Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
Do GLP-1 agonists have measurable anti-inflammatory effects in diseases like RA or spondyloarthropathies beyond weight loss?
There is currently no evidence of efficacy in chronic inflammatory arthritis. Due to their mechanism of action, we can hope that they will be effective because of their anti-inflammatory and immunomodulatory properties, which have been well demonstrated in numerous experimental models. But only rand...
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 optimize retinopathy screening schedules for patients on hydroxychloroquine while also prioritizing cost-effectiveness?
I'll approach this from the cost-effectiveness standpoint as I agree with Drs. @Dr. First Last and @Dr. First Last on their excellent points.Patients with SLE have remarkably high costs when you add up copays, medications, imaging studies, travel, missing work, etc. Anything we can do to help reduce...
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...
Would you start hydroxychloroquine (or another DMARD) in a mid-20s female patient with positive ANA, SSA, SSB, and dsDNA, whose only clinical manifestation is intermittent parotid gland swelling?
Hmm... I think the better question to ask is, do you code as Sjogren's lupus overlap to get way more medication options? Certainly, HCQ is a reasonable DMARD and a place to start for both diseases. I would code as lupus and Sjogren's to have more options for the future. Hope someone can weigh in on ...
How do you approach adding colchicine to a patient who is on a stable statin regimen?
This is a good question and a tough situation, since the drug-drug interaction here can be as subtle as myalgias but as severe as rhabdomyolysis (rare but happens). If you can avoid long-term colchicine in this situation, it is always best. These situations (hypercholesterolemia and crystal arthropa...
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...
In patients with inflammatory arthritis (RA, psoriatic arthritis) and a history of MGUS are there any concerns regarding use of biologics?
There is no absolute contraindication to any particular biologic used to manage active RA in a patient with MGUS. The literature does point out a small potential risk associated with tocilizumab in terms of development of myeloma influenced by the IL-6 pathway (and I would tend to extend that potent...
Do you routinely transition to PO antibiotics for patients with native joint septic arthritis whom have undergone washout and the organism is not S. aureus?
Yes. Even if the organism is Staph aureus, I would feel comfortable with an appropriate, highly bioavailable oral antibiotics after appropriate source control (linezolid in the case of Staph aureus).