Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
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 continue PJP prophylaxis indefinitely in patients on rituximab maintenance therapy?
Risk for PJP infection is usually in the context of moderate-high dose corticosteroid therapy or low T cell counts.
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 ...
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...
Was the methotrexate dose reduced over time in the combination therapy or methotrexate monotherapy groups in the SEAM-RA trial?
No, methotrexate dose was not adjusted. Our goal was basically to answer one question: whether it is better to stop etanercept, stop methotrexate, or continue both. We did not want to be adjusting methotrexate doses at the same time as stopping because this would make results more difficult to inter...
What additional workup and steroid-sparing option would you choose in a patient with potential medium-vessel vasculitis (petechial rash, sensorimotor neuropathy, renal infarcts, renal artery micro-aneurysms and ischemic/ulcerative duodenitis), hypocomplementemia, ASO 1525, negative blood cultures and normal echo?
This is a challenging case. Generally, PAN should be confirmed histologically, particularly if there are atypical features. In this case, hypocomplementemia is atypical, as non-HBV-associated PAN is generally normocomplementemic. Further, PAN more commonly causes ulcers/nodules/reticular lesions tha...
Are there any concerns with live vaccine innoculation and patients who are on denosumab?
This is a complicated question because while denosumab is a biologic therapeutic that has immunomodulatory effects on innate and adaptive immunity its association with serious infections complications appears modest. An increased rate of background infections and some increase in serious infections ...
Would you accept the diagnosis of SLE on the basis of an AVISE CTD panel where the results just showed a positive EC4d or BC4d, positive ANA>1/80 + one clinical criteria such as multiple tender joints but did otherwise not fulfill criteria for SLE?
The answer is "Yes and No."@Dr. First Last: I am so glad you asked this question. I once observed a speaker give incorrect information on this topic with an answer of "yes."The quick answer, is that the AVISE Lupus Test (which uses EC4d and BC4d) result does NOT give a "yes" or "no" answer for someo...
How would you approach immunosuppression in a patient with well-controlled HIV and RF+ rheumatoid arthritis breaking through hydroxychloroquine with ongoing inflammation confirmed on ultrasound?
The Infectious Disease Society of America (IDSA) defines HIV viral suppression as a viral load that is persistently below the level of quantification or detection of the assay used to measure the viral load. Prevention of sexual transmission is thought to occur at levels less than 200 copies of viru...