What is a Rheumatologist?

Transcription:

Melanie Cole (Host): For millions of Americans with arthritis, the pain can affect every part of your everyday life, and if you've never seen a rheumatologist, this might be the time. My guest is Dr. Jonathan Krant; he's the Medical Director in the Department of Rheumatology at Memorial Health System. Dr. Krant, what is a rheumatologist, and how are they trained?

Dr. Jonathan Krant, MD, FACP (Guest): Rheumatologists are specialists in musculoskeletal medicine. We're trained in internal medicine typically, and then go on to fellowship training, often as the clinical fellowship which combines patient care with clinical research. And I was trained in internal medicine at Dartmouth and did my fellowship training at UC San Francisco back in the day. I took my boards back in the 1990's and have been, since that time, been caring for patients in a number of clinical settings. I also do clinical research, which means bringing forward new molecules for the treatment of arthritis.

Host: Tell us about what types of diseases fall within the rheumatology domain. You mentioned arthritis, but there are also metabolic bone disease, other autoimmune diseases; tell us about them.

Dr. Krant: So we care for a broad spectrum of disease ranging from adolescents and even children. The spectrum of disease that falls within our rubric is vast, so we see folks who have garden-variety osteoarthritis, wear and tear arthritis affecting the hands, wrists, elbows, shoulders, hips, and knees. In addition to inflammatory diseases, such as diseases of autoimmune and lupus, and rheumatoid arthritis, that's one of the more exotic diseases which people have heard about including such things as Wegener's granulomatosis and of course the nomenclature has changed over time. As we get more sophisticated, we have more specific names of scientific diagnoses. But for all of that, we also take care of metabolic bone disease, which is most frequently seen in the terms of osteoporosis with fracture as the consequence of untreated disease.

So we see children, adults, and advanced elderly with a range of diseases from garden-variety osteoarthritis, as mentioned, to rheumatoid disease, lupus, inflammatory muscle disease, in addition to metabolic syndromes, which can affect bone, muscle, and so forth.

Host: Tell us a little bit about autoimmune disease. People hear this now, and they hear Crohn's, and lupus, and rheumatoid arthritis, and what does it mean when you say, 'autoimmune disease'? And is this something that has a genetic hereditary component to it?

Dr. Krant: We often think of the quintessential autoimmune hereditary process as rheumatoid arthritis. RA is a disease which is characterized by the body targeting specific cell types resulting in organ damage. Often to an extent, lupus and certainly psoriatic arthritis, inflammatory back disease are genetically dictated. That is to say, if you have a disposition based upon specific gene loci, which are gene frequencies which make you at risk, perhaps some event - in the environment or some event having to do with diet - triggers these expressions. We don't quite yet know what those triggers are.

In the case or rheumatoid arthritis, RA keeps company with diabetes, with a skin disease called acanthosis nigricans, and autoimmune thyroid disease. So that if you have a specific genetic disposition to RA, and we know this because of twin studies that have looked at consanguineous twins within a family that has RA as a phenotype or the disease itself, the incidents of disease expression amongst genetically susceptible hosts is quite high.

Rheumatoid arthritis is a quintessential autoimmune disease, the body attacks itself, resulting in the cardinal signs of inflammation, tenderness, swelling, redness, pain, heat. These are Rubor, Calor , and Dolor, Tumor the Latin name that comes from our Greek ancestors who first characterized inflammation centuries ago.

Rheumatoid disease is the quintessential autoimmune paradigm. We go after it with drugs like Prednisone, disease modifiers like Methotrexate and hydroxychloroquine or Plaquenil. Then finally the biologics, and the biologics have evolved initially to treat rheumatoid arthritis, but now we're using biologic therapies in psoriatic arthritis, and

ankylosis spondylitis and inflammatory bowel. You mentioned IBD, Crohn's, and ulcerative colitis; these too are autoimmune diseases in the sense that we have undetected genetic susceptibility to - we don't know exactly what causes some folks to develop Crohn's versus ulcerative colitis - but it's relatively common and frequently associates with back and peripheral joint swelling, tenderness, warmth, and pain.

So we have a spectrum of diseases ranging from rheumatoid arthritis, lupus, psoriatic arthritis, inflammatory bowel, which are treated with biologic therapies, all of which are becoming more refined, more targeted, more specific as time goes along. So that's the broad overview. We certainly have very specific diagnostic criteria by which people are confined diagnoses of rheumatoid arthritis, lupus, inflammatory bowel. And we can talk about that if you'd like, but just understand that rheumatologists treat a broad spectrum of disease from osteoarthritis, autoimmune disease, metabolic bone, post-infectious complications. So we oftentimes see people who present with swollen tender joints after a simple upper respiratory infection. Tends to be self-limited. We don't treat them in the same way we treat somebody who's got classic autoimmune rheumatoid disease.

Host: You are quite an educator, Dr. Krant. Wow, you're amazing. So when somebody is suffering from- whether it's osteoarthritis, or lupus, rheumatoid arthritis, any number of these conditions, and the first person that would come to mind would be an orthopod. That's what they might think too. What would send someone to a rheumatology- you're giggling because you've heard this before, right?

Dr. Krant: I'm a patient myself, that's why I appreciate this. You know, those of us who damaged themselves playing basketball in college, or lacrosse in my case, certainly have bad knees as a consequence, and you'd never go to a rheumatologist alone if you needed a joint replacement. So for this very same reason, people who have fever, shaking chills, diffuse aches and pains associated with high sed rate or psoriatic protein, white count may be elevated, certainly there may be inflammatory muscle components with an elevation of muscle enzymes. You'd never see an orthopedist for that, you'd go to rheumatology.

So in some ways, the arbiter of who sees rheumatologists versus orthopedists is dictated by the primary care physician. The PCP, family practitioner, or internist looks at a patient and says, "You know, there's more to this than meets the eye. You don't have just plain old tender, swollen, painful knees. But in fact, oh my goodness, your joints are swollen, tender, and they involve the hands, wrists, maybe you have a nodule here and there, maybe you've got some muscle enzyme abnormalities, a high white blood cell count." Those things tend to be beyond the simple mechanical arthritis that's dealt with by orthopedics. But don't get me wrong, my esteem for my orthopedic colleagues is very high. I've had a knee replacement, I know what that's like. But for those of us who suffer from osteoarthritis, it's a very different entity than inflammatory arthritis, and the orthopedist would be the first to say, "We're not prescribing Methotrexate. We're not giving out glucocorticoid like Prednisone and Methylprednisolone. We're sending this person to rheumatology. They need somebody with a comprehensive look."

Host: Wow, what an amazing physician you are. I can hear the passion in your voice, Dr. Krant. So as we wrap up, really you're such a great educator, as we wrap up, what behavioral or lifestyle modifications- would you like to give your best advice to patients that might have autoimmune diseases? And they are rampant, and we didn't even get into the theory of why you might think autoimmune diseases are on the rise in the States today. But as you wrap up, give us your best advice, what you'd like us to know about lifestyle, the environment.

Dr. Krant: I love it. I love it. Listen, I'm working in the Ohio Valley now, it's a wonderful place. I was in the Adirondacks before this, and then the Berkshires of Western Mass before that. And I'll tell you that simply we don't know exactly in a genetic and susceptible individual what triggers will bring about autoimmunity. We suspect that there may be environmental hazards, toxins in the air and water, that in a genetically susceptible individual will trigger disease expression. We're not convinced, but we suspect it.

As regards to that, in RA, Bob Zurier University of Massachusetts was the first to point out that Omega-3 fatty acids - fish oils derived from salmon and others - are wonderful in RA. Maybe not so much in OA, but we see patients taking a variety of things by mouth to try and augment the benefits of anti-inflammatories, especially in the rheumatoid context.

In the osteoarthritis arena, we have folks who often are overweight, and that's a function of diet, education, food choice, culture. We can't address it every day, every second, but we certainly try, because if folks could lose 10% of their additional weight- you want to be your ideal body weight. The IBW is very important, so those calculations of bone marrow, density as regards osteo don't play a role, we're talking about IBW with very specific body mass index calculations. If you can achieve your ideal body weight, you're helping yourself a ton because for every pound above your IBW, you've got ten additional pounds of force pressed upon your knees, hips, ankles. People can lose weight, and it's not a bad idea. It helps your cardiovascular profile as well. Weight reduction, food choice, lifestyle. If you're playing basketball over the age of fifty, you're certainly at risk for knees because you're not limber. Knees, low back. Watch what you do, watch how you bend, watch how you manipulate objects, and watch how you use your body in the world. Rototory motion, bicycles, swimming in open water or in pools; marvelous. Hot water, showers. Watch out with non-steroidals because kidney impairment, especially diabetics. Don't be using over-the-counter Ibuprofen or Naprosyn if you can avoid it. Certainly be careful about your weight, your diet, your choice of anti-inflammatories, and you're taking yourself another step farther, even before you wind up seeing me.

Host: That is absolutely perfect, Dr. Krant. Thank you so much for coming on today and sharing your expertise about the field of rheumatology, what people can expect, what kinds of tools you have in your tool box to deal with these autoimmune diseases. Thank you again for joining us. You're listening to Memorial Health Radio with Memorial Health System. For more information, please visit www.MHSystem.org. That's www.MHSystem.org. This is Melanie Cole, thanks so much for tuning in.