Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you counsel patients with RA stable on csDMARDs on whether to attempt tapering or not?
It is important to recognize that this counseling is highly individualized and that factors such as risks of medication toxicity, age, comorbidities and disease severity all play a part. However, several studies have demonstrated a significantly increased risk of RA flares and radiographic progressi...
In a patient with Class IV lupus nephritis and cardiomyopathy who has received cyclophosphamide, how do you approach the use of biologics such as belimumab or voclosporin in the setting of ongoing proteinuria?
Voclosporin and belimumab have both been shown to have efficacy in the treatment of lupus nephritis, and are exciting options to consider, as also recommended in the ACR guidelines. One of the key questions for ongoing proteinuria is the degree of active disease vs chronicity, and the role of a (rep...
How do you interpret DXA results in cases where there is discordance between normal hip and spine BMD with abnormal one-third radius BMD?
This is an interesting question. To my knowledge, there are no fracture prediction models based only on forearm bone density values so my response is my opinion and not evidence-based. Firstly, we always rule out hyperparathyroidism when there is forearm bone discordance compared to spine and hips s...
How do you approach therapy for severe osteoporosis after an initial 12 months of romosozumab?
After 12 months of romosozumab, most likely the patient will still need additional therapy. If you can get a bone mineral density, that can guide you into what the best next medication can be. If the patient still has significant osteoporosis or fracture during the treatment with romosozumab, I woul...
How would you manage a patient SLE who is planning pregnancy and has serologically active disease (elevated dsDNA, low C3/C4), mild arthritis, and is otherwise asymptomatic on hydroxychloroquine 200 mg BID and methotrexate 15 mg weekly?
Options I'd consider would be sulfasalazine and/or azathioprine, as mentioned. I think the question is will SSZ+HCQ be enough for her SLE or will AZA+HCQ be enough for her arthritis? Could certainly add Belimumab to her HCQ, although it has a much longer onset of action and certainly less pregnancy ...
When do you recommend initiation of targeted therapies in active RA with history of malignancy?
In patient with RA and a history of malignancy, I generally recommend the same therapy that I would recommend in the absence of a malignancy history. This is consistent with the most recent ACR guidelines for the management of RA (Fraenkel et al., PMID 34101387). Consistent with FDA labeling, I'd ge...
How would you approach the treatment of erosive inflammatory arthritis (RA or SpA) in a patient with multiple sclerosis on ocrelizumab who has failed csDMARD therapy?
This is a challenging situation to confront, however, as more non- rheumatological illnesses are being managed with biologics, we will be facing this issue with greater frequency. Regarding multiple sclerosis (MS), one should be aware that the major metabolite of leflunomide, teriflunomide, is a bra...
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...