Rheumatology INFO

11/04/2026

11/04/2026

🧵 Steroids in : Friend, Foe… or Fine Balance?
From cornerstone therapy to cautious precision use

📍 Published in The Lancet Rheumatology (2026)
📄 DOI: 10.1016/S2665-9913(26)00072-X

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• Still a cornerstone → rapid, potent anti-inflammatory effect
• But ⚠️ cumulative toxicity = major concern

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• 🎯 Guideline consensus:
→ Use as short-term bridge
→ Lowest effective dose
→ Taper ≤5 mg/day within months
→ Stop if possible

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• ❗Reality check:
→ Chronic use (>6 months) very common
→ ~40–50% pts remain on steroids in real-world cohorts

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• 🔑 Why mismatch?
→ Difficult-to-treat disease
→ Flares on tapering
→ Limited access to biologics
→ Physician/patient reluctance
→ Implementation gaps

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• ⚖️ Emerging concept:
→ Very low dose (

10/04/2026

𝗣𝗵𝗮𝗿𝗺𝗮𝗰𝗼𝗹𝗼𝗴𝗶𝗰𝗮𝗹 𝗔𝗱𝘃𝗮𝗻𝗰𝗲𝘀 𝗶𝗻 (𝗦𝗦𝗰)-𝗥𝗲𝗹𝗮𝘁𝗲𝗱 𝗗𝗶𝗴𝗶𝘁𝗮𝗹 𝗨𝗹𝗰𝗲𝗿𝘀 (𝗗𝗨𝘀)

Core Approach:
Tailored multimodal therapy targeting endothelial dysfunction and microcirculatory impairment, combined with essential non-pharmacological wound care.

1. Vasodilator/Active Medications (Mainstay)
◦ First-line for Raynaud’s: Calcium channel blockers (CCBs) – limited evidence for DU healing/prevention.
◦ Proven benefit for DU healing & prevention:
- PDE5 inhibitors: sildenafil and tadalafil (supported by RCTs).
- Prostacyclin analogues (PGA): Iloprost has the strongest evidence; extended regimens (>5 days) appear superior. Oral treprostinil and selexipag show mixed/promising results (further RCTs needed).
◦ Endothelin receptor antagonists (ERAs):
- Bosentan: effective for prevention (not healing); recommended by WSF for prevention only.
- Macitentan: no benefit in RCT (reasons unclear, possibly study design differences).
◦ Riociguat: failed primary/secondary endpoints in RESCUE trial (small sample/short duration); newer agents (avenciguat, sotatercept) remain investigational.

2. Immunomodulatory & Antifibrotic Agents
◦ Limited role; considered only in refractory cases with severe skin fibrosis (e.g., baricitinib reduced DU occurrence).
◦ Antifibrotics (e.g., nintedanib): no benefit for DUs.

3. Other Therapies
◦ Statins (atorvastatin): adjunctive benefit for healing and prevention in small RCT.
◦ Antiplatelets: limited evidence; aspirin may be used cautiously as adjunct in refractory cases.

4. Interventional/Surgical Options (Refractory/Severe Cases)
◦ Botulinum toxin injections: safe option for refractory DUs.
◦ Digital sympathectomy: improves perfusion in severe ischemia.
◦ Adipose tissue autograft (ATG): high healing rates in RCT; needs protocol optimization.
◦ Endovascular angioplasty or surgery: limited data, for macrovascular disease or complications (debridement/amputation as last resort).

Key Takeaway:�PDE5 inhibitors + iloprost are cornerstone therapies for healing/prevention; bosentan for prevention. Use adjunctive and interventional approaches selectively in refractory disease. Further studies needed for newer agents.

📊 Multi-disciplinary management approach for SSc-DUs

From: Ozen G, Domsic RT, Hughes M. Systemic sclerosis-related digital ulcers: current understanding and updated management approaches—a primer for clinicians. Semin Arthritis Rheum. Published online April 9, 2026.
🔗doi.org/10.1016/j.sema…

25/03/2026

The 2025 update of recommendations for the management of ’s syndrome, recently published in Annals of the Diseases, include 5 overarching principles and 12 recommendations organised by organ involvement.

◦ Overarching principles stress the relapsing-remitting nature of the disease, individualised treatment based on activity and prognostic factors, a multidisciplinary approach, patient education, and shared decision-making.

◦ Key recommendations:
- Mucocutaneous and joint involvement: Colchicine is first-line; apremilast or TNFα inhibitors for refractory cases.
- Organ-threatening disease: Early aggressive therapy with glucocorticoids + immunosuppressives, with prompt use of monoclonal TNFα inhibitors encouraged for severe or life-threatening manifestations.

Of the 12 recommendations, 1 is entirely new, 7 were modified, and 4 had only wording changes.

*Hatemi G, Ramiro S, Ozguler Y, et al. EULAR recommendations for the management of Behçet’s syndrome: 2025 update. Ann Rheum Dis. Published online March 23, 2026.
🔗doi.org/10.1016/j.ard.…

27/02/2026

26

12/01/2026

🩸 Thrombocytopenia in

🟢 ITP → isolated ↓PLT, no hemolysis
🔴 TMA → ↓PLT + MAHA = TMA until proven otherwise
🟠 MAS → fever + 🚀 ferritin + cytopenias
🔵 Drug-induced → recent drug, abrupt drop, rapid recovery

🚨 Red flags matter. Pattern recognition saves lives.

08/12/2025

Iron Deficiency Anemia vs Anemia of Chronic Disease - same “low Hb,” completely different physiology.
One lacks iron.
One can’t use iron.
Hepcidin is the real traffic cop.

Knowing the difference changes treatment - completely.

@

08/12/2025

🔑 Clinical Pearls: Anaemia Management in CKD (2025 Update)

1. Shift in Treatment Paradigm

The centre of gravity has shifted from
erythropoiesis-stimulating agents(ESAs)→ Iron-first strategies in recent years.

Adequate iron repletion often improves Hb enough to delay or avoid ESA initiation, especially in early CKD.

2. ESA Risks: Less is More

Targeting higher haemoglobin with ESAs increases stroke, venous thromboembolism, and cardiovascular events.

ESA doses should be minimal (just enough to avoid transfusion) and used only after correcting iron deficiency and other reversible causes.

3. High-Dose IV Iron Appears Safe & Beneficial

The PIVOTAL trial changed practice:

Monthly 400 mg IV iron sucrose, guided by cut-offs:

Ferritin ≤700 µg/L

TSAT ≤40%

Liberal IV iron reduces HF hospitalisation, possibly lowers MI risk, and improves ESA efficiency in dialysis patients.

4. HIF–PHIs: A New Era, With Caution

Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) are orally active and stimulate endogenous EPO at physiological levels.

They also improve iron handling by upregulating iron-regulatory genes — useful in inflammatory ESA-resistant CKD.

5. Safety Concerns With HIF-PHIs

By activating broad HIF pathways, these agents may:

Increase VEGF, potentially worsening proliferative diabetic retinopathy.

Raise theoretical risks regarding tumour growth and progression.

Long-term safety data remain inadequate, so selection must be careful and individualized.

6. Iron Deficiency Remains the Cornerstone

In CKD with anemia, always rule out and treat iron deficiency first.

High hepcidin levels make oral iron poorly absorbed → consider IV iron early.

7. Multifactorial Nature of CKD Anaemia

Besides low EPO, remember contributors:

Iron deficiency (absolute or functional)

Inflammation

Reduced RBC lifespan

Dialysis-related blood loss

Correction of these improves response to ESAs and HIF-PHIs.

8. Practical Goal Setting

Aim for Hb 10–11 g/dL in most CKD patients.

Avoid pushing Hb >11.5 g/dL — no benefit, more harm.

9. Who Benefits Most From HIF-PHIs?

Patients with:

Poor response to ESAs

High inflammatory burden

Oral-therapy preference (non-dialysis CKD)

But avoid or use cautiously in active malignancy and diabetic retinopathy.

10. Key Takeaway for Clinicians

Iron optimization is the foundation; ESAs are the supplement; HIF-PHIs are the exciting but still-evaluated frontier

https://academic.oup.com/ndt/article/39/5/770/7452913?login=false

08/12/2025

Algorithm for tapering glucocorticoids
vs

08/12/2025

A toxin-secreting gut bacterium may fuel ulcerative colitis by killing protective immune cells that maintain intestinal homeostasis, according to a new study in Science.

The findings suggest potential for new treatment strategies. https://scim.ag/3LUkJ95

08/12/2025

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08/12/2025

A paradigm shift in corticosteroid therapy for sarcoidosis: WASOG Position Paper

⏩no longer be considered as first-line therapy in all patients with sarcoidosis requiring treatment
⏩ used as bridging therapy, ideally for no longer than 3–4 months

https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(25)00338-8/abstract