Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
Do the results of FIBRONEER-ILD change your approach to antifibrotic treatment in patients with sarcoidosis related PPF?
According to the FIBRONEER-PPF data, no sarcoidosis-specific outcomes have been reported, and one can only infer that the sarcoidosis-related PPF subpopulation has tracked similarly to the other ILD subtypes, which is a big assumption. It is important to remember that in the INBUILD study, which exa...
How will you incorporate nerandomilast into your treatment algorithm for autoimmune ILD with progression, particularly relative to sequencing with immunosuppression?
The sequencing of therapy in CTD-related PPF remains unclear. Recent data suggest that immunosuppression may not alter clinical outcomes in fibrotic ILDs, including those associated with systemic autoimmune disorders (Pugashetti et al., PMID 42432856). In the FIBRONEER-ILD study, nerandomilast impro...
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...
How do you counsel patients with dermatomyositis on sun protection?
We make sure patients know that sun exposure can trigger flares, so we strongly recommend staying out of direct sunlight between 10 AM and 4 PM, using broad spectrum, SPF30+ sunscreen daily even when indoors (as UVA can penetrate through windows), and wearing sun protective clothing (ideally UPF-rat...
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 has the ADVISE trial changed your approach to steroid sparing agents for non-infectious uveitis?
The ADVISE trial was a well-designed, multinational trial that compared adalimumab therapy for non-infectious intermediate, posterior, or panuveitis versus conventional immunosuppressive therapy or CID. Two hundred twenty-seven subjects were enrolled over four years, and a fifth year was required to...
What is the most appropriate next step in management for a patient with dermatomyositis who is maintained on methotrexate 25 mg weekly but develops disease flare when prednisone is tapered below 10 mg daily and is unable to receive IVIG?
The fact that the patient cannot taper prednisone below 10 mg indicates that methotrexate alone, while has some effect, is not sufficient to control the disease. There are several options, depending on the severity of each organ involvement. Since the joints are affected, I would favor an agent that...
Do you recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...