Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you identify immunotherapy-related pneumonitis vs. radiation pneumonitis in a patient status post chemoradiation receiving consolidation immunotherapy?
Unfortunately, it can be quite difficult to discern the two. Radiation pneumonitis is classically more focal within the treatment field, however, it is absolutely possible to get a more diffuse pneumonitis even with focal RT (albeit uncommon).https://www.ncbi.nlm.nih.gov/pubmed/15256622Immunotherapy...
How does the presence of active rheumatoid arthritis on rituxan impact your decision to proceed with prostate radiation?
I am always concerned about irradiating a patient with an active chronic inflammatory condition, as these people may be more prone to toxicity, both acute and late. In the case of a patient with both prostate cancer and rheumatoid arthritis, the latter being treated with rituximab, the fact that he ...
Would you resume biologic treatments such as TNF blockers in patients with symptomatic autoimmune conditions who are in remission from their cancers?
Most guidelines in rheumatology recommend use in patients who have been in remission for 5 years or more, there is data for safety for these patients. However, we do not know yet whether TNFi are safe in patients who have been NED for shorter periods and who may be at higher risk of recurrence given...
How do you approach post operative radiation therapy to someone with head and neck cancer who has high risk of local recurrence who also has scleroderma?
While the risk of morphea (skin and subcutaneous damage ) after radiotherapy to breast ca is well documented, there are very few data about the risk in HNC. Searching Pubmed for: scleroderma, radiotherapy, and head neck, I get only 2 references, one of which is a case report of a severe late toxicit...
How do you approach further treatment of patients who develop grade 2-3 immune colitis from nivolumab/ipilimumab prior to completion of the 4 ipilimumab doses?
If the colitis completely resolves, I would consider a colonoscopy to be sure that subclinical microscopic lymphocytic colitis has completely resolved. If not, I would consider 3 dose of infliximab to reduce recurrence of colitis. Then once off steroids, I would restart single agent anti-PD1.
When do you stop immunosuppressants in patients with GPA?
It depends on the severity of the initial presenting symptoms and which organs were involved. However, generally, I don't stop all treatments and maintain the patient on at least MTX or azathioprine, potentially for life, even if these were not part of the initial remission-inducing regimen, such as...
What do you try in patients with IBD-related spondyloarthritis with predominantly axial symptoms who are refractory to TNF inhibitors?
Treating these patients is challenging. It's always good to circle back to first-line therapy recommendations for axial spondyloarthritis and ensure that patients are doing physical therapy or exercise daily. Patients whose IBD is in remission may be able to add a COX-2 selective NSAID (celecoxib), ...
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...