Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...
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 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 ...
For a patient with orbital sarcoidosis who has achieved sustained clinical remission on adalimumab in combination with mycophenolate mofetil, how long would you recommend continuing mycophenolate before considering a gradual taper and discontinuation?
This is an excellent question. And sarcoidosis is certainly a disease that can enter spontaneous remission.Unfortunately, my answer is based more on eminence (I hope) rather than evidence.We have very little data about withdrawing treatment for sarcoidosis, and I am not aware of data specifically fo...
How would you treat tophaceous gout after a course of pegloticase infusions if the patient has contraindications or intolerance to allopurinol, febuxostat, and probenecid?
Difficult question. I think there are a number of issues to address. What is a "course of pegloticase?" What are the patient's contraindications to treatment? How did intolerance to prior oral uric acid-lowering therapies manifest Was pegltoicase started because of "unresponsiveness to oral ULT" an...
What strategies have you found most effective in improving long-term medication adherence in patients with SLE?
Patient education and buy-in are key for achieving long-term medication adherence. Medication adherence is the outcome of several factors, including but not limited to access to healthcare: appointments, laboratory visits, transportation, health literacy, medication fatigue, and response to therapy,...
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 ...
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 ...
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...
In the setting of new onset severe Raynaud’s with digital ischemia (partial toe amputation), but negative initial rheumatologic evaluation, what additional rheumatologic or hematologic workup should be considered?
This is always a difficult situation. As Rheumatologists, we tend to lean hard on the laboratories, but in cases like this, it is the history and physical examination that tell the better story. The history is critical here, since a smoking/tobacco history gives a lot of information. Any history of ...