Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?
In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving...
How would you approach a patient referred for esophageal aperistalsis with a longstanding history of Raynaud’s phenomenon, but without other clinical features or serologic findings suggestive of systemic sclerosis?
Scleroderma esophagus (distal aperistalsis/absent contractility + hypotensive LES) is a manometric finding, not a diagnosis. There are multiple causes of this finding, including other autoimmune diseases, neuropathic conditions, and metabolic causes.In addition, RP is seen in 3-8% of the population....
How do you counsel patients on the potential benefits of nerandomilast for PPF?
I would frame the benefit as preservation rather than improvement. The goal is to slow the additional loss of lung function over time.In FIBRONEER-ILD, patients receiving placebo lost about 166 mL FVC over a year, compared with 99 mL on nerandomilast 18 mg and 85 mL with 9 mg. This translated into a...
In patients with inflammatory arthritis (RA, psoriatic arthritis) and a history of MGUS are there any concerns regarding use of biologics?
There is no absolute contraindication to any particular biologic used to manage active RA in a patient with MGUS. The literature does point out a small potential risk associated with tocilizumab in terms of development of myeloma influenced by the IL-6 pathway (and I would tend to extend that potent...
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 ...
Would you add romosozumab to denosumab for a year or switch to romosozumab for a year in a patient who fractures on long term denosumab therapy?
My preference, if insurance were not an obstacle, would be to add romosozumab (Romo) rather than switch. The data are limited, and certainly this is "off-label," but the rationale is reasonable. Denosumab (Dmab) treatment leads to increased sclerostin levels which would be targeted by the addition ...
How will you incorporate nerandomilast into your treatment algorithm for autoimmune ILD with progression, particularly relative to sequencing with immunosuppression?
This really depends on the subtype of connected tissue disease as well as radiographic pattern. I think for anyone who requires an anti-fibrotic, nerandomilast should be considered given its excellent tolerance. A caveat is that the FIBRONEER-ILD trial excluded cyclophosphamide, toci, MMF, rituximab...
In routine clinical practice, how do you operationally define ‘progression despite therapy’ in PPF to justify escalation to combination treatment?
This is really difficult. There's a balance between overreacting and waiting until you've lost significant lung function. The other thing to consider is that, at least in our practice, we will have a patient visit where they get testing such as physiology and chest imaging, and then we start a medic...
Would you consider adding dupilumab to adalimumab (or other monoclonal antibodies) in a patient who has RA and refractory atopic dermatitis and already is on MTX 25 mg weekly?
No. Unless the problem has been chronic since childhood, I would first run through the diagnostic checklist for adult-onset generalized dermatitis to be sure this is not a mimic of AD. If no other diagnosis is established after a thorough investigation, I would stop adalimumab and change to upadacit...