Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How long would you recommend that a patient continues guselkumab prior to deciding that the therapy is not effective?
Many trials have a placebo-controlled period of 12-24 weeks. Thereafter, all patients receive active treatment. Even if the original treatment allocation remains unknown to the patient and doctor, they know that from that moment on, everyone receives active treatment. This will have an influence on ...
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...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
How do you counsel patients on use of creatine monohydrate supplementation during a hospitalization for acute rhabdomyolysis from intense physical training?
I was a primary care doctor for the military for a few years. We regularly saw patients presenting with rhabdomyolysis from intense physical training. A standard question for all that present with this is whether supplements are being used. While there isn't a direct linkage to say that the use of c...
Do you counsel patients differently about the risk of radiation induced malignancy when you are treating a proximal joint (hip) vs a distal joint (elbow) for benign conditions such as OA?
The mentality for this must change from radiation oncologist thinking to radiation medicine thinking. There have been no documented cases of malignancy from LDRT treatment of OA. Those who worry about the spine reference old studies giving 20 Gy in 5 fx with an open field pre-linac era. This is not ...
Would you consider a shorter course of Romosozumab (3 months) followed by maintenance therapy given recent evidence that it is noninferior to 12 months of therapy for treatment of severe osteoporosis?
A recent publication led by Leder et al (Lancet Diabetes Endocrinol 2026;14: 216–22) demonstrated that a brief 3-month course of romosozumab followed by denosumab was noninferior to a full 12-month course of romosozumab given in the standard manner. This is consistent with earlier (nonrandomized) ob...
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...
Is it still significant to denote the etiology of ILD in a patient with PPF?
Yes, absolutely! Infact, the most effective treatment in patients without IPF (PPF) is treatment of the cause. So if there is underlying autoimmune disease or exposure, primary treatment should be directed against that trigger and this has potential to stop progression and even improve lung function...
How do you approach screening for ILD in patients with a diagnosis of MCTD given the recommendation discrepancies between the most recent EULAR and ACR/CHEST guidelines?
Another excellent question! While the EULAR guidelines treat MCTD as SSc-equivalent and suggest universal screening, ACR/CHEST guidelines suggest risk-stratified screening with emphasis on symptoms, PFT abnormalities, and high-risk phenotypes.Prevalence of ILD in MCTD can be high, in the range of 30...
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...