Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you manage resuming successful abatacept therapy in a refractory RA patient undergoing resection of stage 1 lung adenocarcinoma?
You can restart the abatacept once the patient has recovered from surgery. There is no signal for increased new solid tumors on abatacept, and you would expect the patient to be cured after resection of a stage 1 tumor.
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
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...
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...
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 checking anti-drug antibodies for patients on TNF inhibitors?
This is a very good question with direct clinical practice implications. I do not check or follow anti-drug antibodies when using TNF inhibitors for the treatment of rheumatoid arthritis or psoriatic arthritis. There are reports that suggest, on a group level, that these antibodies, if present, impa...
How do you approach tapering decisions for disease-modifying therapy for ICI-induced inflammatory arthritis after the patient's cancer treatment has been completed or the ICI has been discontinued?
This is a great question and, honestly, one that every rheumatologist struggles with. Similar to managing other inflammatory diseases, the challenge is determining when a patient is truly in remission and whether therapy can be safely reduced or discontinued.My approach is fairly practical: The pati...
How do you approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?
As with most questions about sarcoidosis, clear understanding of the relevant clinical context should first be established. While interstitial lung disease (ILD) is a common manifestation of sarcoidosis, it often can be safely monitored without treatment, and so radiologically identified sarcoid ILD...
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...
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 ...