Uh thank you both for the the great presentation and and there’s a lot of questions but actually you covered uh a great deal of them during the talk so it’s almost like you were reading the questions and then getting to the answer in it um there are a couple about of and and i guess asking when you’re using it what your experience with it is uh do you let the
Pulmonary people do it or you are you doing it what would you say to that jeff well um it’s good to see everyone too um yeah i think this has been a huge development over the past few years um certainly in our group we’re immersed within the pulmonologist so they are pretty involved in helping us to decide and i think for the most part we are using it a lot in
Uip that’s sort of above that threshold of clinical significance and um i think the experience has been pretty similar to ipf where there certainly are some patients that can’t tolerate it related to rash and diarrhea but in those that do tolerate it um it seems to at least stabilize their disease and maybe even improves it in some jack what do you think i i
Think this is still going to be a drug that’s in the hands of the pulmonologist and i think in the hands of rheumatologists who have a real um autoimmune lung uh interest and that they that people like jeff and you know paul de la ripa and others who are really uh leading this area for our for us as the troops in rheumatology i think we we need to have people
Like jeff and and others and um and and our pulmonary colleagues often there’s pulmonary pulmonologists who specialize in in autoimmune lung disease and i think that uh between us we can identify the patients and i but i do believe that’s largely going to be the script written by the pulmonologist more so than myself i’m willing to do it i personally have not
Yet uh written a script for nintetnum or is it called nintendo super nintendo super nintendo great um so there’s a couple of questions about the atypical mycobacterium uh is uh one about uh looking for them the other is what about treatment and someone has had a history of a typical mycobacterial infection jack you want to start out uh i think you look for it
When you when it’s you know you have a chronic lung condition and or uh extra pulmonary remember extra pulmonary manifestations of mycobacterial infections are common in patients on biologics but i can’t underscore enough it’s t and f t and f t and f t and f t and f t and f t and f t and f and then maybe another biologic or another mechanism you need t f to make
Granuloma and maintain granuloma you inhibit tnf that’s where you get into trouble with mycobacterial and fungal infections so yes this can happen with abbatasip and rituximab and maybe a jack inhibitor but you know pound for pound this is all a tnf story the point being if someone’s had a prior unlike tb if you have treated tb whether it’s latent tb or active tb
If it’s treated they can go back on a tnf inhibitor no problem not at all but atypical mycobacteria you do not fully resolve those infections and you really can’t and luckily for you you’ve got 14 other drugs and 22 biosimilars to choose from but just not a tnf inhibitor just use another moa in those people for the people who you must use a tnf inhibitor which i
Don’t know who that is you would have to go on background you know uh zithromax therapy to prevent the atypical mycobacterial infection um but i think everybody would advise avoiding tnf numbers you can use other biologics though jeff anything uh anything to add on that um i think uh this is a i think we get into these chicken and egg scenarios with with with
The the ntm where it can look really very similar to bronchiectasis that could be sort of due to the underlying ra or maybe the infection sort of trashed the airways i think that’s kind of the quandary i get into is like was there ra lung disease the risk factor for getting it or was the infection you know kind of causing structural abnormalities and you know
How that puts the patient at risk down the line but i agree offloading the tnfs is a really the first thing to do but i think jeff’s point is a real good one it happens in people who have structural lung disease sometimes the interpretation of whether it’s an active ntm infection or not is really difficult and and this is the ats the american thoracic society
Has dealt with this they have guidelines there’s a big problem of colonization that you don’t need to always treat just because you you get an atypical mycobacterium so in these situations you need either a very experienced pulmonologist and or ied specialist who knows the ats guidelines on who really does need to be treated for a non-tuberculous mycobacterial
Infection here’s one for jeff how about azathioprine in the treatment of ild nra you mentioned mycophenolate well i think i touched on this related to that panther trial that had you know the poor outcomes in the arm that was prednisone azathioprine and acetylcysteine and again we’re immersed in the pulmonology group and they really are have backed away from using
Azathioprine uh related to that study and then in the converse we’ve been again having an image makeover for some of our other conventional synthetic demards where i think this is a big change 10 years ago you might have switched them from methotrexate to azathioprine just because it felt lung friendly and it’s really the exact course um sort of right now but
Certainly there are some patients that you might need to use it where you’ve really exhausted some other options and um you know they have some it does work for for joints so they’re certainly situations where you might consider it jeff what’s your opinion about the reports in the literature historic more or less about uh ira ild being brought on by laflinamide
Or by tnf inhibitors this i think sometimes we rheumatologists get saddled with that impression either from the literature or from our colleagues in pulmonary yeah i didn’t touch on it or i’d still be talking but yeah i think laflunamide you know we’ve already talked about methotrexate quite a bit but laflunamide and and tnf inhibitors seem to be the other
Ra medications that have that at least perception and um i i do think it’s a little bit unclear but i mean i’ve had a few patients where you start tnf and they start coughing and they have a lot of lung inflammation that doesn’t seem to be pneumonia um however we did a study trying to really look head-to-head and there didn’t seem to be a difference as far as
Observational studies i do typically given all the other options i don’t necessarily want to start laflunamide or tnf inhibitors and often they’ve already been on those meds in the past by the time the reality has been uh detected all right we have a question here live dr phong yes uh about about the next room i actually at one time the insurance would not pay
For it because they say there might be a problem with the interstitial lung disease and i have revealed there are about 200 cases and they say the fundamental i have not increased ild and so the ins so the insurance finally approved it but actually that’s not why i’m not here and my question is for you you talk about the bronchial aveola lava or biopsy now you
Wisely show up the good radiology will tell us whether that is a you know nsip or uip so do we need you need to go on to lavato biopsy if we have finding something like lip or you know boop would that make a difference for how you treat the paper well you know i think i do agree that the uh the lung imaging is it seems to be the expertise and maybe the actual
Images themselves are of higher quality such that we’re doing less biopsies and bals but having said that you know these are complicated patients that are immunosuppressed and they can have more than one thing going on and i’m sure everyone has their anecdote of something where you thought the lung imaging was inflammatory or infectious and it turned out to be
Cancer so you know i think you have to have your antenna up and you know you there’s sort of a sweet spot where you need to be biopsy enough to catch all the cancers but not too much where you’re causing the complications and this is why it’s a multi-disciplinary approach and it’s not a one-size-fits-all solution yeah gene i i think that the uh and these people
I like more information i know that uh the things you talk about biopsy and lavage are kind of invasive and whatnot but these are the things we’re considering here are never mild these are these are bad patients and i think sometimes more information um might be better in these kind of situations i don’t know but i think it’s always going to be a tailored kind
Of uh answer depending on the case yeah so the point is uh we want to rule out something else but i think the pathology now having a boob having a dad having an lip would that make a difference how you treat them do you know any better treatment lip versus uip no i i i i’m handing that off i did my job to disclose what what’s on the table and now um it’s either
Jeff or the pulmonologist is going to manage that not me so jeff have an answer for it if you knew it was boop or lip would you would it change your treatment um well i think i think it’s typically trying to make sure it’s not uip and how you know what is really causing the clinical symptoms and the hypoxia or whatever is bringing them to you so i think it’s a
Bit hard to answer but certainly there certainly are patients where the imaging is enough and you do um you can treat appropriately and certainly if things don’t go as you expect if they’re progressing through your treatment or you know those are patients where you re-image and maybe think about a biopsy i think in those days they talk about the watch if you
See a lot of discrimination that might mean you have more inflammatory disease do you still believe that’s true more inflammatory disease yeah with more yeah when you see more discrimination on the pancreas large oh um yeah the pulmonologists really get in the weeds about that i let them try to figure that out i think obviously i think i’m trying to roll out
Infection and hemorrhage usually so how about this came up you’re talking about patient ri patients with dyspnea what about the pulmonary hypertension workup where does that fit into your algorithm jeff yeah it’s on that long list of differential diagnosis considerations um you know it’s not as common as systemic sclerosis for instance but certainly there
Are some patients that seem to you know have pulmonary hypertension and right heart failure maybe even unrelated to ra they’re just someone that happens to have that and r.a so i think it’s you got to keep an open mind and be a good good good medicine doctor okay another question i have a question about the biopsy when would you consider doing one i mean after
They failed say something like gazathiopran and or mycophenolate or would you proceed to write tuxomab before you did a biopsy and what kind of biopsy are we talking about the transbronchial or open lung biopsy yeah well i mean you can think of basically two types of patients ones that are really um very clearly ra ild of a particular subtype and you treat
Them and maybe they progress and maybe they’re not going well and you’re just very convinced that you really know what you’re dealing with and you switch therapy honestly i think the the messier patient is more common they’re a smoker they’ve got copd they’ve had pneumonias in the past they have a viral syndrome now maybe they had covid and you know they’ve got
Risk factors for everything so um you know that’s when you would probably consider some procedure as far as the type of procedure you know i don’t think the trans-bronchial biopsies have really been that helpful but obviously the other types of biopsies are more invasive so certainly sometimes the pulmonologist will do a bal while they’re there do it try to do
A trans-bronchial biopsy it’s typically not diagnostic and then and then it’s a bigger decision about you know getting uh more tissue um with a you know more of a more of an ordeal okay uh jack give me some time too jack and ibs and r-a-i-l-d yeah i didn’t i didn’t put that on my uh on my list there i think the jury’s out i mean obviously a lot of patients are
Getting treated unwittingly because of the you know predominance of subclinical findings i haven’t really seen a lot of a lot of literature plus or minus about ild with jax have you jack no no i mean i and and if anything maybe you could say that since um jacks have been on the market since 2012 i might have expected to see a some sort of hint at this point that
That might have been a part of the spectrum of their benefit instead all the benefits seems to have gone to baldness and eczema so uh a lot of a lot of questions and read questions about the the screening you mentioned this jeff and you said you’ll do a chest like crazy baseline even without symptoms and then the rest of your workup is it really will be based
On uh symptoms but asymptomatic nothing beyond a baseline chest x-ray uh with when starting methotrexate yeah uh ra asymptomatic from a pulmonary standpoint okay yeah i i don’t do pfts un until they start saying i’m short of breath and and that’s usually my first two steps is it is a chest x-ray maybe a repeat chest x-ray and then uh and then getting pfts to
See what we’re dealing with and whether they need to be in my hands and allergist hands or a pulmonologist’s hand and did you jeff do you have any sort of pro that you use or is it just part of your routine to ask them about the pulmonary symptoms yeah we we aren’t really systematically implementing dyspneus grains there are a few that are pretty easy to do i
Think the problem is almost all right patients are positive for it so it’s it’s it’s a it’s too sensitive at this point and there’s a large battery of questions we do for research that are not practical for clinic can can ask a question about um a six-minute walk time and so you one can you bill for it two can you send the patient for a six-minute walk and see
Two other patients while they’re walking and you’re making money i mean it just seems like an odd kind of um diagnostic or assessment test do you think it has utility for us rheumatologists i don’t bill for it i don’t know if you can i should probably figure that out by now i don’t think you can consider the hallway another clinic granted all right well thank
You very much dr sparks and dr kush
Transcribed from video
RNL 2021 – ILD Faculty Panel and Discussion: Drs. Jack Cush and Jeff Sparks By RheumNow
