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 ...
Do you favor obinutuzumab over voclosporin for patients with lupus nephritis and significant proteinuria and a history of non-adherence to medications?
Non-adherence to medications is a common issue in lupus patients, but this can be even more of a concern in lupus nephritis, where the pill burden for patients can be so high. I usually prefer to use intravenous medications for patients who have had difficulty adhering to oral medications in the pas...
In the setting of new onset severe Raynaud’s with digital ischemia (partial toe amputation), but negative initial rheumatologic evaluation, what additional rheumatologic or hematologic workup should be considered?
This is always a difficult situation. As Rheumatologists, we tend to lean hard on the laboratories, but in cases like this, it is the history and physical examination that tell the better story. The history is critical here, since a smoking/tobacco history gives a lot of information. Any history of ...
What would be your treatment approach for a patient with concomitant diagnoses of multiple myeloma and axial spondyloarthritis?
The treatment of multiple myeloma would take precedence in this situation. I would get in touch with the oncologist, ask them about their treatment plans, explain to them how we treat axSpA (NSAIDs, csDMARDs for peripheral manifestations, and biologics, small molecules for axial disease), and then c...
In a young patient with relapsing polychondritis and aortitis which has led to severe aortic valve regurgitation, is there any preference for a mechanical versus bioprosthetic valve replacement?
There is no data specifically on valve replacement for RP. If the patient can be safely anticoagulated, a mechanical valve would be likely better since it is a young patient. Data from TAK regarding valve replacement suggest subsequent complications are less likely when the aortic root is also repla...
How do you envision incorporating CAR-T therapy into your clinical rheumatology practice?
This is an excellent question—one that, for now, might best be explored over a glass of white wine and some lively hand-waving. It’s a question I often find myself reflecting on every time I hear a presentation or read a new paper on the subject. Here’s a brief editorial response outlining how I env...
How do you explain the concept of CAR-T therapy and why it may work to patients with autoimmune disease who are interested in pursuing a clinical trial?
In full transparency, I have not personally obtained informed consent from a patient immediately before CAR-T or a related cellular therapy. My center has a highly active immune therapeutics program, however, and I have spoken and written extensively about this area. I also serve on our health syste...
How do you assess and manage cavitating pulmonary rheumatoid nodules?
I will consult with a pulmonologist about it. Start treatment that is suitable for rheumatoid arthritis as well as lung disease, and monitor the patient closely.
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 young female with lupus cerebritis with seizures would you start induction therapy with Rituximab over cyclophosphamide?
I am not aware of a direct comparison of the efficacy of cyclophosphamide versus rituximab for treating lupus cerebritis with seizures. In cases of life-threatening progressive disease, giving both agents has been reported. Choosing between the two should involve in-depth patient education and invol...