Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are the results of the SEAM-RA trial generalizable to other TNF inhibitors given the differences in immunogenicity?
This is a great question, and an important one because different TNF inhibitors have different immunogenicity and patients can make anti-drug antibodies that can effectively neutralize the drug and render it a less effective treatment option. This tends to happen more with some molecular constructs ...
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 ...
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?
If patients were on less than or equal to prednisone 10 mg, they could continue that in the background during the trial, but note that only 20% of patients were on prednisone, a much lower figure than a typical rheumatoid arthritis trial, which is consistent with the point that rheumatologists shy a...
Do you routinely apply the 2010/2011 ACR symptom-based diagnostic criteria for fibromyalgia in your practice, or do you continue to use the 1990 tender point examination to make the diagnosis?
I don’t use tender point counts in my practice: they were discarded after the 1990 criteria for many reasons, including poor inter-rater reliability and the sort of nebulous nature of what was really being measured. The ACR 2016 criteria reference this very issue, noting that some have described ten...
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 ...
In a young patient with relapsing polychondritis and aortitis which has led to severe aortic valve regurgitation, is there any preference for a mechanical versus bioprosthetic valve replacement?
There is no data specifically on valve replacement for RP. If the patient can be safely anticoagulated, a mechanical valve would be likely better since it is a young patient. Data from TAK regarding valve replacement suggest subsequent complications are less likely when the aortic root is also repla...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
Do you consider metformin as a disease-modifying adjunct in the management of patients with OA, particularly in those with comorbid metabolic syndrome or type 2 diabetes?
Based on the Pan et al., PMID 40274279, and the broader literature, I would not yet formally classify metformin as a disease-modifying osteoarthritis drug (DMOAD), but the evidence is increasingly compelling, particularly in the metabolic osteoarthritis (OA) phenotype.This randomized controlled tria...
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...
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 ...