Over the next three days, the ARHP is sponsoring a series of five Rheumatic Disease Update sessions that will offer the latest news on vasculitis, inflammatory eye disease, gout, low back pain, and lupus.
Philip Seo, MD, MHS, Assistant Professor of Rheumatology at Johns Hopkins University School of Medicine, will present the first of two update sessions today. Dr. Seo will provide an update on the evaluation and management of vasculitic conditions, which are relatively uncommon but carry some of the highest morbidity and mortality rates among rheumatic conditions. Dr. Seo’s one-hour session will begin at 11:00 am in Room 204 A at the Washington Convention Center.
Also today, Gary N. Holland, MD, will provide an update on inflammatory eye disease from 2:30 – 4:00 pm in Room 206. Dr. Holland, who is the Jack H. Skirball Professor of Ocular Inflammatory Diseases at the David Geffen School of Medicine at the University of California, Los Angeles, is particularly interested in chronic anterior uveitis in children, which is often associated with rheumatic conditions. “We have had two consensus conferences that included pediatric rheumatologists, uveitis specialists, and pediatric ophthalmologists to address some of the problems that have come to light in the management of kids with uveitis, and especially those with JIA,” Dr. Holland said.
“We have formulated recommendations for a more uniform approach to the evaluation and management of children with uveitis. This lecture will be one of the first public presentations of our findings. Eventually, our recommendations will be published in a set of whitepapers.”
A key concern, Dr. Holland explained, is the significant variation in care that children with uveitis receive. Under treatment is common, he said, because many clinicians fail to appreciate the severity of pediatric uveitis, which can to lead vision-limiting complications that could be avoided with more aggressive treatment. Furthermore, clinicians may not realize the speed with which uveitis can progress in children — complications can develop between scheduled visits.
There are also special concerns when dealing with pediatric patients. “Children with uveitis are probably more prone than adults to developing glaucoma as a complication of the disease, yet glaucoma is a difficult problem to diagnose and manage in a small child,” Dr. Holland said. “It can get out of control even before it is recognized.”
The drugs used to manage uveitis and its complications in adults may not be appropriate for children. Brimonidine, which is commonly used for glaucoma in adults, can cause somnolence or respiratory suppression in children.
There are also misconceptions about the disease itself. Uveitis in children with JIA is a chronic condition that requires long-term therapy. Discontinuation of treatment when inflammation is controlled is almost always associated with recurrent inflammation, Dr. Holland explained. Clinicians must make a commitment to ongoing treatment that often includes chronic immunosuppression.
Children with chronic anterior uveitis are best managed through a team approach, Dr. Holland said. Pediatric rheumatologists are not able to monitor the effects of immunosuppression on the eye, and may not be familiar with issues like amblyopia, or lazy eye, which can cause a child with uveitic complications to lose vision permanently, even if the complication is eventually addressed. On the other hand, pediatric ophthalmologists may not have extensive experience with uveitis issues, while not all uveitis specialists are familiar with the special needs kids have in medication selection or followup.
“And not everyone with inflammatory eye disease can be managed by a uveitis specialist — there just aren’t enough of us to go around,” Dr. Holland said. “We want to disseminate these recommendations to everyone who may be involved in the management of a child, whether it is a pediatric rheumatologist, a uveitis specialist, a pediatric ophthalmologist, a general ophthalmologist, or an adult rheumatologist.”
Gout is saddled with centuries of misconceptions. Often viewed as a disease of elderly men, gout also affects elderly women. In fact, gout is the most common inflammatory arthritis of humans. Some 8.3 million Americans have gout, or about 4 percent of the population.
Naomi Schlesinger, MD, Professor of Medicine and Chief of Rheumatology at the University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School, will address the most common myths and misconceptions about gout tomorrow during another ARHP update session. Dr. Schlesinger’s one-hour session will begin at 9:00 am in Room 206.
Another misconception: Gout is typically seen as a lifestyle disease, the result of inactivity and a rich diet. If patients simply ate a more balanced diet, the thought goes, their gout would disappear. Neither the cause nor the treatment of gout are that simple, Dr. Schlesinger said.
“Diet is only helpful to a very small degree because most of the uric acid in gout is not the result of diet but from the breakdown of cells,” she explained. “If you have gout, you need to be on medication.”
X-rays are essentially useless in the diagnosis of gout because it takes years to produce joint changes that are visible on an X-ray. And serum urate levels may not be diagnostic because about half of patients with acute gout have normal serum urate levels.
To make a definitive diagnosis of gout, monosodium crystals need to be found in synovial tissue and/or tophi.
Topical ice also may be helpful in diagnosing gout because patients with acute gout typically present with hot joints and the ice often relieves their joint pain, Dr. Schlesinger explained. Therefore, application of topical ice should be part of the history taking and physical examination when one suspects acute gout, or if the nature of the inflammatory arthritis is unclear.
There are different treatment approaches for acute and chronic gout. Pain relief and anti-inflammatory action are essential for acute treatment. Nonsteroidal drugs, colchicine, and corticosteroids are the most commonly used drugs for acute gout. Recent trials with an interleukin-1 inhibitor have also shown promise.
Urate-lowering therapies, as well as chronic anti-inflammatory therapy, are used for chronic treatment. Xanthine oxidase inhibitors such as allopurinol and febuxostat are the standard of care. Pegloticase, a uricase, is new to the market and may be important for the induction of urate-lowering therapy. A variety of new agents, mostly uricosuric drugs, are currently in development.
“Clinicians and patients will say, ‘It’s just gout,’” Dr. Schlesinger said. “It’s not just gout, it’s a serious disease. Gout is under diagnosed and at times over diagnosed. People get adverse events and may even die from treatment. Education regarding the diagnosis and treatment of gout are key.”
Gout needs to be accurately diagnosed and treatment needs to be improved, Dr. Schlesinger added. “One needs to terminate the acute attacks, control hyperuricemia and tissue deposition using the target serum urate level of <6.0 mg/dL, as well as using prophylactic medications to prevent acute attacks,” she said.
Low Back Pain
Fully 80 percent of the population will have at least one episode of low back pain in their lifetime. But many rheumatologists are unsure about how to deal with this common problem.
“Low back pain is one of the most common complaints in the rheumatology practice,” said Jeffrey N. Katz, MD, MSc, Professor of Medicine and Orthopedic Surgery at Harvard Medical School and Director of the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital. “There is a wealth of clinical trial data on back pain treatments, some of which is not well appreciated by rheumatologists.”
Dr. Katz will explore treatment approaches to low back pain from 9:00 – 10:00 am Tuesday in Room 143 A.
Back pain tends to be episodic, he explained. About 80 percent of patients who present with low back pain will have another episode within 12 months. The good news is that the natural history of low back pain is good. Most patients recover regardless of treatment or lack of treatment. “
A lot of attention is paid to how you treat an episode of low back pain,” Dr. Katz said. “It turns out that is not so important. How a particular episode is treated should not be the focus. Our effort should be focused on preventing future episodes because they are very costly and disabling. It is a chronic, episodic disease and we would like to figure out how to reduce the number of episodes.”
Diet and exercise are among the most effective preventive steps, he said. Increasing flexibility and core muscle strength are key steps in preventing future episodes.
Sciatic pain due to a herniated disk is more difficult to treat because the natural history of disk protrusions is less positive than for garden variety back pain, Dr. Katz said.
“The question of whether to think about surgery or injections should be a preference-based decision,” he said. “There are no strict indications for these more invasive procedures. We need to understand the risks and benefits to help patients make choices based on their own preferences.”
Spinal stenosis is a growing problem for older patients. Fortunately, stenosis is highly responsive to surgery, Dr. Katz said, and rheumatologists should be more familiar with the common indications for spinal stenosis surgery.
“Garden variety back pain gets better and sciatica gets better, but more slowly. Spinal stenosis often doesn’t get better,” he said. “For many patients, surgery becomes the wiser decision even though they are older and the risks of surgery are higher. The more back pain you see, the more surgical decision-making you can engage in with your patients before referring them to a surgeon.”
The final ARHP Rheumatic Disease Update session will be held from 2:30 – 4:00 pm Tuesday in Room 145 A. Michelle Petri, MD, MPH, Professor of Medicine and Director of the Lupus Center at Johns Hopkins University School of Medicine, will provide an update on systemic lupus erythematosus