Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In routine clinical practice, how do you operationally define ‘progression despite therapy’ in PPF to justify escalation to combination treatment?
ILD patients undergo regular monitoring with intervals based on concern for progression. In addition to symptom review, objective testing includes PFTs with spirometry and DLCO, 6-minute walk testing that provides information on distance walked, symptoms experienced, and whether or not the patient d...
How do you counsel patients on the potential benefits of nerandomilast for PPF?
Nerandomilast is an inhibitor of phosphodiesterase 4 (PDE4), which leads to elevated intracellular cAMP, which reduces the expression of profibrotic cytokines and growth factors. It has both antifibrotic and immunomodulatory activity and may be useful in active inflammatory ILD based on these charac...
In patients with ILD who are started on nerandomilast on top of background nintedanib, what monitoring is most important early in therapy?
While it may seem initially that combining antifibrotics is a bad idea due to side effect profiles, it has, in fact, been done with some success. The INJOURNEY trial combined nintedanib AND perfenidone in patients with IPF, and during the study period (12 weeks), those on combined therapy lost only ...
Do the results of FIBRONEER-ILD change your approach to antifibrotic treatment in patients with sarcoidosis related PPF?
There is limited data regarding antifibrotics in sarcoidosis-associated pulmonary fibrosis. The INBUILD study of nintedanib in progressive pulmonary fibrosis did include a small group of patients with fibrotic sarcoidosis. The overall results did show a slowing in FVC loss, but specific information ...
How will you incorporate nerandomilast into your treatment algorithm for autoimmune ILD with progression, particularly relative to sequencing with immunosuppression?
All current ILD guidelines suggest initiating therapy with immunosuppression and then adding an antifibrotic IF there is evidence for progression of fibrosis. This is based on low-quality evidence and driven by not only a lack of quality data but also cost and common side effects. Two of the guideli...
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 ...
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 ...
Do you expect a different response rate to neradomilast depending on the ILD phenotype?
As a rheumatologist, I am particularly interested in the autoimmune ILD subtype and reviewed with great interest the subgroup analysis published in the Annals of Rheumatic Diseases by Anna-Maria Hoffman-Vold et al., PMID 42062162, which reports specifically on the 324 patients with autoimmune ILDs (...
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....
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...