Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to long-term immunosuppression in patients with Adult Onset Stills Disease?
For persistent or recurring disease flares, IL-1 blockers (canakinumab or anakinra).
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...
How do you counsel and manage patients with chronic pain conditions such as fibromyalgia or osteoarthritis who are taking centrally acting agents (gabapentin, duloxetine) and are planning to use or self administer psychedelics for symptom management?
Interesting query since some studies do suggest that psychedelics may be useful in treating chronic pain, and their mechanism of action regarding neuroplasticity is similar to approved centrally acting agents, like duloxetine. I would first review the limited role of medications in chronic pain and ...
Do elevated neutrophils in the bronchoalveolar lavage of patients with sarcoidosis have any prognostic value?
Neutrophils in the alveolar space are uncommon in healthy non-smoking individuals, accounting for around 1% of cells in bronchoalveolar lavage (BAL). Macrophages compose 80–90% of the cells policing the alveolar surface, with the remaining cells being lymphocytes, rare eosinophils, and basophils. A ...
What are the best labs to trend improvement in HLH?
Unfortunately, there is not one specific laboratory test to definitively trend responses to HLH directed therapy. In general, our approach is to obtain baseline inflammatory labs including CBC with differential, ferritin, soluble IL2 receptor (sIL2r), triglycerides, coagulation studies (PT/PTT) incl...
In the treatment of osteoarthritis with low-dose radiation therapy is there data to support the claim that LDRT does not limit or preclude later orthopedic surgery?
At LDRT doses, the biological effects are anti-inflammatory and immunomodulatory rather than cytotoxic or fibrogenic, and there is no evidence of vascular injury, impaired cellular proliferation, or tissue destruction. Animal models and cellular studies provide robust evidence that LDRT at OA releva...
Do you check mycophenolate levels in patients prescribed mycophenolate who present with a lupus nephritis flare?
In general, I tend to shoot for an induction dose (3 grams) if I am using Cellcept with steroids for a flare, unless I am doing multitarget therapy or there are side effects such as GI symptoms or cytopenias. In those cases, I lower the dose to 2 grams (1000 mg BID). If there is concern for unsatisf...
Were the patients enrolled in the SEAM-RA trial prior methotrexate monotherapy non-responders?
Yes, presumably at one time, most of these patients were methotrexate non-responders because otherwise, it’s unlikely they would have required escalation to TNFi. Clinicians would typically not add TNFi therapy unless the patient had first failed DMARDs (i.e., methotrexate in this case). It is impor...
How should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...
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 ...