Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Can you use leflunomide and rituximab in a patient with both multiple sclerosis and rheumatoid arthritis?
It is rare for a patient to have both diseases, but immunosuppressive therapy can be used for the management of both conditions. A study published in 2021 investigated the use of a combination of rituximab and leflunomide in rheumatoid arthritis (Behrens et al., PMID 33738492). Rituximab has previou...
In patients with a history of retinal vein occlusion, how should the risk of recurrent thromboembolic events influence the selection of osteoporosis therapies?
The FDA-approved prescribing information for raloxifene explicitly lists retinal vein thrombosis alongside deep vein thrombosis and pulmonary embolism as contraindications.
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...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
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...
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...
How do you approach management of a patient with coexisting psoriasis and systemic sclerosis, particularly when both active psoriasis and skin tightening are present?
It depends if both diseases are considered significant and active. If so, a JAK-inhibitor would kill two birds with one stone. JAK's are already approved for psoriatic arthritis, and there is decent data for skin psoriasis as well, on par with some of our currently FDA-approved therapies. There is s...
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...
Do you expect a different response rate to neradomilast depending on the ILD phenotype?
The best data to address this query come from the FIBRONEER-ILD trial, where approximately 70% of patients at enrollment had a UIP or UIP-like pattern on CT. The response to nerandomilast therapy was significant in both groups (with UIP or another pattern). In fact, the numerical results were greate...
How do you approach evaluation and management of a patient with recurrent monoarticular inflammatory arthritis of unclear etiology?
Routine testing will not identify Lyme disease, although the WBC count is higher than usual. If the antibiotic does not target B. burgdorferi, recurrence might mean inappropriate therapy previously. WBC count is WAAAY too high for mere trauma or internal derangement. Anything else to suggest psorias...