Transcription:

Melanie Cole (Host): Welcome. Today we’re talking about the field of rheumatology. My guest is Dr. Tuhina Neogi. She’s the new Chief of Rheumatology at Boston Medical Center. Dr. Neogi, tell us a little bit about the field of rheumatology. What is a rheumatologist? How are they trained?

Tuhina Neogi MD, PhD (Guest): Sure, so rheumatology encompasses diseases of the joint. So typically people are familiar with arthritis and there are many different forms of arthritis. And rheumatology also encompasses other autoimmune diseases that can affect a number of different organs. Rheumatologists are internal medicine trained physicians who do specialty training in rheumatology typically two to three or even four years of additional training after internal medicine training where we specialize in taking care of these common and rare diseases.

Host: Well thank you for that clarification. So, as you say, there are many diseases that fall within the rheumatology domain. These autoimmune diseases seem to be on the rise as I’ve noticed. Why are we seeing more of them? Are you seeing more of them?

Dr. Neogi: So, I think that’s a complicated question. I think part of it is greater awareness by the general community and by primary care physicians about various autoimmune diseases. And certainly, there is likely an interaction with the environment and environmental exposures that might be increasing the prevalence of certain autoimmune diseases.

Host: Doctor as you have told us about the types of diseases that fall within the rheumatology domain; who is at risk for these and is there a genetic component to autoimmune diseases?

Dr. Neogi: Sure, yes. So, for some of the autoimmune diseases that we take care of in rheumatology such as rheumatoid arthritis, lupus, et cetera, there’s definitely a genetic component but it doesn’t necessarily mean that it’s going to definitely run in the family. There is something about an individual’s predisposition based on their genetic makeup plus other triggers that they might have been exposed to during their lifetime.

Host: So, then let’s talk about arthritis which is very common and so many people have it. differentiate for us the difference between rheumatoid and osteoarthritis, why one is considered autoimmune and one is really orthopedic.

Dr. Neogi: So, I will quibble with osteoarthritis being considered orthopedic. I think that stems from the fact that currently we don’t have great therapies for osteoarthritis and often the definitive treatment for end-stage osteoarthritis is joint replacement surgery which is why it is considered in the orthopedic domain. But osteoarthritis is the most common form of arthritis. It’s actually affecting 300 million people worldwide. It commonly affects the knees, the hips, and the hands and is one of the leading causes of disability worldwide.

In the US alone, about 30 million people are affected by osteoarthritis. And so that’s about 10 to 15% of the population. In contrast, rheumatoid arthritis is seen in less than one percent of the population and it is considered an autoimmune disease because the immune system is causing inflammation that can damage the joints. And treatments targeting rheumatoid arthritis are treatments that modulate the immune system to reduce that inflammation and reduce joint damage.

In contrast, osteoarthritis is a biomechanically driven disease largely biomechanically driven but it does have some components of inflammation that are thought to perhaps be secondary to the joint damage and not the driving force. And so while rheumatoid arthritis has a lot of different treatments available; currently for osteoarthritis, we really only have symptom relieving medications without any medications that can prevent the disease progression or prevent it’s onset.

And the mainstays of osteoarthritis treatment are physical activity and weightloss.

Host: And what about for rheumatoid? What types of treatments do you look to?

Dr. Neogi: So, we have a lot of different medications that are available that alter the immune system’s causing inflammation in the joints. And so, they vary from medications that are pills that are taken daily, pills that are taken weekly, injections and even intravenous infusions. And so all of them affect the immune system in one way or another to try to reduce the inflammation that’s damaging the joints.

Host: That was a great explanation. So, tell us how you’ve been engaged in developing new classification criteria for a number of rheumatic diseases.

Dr. Neogi: So, in addition to seeing patients and teaching our junior colleagues about rheumatology; I spend a lot of my time also doing research. My research varies from focusing on understanding why certain diseases occur, what are the risk factors for those diseases, what are the consequences of those diseases and how should we treat those diseases and what are some new treatments.

So, one of the issues with studying rheumatic diseases is that we need to know how to define them to study them. And so, classification criteria are a means of identifying the key common features that are present in most people with a given condition so that we can enroll them into studies to test treatments et cetera. So, I was involved in leading the classification criteria for rheumatoid arthritis which has really revolutionized the way in which rheumatoid arthritis trials are done because we can now identify a much broader group of people at an earlier stage of disease to be included into clinical trials and as a result, people can access treatments for rheumatoid arthritis at earlier stages of disease.

And similarly, I lead the gout classification criteria where we updated how we can identify people with gout to be included in trials and those criteria are also being used in clinical trials presently. But I would say more importantly, one of the things that I’m most proud of is being involved in developing national treatment guidelines where we take all the medical literature, all of the scientific evidence about various treatments for diseases and put together treatment guidelines based on the medical evidence together with guidance by experts in the field.

And so, I’m currently leading the gout treatment guidelines for the American College of Rheumatology and I’m also on the team leading the osteoarthritis treatment guidelines for the American College of Rheumatology. And we hope that with these high quality evidence-based treatment recommendations, that we can improve the lives of people living with these diseases.

Host: What an exciting time to be in your field Dr. Neogi. So, when would a person see a rheumatologist? How would they know? Are there some early signs and symptoms that would tell somebody you know maybe you should go see a rheumatologist and get this checked out?

Dr. Neogi: That’s a great question. Oftentimes when people have pain, they are not sure what it’s due to and I think it’s very reasonable for an individual to see if the pain will go away. When the pain persists, the first stop is to see the primary care physician. Because there are a lot of things that could be contributing to pain that is not necessarily a rheumatologic problem.

But with the evaluation of a primary care physician, where certain joints are affected, and the pain is persistent; that is usually a good indication that a rheumatologist could be useful in evaluating those symptoms. When someone has a lot of stiffness in their joints in the morning, where it takes them more than half an hour to really feel that they can move their fingers and toes and get moving or they need a hot shower to really get moving; that is often an indication of inflammation in the joints that would merit evaluation by a rheumatologist.

If they have obvious joint swelling, that would indicate a need for evaluation and again, sometimes it might be that they just twisted their ankle or twisted their knee while they were jogging and it might be nothing more than a mechanical issue; but if there’s something persisting, something out of the ordinary; then that should also be considered for a referral to a rheumatologist.

Another area that’s quite difficult for primary care physicians is differentiating mechanical low back pain from inflammatory back pain such as might be seen in ankylosing spondylitis. And so, again in that case, most of the time, mechanical low back pain does not need to see a rheumatologist. The first line approach is going to physical therapy. But in instances where a primary care physician isn’t quite sure if there might be an inflammatory component, that might be another instance where a rheumatologist can be seen.

Frankly, there are so many variations in how people can present with a rheumatologic disease that we are looked upon sometimes as a detective when someone can’t figure out what’s going on with a patient. Sometimes it might be muscle weakness. Sometimes it might be a rash. Sometimes it might be inflammation in the lungs, and they are trying to piece it together. And so, I think we really have a challenge in giving a sort of one size fits all answer to the question of when should someone see a rheumatologist. But the most common issues are related to joint related symptoms.

Host: Wow. That gives us a good understanding. Dr. Neogi, as we wrap up, your best advice for what you would like people to know that might suffer from lupus, or rheumatoid arthritis or any of these diseases you’ve mentioned today and when they should see a rheumatologist, what you’d like them to know.

Dr. Neogi: So, I think with a diagnosis such as lupus or rheumatoid arthritis, it’s really important to establish care with a rheumatologist because these diseases do require careful monitoring of treatments and titration of treatments. Sometimes we have to switch medications and so this is something that needs to be done in partnership with a rheumatologist. And while some patients might live far away from a rheumatologist, checking in with a rheumatologist to get overall management plans and then having close follow up with the local providers would be appropriate and the safest course of action.

When people have a disease like lupus or rheumatoid arthritis or osteoarthritis; some of the basics of what needs to be done include having a healthy lifestyle. Eating healthy, maintaining a healthy weight, being physically active. Having one of these diseases, one of these rheumatic diseases does not mean that you can’t exercise. And in fact, exercising and keeping a healthy weight is good for all of these diseases.

And then really, making sure you understand the medications the rheumatologist is prescribing, how to take it, when to take it, being sure to take it on a regular basis as prescribed and getting the blood tests done on a regular basis because these medications while they help to keep the disease under control; they are not without potential side effects. And the rheumatologist can only help keep the patient safe on these medications by ensuring that we have an opportunity to review the blood tests and make sure that they are on the right dose and a safe dose.

Host: Great information Doctor. Thank you so much for joining us today, for sharing your expertise as the new Chief of Rheumatology at Boston Medical Center. Thank you again.

And that wraps ups this episode of Boston MedTalks with Boston Medical Center. Head on over to our website at www.bmc.org for more information and to get connected with one of our providers. If you found this podcast as cool as I did, please share with your friends and family, share on your social media and be sure to check out all the other interesting podcasts in our library. Until next time, I’m Melanie Cole.