Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
When a patient with ICI-induced inflammatory arthritis requires biologic DMARD therapy, how do you balance need to treat with concern for faster cancer progression?
More data is needed to fully understand whether biologic therapy affects the risk of cancer progression in the setting of ICI therapy. We do know that higher doses of corticosteroids are associated with progression. If the patient cannot get down to a low dose of steroids, biologic therapy is likely...
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...
Have you utilized denosumab in treatment of erosive hand osteoarthritis?
I have not prescribed denosumab for patients with erosive hand osteoarthritis. While the 2024 double-blind placebo-controlled trial suggested that this RANK ligand inhibitor may have structure-modifying effects by inducing remodeling and preventing new erosions, the phase 2a study of 100 patients di...
How do you approach treatment in a patient with +anti-CCP antibodies, negative RF and no current evidence of active inflammatory arthritis, but progression of NSIP?
In these cases, observing a positive CCP suggests some form of an immunologic or autoimmune driven porcess responsible for the NSIP. The result may justify the use of immunosuppressive therapies, including corticosteroids and other drugs, to treat the lung disease. Anecdotally, the CCP positivity co...
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...
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...
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...
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...
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 ...