Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How has the ADVISE trial changed your approach to steroid sparing agents for non-infectious uveitis?
The ADVISE trial was a well-designed, multinational trial that compared adalimumab therapy for non-infectious intermediate, posterior, or panuveitis versus conventional immunosuppressive therapy or CID. Two hundred twenty-seven subjects were enrolled over four years, and a fifth year was required to...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
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 ...
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...
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 ...
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...
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 a young female with lupus cerebritis with seizures would you start induction therapy with Rituximab over cyclophosphamide?
I am not aware of a direct comparison of the efficacy of cyclophosphamide versus rituximab for treating lupus cerebritis with seizures. In cases of life-threatening progressive disease, giving both agents has been reported. Choosing between the two should involve in-depth patient education and invol...
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Here is a recent expert consensus by Joel Block on the use of low-dose radiation therapy in OA: Some highlights: "Placebo-controlled randomized clinical trials have now been reported using LDRT for OA of the knees and of the hands. Taken together, they do not show benefit beyond placebo... While a d...
What are your practice recommendations regarding live vaccinations in infants/children of women who are currently on DMARDs and are breastfeeding?
This question needs some clarification to provide an exact answer. However, in regards to DMARDs in lactation, per the ACR 2020 Reproductive Health Guidelines and resources like LactMed and Mother to Baby (both free!), Methotrexate, Leflunomide, and Mycophenolate are not recommended in lactation. Th...