Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is cellular therapy for autoimmune disease realistically scalable as a mainstream treatment, or is it more likely to remain reserved for a narrow, most-severe subset of patients?
The answer is that this remains very much a work in progress. Before we can meaningfully address scalability, we need greater certainty about several things: the magnitude and durability of clinical benefit; whether patients can remain drug-free or will require concomitant therapy after treatment; a...
What treatment options do you consider after TNF failure in intestinal Behcet's with ongoing steroid dependence?
Colonic Behcet’s does not necessarily respond the way that IBD does. The evidence base for alternative therapies includes anti-interleukin-1, -6 and anti CD20. Anti Il-12/23 have also been used. Would discuss with a rheumatologist about which options are reasonable, depending on where else there are...
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...
Do you routinely check HLA-B*58:01 allele status in patients of Vietnamese descent before starting allopurinol?
Of Asian or African American descent
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...
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 ...
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...
For patients with evidence of prior bilateral uveitis (PS, pupillary membranes, inactive KP, no view posteriorly) who reports no prior symptoms and who has had negative lab work-up, when do you consider repeat work-up and which labs would you repeat?
This is a difficult question to answer succinctly, as so much information is missing to provide a complete response. However, it does raise some important points that are worth mentioning:There is a prevailing tenet, which I was taught as a resident and hear often from residents today, that 1st epis...
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...
Based on Together-PsA, would you favor starting all patients with PsA and comorbid obesity on combination therapy with tirzepatide + bDMARD or will you pursue initial bDMARD monotherapy with tirzepatide rescue in the event of bDMARD non-response?
I think that really is up to the rheumatologist and the patient. This is really a shared decision-making kind of question.I usually find it’s easier to start one at a time. The reason for that is that if you start both at the same time and the patient has side effects, you’re not really sure which o...