Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you monitor for pulmonary toxicity for patients on trastuzumab deruxtecan?
Eligibility criteria for T-DXd trials were based on clinical history and not on objective findings such as PFTs or radiographic criteria. Therefore, risk for factors for T-DXd-related ILD or other pulmonary toxicity are not at all clear, although they may emerge with larger pooled safety analyses an...
Do you recommend on-demand versus fixed-schedule dosing for rituximab maintenance in ANCA vasculitis?
This is a fairly hot question in the field, and one that reflects the success we have had with advancing therapy for ANCA-associated vasculitis; it’s nice to have choices! Although there are data for both approaches, there are more data (larger numbers, etc.), in my opinion, for fixed-dosing. The tr...
What clinical factors do you use to determine timing of on-demand dosing of rituximab in ANCA vasculitis maintenance therapy?
I tend to use scheduled dosing (q 6 months) with RTX for maintenance in my GPA/MPA patients, but will occasionally use "on-demand" dosing in those who are eager to minimize their RTX, do not tolerate the infusions well, or occasionally those who have lower risks of flare (mild disease, no history of...
How do you treat RA in patients with pulmonary mycobacterium avium complex (MAC) infections?
This is a very complex situation and requires teamwork between rheumatology and infectious disease with close patient follow-up and treatment. In general, avoiding TNF inhibitors in these patients is preferred, in particular the monoclonals, with close monitoring. Methotrexate is an option, and in t...
How does your treatment algorithm differ for drug-induced ANCA vasculitis compared to non drug-induced ANCA vasculitis in cases with severe/organ-threatening manifestations?
When end-organ manifestations are present, my initial treatment approach is similar for drug-induced and non-drug induced AAV and typically consists of glucocorticoids and rituximab, including pulse glucocorticoids with severe end-organ involvement. Common drug culprits such as PTU, hydralazine, min...
Do you consider cystic fibrosis a contraindication to lung SBRT for primary NSCLC or oligometastases?
Just when you think you've done every odd thing in thoracic RT... I have never done RT on a patient with CF. The median survival, according to Dr. Google (advanced edition), is around 40 years which is most likely why I haven't seen that presentation. Double advanced Dr. Google (scholar.google.com) ...
How would you manage a patient with newly diagnosed locally advanced NSCLC and concurrent, active tuberculosis on anti-TB therapy?
Excellent question @Dr. First Last! Assuming the patient is otherwise a good candidate for concurrent chemoRT, my bias would be to proceed with concurrent therapy once the 3 negative AFBs are available, rather than pursue sequential RT then chemo. This recommendation is based upon the observation th...
Which EGPA patients are most likely to benefit from treatment with anti-IL-5 agents such as mepolizumab?
This is a question that is an important area of current investigation in vasculitis. In my view, patients who have primarily pulmonary and sinonasal symptoms (e.g., asthma, rhinosinusitis) are most likely to benefit from mepolizumab, given current knowledge.It is unknown to what degree mepolizumab a...
What is considered an adequate treatment period to assess response of AAV induction therapy with rituximab or cyclophosphamide?
This is an issue of considerable interest both clinically and for research studies, and the approach to both settings is currently similar: are there any signs or symptoms of ongoing active disease? The key words being “ongoing” and “active”. The expectation once glucocorticoids are started and then...
Are there AAV patients for whom you would consider combination therapy with cyclophosphamide and rituximab?
The combination of RTX and CYC does not have a significant evidence base. The rationale for this regimen comes from the hypothesis that CYC acts quicker than RTX and can serve to quiet down the disease early and potentially spare steroids. However, there is no empirical support for this concept so f...