Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In patients with isolated anti-Centromere antibody positivity and Raynaud's phenomenon without other features of systemic sclerosis, what is your approach to screening for pulmonary complications?
In patients with isolated anti-centromere antibody (ACA) positivity and Raynaud's phenomenon, even without overt systemic sclerosis, the primary concern is pulmonary arterial hypertension (PAH), which can develop at any point, including decades after initial presentation. Notably, ACA-positive patie...
In a patient with persistent symptoms of Lyme arthritis after initial treatment course with oral antibiotics, do you prefer a second course of oral antibiotics or do you frequently offer a course of IV ceftriaxone?
Patients diagnosed with Lyme arthritis should receive a 28-day course of oral antibiotics, preferably doxycycline. If patients achieve at least a partial response, a second course of oral antibiotics may be given. However, in patients with minimal to no response following the initial course of oral ...
For a patient with ICI toxicity who is resistant to the use of high-dose steroids, are there scenarios where you would consider the use of first-line conventional synthetic DMARD in place of steroids?
Loaded question — I think we need a reframing of ICI-toxicity, much of the ICI side effects are just an autoimmune reaction in a specific organ. High doses of steroids are used if there is a true risk for organ damage (like when you have acute ANCA vasculitis, lupus nephritis, etc.). So if a patient...
How would you manage resuming successful abatacept therapy in a refractory RA patient undergoing resection of stage 1 lung adenocarcinoma?
You can restart the abatacept once the patient has recovered from surgery. There is no signal for increased new solid tumors on abatacept, and you would expect the patient to be cured after resection of a stage 1 tumor.
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...
When a patient with ICI-induced inflammatory arthritis requires biologic DMARD therapy, how do you balance need to treat with concern for faster cancer progression?
More data is needed to fully understand whether biologic therapy affects the risk of cancer progression in the setting of ICI therapy. We do know that higher doses of corticosteroids are associated with progression. If the patient cannot get down to a low dose of steroids, biologic therapy is likely...
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 ...
Do you recommend checking anti-drug antibodies for patients on TNF inhibitors?
This is a very good question with direct clinical practice implications. I do not check or follow anti-drug antibodies when using TNF inhibitors for the treatment of rheumatoid arthritis or psoriatic arthritis. There are reports that suggest, on a group level, that these antibodies, if present, impa...
How do you approach tapering decisions for disease-modifying therapy for ICI-induced inflammatory arthritis after the patient's cancer treatment has been completed or the ICI has been discontinued?
This is a great question and, honestly, one that every rheumatologist struggles with. Similar to managing other inflammatory diseases, the challenge is determining when a patient is truly in remission and whether therapy can be safely reduced or discontinued.My approach is fairly practical: The pati...
How do you approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?
As with most questions about sarcoidosis, clear understanding of the relevant clinical context should first be established. While interstitial lung disease (ILD) is a common manifestation of sarcoidosis, it often can be safely monitored without treatment, and so radiologically identified sarcoid ILD...