This Week in Rheumatology — Oct 29, 2026
Generated Oct 29, 2026 · 11:22
The week's practice-changing Rheumatology research, summarized for clinicians.
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Rituximab vs Azathioprine for Eosinophilic Granulomatosis With Polyangiitis Maintenance Therapy: A Randomized Clinical Trial.
In a blinded trial of 98 EGPA patients, rituximab maintenance was not superior to azathioprine for remission duration and roughly doubled severe infections, largely from COVID-19.
JAMA · 2026 · PubMed
This week’s papers
- 01
Ianalumab for the Treatment of Patients with Sjögren's Disease.
Monthly ianalumab modestly lowered ESSDAI disease activity versus placebo in two phase three Sjögren's trials, but did not improve response rates or patient-reported symptom scores.
Mariette X et al. · New England Journal of Medicine · 2026
From the briefingWe start with two randomized trials that put B-cell directed therapy to the test, one in Sjögren's disease and one in eosinophilic granulomatosis with polyangiitis. In the New England Journal of Medicine, Mariette and colleagues report the paired NEPTUNUS-1 and NEPTUNUS-2 trials of ianalumab, a monoclonal antibody that both depletes B cells and blocks the receptor for B-cell activating factor [1]. Across nearly 780 patients with active Sjögren's disease followed for 52 weeks, 300 milligrams given subcutaneously each month reduced the ESSDAI disease activity score more than placebo in both trials, but the margin was small, about one point on a scale running to 123, and only just reached statistical significance. Just as important, there was no difference in the proportion of patients achieving a meaningful ESSDAI response of five points or more, and no improvement in the patient-reported symptom scores, including ESSPRI. Serious adverse events were similar between arms, while injection-site and injection-related reactions were more common on ianalumab. So this is the first targeted agent to hit a primary endpoint in two phase three Sjögren's trials, which matters for a disease with no approved targeted therapy, but the clinical size of the effect is modest and patients' symptoms did not measurably change, which leaves open how much this will mean at the bedside.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 02
Rituximab vs Azathioprine for Eosinophilic Granulomatosis With Polyangiitis Maintenance Therapy: A Randomized Clinical Trial.
In a blinded trial of 98 EGPA patients, rituximab maintenance was not superior to azathioprine for remission duration and roughly doubled severe infections, largely from COVID-19.
Puéchal X et al. · JAMA · 2026
From the briefingFrom JAMA, Puéchal and colleagues ran a double-blind, double-dummy French trial comparing rituximab with azathioprine for maintenance in 98 patients with EGPA who had recently reached remission [2]. Rituximab, given as 500 milligrams every six months for 18 months, was not superior: time in remission on 7.5 milligrams of prednisone or less was essentially the same in both groups, at a little over 90 weeks. Rates of vasculitis relapse and of asthma or sinus flares were numerically similar too. Severe infections, however, were roughly twice as common with rituximab, affecting just under half of rituximab recipients, driven largely by severe COVID-19 during a pre-vaccine period. The trial is modest in size, but it is randomized and blinded, and it does not support the idea that rituximab outperforms azathioprine as EGPA maintenance.
If you only have time for one paper this week, make it the JAMA trial of rituximab versus azathioprine for EGPA maintenance [2]. It is the first blinded head-to-head trial in this setting, and it challenges the assumption that rituximab is the stronger maintenance option while highlighting its infection cost.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 03
Real-world association of biologic and targeted synthetic DMARD use with mortality in rheumatoid arthritis-associated interstitial lung disease: a nationwide cohort study.
In over 6,000 Korean patients with RA-associated ILD, biologic or targeted synthetic DMARD use was associated with about a quarter lower all-cause and respiratory mortality.
Joo YB et al. · RMD Open · 2026
From the briefingIn RMD Open, Joo and colleagues used Korean national insurance data on more than 6,000 patients with rheumatoid arthritis-associated ILD [3]. Patients who went on to receive a biologic or targeted synthetic drug had about a quarter lower all-cause mortality than those on conventional agents alone, with similar reductions in respiratory and ILD-related deaths, and no clear association with cardiovascular, cancer or infection deaths. The signal was seen across TNF inhibitors, abatacept, tocilizumab and JAK inhibitors, but not clearly with rituximab, where numbers were small. Notably, TNF inhibitors carried no apparent harm, which runs against long-standing concern about these drugs in RA-ILD. The authors are candid that claims data lack lung function and imaging, so confounding by disease severity remains possible.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 04
Survival and immunomodulatory therapy in autoimmune disease-associated progressive pulmonary fibrosis: a multicenter registry (NEREA).
Among autoimmune ILD patients with progressive pulmonary fibrosis, immunomodulatory therapy was independently associated with markedly lower ILD-related mortality, while low DLCO and emphysema increased risk.
Vadillo C et al. · Rheumatology · 2026
From the briefingWriting in Rheumatology, Vadillo and colleagues followed 158 patients with autoimmune ILD meeting progressive pulmonary fibrosis criteria in the Madrid NEREA registry [4]. Most deaths in this cohort were attributed to the lung disease itself, and patients receiving immunomodulatory therapy had about a third of the risk of ILD-related death, with mean survival under five years untreated versus more than ten years treated. Low diffusing capacity and coexisting emphysema independently worsened outlook. Again, this is observational and single-region, but it points the same direction as the Korean data: immunomodulation in fibrosing autoimmune ILD was associated with longer survival, not shorter.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 05
Predictors of response and long-term efficacy and safety of nintedanib in systemic sclerosis-interstitial lung disease: data from an Italian multicentre study.
In 151 Italian patients with SSc-ILD, nintedanib initiation was followed by stabilized lung function, with concomitant mycophenolate linked to less progression but frequent gastrointestinal dose reductions.
Campochiaro C et al. · Seminars in Arthritis and Rheumatism · 2026
From the briefingThen in Seminars in Arthritis and Rheumatism, Campochiaro and colleagues describe 151 patients with systemic sclerosis ILD starting nintedanib across 13 Italian centres [5]. Lung function had been falling in the year before treatment and then stabilized, with the share of patients meeting progression criteria dropping from about two thirds to about a quarter. Concurrent mycophenolate was associated with lower odds of progression, supporting the combination approach. The tolerability picture is real: more than a third of patients needed a dose reduction, and about one in six stopped, mainly for gastrointestinal effects, with heavy proton pump inhibitor use predicting trouble. The before-and-after design and the small number with two-year data limit firm conclusions.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 06
Comparative effectiveness and safety of five Janus kinase inhibitors in real-world clinical practice: the multicentre ANSWER cohort.
In a Japanese RA cohort, upadacitinib and filgotinib showed lower discontinuation for ineffectiveness than tofacitinib, and their persistence was not clearly reduced by prior IL-6 or JAK inhibitor exposure.
Etani Y et al. · Rheumatology · 2026
From the briefingIn Rheumatology, Etani and colleagues used the Japanese ANSWER cohort to compare five JAK inhibitors across about 1,800 treatment courses in rheumatoid arthritis [6]. Compared with tofacitinib, upadacitinib cut the risk of stopping for lack of effect by roughly two thirds, and filgotinib by about 40 percent, while baricitinib and peficitinib did not differ significantly. Upadacitinib was also less often stopped for adverse events than peficitinib. Prior IL-6 inhibitor or JAK inhibitor exposure predicted failure with tofacitinib, baricitinib and peficitinib, but not clearly with upadacitinib or filgotinib. This is retrospective, adjusted data from one country, so it is hypothesis-strengthening rather than definitive. By contrast, in psoriatic arthritis the message is one of parity.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 07
Real‑world assessment of the effectiveness and response profiles of biologic DMARDs in psoriatic arthritis: findings from an emulated multicentre clinical trial.
In nearly 1,000 Italian psoriatic arthritis patients, TNF, IL-17 and IL-23 pathway inhibitors produced comparable six-month disease activity improvements and similar long-term drug retention.
Ruscitti P et al. · Annals of the Rheumatic Diseases · 2026
From the briefingIn the Annals of the Rheumatic Diseases, Ruscitti and colleagues applied a target trial emulation to nearly 1,000 Italian patients starting TNF, IL-17 or IL-23 pathway inhibitors [7]. Disease activity fell substantially in all three groups over six months, with no significant differences between classes, and long-term retention among patients still on drug at six months was also similar. Shorter disease duration was linked to better outcomes in exploratory analyses. For psoriatic arthritis, then, this real-world evidence suggests class choice can rest on comorbidities and patient factors rather than expected efficacy, though residual confounding cannot be excluded.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 08
International recommendations for the use of imaging in the diagnosis and assessment of polymyalgia rheumatica.
New EULAR-standard recommendations keep polymyalgia rheumatica a clinical diagnosis, reserving imaging for intermediate-probability or overlap cases and not supporting it for monitoring or subclinical vasculitis screening.
Bond M et al. · Annals of the Rheumatic Diseases · 2026
From the briefingThe Annals of the Rheumatic Diseases also carries the first EULAR-standard international recommendations on imaging in polymyalgia rheumatica, from Bond and colleagues [8]. The task force concludes that PMR remains a clinical diagnosis, that imaging is neither needed to confirm high-probability cases nor to exclude low-probability ones, and that it adds most in atypical or overlapping presentations. No single modality, whether ultrasound, MRI or PET, was accurate enough to be named first-line, vascular imaging is endorsed when giant cell arteritis overlap is suspected, and routine screening for subclinical vasculitis or imaging for monitoring is not supported by current evidence.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 09
Extra-renal disease patterns in lupus nephritis: clinical and serological activity confers increased risk of renal flares and damage accrual.
After renal response in lupus nephritis, combined serological and clinical extra-renal activity, driven mainly by anti-dsDNA positivity, was associated with more renal flares and organ damage.
Drougkas K et al. · Rheumatology · 2026
From the briefingIn Rheumatology, Drougkas and colleagues followed 168 patients with biopsy-proven lupus nephritis after renal response [9]. Nearly all patients showed some extra-renal activity during follow-up, and higher non-renal disease activity predicted both renal flares and damage. Major extra-renal flares were associated with roughly a tenfold rise in damage accrual, and the combination of serological and clinical activity, rather than either alone, roughly doubled to tripled the risk of renal flare, with anti-dsDNA positivity emerging as the key driver. It is retrospective, but it supports treating post-response serology and extra-renal symptoms together as a warning sign.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 10
First trimester exposure to hydroxychloroquine during pregnancy and major congenital malformations: a systematic review and meta-analysis.
First-trimester hydroxychloroquine was associated with slightly higher odds of major malformations on low-certainty evidence, which the authors judge insufficient to change its use in lupus pregnancy.
Cournand E et al. · RMD Open · 2026
From the briefingFinally, in RMD Open, Cournand and colleagues pooled 20 studies covering more than 4,000 pregnancies exposed to hydroxychloroquine in the first trimester [10]. They found a slight increase in major congenital malformations, roughly a quarter higher odds, but most included studies had serious or critical risk of bias and certainty was rated low. The authors conclude this does not justify changing hydroxychloroquine use in lupus pregnancy, given its established benefits, while suggesting case-by-case decisions for indications where alternatives exist.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
The full briefing
This AudioScholar briefing is generated by artificial intelligence for healthcare professionals and trainees. It is not medical advice.
Welcome to This Week in Rheumatology. This week we're covering 10 notable papers spanning B-cell targeted therapy in two difficult systemic diseases, interstitial lung disease across the connective tissue diseases, and real-world comparisons of targeted drugs, along with new guidance on imaging, lupus monitoring and pregnancy safety. Let's dive in.
We start with two randomized trials that put B-cell directed therapy to the test, one in Sjögren's disease and one in eosinophilic granulomatosis with polyangiitis. In the New England Journal of Medicine, Mariette and colleagues report the paired NEPTUNUS-1 and NEPTUNUS-2 trials of ianalumab, a monoclonal antibody that both depletes B cells and blocks the receptor for B-cell activating factor [1]. Across nearly 780 patients with active Sjögren's disease followed for 52 weeks, 300 milligrams given subcutaneously each month reduced the ESSDAI disease activity score more than placebo in both trials, but the margin was small, about one point on a scale running to 123, and only just reached statistical significance. Just as important, there was no difference in the proportion of patients achieving a meaningful ESSDAI response of five points or more, and no improvement in the patient-reported symptom scores, including ESSPRI. Serious adverse events were similar between arms, while injection-site and injection-related reactions were more common on ianalumab. So this is the first targeted agent to hit a primary endpoint in two phase three Sjögren's trials, which matters for a disease with no approved targeted therapy, but the clinical size of the effect is modest and patients' symptoms did not measurably change, which leaves open how much this will mean at the bedside. From JAMA, Puéchal and colleagues ran a double-blind, double-dummy French trial comparing rituximab with azathioprine for maintenance in 98 patients with EGPA who had recently reached remission [2]. Rituximab, given as 500 milligrams every six months for 18 months, was not superior: time in remission on 7.5 milligrams of prednisone or less was essentially the same in both groups, at a little over 90 weeks. Rates of vasculitis relapse and of asthma or sinus flares were numerically similar too. Severe infections, however, were roughly twice as common with rituximab, affecting just under half of rituximab recipients, driven largely by severe COVID-19 during a pre-vaccine period. The trial is modest in size, but it is randomized and blinded, and it does not support the idea that rituximab outperforms azathioprine as EGPA maintenance.
Our second theme is interstitial lung disease, where three observational studies look at whether treatment changes the trajectory. In RMD Open, Joo and colleagues used Korean national insurance data on more than 6,000 patients with rheumatoid arthritis-associated ILD [3]. Patients who went on to receive a biologic or targeted synthetic drug had about a quarter lower all-cause mortality than those on conventional agents alone, with similar reductions in respiratory and ILD-related deaths, and no clear association with cardiovascular, cancer or infection deaths. The signal was seen across TNF inhibitors, abatacept, tocilizumab and JAK inhibitors, but not clearly with rituximab, where numbers were small. Notably, TNF inhibitors carried no apparent harm, which runs against long-standing concern about these drugs in RA-ILD. The authors are candid that claims data lack lung function and imaging, so confounding by disease severity remains possible. Writing in Rheumatology, Vadillo and colleagues followed 158 patients with autoimmune ILD meeting progressive pulmonary fibrosis criteria in the Madrid NEREA registry [4]. Most deaths in this cohort were attributed to the lung disease itself, and patients receiving immunomodulatory therapy had about a third of the risk of ILD-related death, with mean survival under five years untreated versus more than ten years treated. Low diffusing capacity and coexisting emphysema independently worsened outlook. Again, this is observational and single-region, but it points the same direction as the Korean data: immunomodulation in fibrosing autoimmune ILD was associated with longer survival, not shorter. Then in Seminars in Arthritis and Rheumatism, Campochiaro and colleagues describe 151 patients with systemic sclerosis ILD starting nintedanib across 13 Italian centres [5]. Lung function had been falling in the year before treatment and then stabilized, with the share of patients meeting progression criteria dropping from about two thirds to about a quarter. Concurrent mycophenolate was associated with lower odds of progression, supporting the combination approach. The tolerability picture is real: more than a third of patients needed a dose reduction, and about one in six stopped, mainly for gastrointestinal effects, with heavy proton pump inhibitor use predicting trouble. The before-and-after design and the small number with two-year data limit firm conclusions.
Our third theme is choosing between targeted therapies in routine practice. In Rheumatology, Etani and colleagues used the Japanese ANSWER cohort to compare five JAK inhibitors across about 1,800 treatment courses in rheumatoid arthritis [6]. Compared with tofacitinib, upadacitinib cut the risk of stopping for lack of effect by roughly two thirds, and filgotinib by about 40 percent, while baricitinib and peficitinib did not differ significantly. Upadacitinib was also less often stopped for adverse events than peficitinib. Prior IL-6 inhibitor or JAK inhibitor exposure predicted failure with tofacitinib, baricitinib and peficitinib, but not clearly with upadacitinib or filgotinib. This is retrospective, adjusted data from one country, so it is hypothesis-strengthening rather than definitive. By contrast, in psoriatic arthritis the message is one of parity. In the Annals of the Rheumatic Diseases, Ruscitti and colleagues applied a target trial emulation to nearly 1,000 Italian patients starting TNF, IL-17 or IL-23 pathway inhibitors [7]. Disease activity fell substantially in all three groups over six months, with no significant differences between classes, and long-term retention among patients still on drug at six months was also similar. Shorter disease duration was linked to better outcomes in exploratory analyses. For psoriatic arthritis, then, this real-world evidence suggests class choice can rest on comorbidities and patient factors rather than expected efficacy, though residual confounding cannot be excluded.
Our final theme gathers diagnosis, monitoring and safety. The Annals of the Rheumatic Diseases also carries the first EULAR-standard international recommendations on imaging in polymyalgia rheumatica, from Bond and colleagues [8]. The task force concludes that PMR remains a clinical diagnosis, that imaging is neither needed to confirm high-probability cases nor to exclude low-probability ones, and that it adds most in atypical or overlapping presentations. No single modality, whether ultrasound, MRI or PET, was accurate enough to be named first-line, vascular imaging is endorsed when giant cell arteritis overlap is suspected, and routine screening for subclinical vasculitis or imaging for monitoring is not supported by current evidence. In Rheumatology, Drougkas and colleagues followed 168 patients with biopsy-proven lupus nephritis after renal response [9]. Nearly all patients showed some extra-renal activity during follow-up, and higher non-renal disease activity predicted both renal flares and damage. Major extra-renal flares were associated with roughly a tenfold rise in damage accrual, and the combination of serological and clinical activity, rather than either alone, roughly doubled to tripled the risk of renal flare, with anti-dsDNA positivity emerging as the key driver. It is retrospective, but it supports treating post-response serology and extra-renal symptoms together as a warning sign. Finally, in RMD Open, Cournand and colleagues pooled 20 studies covering more than 4,000 pregnancies exposed to hydroxychloroquine in the first trimester [10]. They found a slight increase in major congenital malformations, roughly a quarter higher odds, but most included studies had serious or critical risk of bias and certainty was rated low. The authors conclude this does not justify changing hydroxychloroquine use in lupus pregnancy, given its established benefits, while suggesting case-by-case decisions for indications where alternatives exist.
If you only have time for one paper this week, make it the JAMA trial of rituximab versus azathioprine for EGPA maintenance [2]. It is the first blinded head-to-head trial in this setting, and it challenges the assumption that rituximab is the stronger maintenance option while highlighting its infection cost.
Here is what this week's evidence adds up to in Rheumatology. First, B-cell targeting is not a universal win: ianalumab met its primary endpoint in Sjögren's disease but with a small effect and no symptom benefit, and rituximab did not beat azathioprine for EGPA maintenance, both from randomized trials. Second, three observational cohorts consistently associate immunomodulatory and antifibrotic treatment in autoimmune ILD with better survival or stabilized lung function, though none can fully exclude confounding. Third, real-world data suggest differences among JAK inhibitors in rheumatoid arthritis, favouring upadacitinib and filgotinib for persistence, but broad parity across biologic classes in psoriatic arthritis. Fourth, new EULAR recommendations position imaging in polymyalgia rheumatica as a selective adjunct rather than a routine test. And fifth, the small malformation signal for hydroxychloroquine rests on low-certainty evidence and, according to the authors, does not outweigh its benefits in lupus pregnancy.
That's your roundup for This Week in Rheumatology. The full transcript and references are available on the episode page. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.
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