Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
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.
Do you need to hold Humira (adalimumab) during radiation for breast cancer in a patient with psoriatic arthritis?
To my knowledge, there is not a lot of data on the interaction of adalimumab or other similar meds and radiation therapy. I am increasingly seeing this in my practice, however, for patients with psoriatic or rheumatoid arthritis. I discuss with patients that we have limited data on potential interac...
Would you consider the use of low-dose naltrexone in patients with fibromyalgia and/or type 2 lupus symptoms?
Yes, I think it is worth trying low-dose naltrexone in fibromyalgia - seems safe and may be effective.
How do you approach management of a patient with a retroperitoneal soft tissue mass and elevated IgG4 level when tissue biopsy is not feasible?
The question of whether to biopsy in presumed retroperitoneal fibrosis is asked in almost every case. The reason for the biopsy is to primarily rule out other causes of retroperitoneal masses, such as lymphoma, infection, and other rare variants. The mildly elevated IgG4 is not very helpful due to t...
How would you treat an asymptomatic patient with a positive Blastomyces antibody, evidence of prior granulomatous lung disease on imaging, and who may require immunosuppression in the future?
We practice in an area with a good bit of blastomycosis and rarely see a positive Blastomyces antibody, even in patients with culture-proven blastomycosis. The newer EIA antibody that MiraVista lab is doing may be more reliable. If the prior granulomatous lung disease has been worked up with negativ...