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 ...
How should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...
How do you approach hypogammaglobulinemia monitoring when using obinutuzumab for refractory nonrenal SLE patients?
I would start with a baseline evaluation that includes quantitative IgG levels, HBV serologies, including HBsAg and anti-HBc, to assess reactivation risk even if HBsAg-negative, and a CBC with differential. Before treatment, I would make sure all non-live vaccines are completed, and I would avoid li...
What would be the clinical role of SGLT-2 inhibitors for lupus nephritis given it has an indication for proteinuria related to CKD?
The benefit for SGLT-2 inhibitors at slowing the progression of kidney disease or death from cardiovascular causes had been well established in patients with diabetic nephropathy. Further studies continued to demonstrate benefit in non-diabetic, proteinuric kidney disease (HR, 0.72 (95% CI, 0.64-0.8...
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...
In patients with ILD who are started on nerandomilast on top of background nintedanib, what monitoring is most important early in therapy?
I do not use combined therapy often, and I usually stop nintedanib to start nerandomilast. This does depend on how long they've been on nintedanib. If it's within the first three months, lab monitoring as required for nintedanib is important. Otherwise, it's really just side effects. Obviously, from...
How long would you recommend that a patient continues guselkumab prior to deciding that the therapy is not effective?
Many trials have a placebo-controlled period of 12-24 weeks. Thereafter, all patients receive active treatment. Even if the original treatment allocation remains unknown to the patient and doctor, they know that from that moment on, everyone receives active treatment. This will have an influence on ...
What clinical history or findings make you more concerned for an amyloid-related neuropathy?
Many, including: Presence of a monoclonal IgG or IgA protein on serum or urine protein immunofixation, especially lambda light chain, and especially if kappa to lambda light chain ratio is very low. Unexplained autonomic dysfunction, especially orthostatic hypotension without compensatory tachycard...
Are there adverse consequences of suppressing serum urate levels too much?
It's an interesting question. I personally do not have a lower limit that I have in mind per se, and frankly rarely see anything less than 3 in any of my patients. But I would consider 2-3 being a range which could be deemed low and potentially an issue long term in brain health and because of its n...
Do you recommend that a patient with pre-existing rheumatoid arthritis who requires immune checkpoint inhibitor therapy for a new cancer diagnosis continue their existing DMARD or biologic therapy during ICI treatment?
Excellent question. The initial ICI trials excluded patients with pre-existing autoimmune disease, so most of the data we currently have are from retrospective data series. The current data suggest that RA is a risk factor for ICI-inflammatory arthritis flares. In fact, one study (McCarter et al., P...