Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
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 ...
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...
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...
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 ...
Do you have safety concerns when prescribing GLP-1 medications in patients on corticosteroids or immunosuppressive therapy?
I think we need to be particularly careful when co-prescribing with systemic corticosteroids because of the risk of sarcopenia. We know that rapid weight loss is accompanied not only by a loss of fat tissue but also of muscle. Corticosteroids can also have myotoxicity and cause muscle atrophy. I the...
Do you think we can extrapolate the results of TOGETHER-PsA and expect similar results and safety when adding Tirzepatide to another IL-17 inhibitor or to a bDMARD with different mechanism of action?
Yes and no. We don't have hard randomized controlled trial (RCT) data with biologic disease-modifying antirheumatic drugs (bDMARDs) other than ixekizumab at present. However, if we extrapolate data from prior weight loss studies in psoriatic arthritis (PsA) and psoriasis (PsO), it would be reasonabl...
Will you give a trial of tirzepatide in patients with PsA and obesity who have a partial response to bDMARD rather than switching their immunosuppressive regimen?
I don't believe the data on the magnitude of the benefit of GLP-1 agonists in arthritis symptoms is sufficient to suggest that adding one of these agents would be preferable to changing DMARDs in a patient with inadequate response.
Based on Together-PsA, would you favor starting all patients with PsA and comorbid obesity on combination therapy with tirzepatide + bDMARD or will you pursue initial bDMARD monotherapy with tirzepatide rescue in the event of bDMARD non-response?
In looking at the Together-PsA data, this was a challenging cohort to treat, and a reasonable increase in treatment response was seen with combination therapy. Multiple studies have shown that obese psoriatic arthritis (PsA) patients are less likely to achieve minimal disease activity (MDA) and have...