Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach prescribing analgesics for osteoarthritis related pain in patients with comorbidities, particularly given new evidence that even acetaminophen is associated with increased risk of GI complications (bleeding, peptic ulcer disease), heart failure and CKD?
Acetaminophen is still preferred, but at 3,000 mg or less per day. The next consideration is a COX-2 specific inhibitor, such as celebrex. Narcotics and steroids play no role in management of osteoarthritis.
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...
Do you recommend that a patient with pre-existing rheumatoid arthritis who requires immune checkpoint inhibitor therapy for a new cancer diagnosis continue their existing DMARD or biologic therapy during ICI treatment?
Excellent question. The initial ICI trials excluded patients with pre-existing autoimmune disease, so most of the data we currently have are from retrospective data series. The current data suggest that RA is a risk factor for ICI-inflammatory arthritis flare. In fact, one study suggests that 46% of...
How has the ADVISE trial changed your approach to steroid sparing agents for non-infectious uveitis?
The ADVISE trial was a well-designed, multinational trial that compared adalimumab therapy for non-infectious intermediate, posterior, or panuveitis versus conventional immunosuppressive therapy or CID. Two hundred twenty-seven subjects were enrolled over four years, and a fifth year was required to...
In a patient with statin induced immune-mediated necrotizing myopathy (+ anti-HMGCR antibodies), would you consider brepocitinib in the treatment algorithm?
Unlike dermatomyositis, anti-HMGCR IMNM generally lacks a strong interferon signature. Therefore, the biologic rationale for JAK inhibition is less compelling, and I would not routinely consider brepocitinib in this setting.
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...
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 will you incorporate nerandomilast into your treatment algorithm for autoimmune ILD with progression, particularly relative to sequencing with immunosuppression?
All current ILD guidelines suggest initiating therapy with immunosuppression and then adding an antifibrotic IF there is evidence for progression of fibrosis. This is based on low-quality evidence and driven by not only a lack of quality data but also cost and common side effects. Two of the guideli...
Were the patients enrolled in the SEAM-RA trial prior methotrexate monotherapy non-responders?
Yes, presumably at one time, most of these patients were methotrexate non-responders because otherwise, it’s unlikely they would have required escalation to TNFi. Clinicians would typically not add TNFi therapy unless the patient had first failed DMARDs (i.e., methotrexate in this case). It is impor...
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...