Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What strategies have you found most helpful to improve adherence to hydroxychloroquine among patients with lupus?
In my practice, three approaches have been most useful: Make adherence measurable. I routinely check whole-blood hydroxychloroquine levels and review the trend with patients in a nonjudgmental way. This creates accountability and turns an otherwise “invisible” treatment into something concrete that ...
Do you obtain mycophenolate levels before escalating therapy in patients with extrarenal SLE?
I do not check them routinely unless I am concerned about compliance or potential side effects. It is reasonable to do so now that checking levels is readily available. It is not routine for lupus, as it is for transplant patients. In searching the literature, there is no controlled trial in lupus r...
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 ...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?
In an article by the Yale group, Gallegos et al., PMID 33997256 give a nice summary of the literature cited options for managing cardiac sarcoidosis (Non-steroidal treatment of cardiac sarcoidosis: A systematic review.Options cited here that have not been discussed include cyclophosphamide, cyclospo...
Can sIL2-R differentiate between active sarcoidosis affecting small airways vs uncontrolled asthma and guide treatment with methotrexte vs biologics?
This is an interesting question. Just to provide a little context, I used to have a sarcoidosis-focused clinic where one day each week I would see only sarcoidosis patients. I also had a day of seeing only neurosarcoidosis patients once per month, together with neuroimmunology. To be honest, since I...
How do you approach management in patients with adult-onset Still’s disease presenting with active polyarthritis (without macrophage activation syndrome) who remain symptomatic despite prednisone 15 mg/day and methotrexate 25 mg/week?
Biologics, especially IL-1 but also IL-6 blockers, have been shown to be beneficial for patients with Still's disease. In fact, there seems to be a window of opportunity whereby patients that are started early on cytokine blockade are more likely to achieve drug-free remission in the future. Anakinr...
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...
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...
Do you check for JCV before starting belimumab?
No. The John Cunningham virus (JCV) is highly prevalent in adults (around 85% of us), and developing progressive multifocal leukoencephalopathy (PML) is incredibly rare in belimumab (BEL) patients. It would not change my patient management. Even if someone tested negative for JCV prior to starting ...