib) could be an option, but may ...
When do you prefer bariatric surgery such as sleeve gastrectomy or gastric bypass over an initial trial of a GLP-1 receptor agonist in patients with severe obesity and painful knee or hip osteoarthritis?
I believe that this type of decision should be made by obesity specialists and not by rheumatologists. However, we can anticipate that the patient's choice is paramount: some prefer radical options such as surgery, while others cannot bear to hear about it. The decision should only be made through d...
How do you approach the management of a patient with strongly positive SSA antibodies and an extraglandular feature such as ILD or peripheral neuropathy, but without sicca symptoms or parotid abnormalities?
The ACR/EULAR 2016 criteria are clear that a patient with a +SSA antibody needs to also have some degree of measurable sicca in order to be clinically diagnosed with SjD. In my experience, many patients may not perceive that they are dry because they have been able to tolerate the symptoms over time...
How do you approach treating a patient with RA and cirrhosis who did not respond to csDMARDs?
While cirrhosis patients are considered high risk for infection and related acute-on-chronic liver failure, I would not consider it an absolute C/I for biologics if they have active RA and need escalation of treatment. Data on infection outcomes in cirrhosis patients on biologics is limited. I agree...
Is it safe to continue teriparatide beyond 3 years in a patient with severe osteoporosis and atypical fracture of the femur?
The original label for teriparatide limited its lifetime use to 2 years. Two years is as long as the Phase 3 trial in postmenopausal women had gone when a decision to terminate the trial voluntarily was made by Eli Lilly, due to the finding of osteosarcoma in rats. Thus, the safety data was limited ...
How would you manage active axial spondyloarthritis in a patient with recent (<5 years) solid malignancy who completed chemotherapy?
I wouldn't be too concerned about employing a TNF inhibitor, but the malignancy data for IL-17 inhibitors—and the lack of any black box malignancy warning—are more reassuring. I would probably choose the IL-17 inhibitor unless there is comorbid IBD.