Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.
Would you favor the use of denosumab over bisphosphonate therapy for treatment of osteoporosis in patients who are at high risk for osteoarthritis given recent data suggesting reduced risk of developing knee OA?
Although the overall data to date concerning the impact of denosumab to reduce incident knee OA or lessen established disease remain limited, there are sufficient signals that warrant further investigation and support the need for an appropriately powered RCT with endpoints that include both patient...
In patients with RA on methotrexate and a TNF inhibitor who develop PJP pneumonia, how long do you hold immunosuppression before restarting therapy?
I would typically hold immunosuppression until the patient has completed therapy unless they had significant respiratory failure, in which case I would await full recovery. The patient should be placed on appropriate PJP prophylaxis prior to resuming therapy.
In patients with relapsing polychondritis with suboptimal response to NSAIDs and prednisone, what are strategies you use for flare treatment?
It depends on multiple variables, including organ involvement, disease activity, and associated manifestations. I would be happy to discuss it further if you would like. You can reach me on my cell at 240-519-4935.
What are the current recommendations for the management of pediatric non-infectious uveitis?
Agree with Dr. @Dr. First Last's answer. By the time these patients see pediatric rheumatology, they have had a number of labs drawn looking for infectious and non-infectious etiologies of uveitis and have also usually been trialed on topical steroid drops (predforte or otherwise) +/- oral prednison...
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...
Would you pursue a kidney biopsy in a patient with stable stage 1 AKI, bland urine sediment, and a positive MPO titer without systemic signs of vasculitis?
PR3-ANCA and MPO-ANCA are associated with substantially higher specificities and positive predictive values for ANCA-associated vasculitis (AAV) than the immunofluorescence patterns to which they usually correspond (C-ANCA and P-ANCA, respectively). However, false-positive results remain a concern. ...
How do you interpret treatment response in the DISCOVER-2 Trial when patients were allowed to remain on up to 10mg of prednisone equivalent for disease control while on guselkumab?
The dependence on the use of systemic glucocorticoids may indeed be a good reason to change treatment. Especially in patients with psoriatic arthritis. So, if patients are unable to stop systemic glucocorticoids and there are still treatment options for the patient, this could be tried. It is diffic...
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...
How do you counsel patients with postural orthostatic tachycardia syndrome (POTS) regarding safe and effective exercise regimens?
It depends on where they're starting from. If they're starting from scratch, I give them two recommendations: first is the Children's Hospital of Philadelphia protocol, and if they live in town, I refer them to our PT facility at Vanderbilt (The Dayani Center) to have our PT folks help them get star...