Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you explain the concept of CAR-T therapy and why it may work to patients with autoimmune disease who are interested in pursuing a clinical trial?
In full transparency, I have not personally obtained informed consent from a patient immediately before CAR-T or a related cellular therapy. My center has a highly active immune therapeutics program, however, and I have spoken and written extensively about this area. I also serve on our health syste...
What treatment options do you consider after TNF failure in intestinal Behcet's with ongoing steroid dependence?
Colonic Behcet’s does not necessarily respond the way that IBD does. The evidence base for alternative therapies includes anti-interleukin-1, -6 and anti CD20. Anti Il-12/23 have also been used. Would discuss with a rheumatologist about which options are reasonable, depending on where else there are...
Based on Together-PsA, would you favor starting all patients with PsA and comorbid obesity on combination therapy with tirzepatide + bDMARD or will you pursue initial bDMARD monotherapy with tirzepatide rescue in the event of bDMARD non-response?
I think that really is up to the rheumatologist and the patient. This is really a shared decision-making kind of question.I usually find it’s easier to start one at a time. The reason for that is that if you start both at the same time and the patient has side effects, you’re not really sure which o...
Is cellular therapy for autoimmune disease realistically scalable as a mainstream treatment, or is it more likely to remain reserved for a narrow, most-severe subset of patients?
The answer is that this remains very much a work in progress. Before we can meaningfully address scalability, we need greater certainty about several things: the magnitude and durability of clinical benefit; whether patients can remain drug-free or will require concomitant therapy after treatment; a...
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 recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...
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...
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...
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Here is a recent expert consensus by Joel Block on the use of low-dose radiation therapy in OA: Some highlights: "Placebo-controlled randomized clinical trials have now been reported using LDRT for OA of the knees and of the hands. Taken together, they do not show benefit beyond placebo... While a d...
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 ...