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 ...
Do you always pursue biopsy confirmation before diagnosing IgA vasculitis?
Technically, yes (by definition), but practically, not necessarily: Biopsy for direct immunofluorescence (DIF) testing would be required to confirm the status of IgA in cutaneous vasculitis. However, the presence of lesional IgA correlates positively with the clinical presentation (e.g., Henoch Schö...
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 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...
In the treatment of osteoarthritis with low-dose radiation therapy is there data to support the claim that LDRT does not limit or preclude later orthopedic surgery?
At LDRT doses, the biological effects are anti-inflammatory and immunomodulatory rather than cytotoxic or fibrogenic, and there is no evidence of vascular injury, impaired cellular proliferation, or tissue destruction. Animal models and cellular studies provide robust evidence that LDRT at OA releva...
In patients with osteoporosis at high fracture risk, what factors most influence your decision to prescribe teriparatide versus abaloparatide?
Both abaloparatide and teriparatide are very effective anabolic agents to reduce vertebral and nonvertebral fracture risk in patients with osteoporosis (although clinical trials did not demonstrate reduction of hip fracture risk). The two agents are more similar than different and both induce an an...
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
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...
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...