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 ...
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?
If patients were on less than or equal to prednisone 10 mg, they could continue that in the background during the trial, but note that only 20% of patients were on prednisone, a much lower figure than a typical rheumatoid arthritis trial, which is consistent with the point that rheumatologists shy a...
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).
Would you offer re-irradiation LDRT for someone with osteoarthritis or tendinitis if symptoms recur?
I have not personally offered a patient a third round of LDRT and do not know of any data that shows efficacy. However, I might offer a third round if a particular patient got adequate results with the first two and there was some separation in time (perhaps >1 year) since the last round.
In a patient with known APS (triple positive) and interstitial lung disease (NSIP), how do you distinguish APS associated lung involvement from connective tissue disease related ILD?
Patients with APS typically have vascular and thrombotic pulmonary disease, and very rarely has interstitial disease been ascribed to APS. The most common pulmonary manifestation of APS is pulmonary embolism, occurring in 14-16% of patients, followed by pulmonary hypertension often caused by chronic...