Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
How do you counsel patients on the potential benefits of nerandomilast for PPF?
I reference the FIBRONEER-ILD trial with nerandomilast, which improved outcomes (including mortality) in the setting of fibrotic lung disease with progression (including CTD-associated fibrotic ILD), provided the patient met the diagnostic criteria (including a diagnosis of fibrotic lung disease wit...
In patients with ILD who are started on nerandomilast on top of background nintedanib, what monitoring is most important early in therapy?
I do not use combined therapy often, and I usually stop nintedanib to start nerandomilast. This does depend on how long they've been on nintedanib. If it's within the first three months, lab monitoring as required for nintedanib is important. Otherwise, it's really just side effects. Obviously, from...
Do the results of FIBRONEER-ILD change your approach to antifibrotic treatment in patients with sarcoidosis related PPF?
It changes my thinking somewhat, but I would be careful not to overinterpret the sarcoidosis results. FIBRONEER-ILD supports the broader concept that once different non-IPF ILDs develop a progressive fibrotic phenotype, targeting fibrosis may be beneficial regardless of the original diagnostic label...
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 ...