Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How often are you performing CT screening in CVID patients to screen for ILD?
CT once every 1-2 years, depending on symptoms and PFTs. PFTs, including DLCO, are annually performed.
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...
For ICI arthritis, how soon do you start DMARDs?
Great question! This is complicated- is it one joint? Inject with steroids! Are there many joints? Is it gout-based, spondyloarthropathy, or more like seronegative RA or PMR-like?Also, where are they in the cancer space? In surveillance but high risk, what type of cancer, etc, etcI start this way: 2...
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 approach incidental NXP-2 antibody positivity in patients without current clinical evidence of myositis or systemic autoimmune disease?
A positive anti-NXP2 antibody in an asymptomatic patient may indicate either a false positive or a subclinical form of dermatomyositis. The initial step is to review the testing method (e.g., ELISA, immunoblot). If possible, confirm the result with a different assay, ideally immunoprecipitation, tho...
How do you approach management and monitoring of a patient with features suggestive of early or incomplete antisynthetase syndrome (mechanics hands and positive antisynthetase antibody) but no objective evidence of myositis, arthritis, or ILD at presentation?
Anti-Ha is a very rare antibody, and its positive predictive value is low, particularly when relying on line blot or multiplex bead assays. Especially in the setting of a high ANA titer, a low-level anti-Ha signal may represent cross-reactivity or a false positive, as anti-Ha antibodies are cytoplas...
Is there a difference in efficacy between steroid-sparing agents like methotrexate, mycophenolate, and azathioprine in the treatment of immune-mediated myopathies?
Currently, there is no high-quality evidence favoring one immunosuppressive agent over another in the treatment of immune-mediated myopathies, as there are no head-to-head comparative trials and most available data come from small, observational, or retrospective studies. As a result, the choice of ...
Do you routinely evaluate patients with collagen disorders or Ehlers-Danlos for platelet defects?
Yes, I routinely carry out a full hemostasis evaluation, including platelet aggregation and release studies, in patients referred to me with easy bruising and hypermobility with an increased Beighton score suggesting EDS and in those already diagnosed genetically with EDS. EDS patients typically hav...
How do you approach the decision to initiate or continue bisphosphonate therapy in an older patient with significant esophageal disease or swallowing dysfunction?
Unless there are indications to turn first to non-bisphosphonate therapies, I would first consider whether the patient would be a candidate for IV bisphosphonate therapy. Many patients, even those without esophageal disease or dysphagia, find the convenience of an annual outpatient infusion appealin...
With the increasing availability of biosimilars and their adoption onto payer formularies, how do you approach selection among available biosimilars in clinical practice?
Insurance payers consider FDA‑approved biosimilars to be clinically equivalent. In my experience, selection is ultimately driven by the insurance payer formulary - what you can get for the patient on the time. This can be fleeting and quickly changing at times. Cases can be made for patient experien...