Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your next step in patients with polymyositis without interstitial lung disease who are refractory to methotrexate?
In general, first-line treatment for myositis patients includes methotrexate, azathioprine or CellCept. The exact choice of agent depends on concomitant manifestations of the disease, like lung disease or arthritis, and can move on to the next one if they fail one of them. At the same time though, w...
What agent do you try next in patients with myositis-related interstitial lung disease who are refractory to mycophenolate mofetil and azathioprine?
In those refractory to MMF or AZA, tacrolimus would be the next good option. There is data to support the use of tacrolimus in those who are more refractory, especially those who are MDA5 or have an antisynthetase syndrome.
When do you use tacrolimus in patients with myositis-related interstitial lung disease?
Tacrolimus can be used as a first-line treatment for any myositis-related ILD; however, it does require more frequent monitoring than other agents. I usually use tacrolimus as a first-line treatment for MDA5-associated ILD given the published literature from Japan and China. In the majority of cases...
What is the role of nintedanib in the treatment of SSc-ILD?
Nintedanib has shown to be effective for treating patients with ILD associated with systemic sclerosis, as the annual rate of decline in FVC was lower with nintedanib than with placebo (SENSCIS trial). However, the majority of patients treated with nintedanib in this trial were also on MMF therapy. ...
How do you manage early and symptomatic fibrosis in lung cancer patients after RT?
Fibrotic changes following lung radiotherapy are common, and I think the challenge here is determining whether the pulmonary symptoms are due to radiotherapy (pneumonitis) or exacerbation of underlying pathology.Initiating a patient on steroids is typically a several week commitment, with subsequent...
Do you recommend on-demand versus fixed-schedule dosing for rituximab maintenance in ANCA vasculitis?
This is a fairly hot question in the field, and one that reflects the success we have had with advancing therapy for ANCA-associated vasculitis; it’s nice to have choices! Although there are data for both approaches, there are more data (larger numbers, etc.), in my opinion, for fixed-dosing. The tr...
What clinical factors do you use to determine timing of on-demand dosing of rituximab in ANCA vasculitis maintenance therapy?
I tend to use scheduled dosing (q 6 months) with RTX for maintenance in my GPA/MPA patients, but will occasionally use "on-demand" dosing in those who are eager to minimize their RTX, do not tolerate the infusions well, or occasionally those who have lower risks of flare (mild disease, no history of...
How do you treat RA in patients with pulmonary mycobacterium avium complex (MAC) infections?
This is a very complex situation and requires teamwork between rheumatology and infectious disease with close patient follow-up and treatment. In general, avoiding TNF inhibitors in these patients is preferred, in particular the monoclonals, with close monitoring. Methotrexate is an option, and in t...
How does your treatment algorithm differ for drug-induced ANCA vasculitis compared to non drug-induced ANCA vasculitis in cases with severe/organ-threatening manifestations?
When end-organ manifestations are present, my initial treatment approach is similar for drug-induced and non-drug induced AAV and typically consists of glucocorticoids and rituximab, including pulse glucocorticoids with severe end-organ involvement. Common drug culprits such as PTU, hydralazine, min...
Do you consider cystic fibrosis a contraindication to lung SBRT for primary NSCLC or oligometastases?
Just when you think you've done every odd thing in thoracic RT... I have never done RT on a patient with CF. The median survival, according to Dr. Google (advanced edition), is around 40 years which is most likely why I haven't seen that presentation. Double advanced Dr. Google (scholar.google.com) ...