Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
What is the clinical significance of a low titer RNP, negative Sm, but Sm/RNP that is very high titer?
Important question as I've seen clinicians incorrectly interpret anti-Sm-RNP as anti-Smith antibody.The different autoantibodies (RNP, Smith, Sm/RNP) react to different antigens as follows: Anti-RNP can react to multiple components (antigens) of the U1 small nuclear RNP particle (snRNP), Anti-Smith ...
How do you try to encourage interested medical students and residents to consider a career in rheumatology?
I try to expose them to the practice of Rheumatology and the depth and breadth of what we do, not merely musculoskeletal medicine but every organ system. The beauty of the immune system when it works properly and the many ways we try to control it when it does not behave. The chronic care of these d...
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 maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.
How will you incorporate nerandomilast into your treatment algorithm for autoimmune ILD with progression, particularly relative to sequencing with immunosuppression?
This really depends on the subtype of connected tissue disease as well as radiographic pattern. I think for anyone who requires an anti-fibrotic, nerandomilast should be considered given its excellent tolerance. A caveat is that the FIBRONEER-ILD trial excluded cyclophosphamide, toci, MMF, rituximab...
How do you counsel patients on the potential benefits of nerandomilast for PPF?
Nerandomilast is an inhibitor of phosphodiesterase 4 (PDE4), which leads to elevated intracellular cAMP, which reduces the expression of profibrotic cytokines and growth factors. It has both antifibrotic and immunomodulatory activity and may be useful in active inflammatory ILD based on these charac...
In routine clinical practice, how do you operationally define ‘progression despite therapy’ in PPF to justify escalation to combination treatment?
This is really difficult. There's a balance between overreacting and waiting until you've lost significant lung function. The other thing to consider is that, at least in our practice, we will have a patient visit where they get testing such as physiology and chest imaging, and then we start a medic...
In what clinical situations do you consider azathioprine for treatment of inflammatory arthritis?
Azathioprine (AZA) is among the oldest pharmacologic immunosuppressive agents in use today. Initially developed as a long-lived prodrug of 6-mercaptopurine (6-MP), it was quickly found to have a more favorable therapeutic index. Gertrude B. Elion (Winner of 1988 Nobel Prize in Medicine for “importa...
What is the clinical significance of elevated serum complement (C3 and/or C4) levels?
I have always considered elevated complement levels to be an acute phase reaction and an indication of inflammation, be it infection or cancer, similar to the ESR and CRP. Recent data have linked these elevated levels with obesity and metabolic syndrome. We have known for years that levels of C3 and...