Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?
I do screen all newly diagnosed IIM patients with PFTs and chest CT. This has a double purpose: establishing a baseline of lung function and, screening for lung cancer. While the patient might not have lung symptoms on presentation, respiratory involvement can manifest later on the course of the d...
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...
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...
How do you approach evaluation of a patient referred for mononeuritis multiplex and +SSB?
I would look at the history/timeline of the illness and any other lab studies suggesting inflammation and/or immune activation, along with any family history of autoimmunity (or cancer).Mononeuritis multiplex is primarily a result of small vessel vasculitis resulting in ischemia to nerves and often ...
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 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 ...
In an infant whose mother resumes TNF inhibitor therapy (e.g., adalimumab, infliximab, certolizumab) after delivery and is breastfeeding, do you recommend delaying live vaccinations?
IgG-based biologic therapies - including TNF inhibitors - are all considered compatible with breastfeeding, since IgG passes only minimally into breast milk. Given these agents are proteins, the minimal drug that is transferred is unlikely to remain intact (or active) with passage through the infant...
With the increasing availability of biosimilars and their adoption onto payer formularies, how do you approach selection among available biosimilars in clinical practice?
Insurance payers consider FDA‑approved biosimilars to be clinically equivalent. In my experience, selection is ultimately driven by the insurance payer formulary - what you can get for the patient on the time. This can be fleeting and quickly changing at times. Cases can be made for patient experien...
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...