Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In routine clinical practice, how do you operationally define ‘progression despite therapy’ in PPF to justify escalation to combination treatment?
ILD patients undergo regular monitoring with intervals based on concern for progression. In addition to symptom review, objective testing includes PFTs with spirometry and DLCO, 6-minute walk testing that provides information on distance walked, symptoms experienced, and whether or not the patient d...
How would you approach evaluation and management of a patient with chronic arthralgias and bilateral hand weakness who has a positive ANA (1:160) and low-titer anti-SSB positivity, in the setting of otherwise negative ENA panel, normal inflammatory markers, normal complement levels and immunoglobulins, and unrevealing EMG/NCS testing?
The low titer SSB/La antibody would only factor into the consideration of SjD if there were other suggestive features, like documented hypo salivation and/or high ocular staining score, neuropathy, etc. Would learn when they were totally well and what potential triggering events may have occurred. I...
How do you approach a patient with idiopathic anterior uveitis who has ongoing disease despite adalimumab every two weeks?
This is a style question, I think. I thought it would be useful to note the choice here might depend on testing for anti-adalimumab antibodies as there is some suggestion that changing to once weekly adalimumab in the presence of anti-adalimumab antibodies might not be efficacious. (Ismayilova et al...
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 ...
How should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...
How do you approach hypogammaglobulinemia monitoring when using obinutuzumab for refractory nonrenal SLE patients?
I would start with a baseline evaluation that includes quantitative IgG levels, HBV serologies, including HBsAg and anti-HBc, to assess reactivation risk even if HBsAg-negative, and a CBC with differential. Before treatment, I would make sure all non-live vaccines are completed, and I would avoid li...
What would be the clinical role of SGLT-2 inhibitors for lupus nephritis given it has an indication for proteinuria related to CKD?
The benefit for SGLT-2 inhibitors at slowing the progression of kidney disease or death from cardiovascular causes had been well established in patients with diabetic nephropathy. Further studies continued to demonstrate benefit in non-diabetic, proteinuric kidney disease (HR, 0.72 (95% CI, 0.64-0.8...
How do you manage worsening cutaneous dermatomyositis when muscle disease appears controlled?
The fact that the patient still has an active pruritic rash while tapering steroids suggests that the current regimen isn't fully controlling the disease, and it can affect quality of life. I would consider adjusting immunosuppression, either adding another agent or switching therapies. The specific...
In patients with ILD who are started on nerandomilast on top of background nintedanib, what monitoring is most important early in therapy?
I do not use combined therapy often, and I usually stop nintedanib to start nerandomilast. This does depend on how long they've been on nintedanib. If it's within the first three months, lab monitoring as required for nintedanib is important. Otherwise, it's really just side effects. Obviously, from...
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 ...