Interdisciplinary Medicine Is Best in Rheumatology

In this week’s news roundup from Rheumatology Network, we feature a study that finds patients with axial spondyloarthritis who smoke may be more likely to have joint inflammation. We conducted Q&A with study author Elena Nikiphorou, M.B.B.S./B.Sc., M.D.(Res), a rheumatologist with King's College Hospital in London who said that the study shows associations between smoking and structural damage, spinal and SIJ inflammation with the latter exclusively affecting patients in blue collar professions. The findings were reported in Arthritis and Rheumatology.

We also published a Q&A with Jean Liew, M.D., a senior fellow with University of Washington who reports that overweight or obese patients with axial spondyloarthritis may be more susceptible to higher disease activity. Her findings are based on the publication of systematic literature review and meta-analysis published in RMD Open.

And, we highlighted a second study from RMD Open, that finds tocilizumab (Actmera)may be associated with increased gastrointestinal ruptures in rheumatoid arthritis patients. The condition, they say, may be due to the inflammatory process associated with RA or perhaps medications.

And, how well verse are you on treat-to-target in rheumatoid arthritis? We posted a quiz this week to test your knowledge. You might want to check that out online.

And, in today’s one-on-one interview, we talk with Dr. Jeffrey Sparks from Brigham and Women’s Hospital in Boston. He recently presented a study at the Interdisciplinary Autoimmune Summit that addresses the importance of interdisciplinary collaborations in treating rheumatic disease patients with interstitial lung disease (ILD).

Welcome Dr. Sparks.

PARTIAL TRANSCRIPT FOLLOWS:

Dr. Sparks: I’m Jeffrey Sparks, M.D. I am a rheumatologist and clinical researcher at Brigham and Women's Hospital and Harvard Medical School in Boston. I have a particular interest in the role of the lung and the pathogenesis and outcomes of systemic rheumatic diseases in particular rheumatoid arthritis.

Rheumatology Network: Welcome to Rheumatology Network. I appreciate your time. I invited you here today to talk about a presentation you recently presented at the International Autoimmune Summit, a meeting that was held virtually this summer. Your area of expertise, just as you said is rheumatoid arthritis and pulmonary diseases. And, in your presentation you talked about the importance of recognizing this as condition that is best treated as an interdisciplinary condition that should ideally be treated by both a rheumatologist and pulmonologist.

In your presentation you talked about the importance of recognizing this as an interdisciplinary condition. Let’s begin by summarizing your presentation.

Dr. Sparks: Sure and thank you again for having me. It’s also great to present this topic. It’s the Interdisciplinary Autoimmune Summit. As know, most things these days are virtual this time of year so we’re glad that this happen even if it’s not in person.

So, I had a big topic: Pulmonary manifestations of rheumatic diseases. It’s something I could have talked about for a long time, but we broadly talked about the approach to diagnosis of pulmonary manifestations of rheumatic diseases. It’s something I could have talked about for a long time, but broadly talked about the approach to diagnosis of pulmonary manifestations of rheumatic diseases and what sort of symptoms patients might have, the differential diagnoses and what kind of modalities you might think about for imaging and monitoring.

We then went into disease specific characteristics about pulmonary manifestations for rheumatic diseases. In particular, rheumatoid arthritis, systemic sclerosis, anca vasculitis, lupus and the different pulmonary manifestations that might expect. For instance, in systemic sclerosis and rheumatoid arthritis you might expect interstitial lung disease. Whereas in anca-associated vasculitis, it can present with alveolar hemorrhage.

We then talked about the management approach as far as how the medications you might think about for treating pulmonary manifestations of rheumatic disease, such as rituximab, [indiscernible] an antifibrotic. And, then we also talked about the controversy about some of the medications that might either have a positive or negative effect on pulmonary manifestations of rheumatic diseases. And that really highlights some of the gaps from the literature as far as some of the difficulties in diagnosing and treating these patients that are obviously quite complex.

Rheumatology Network: So, it is complex just as you said. It manifests differently in patients with different rheumatic conditions. In a rheumatoid arthritis patient, for example, what symptoms might they have in the early stage that might suggest the presence of some kind of pulmonary manifestation.

Dr. Sparks: The typical symptoms of interstitial lung disease within rheumatoid arthritis would be dyspnea, typically a dry cough, sometimes chest pain, but as you can see these symptoms are quite nonspecific so often this is guided by imaging. For instance, computed tomography scans to really see the features of interstitial lung disease.

However, the quandary is that some patients may have some imaging abnormalities that are not necessarily diagnostic and have these symptoms and it can become difficult to understand whether the imaging abnormalities correlate with the symptoms and maybe people with mild imaging abnormalities might progress to something more severe. I think that, in particular, we are trying to shed more light on in patients with rheumatoid arthritis.

Rheumatology Network: So, then, is imaging routine for rheumatoid arthritis patients with this condition for this very reason?

Dr. Sparks: Well, we’re doing research now to understand the role of screening for RA-related lung diseases. I think right now it’s in the research sphere. But certainly, it’s pretty common for clinicians to obtain these scans for many different purposes. I think right now it’s still to the point where many patients will get test imaging there could be abnormalities and it’s a real complex decision about how to diagnose and mange these patients and leads to an interdisciplinary approach.

I’ll add that some other rheumatic diseases, for example, systemic sclerosis actually have maybe a bit more solid evidence base about screening given that patients with systemic sclerosis have a really high burden of subclinical disease and many of these patients do progress to clinically significant interstitial lung disease. So, it really varies by disease and patients.

Rheumatology Network: Then, at what point, would a pulmonologist become involved in the care of a patient?

Dr. Sparks: Everyone’s local situation a bit different. I think that this is such a common issue that patients might have a pulmonary manifestation of pulmonary disease that it’s nice to have a relationship with an expert pulmonologist who’s really comfortable in diagnosing and managing these patients such that when some subtle imaging abnormalities come up it would be good to run the case by an expert, a thoracic radiologist as well, to try to understand whether this might need someone who needs to be evaluated in person or need more dedicated imaging or serial follow-up. I am blessed with great pulmonary colleagues who I am able to run cases by. I think for me you kind of need this as part of your arsenal to have these experts on your side and also know that you as a rheumatologist can’t be the expert in everything and having someone who is really thoughtfully thinking about the lung manifestations would be a real hope to many of the patients.

Rheumatology Network: This has been interesting. Would you like to leave us with any other final thoughts on ILD?

Dr. Sparks: I think the real key is this interdisciplinary and individualized approach is not a one size fits all solution. So, try to understand what your local landscape is. Have an expert radiologist and pulmonologist who you can really think thoughtfully about cases. And, if the volume is high enough, really think about interdisciplinary conferences that meet periodically---that’s certainly what we do at our institution. And, don’t discount this because these patients really have worsen quality of life and worsen morbidity and mortality. So, it’s really going to be something that will really help the patient to have your antenna up related to all the varied manifestations that can affect our patient.