Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
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...
How do you decide which children need early steroid-sparing therapy rather than hydroxychloroquine plus a short steroid course in pediatric non-renal SLE?
Unfortunately, the majority of our pediatric systemic lupus erythematosus patients have renal disease. Of those who do not, I cannot think of anyone I only treated with hydroxychloroquine after a brief steroid burst. If they have systemic disease, they need a DMARD to spare steroids beyond hydroxych...
Does your practice currently use low-dose radiation in the treatment of osteoarthritis?
Yes, we do. There is a long and storied history of utilizing LD-RT for benign inflammatory conditions in Germany. Much of the literature comes from there. I have had great success and truly believe it is a valuable tool to add to our toolbox. Pearls: At this time, I am limiting treatment to osteoar...
When in the treatment of OA do you think it is optimal to offer LDRT?
Evidence reality check: Two well-conducted sham-controlled RCTs (hand and knee OA) were negative for clinically meaningful benefit at their primary endpoints. (Minten et al., PMID 30231990, Mahler et al., PMID 30366945). ArthroRad (multicenter randomized, single-blinded) compared standard-dose vs ve...
Would you avoid use of JAK inhibitors in patients with dermatomyositis with autoantibody subtypes with increased risk of malignancy (TIF1y, NXP2)?
This is a difficult question to answer with certainty. Most of the direct data on malignancy risk with JAK inhibitors come from rheumatoid arthritis studies, and primarily involve tofacitinib. It is therefore possible that the risk is not the same across all JAK inhibitors, especially since they dif...
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...
If methotrexate is contraindicated or not tolerated, what systemic treatments do you use for generalized morphea?
I typically reach for mycophenolate as a second-line agent if methotrexate failed or is contraindicated. If the generalized morphea is actively progressing, I will add a steroid taper as a bridge until the DMARD has time to take effect. Whole body UVA1 is also a helpful adjunctive treatment to a DMA...
What recommendations do you provide patients regarding immunization or boosters prior to initiating rituximab?
To my knowledge, there is no unified recommendation, although the majority of us recommend all age-appropriate immunizations plus strong consideration of younger-than-standard-age immunization for diseases such as pneumococcus and VZV prior to initiation of rituximab when medically feasible. Timing ...
How do you manage worsening cutaneous dermatomyositis when muscle disease appears controlled?
The fact that the patient still has an active pruritic rash while tapering steroids suggests that the current regimen isn't fully controlling the disease, and it can affect quality of life. I would consider adjusting immunosuppression, either adding another agent or switching therapies. The specific...