Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
Do you taper glucocorticoids less aggressively when symptoms improve but serologies remain active in a patient with non-renal SLE?
in addition I would monitor creatinine, urine protein and albumin very closely.
Would you be comfortable combining rituximab with voclosporin in patients with lupus nephritis not responding to standard therapy?
1st: Voclosporin is standard therapy :-). I find it interesting that we often use "standard therapy" to mean "a mycophenolate analogue or cyclophosphamide (CYC)." I consider these "old therapies" that only achieve a 25% to 30% clinical remission, leaving 65% - 70% of those patients at high risk of e...
What were your top takeaways in Myositis from ACR Convergence 2025?
ACR Convergence had an outstanding selection of myositis offerings, and the number of people attending the sessions reflects the increasing recognition of these heterogeneous diseases, coupled with the frequency that non-myositis specialist clinicians will encounter these entities. The convention pr...
How do you manage worsening cutaneous dermatomyositis when muscle disease appears controlled?
The fact that the patient still has an active pruritic rash while tapering steroids suggests that the current regimen isn't fully controlling the disease, and it can affect quality of life. I would consider adjusting immunosuppression, either adding another agent or switching therapies. The specific...
What recommendations do you provide patients regarding immunization or boosters prior to initiating rituximab?
To my knowledge, there is no unified recommendation, although the majority of us recommend all age-appropriate immunizations plus strong consideration of younger-than-standard-age immunization for diseases such as pneumococcus and VZV prior to initiation of rituximab when medically feasible. Timing ...
How do you approach a patient with Paget’s disease of bone with elevated alkaline phosphatase and history of chronic kidney disease?
You can give Zol IV, which is clearly the optimal treatment for active Paget's. Those in the field that treat many such patients just administer this very slowly over 1-2 hours and assure good hydration concomitantly. I have treated a number of patients like this, with this scenario, without any pro...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...
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.