Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In managing non-renal SLE, how do you approach choosing between belimumab and anifrolumab?
Dr. @Dr. First Last, You are asking what we are all dreaming of... personalized medicine where we could identify a patient's immunologic endotype and better choose disease-modifying drugs rather than cycling patients from one combination of drugs to another.Right now, it is a dream. With so many bio...
What is your preferred management approach for scleroderma renal crisis in a patient with a history of anaphylaxis to ACE inhibitors?
The important thing is to lower the BP regardless of the how. ACE I were the first medication to show survival benefit in patients with scleroderma renal crisis so they have become the treatment mainstay. Time is kidney so the best treatment is to lower the BP with whatever BP lowering medication yo...
How would you manage axial spondyloarthritis in a patient who was doing well on TNF inhibitor therapy then developed a new solid organ malignancy while on treatment?
The story here is an important one. I was able to discuss this with @Dr. First Last, who supplied important insights. Most of the good (and bad) data supporting what to do when your patient had a prior malignancy in remission or who develops one on treatment comes from experience with treating rheum...
Does the presence of psoriatic arthritis affect your decision to use an anti-IL-17 or IL-23 drug in your psoriasis patients?
I tend to prefer IL-17s in patients with PsA as an indirect assessment of clinical trials suggests they are more effective than IL-23s (which fits my clinical experience) for PsA. IL-17s are also more effective for axial disease (IL-23s are not very effective in axial disease). If there is a history...
How do you approach the significance of +RNP III antibody in a patient with positive ANA but no other signs or symptoms of systemic sclerosis?
RNA polymerase III is a specific autoantibody for a subset of systemic sclerosis associated with severe diffuse cutaneous scleroderma, renal crisis, GAVE, and a strong association with malignancy. If this antibody is identified in the absence of Raynaud's or other symptoms of scleroderma, its signif...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
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...
What minimum clinical features or risk factors drive you to obtain a baseline HRCT in a patient with RA or Sjogren's disease?
Overall, about 10% of RA patients will develop clinically significant ILD, as will 20% of those with SjD. Those are a significant number of people, and ILD should be on our radar as clinicians. Knowledge of risk factors for ILD can help us focus on people most likely to be affected. Several risk fac...
Do you recommend initiating immunosuppression and plasmapheresis in patients with dialysis dependent AKI in the setting of anti-GBM disease who do not have pulmonary involvement?
Anti-GBM disease is a rare disorder (incidence perhaps 1:1,000,000 adults/year) that is characterized as a small vessel vasculitis mediated by anti-GBM antibodies directed against the alpha-3-chain of collagen IV in basement membranes. Perhaps half of patients have disease that involves both the kid...
What is your approach to monitoring patients referred for high titer +RF and +CCP but without active symptoms of inflammatory arthritis?
It has been well described that patients with a +RF and + CCP autoantibody may develop clinically active RA up to two decades or more (potentially lifelong) after the detection of these autoantibodies in a patient. It is now thought that there is a preclinical phase of autoimmune diseases including ...