Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...
Do you taper glucocorticoids less aggressively when symptoms improve but serologies remain active in a patient with non-renal SLE?
Cautious tapering of glucocorticoids is a good idea in the setting of ongoing serologic activity. However, given there is clinical improvement in symptoms, one can go ahead and proceed with tapering steroids. It is important to recognize that a subset of patients with SLE may have persistent abnorma...
What recommendations do you provide patients regarding immunization or boosters prior to initiating rituximab?
To my knowledge, there is no unified recommendation, although the majority of us recommend all age-appropriate immunizations plus strong consideration of younger-than-standard-age immunization for diseases such as pneumococcus and VZV prior to initiation of rituximab when medically feasible. Timing ...
What is the clinical significance of elevated serum complement (C3 and/or C4) levels?
I have always considered elevated complement levels to be an acute phase reaction and an indication of inflammation, be it infection or cancer, similar to the ESR and CRP. Recent data have linked these elevated levels with obesity and metabolic syndrome. We have known for years that levels of C3 and...
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 ...
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
Would you be comfortable combining rituximab with voclosporin in patients with lupus nephritis not responding to standard therapy?
1st: Voclosporin is standard therapy :-). I find it interesting that we often use "standard therapy" to mean "a mycophenolate analogue or cyclophosphamide (CYC)." I consider these "old therapies" that only achieve a 25% to 30% clinical remission, leaving 65% - 70% of those patients at high risk of e...
What were your top takeaways in Myositis from ACR Convergence 2025?
ACR Convergence had an outstanding selection of myositis offerings, and the number of people attending the sessions reflects the increasing recognition of these heterogeneous diseases, coupled with the frequency that non-myositis specialist clinicians will encounter these entities. The convention pr...
How do you manage worsening cutaneous dermatomyositis when muscle disease appears controlled?
The fact that the patient still has an active pruritic rash while tapering steroids suggests that the current regimen isn't fully controlling the disease, and it can affect quality of life. I would consider adjusting immunosuppression, either adding another agent or switching therapies. The specific...