Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you routinely evaluate patients with collagen disorders or Ehlers-Danlos for platelet defects?
Yes, I routinely carry out a full hemostasis evaluation, including platelet aggregation and release studies, in patients referred to me with easy bruising and hypermobility with an increased Beighton score suggesting EDS and in those already diagnosed genetically with EDS. EDS patients typically hav...
Do you routinely supplement folic acid in patients with rheumatoid arthritis who are taking sulfasalazine?
Full disclosure. I'm not a fan of SSZ in general. I think it is a relic of 20th-century rheumatology when the choices were gold, penicillamine, and a few other toxic molecules. Nonetheless, I know that there is an audience for SSZ where biological options are less readily available. In my own experi...
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
What is your approach to differentiating between drug induced lupus versus elderly onset SLE?
Close to 50% of SLE patients are anti-histone positive. In a scenario like this, it is not helpful. This is SLE until proven otherwise. Regarding elderly onset SLE vs drug induced lupus, I evaluate and distinguish them similar to how I do in younger patients.
How often are you performing CT screening in CVID patients to screen for ILD?
CT once every 1-2 years, depending on symptoms and PFTs. PFTs, including DLCO, are annually performed.
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
For ICI arthritis, how soon do you start DMARDs?
Great question! This is complicated- is it one joint? Inject with steroids! Are there many joints? Is it gout-based, spondyloarthropathy, or more like seronegative RA or PMR-like?Also, where are they in the cancer space? In surveillance but high risk, what type of cancer, etc, etcI start this way: 2...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
How do you approach incidental NXP-2 antibody positivity in patients without current clinical evidence of myositis or systemic autoimmune disease?
A positive anti-NXP2 antibody in an asymptomatic patient may indicate either a false positive or a subclinical form of dermatomyositis. The initial step is to review the testing method (e.g., ELISA, immunoblot). If possible, confirm the result with a different assay, ideally immunoprecipitation, tho...