Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Can sIL2-R differentiate between active sarcoidosis affecting small airways vs uncontrolled asthma and guide treatment with methotrexte vs biologics?
Not exactly, and probably not with enough compelling precision to use it clinically. sIL-2R cannot reliably differentiate active small-airway sarcoidosis from uncontrolled asthma, nor can it independently select methotrexate versus biologic therapy. It is a marker of systemic T-lymphocyte/granuloma ...
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 strategies have you found most helpful to improve adherence to hydroxychloroquine among patients with lupus?
In my practice, three approaches have been most useful: Make adherence measurable. I routinely check whole-blood hydroxychloroquine levels and review the trend with patients in a nonjudgmental way. This creates accountability and turns an otherwise “invisible” treatment into something concrete that ...
How often do you draw screening ANAs for discoid lupus?
Because a positive ANA is associated with an increased risk of progression to SLE in patients with discoid lupus, I routinely check an ANA at the initial visit in virtually all patients. If negative, I repeat it only if new symptoms concerning systemic involvement arise (e.g., joint pain, cytopenias...
How do you counsel patients on the potential benefits of nerandomilast for PPF?
Nerandomilast is an inhibitor of phosphodiesterase 4 (PDE4), which leads to elevated intracellular cAMP, which reduces the expression of profibrotic cytokines and growth factors. It has both antifibrotic and immunomodulatory activity and may be useful in active inflammatory ILD based on these charac...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
How do you approach management autoimmune lymphoproliferative syndrome (ALPS) complicated by HLH?
Excellent and tough question. There are no direct guidelines for this specific question. We will have to extrapolate from other evidence and clinical reasoning.Investigation of the trigger must occur in parallel with management. I will discuss how I approach investigation first and then management.I...
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 ...
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 ...
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...