Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to the management of nodular regenerative hyperplasia of the liver in patients with SLE?
There are no large studies regarding the treatment of nodular regenerative hyperplasia (NRH) in systemic lupus erythematosus (SLE). It is rarely recognized, and the vast majority of reported cases are single-case reports, literature reviews, and a few very small case series. A Japanese autopsy serie...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
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 ...
Do you offer adjuvant radiation therapy for a breast cancer patient with dermatomyositis?
This is an exceptionally important question for clinicians. I'm a little biased as I run an autoimmune Myositis Clinic, but here are my two cents: Paraneoplastic dermatomyositis (DM) is a fairly common occurrence (roughly about 15% of all DM cases, but up to 30-40% in some subtypes, such as adult pa...
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 the treatment of lupus nephritis, which patients may benefit from the use of rituximab or other B-cell depleting agents during induction?
I agree with @Dr. @Dr. First Last's previous answer (posted July 2020). In addition, the 2024 ACR Lupus Nephritis guidelines (discussed at the 2024 ACR meeting) still recommend mycophenolate (MMF) or cyclophosphamide as first-line induction therapies for lupus nephritis (LN), rather than B-cell depl...
In patients with osteoporosis at high fracture risk, what factors most influence your decision to prescribe teriparatide versus abaloparatide?
Both abaloparatide and teriparatide are very effective anabolic agents to reduce vertebral and nonvertebral fracture risk in patients with osteoporosis (although clinical trials did not demonstrate reduction of hip fracture risk). The two agents are more similar than different and both induce an an...
Would you consider combining voclosporin and obinutuzumab for pure Class V lupus nephritis?
I agree with @Andras Perl. Changing his regimen is indicated since target proteinuria (<700 mg/day by 1 year) has not been achieved, and renal biopsy shows ongoing active inflammatory class V (very smart to get that biopsy, by the way!).Obinituzumab (OBI) is the better choice than belimumab in patie...
How would you approach rituximab dosing in a patient with SLE-Myositis overlap with LN Class III, now with worsening UPCR and concern for worsening ILD 4 months post induction and incomplete B-Cell depletion on recent labs?
This is a challenging and concerning situation, as the patient is declining after rituximab. Without knowing which other medications have been tried, I would prioritize medications targeting life-threatening manifestations, i.e., the LN and ILD. In that case, I would start treatment with steroids, m...
What is your approach to use of IL-17 inhibitors in patients with axial spondyloarthritis and a family history of inflammatory bowel disease?
I would have no hesitation in using an IL-17i in an axSpA patient with a family history of IBD as long as the patient themselves do not have active IBD. Clinical trials on Secukinumab, Ixekizumab, and Bimekizumab did not exclude patients with a history of IBD, and family H/O IBD was not recorded. Ac...