How do you envision incorporating CAR-T therapy into your clinical rheumatology practice?

This is an excellent question—one that, for now, might best be explored over a glass of white wine and some lively hand-waving. It’s a question I often find myself reflecting on every time I hear a presentation or read a new paper on the subject. Here’s a brief editorial response outlining how I envision using such therapies in the future, a decision that I believe will depend on four key variables.

EFFICACY

CAR-T data from ongoing trials in various autoimmune diseases (118 registered protocols as of February 12, 2025, per ClinicalTrials.gov) are still in the early stages of their development journey. Current knowledge is primarily derived from data on fewer than 200 patients with autoimmune diseases (e.g., IMIDs) treated with first-generatio...

I agree with Dr. @Dr. First Last who gives a nice detailed answer. I'm very impressed with this technology. Over 43 patients with severe SLE have been treated with CAR-T and reported in the literature. Almost all went into a prolonged drug-free remission The 1st two from China post-BCMA/CD-19 CAR-T are now past 4 years! The concerns about ICANs and CRS have not been born out in SLE patients. I suspect this is probably because their B-cell load is so much lower than B-cell malignancies. There have been some mild, treatable CRS but I do not recall any ICANs.

The incredible number of possibilities (other cell lines as Dr. Calabrese points out), and even directed cell therapies that target just one type of autoantibody-producing B-cell (e.g., a...

I view CAR-T therapy much the way rheumatologists viewed infliximab (Remicade) in the late 1990s: not as the end of the story, but as the beginning of a new therapeutic era.

When Remicade was introduced, it transformed our ability to treat autoimmune disease. Yet its greatest contribution may have been proving that targeted immune intervention could fundamentally alter disease outcomes. That breakthrough opened the door to an entire generation of biologic and targeted therapies that followed.

I see CAR-T in a similar light. While I anticipate its use for carefully selected patients with severe, refractory autoimmune diseases, I think its broader significance lies in establishing cellular therapy as a new therapeutic platform in rheumatology...

I envision incorporating CAR-T therapy into clinical rheumatology by first identifying the right patient. At present, this would mean carefully selected patients with severe, refractory, or progressive autoimmune disease despite appropriate standard therapies, particularly those with organ-threatening disease and evidence of ongoing, potentially reversible inflammation rather than irreversible damage. In the future, validated clinical, serologic, cellular, or molecular biomarkers may allow us to identify patients at high risk of progression and intervene earlier, before substantial organ damage occurs.

A second priority is developing strong relationships with established cellular-therapy units. Rheumatologists should participate in patient ...