Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you interpret treatment response in the DISCOVER-2 Trial when patients were allowed to remain on up to 10mg of prednisone equivalent for disease control while on guselkumab?
If patients were on less than or equal to prednisone 10 mg, they could continue that in the background during the trial, but note that only 20% of patients were on prednisone, a much lower figure than a typical rheumatoid arthritis trial, which is consistent with the point that rheumatologists shy a...
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 ...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
Do you reduce the dose of hydroxychloroquine in patients with skin graying if they are not particularly bothered by this side effect?
1. I would check a trough whole blood HCQ level. Nathalie Costedoat-Chalumeau and her colleagues found higher levels in patients who developed skin pigmentation (Jallouli et al., PMID 23824340), but actual levels were not reported. Petri et al also showed that levels above 1200 ng/mL were associated...
Do you recommend medical therapy for extensive atraumatic osteonecrosis of the femoral head to mitigate pain or prevent femoral head collapse?
This is a good question. Extensive atraumatic ON of the femoral head will probably not respond to any medical therapy; eventually, the patient will need a replacement. However, ON that is from a systemic insult (drugs, alcohol) is often bilateral so if the other hip is less affected or not affected,...
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 decide between initiating systemic immunotherapy versus local treatment for uveitis with associated HLA-B27 and spondyloarthropathy?
I find that most, but not all, HLA-B27 iritis can be controlled with topical therapies. To do so requires eliminating other causes of inflammation. Many patients have GI inflammation due to gluten and dairy, despite not having classic celiac disease or lactose intolerance. Reducing their intake, mod...
How often are you repeating screening PFTs in patients with SARDs who have 3 or more years of normal or stable PFTs?
The answer to this question is complex and needs to be tailored to the individual patient’s risk for ILD and the particular SARD.Approximately 30-40% of patients with systemic sclerosis (SSc) will develop ILD, typically within the first 5 years after the first non-Raynaud’s manifestation and rarely ...
What is the most appropriate next step in management for a patient with dermatomyositis who is maintained on methotrexate 25 mg weekly but develops disease flare when prednisone is tapered below 10 mg daily and is unable to receive IVIG?
The fact that the patient cannot taper prednisone below 10 mg indicates that methotrexate alone, while has some effect, is not sufficient to control the disease. There are several options, depending on the severity of each organ involvement. Since the joints are affected, I would favor an agent that...
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...