Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
In a patient with longstanding Sjogren’s disease (+SSA/SSB and RF with polyclonal hypergammaglobulinemia) who develops new asymmetric parotid fullness what is your preferred initial imaging modality to further evaluate?
I would usually start with ultrasound in this case, specifically looking for signs of lymphoma, and let the results guide any further workup necessary. I have often seen benign parotid swelling in these patients, but an asymmetric presentation such as this requires further workup and potentially bio...
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...
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
How would you treat active SLE with high level crithidia dsDNA abs and recurrent pleuritis with effusions still requiring corticosteroids despite combination therapy with full doses of mycophenolate, hydroxychloroquine, and Benlysta for over 6 months after no response to Saphnelo for 6 months?
There are no controlled trials of different therapies for treating refractory pleuritis in lupus as the primary manifestation. Due to refractory pleuritis being relatively uncommon, the trials of benlysta and anifrolumab did not have enough patients to assess response. In the literature, there are a...
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 ...
How do you approach prescribing analgesics for osteoarthritis related pain in patients with comorbidities, particularly given new evidence that even acetaminophen is associated with increased risk of GI complications (bleeding, peptic ulcer disease), heart failure and CKD?
Acetaminophen is still preferred, but at 3,000 mg or less per day. The next consideration is a COX-2 specific inhibitor, such as celebrex. Narcotics and steroids play no role in management of osteoarthritis.
How do you approach hypogammaglobulinemia monitoring when using obinutuzumab for refractory nonrenal SLE patients?
I would start with a baseline evaluation that includes quantitative IgG levels, HBV serologies, including HBsAg and anti-HBc, to assess reactivation risk even if HBsAg-negative, and a CBC with differential. Before treatment, I would make sure all non-live vaccines are completed, and I would avoid li...
Is a history of Zoster ophthalmicus a contraindication to starting upadacitinib?
A history of HZO (herpes zoster ophthalmicus) or herpes zoster in any dermatome is a relative contraindication to the use of upadacitinib or any JAK inhibitor. HZO is often a very unpleasant disease with pain, ocular discomfort, and vision loss, so the chance of reactivation should be minimized. The...