Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Has the MAJESTY trial changed your approach to the rituximab versus obinutuzumab choice in a patient with newly diagnosed primary membranous nephropathy and nephrotic syndrome?
The Bottom Line: Recent landmark trials—MENTOR and MAJESTY—confirm that anti-CD20 therapies are superior to calcineurin inhibitors (CNIs) for the treatment of MN.Key Trial DataMENTOR: Demonstrated that RTX was noninferior to cyclosporine at 12 months, and decisively superior by 24 months (60% vs. 20...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
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 ...
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...
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...
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Almost any and all circumstances.
When is the ideal time in the disease course to offer radiotherapy for Dupuytren's disease for the most optimal outcomes?
Radiotherapy is most effective when fibroblasts are actively proliferating, i.e., during the cellular or proliferative phase of the disease, when there is a palpable, progressive nodule or cord but no fixed contracture.Prospective German trials show that treating during this biologically active peri...
Would you consider re-irradiation for recurrence of Dupuytren's Contracture?
I have, in fact, re-treated one patient about two years after the first course because some nodules were progressing. I did a limited electron field with bolus to cover just the affected area and gave 200 x 10. Things seemed to stabilize after that. I would not treat a third time, however, but I hav...
What factors do you consider when advising a patient with lupus nephritis on the safety of becoming pregnant?
I agree with Dr. @Dr. First Last's excellent suggestions (with just one exception!). I don't increase prednisone prophylactively for lupus pregnancy - I would only add or increase steroid if there is a flare. The risks of steroid in pregnancy impact both maternal and pregnancy outcomes, so we try to...