Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?
I do screen all newly diagnosed IIM patients with PFTs and chest CT. This has a double purpose: establishing a baseline of lung function and, screening for lung cancer. While the patient might not have lung symptoms on presentation, respiratory involvement can manifest later on the course of the d...
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 ...
For a patient with ICI toxicity who is resistant to the use of high-dose steroids, are there scenarios where you would consider the use of first-line conventional synthetic DMARD in place of steroids?
Loaded question — I think we need a reframing of ICI-toxicity, much of the ICI side effects are just an autoimmune reaction in a specific organ. High doses of steroids are used if there is a true risk for organ damage (like when you have acute ANCA vasculitis, lupus nephritis, etc.). So if a patient...
How do you approach tapering decisions for disease-modifying therapy for ICI-induced inflammatory arthritis after the patient's cancer treatment has been completed or the ICI has been discontinued?
This is a great question and, honestly, one that every rheumatologist struggles with. Similar to managing other inflammatory diseases, the challenge is determining when a patient is truly in remission and whether therapy can be safely reduced or discontinued.My approach is fairly practical:The patie...
What is your approach to refractory oral ulcers in SLE?
I echo @ Cuoghi Edens thoughts! Failure of HCQ does not mean refractory disease. Oral ulcers in SLE often correlate with underlying disease activity and their presence signals a better need for disease control. I would consider escalation to a systemic DMARD, such as MMF, MTX, anifrolumab, or bel...
In patients with isolated anti-Centromere antibody positivity and Raynaud's phenomenon without other features of systemic sclerosis, what is your approach to screening for pulmonary complications?
In patients with isolated anti-centromere antibody (ACA) positivity and Raynaud's phenomenon, even without overt systemic sclerosis, the primary concern is pulmonary arterial hypertension (PAH), which can develop at any point, including decades after initial presentation. Notably, ACA-positive patie...
How do you manage severe Raynaud's phenomenon with ulceration in scleroderma patients that is refractory to oral agents (CCBs, PDEis, ARBs, and ERAs)?
Difficult question. First, I would make sure that the ulcers you are trying to treat are really ischemic in etiology. These would typically be ulcers that are on the fingertips in association with significant Raynaud's. Other etiology for ulcers would be trauma/skin fragility (over PIP joints most c...
In postmenopausal osteoporosis, would you switch to romosozumab (rather than a PTH/PTHrP analog) if a patient fractures while on denosumab?
This is an interesting question because it raises the subject of how one defines "treatment failure" among patients who are using bone-strengthening medications. I remind patients that our drugs are most effective at preventing spinal fractures with efficacy that can exceed 70% relative risk reducti...
In patients with connective tissue disease-associated interstitial lung disease (CTD-ILD) who have achieved clinical and physiologic stability after successful discontinuation of prednisone while on mycophenolate mofetil, how do you typically approach tapering or discontinuing the mycophenolate?
Unfortunately, there are no high-quality, evidence-based guidelines that specifically address tapering or discontinuing mycophenolate mofetil (MMF) in CTD-ILD after achieving clinical stability. The available literature strongly favors prolonged maintenance therapy rather than early discontinuation,...
How do you determine whether to add abatacept or rituximab to the treatment regimen in patients with mild RA-ILD on methotrexate?
I think of many agents before rituxan for RA ILD: all in various stages of being studied MMF, Orencia/abatacept, Tocli/actemra, and even JAK inhibitors xeljanz/rinvoq. Generally, if I treat and control the joints, the lungs stabilize. 10-20% run independently from joints or extra-articular ILD witho...