Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...
For a patient on appropriate treatment for invasive aspergillosis, how do you determine if and when it is acceptable to reintroduce a TNF inhibitor that likely contributed to their acquisition of the infection but is considered essential for control of their inflammatory condition?
There is no established answer to this question. The reintroduction of a TNF inhibitor must be individualized based on the clinical situation of the patient under consideration. There are two critical questions. First, how much does the patient need the inhibitor”? The more the patient is dependent ...
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 ...
How should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...
In patients with severe osteoporosis, history of retinal artery occlusion, and hypercalciuria, would you favor PTH analogue therapy or Evenity?
Assuming that PTH and vitamin D are normal, neither. Chlorthalidone is the treatment of choice in this scenario. Chlorthalidone is usually better than HCTZ, as HCTZ often must be given BID, whereas chlorthalidone can be given daily. I have seen very large improvements in BMD with thiazide therapy, o...
What factors do you weigh most heavily when choosing between belimumab and voclosporin as part of a triple therapy regimen for newly diagnosed class IV LN?
When I would choose belimumab: If the urine protein creatinine ratio (UPCR) is < 3 gm/gm and if there are significant extra-renal manifestations. In patients with adherence problems with oral medications, especially noting the high pill burden of voclosporin. In patients with severe renal dysfuncti...
How would you escalate treatment for a pediatric patient with CNO with mandibular involvement and only partial response to biweekly TNFi?
If you are convinced of the correct diagnosis, then adding pamidronate to TNFi would be my suggestion. Additionally, you could maximize TNFi dose/interval (e.g., adalimumab 40 mg weekly).
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 ...
Is it still significant to denote the etiology of ILD in a patient with PPF?
Yes, absolutely! Infact, the most effective treatment in patients without IPF (PPF) is treatment of the cause. So if there is underlying autoimmune disease or exposure, primary treatment should be directed against that trigger and this has potential to stop progression and even improve lung function...
In a patient with gout previously treated with pegloticase who then discontinued therapy, can pegloticase be safely and effectively restarted?
It depends on the reason for discontinuation of Pegloticase therapy in the first place, since efficacy and safety data varies with it.Pegloticase can be safely and effectively restarted if the initial discontinuation was not due to a loss of efficacy or a severe infusion reaction, and should be done...