Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How long would you wait to start another biologic agent after Rituximab administration in patients with dermatomyositis and refractory inflammatory arthritis (intolerant to traditional DMARDs)?
The time frame between rituximab infusion and initiation of a different biologic agent depends on the severity of the symptoms. In case of life-threatening complications (like RP-ILD), then rituximab could be given simultaneously with an agent like tofacitinib. If the main symptom though is arthriti...
Which other agent would you consider for a patient with VEXAS who has failed methotrexate, multiple TNF inhibitors, Tocilizumab, and Ruxolitinib?
I would strongly consider referring for hematopoietic stem cell transplant. The NIH/National Cancer Institute has a trial that is currently recruiting:Koster et al., PMID 36251488
In light of the RECITAL study, would rituximab be a reasonable choice in a patient with PL-12 antibodies, rapidly progressive pulmonary disease with organizing pneumonia on biopsy?
The findings from the RECITAL study have confirmed the validity of our clinical approach, advocating for rituximab as the primary treatment for CTD-ILD, considering the elevated risks associated with the use of cyclophosphamide. Therefore, it is entirely justifiable to opt for rituximab in cases of ...
Do you avoid ESA use in patients with anemia and chronic kidney disease who also have APLS and risk for thrombosis?
I normally don't. I would make sure the patient is getting anticoagulated if indicated. I don't believe making the hemoglobin closer to normal in the setting of being anticoagulated increases thrombosis risk that much. I would shoot for a hemoglobin goal of 10-11.
How do you approach GI prophylaxis (e.g., PPIs, H2 blockers) in patients on long-term NSAIDs?
Risk analysis is at the heart of all therapies that we prescribe for our patients. Patients on long-term daily NSAIDS are at higher risk for GI symptoms, bleeding, and perforations. These risks can be between 2-4%/per year, and vary based on risk factors such as age, general health, cigarettes, prop...
Does hepatitis B vaccination reduce the risk of HBV reactivation associated with immunosuppressive therapy?
Hepatitis B reactivation is a critical concern when patients are undergoing immunosuppressive therapy, often described as 'deadly but preventable.' Screening for HBV is strongly advised before initiating biologic therapies, targeted synthetic therapies, or high-dose immunosuppression, including HBsA...
What would be your next step in management of a dermatomyositis patient on hydroxychloroquine and methotrexate whose skin is still active?
There are many different options for this kind of scenario. Depending on the physician's preference, patient's lifestyle, and insurance coverage, one could switch to mycophenolate, which seems to be more effective for skin manifestations, or azathioprine. If the patient did have a partial response t...
What immunosuppressive agents would be available to patients with a history of melanoma?
Generally, we try to use conventional synthetic DMARDs when possible. However, studies in RA have not shown an increase in de novo melanoma or recurrence of cancers more generally with TNF-inhibitors. So this is an option for patients with RA and melanoma history who are not responding to csDMARDs. ...
How long do you continue PJP prophylaxis in a patient with GPA who is able to wean steroids and remains only on rituximab for maintenance therapy?
Great question! For my ANCA patients and the OSU vasculitis clinic, we leave them all on Bactrim for the life of the disease. Less about PJP, and more about helping minimize infections due to the sinus and respiratory inflammation creating a nice environment for bacteria to live. Also, there is some...
Would you consider the use of doxycycline or minocycline in the management of RA?
When faced with an issue of a TNF side effect or an infectious complication, I have used minocycline for the management of RA. This is based on an observation of minocycline’s effectiveness in early RA. A patient of mine developed optic neuritis while administering adalimumab, and Opthalmology (appr...