Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are there patients with granulomatosis with polyangiitis on maintenance rituximab therapy for whom you do not co-administer glucocorticoid therapy?
I think this is a great question. @Dr. First Last et al (NCT01933724) have conducted a study to answer that question (conveniently called TAPIR). In their analysis that was presented 1 week ago at the International Vasculitis Workshop, they found that patients on low-dose prednisone along with other...
Do you extend the duration of maintenance therapy past 24 months for patients with ANCA glomerulonephritis who have multiple organ involvement?
The duration of maintenance therapy in patients with AAV depends on many factors and should be individualized. Some factors that are associated with a higher risk of relapse include PR3 positivity, seroconversion from negative to positive, ENT disease, use of a tailored approach to RTX dosing, and u...
What is your approach for steroid dosing for patients with ANCA vasculitis on induction treatment with rituximab, avacopan, and glucocorticoid therapy?
I do not personally have a one-size-fits-all approach. Remember that ADVOCATE had a screening window of up to 2 weeks where many patients got steroids before they were randomized. At the time of randomization, patients had to be on less than 20mg of prednisone which was tapered over 4 weeks.In addit...
Would you offer lung SBRT to a medically inoperable patient with systemic lupus erythematosus or other connective tissue disorders if well controlled?
This is a very timely and clinically relevant question that had intrigued us for quite a while. Thus, we looked into our over 10 year experience at UCLA for 197 adult patients with collagen vascular disease. This work was recently published in JAMA Open Network: Yoon et al., PMID 33599771.The hypoth...
How do you treat CTD-associated organizing pneumonia?
I agree with what Dr. @Dr. First Last has said. To answer your question specifically, organizing pneumonia is slightly different to other forms of ILD. OP tend to have much better response to steroids in general. As with most other ILD patterns, CTD-OP has slightly worse prognosis than COP. So I am ...
Would you consider caplacizumab in a pregnant patient with iTTP?
As noted, caplacizumab was not studied in pregnancy (was an exclusion criteria) and is not approved in this setting.With that being said, as noted, caplacizumab use in pregnancy has been described in case reports (1, 2, 3) and in the post-partum setting (4). I would consider the use of caplacizumab ...
What would be the main indications for opting for biosimilars over an original biologic, outside of insurance barriers?
A timely question, as we head to 2023! The only reason to use biosimilars is for the broad purpose of resource stewardship. There isn't a medical reason to prefer a biosimilar over a reference product (or vice versa), because if a product were found to have a significantly different therapeutic effe...
Do you require lupus patients with ESKD or advanced CKD to be on minimal immunosuppression around the time of kidney transplantation?
Patients with SLE needs to have overall clinically quiescent disease to be actively listed for kidney transplant. They can be on stable/reduced dose of immunosuppression medications to keep the disease clinically under control. They can still have low complement levels (serologically active).
How do you approach monitoring for lymphoproliferative disease in Sjogren's patients?
I have an increased index of suspicion for lymphoma, myeloma, and amyloid in Sjogren's. Increased age, longer disease duration, and greater disease activity increase the lymphoproliferative risk.Persistent unilateral parotid or other salivary gland enlargements, lymphadenopathy, vasculitis (purpura,...
Would you treat a patient aggressively for lupus nephritis if they have persistent proteinuria over 1 gram but cannot get a timely kidney biopsy?
It all depends. I would keep pushing for a biopsy and try to overcome the barriers ASAP. If it is the patient who is the barrier (not wanting the biopsy), I would educate them on how a biopsy ends up not even being due to SLE in some cases and immunosuppressant treatment therapy would be exposing t...