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 ...
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...
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...
Do you routinely check HLA-B*58:01 allele status in patients of Vietnamese descent before starting allopurinol?
Of Asian or African American descent
In a patient with GCA and underlying cardiovascular risk factors, how do you approach antiplatelet therapy and statin use when starting tocilizumab as steroid sparing treatment?
I don't generally start ASA or other anti-platelet therapy for GCA without reviewing the need ( if any) with a cardiologist. Neither the ACR nor the BSR guidelines for vasculitis recommend these drugs for GCA.On the other hand, managing lipids and blood pressure in all cases of GCA is essential. The...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
How do you counsel families of pediatric patients on methotrexate about live vaccine schedules?
Recommendations on vaccinating children with rheumatic diseases vary and seem to be changing frequently. Many of the ACR's specific timing recommendations are categorized as "conditional recommendations" based on low-to-moderate certainty of evidence, and because of this, they must frequently update...
When would you recommend uric acid-lowering therapy for a patient with asymptomatic hyperuricemia without comorbidities but with family history of gout?
I would not recommend treating asymptomatic hyperuricemia unless the patient has clinical gout or concern for proven urate nephropathy (such as with uric acid kidney stones). The family history component is important to acknowledge that the patient may be at greater risk in the future, however, it d...
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
Do you refer for autonomic testing or manage symptomatically when dysautonomia symptoms complicate chronic musculoskeletal pain?
Great question. Dysautonomia is very common in patients with chronic overlapping pain conditions (e.g., ME/CFS & post-acute infectious syndromes), and it can be disabling. This is more of a clinically salient phenomenon in pt w/ ME/CFS, in my experience, whereas rheumatic patients with RA/SS/SLE, et...