CHICAGO—At ACR Convergence 2025, the Secrets and Pearls of Rheumatology session presented on important clinical pearls for rheumatologists to know.
Connective Tissue Diseases
Dr. Pope
Janet Pope, MD, FRCPC, MPH, professor of medicine in the Division of Rheumatology at the University of Western Ontario Schulich School of Medicine, London, Ontario, spoke first on connective tissue diseases.
Cutaneous Rashes
To kick the talk off, Dr. Pope explained how different rashes confer different risks of the patients having systemic lupus erythematosus (SLE). For example, 5–10% of discoid patients have SLE, 50% of patients with subacute cutaneous lupus have SLE and nearly 100% of those with true malar rash have SLE.1
The pathology of cutaneous lupus on a skin biopsy may show interface dermatitis, follicular plugging and/or lymphocytic infiltrates, plus lupus band staining with immunoglobulin M (IgM) +/- C3 deposition. To differentiate lupus rash from myositis on the hands, Dr. Pope said to look at the location. “A lupus rash is between knuckles while the dermatomyositis rash is on the knuckles (Gottron papules),” Dr. Pope explained, “but if either rash is severe, they can look similar, throughout the extensor surfaces of the digits.”
Lupus Nephritis
The first episode concerning for renal involvement in a patient with SLE requires obtaining a kidney biopsy. “The biopsy is important to determine activity or damage, the class of nephritis and the prognosis,” Dr. Pope said.
Dr. Pope explained her opinion that the treatment of lupus nephritis could be improved by both sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) therapy. GLP-1 receptor agonist use demonstrated some protection against renal progression, although limited to observational studies where patients have diabetes or obesity.2
Finally, immunosuppression can be tapered after around five years of remission of nephritis, Dr. Pope said. She referenced the WIN-Lupus Trial that tested withdrawal of immunosuppression in lupus nephritis after two years of treatment, which was not successful; the discontinuation of immunosuppressive therapy was associated with a higher risk of severe SLE flare.3
Myositis
Dr. Pope expressed her opinion that cancer screening beyond the usual recommendations in inflammatory myositis is not recommended for all patients. “This might be controversial, but low-risk patients only need routine cancer screening. You can stratify by clinical and antibody risk,” she said.
For example, an elderly patient with significant weight loss and severe dysphagia should have more extensive investigation for cancer, Dr. Pope noted. Additionally, cancer risk is increased in specific myositis antibodies, such as TIF1-gamma and NXP2.4
