Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you treat active SLE with high level crithidia dsDNA abs and recurrent pleuritis with effusions still requiring corticosteroids despite combination therapy with full doses of mycophenolate, hydroxychloroquine, and Benlysta for over 6 months after no response to Saphnelo for 6 months?
There are no controlled trials of different therapies for treating refractory pleuritis in lupus as the primary manifestation. Due to refractory pleuritis being relatively uncommon, the trials of benlysta and anifrolumab did not have enough patients to assess response. In the literature, there are a...
In what cases, if any, do you find the use of naltrexone to augment lifestyle interventions (i.e., cognitive behavioral therapy, graded exercise therapy) for chronic fatigue to be helpful?
Absolutely no.
Was the methotrexate dose reduced over time in the combination therapy or methotrexate monotherapy groups in the SEAM-RA trial?
No, methotrexate dose was not adjusted. Our goal was basically to answer one question: whether it is better to stop etanercept, stop methotrexate, or continue both. We did not want to be adjusting methotrexate doses at the same time as stopping because this would make results more difficult to inter...
Would you consider using avacopan in PR3+ mononeuritis multiplex without other systemic involvement?
I would certainly consider using avacopan in AAV mononeuritis multiplex. While we don't know the outcomes of mononeuritis in avacopan-treated patients specifically, ~20% of patients in the ADVOCATE trial (Jayne et al., PMID 33596356) had neuropathy and the outcomes overall suggest a robust response ...
Are the results of the SEAM-RA trial generalizable to other TNF inhibitors given the differences in immunogenicity?
This is a great question, and an important one because different TNF inhibitors have different immunogenicity and patients can make anti-drug antibodies that can effectively neutralize the drug and render it a less effective treatment option. This tends to happen more with some molecular constructs ...
Were the patients enrolled in the SEAM-RA trial prior methotrexate monotherapy non-responders?
Yes, presumably at one time, most of these patients were methotrexate non-responders because otherwise, it’s unlikely they would have required escalation to TNFi. Clinicians would typically not add TNFi therapy unless the patient had first failed DMARDs (i.e., methotrexate in this case). It is impor...
What was the rationale for abrupt discontinuation of etanercept rather than gradual tapering in the SEAM-RA trial?
The main goal of this trial was to get RA patients off of therapy and to see whether they would flare or maintain remission. We didn’t expect that the ultimate likelihood of success or failure was going to be primarily related to how long it took to do that. While a gradual withdrawal of the drug ma...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
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 ...
In a patient with longstanding Sjogren’s disease (+SSA/SSB and RF with polyclonal hypergammaglobulinemia) who develops new asymmetric parotid fullness what is your preferred initial imaging modality to further evaluate?
I would usually start with ultrasound in this case, specifically looking for signs of lymphoma, and let the results guide any further workup necessary. I have often seen benign parotid swelling in these patients, but an asymmetric presentation such as this requires further workup and potentially bio...