In October 2023, Megan E.B. Clowse, MD, MPH, a renowned expert in the field of rheumatology and immunology, was named the new chief of the Division of Rheumatology and Immunology at Duke University School of Medicine, Durham, N.C. Dr. Clowse, who serves as an associate professor of medicine in Duke’s Division of Rheumatology and Immunology and the Department of Population Health Sciences, says the new appointment comes during a significant realignment within the health system.
“We’re working toward optimizing the Division of Rheumatology within this new framework,” she says. “In addition, we’re striving to build collaborations between our providers, advanced practice providers and researchers to expand the work we’re doing. We’re looking to build on the success of the Duke Lupus Clinic, where a team of doctors and researchers works closely to turn clinical experience and data into discovery. Many of our faculty want to build similar teams to breach the gap between clinic and research.”
Dr. Clowse says the division is also looking at increasing its educational offerings. “We already have an established fellowship program for advanced practice providers in rheumatology, which is unique, and we’re looking at ways to expand those offerings,” she says.
One of the ways Duke is addressing the rheumatology workforce shortage is by connecting with medical students earlier. “We have a lot of great educators on our faculty, which is allowing us to partner with medical students and residents very early in their training. We also have third-year medical students who spend a good quantity of time conducting research with us,” Dr. Clowse says. “We’re very involved in internship and residency rotations and have found that by interacting with students earlier, we’re increasing the number of medical students and residents who are interested in pursuing a career in rheumatology.”
Duke is also working to recruit more diverse rheumatology providers. In a program, funded in part by a Diversity, Equity and Inclusivity award from the Arthritis Foundation, Lisa Criscione-Schreiber, MD, MEd, professor of medicine and vice chair for education in the Department of Medicine at Duke University School of Medicine, is educating medical students and providers about inclusive practices in rheumatology, while also recruiting more students from under-represented groups in medicine.
Improving Pregnancy Outcomes
Over the past two decades, Dr. Clowse has established a reputation as an international expert in how rheumatic diseases affect pregnancy. She’s the founder and director of the Duke Autoimmunity in Pregnancy Clinic, and has created two websites, LupusPregnancy.org and ReproRheum.Duke.edu, to assist rheumatologists in providing care to pregnant women with rheumatic diseases.
Her most recent research focuses on how rheumatologists can help patients build the families they want as safely as possible.
“While we’ve known for a long time that patients with lupus have poorer pregnancy outcomes when their disease was active or they were taking dangerous medications, my work now focuses on how rheumatologists can help their patients turn this knowledge into a plan for a safe pregnancy,” she says. Without this approach, Dr. Clowse says a lot of patients begin their pregnancy without a plan from a rheumatology standpoint. Data show these pregnancies more often lead to pregnancy loss, preeclampsia, early deliveries, and sick babies and moms.
“We’re spending a lot of time working on ways to make pregnancy planning a regular part of rheumatology care,” Dr. Clowse says. “We’ve developed tools and educational programs to help providers feel comfortable discussing a pregnancy plan with their patients.”
Taking a proactive approach to pregnancy planning is critical, Dr. Clowse says, because many of the complications (e.g., pregnancy loss, preterm birth and preeclampsia) that occur in patients with lupus are avoidable. “We can cut the risk of poor outcomes in half if the patient conceives while her disease is well controlled or when she’s not taking medicines that cause major birth defects,” Dr. Clowse says. “If we can help patients plan for pregnancy long before they become pregnant, we see much better outcomes.”
A healthy pregnancy with lupus is possible without taking patients off all medicine, Dr. Clowse says. She recommends rheumatologists prescribe pregnancy-compatible medicines while their patients are trying to get pregnant, as well as after they’ve conceived. “There are a few medicines we can’t use safely in pregnancy, including methotrexate, mycophenolate and cyclophosphamide,” Dr. Clowse says. “Although there’s a risk–benefit ratio with all medications, the other drugs we prescribe, such as hydroxychloroquine, lead to better pregnancy outcomes.”
With funding from the Rheumatology Research Foundation, Dr. Clowse and her team at Duke are currently working with some private clinics, as well as academic clinics to build the question “Are you thinking about getting pregnant in the next year?” into appointments and to document current contraception choices so doctors can have accurate, timely conversations about pregnancy planning with their patients.
Along with her colleagues Jennifer Rogers, MD, David Pisetsky, MD, PhD, and Amanda Eudy, PhD, MSPH, Dr. Clowse has classified systemic lupus erythematosus (SLE) symptoms into two categories: type 1, which includes autoimmune inflammation of tissues (e.g., arthritis, cutaneous lupus, lupus nephritis) and type 2, which encompasses the features of systemic lupus erythematosus that are nearly ubiquitous but have unknown causes (e.g., brain fog, myalgia and fatigue).
“These classifications came about because of a disconnect between how patients felt physically and how we had been trained to measure lupus activity,” she says. “What we found is that patients talk about having a lot of fatigue and achiness and feeling poorly, but we couldn’t identify inflammation as the cause.
“It was this real conundrum that made us take a step back and decide to start measuring patient-reported outcomes and their reported disease activity,” she says. “This led us to devise a conceptual model with two domains of disease activity in lupus.1 Patients tend to describe type 2 as the worst part of lupus, so we started measuring both. We’ve seen some really interesting patterns,” she says.
“Some patients don’t appear to have a correlation between type 1 and 2 symptoms. A small group of patients can have very active lupus—particularly in their kidneys or with low blood counts—but don’t have the fatigue and achiness of type 2.” Dr. Clowse says these patients don’t feel their lupus.
More patients have persistent type 2 symptoms despite resolution of type 1 activity. “We are developing strategies to understand the origin of their ongoing symptoms,” she says.
“On the other hand, many patients report a correlation between their type 1 and 2 symptoms. In these patients, when their type 1 activity increases, they also experience fatigue and achiness; when the type 1 subsides, they feel significantly better. We suspect the type 2 symptoms in these patients may be driven by inflammation and respond to more aggressive immunosuppression,” she says.
Linda Childers is a health writer located in the San Francisco Bay Area.
- Eudy AM, Rogers JL, Corneli A, et al. Intermittent and persistent type 2 lupus: Patient perspectives on two distinct patterns of type 2 SLE symptoms. Lupus Sci Med. 2022 Aug;9(1):e000705.