If she learned nothing else at her first Society of Hospital Medicine annual meeting in Las Vegas in March 2014, Chika Madike, MD, learned about what she called “subtle signs” of infection among her inpatients on biologic medications.
“Inpatients on biologics may not have a roaring fever, [may] not have a white [blood cell] count of 15,000 or be complaining that they are not feeling like themselves. You can easily miss that [infection],” said Dr. Madike, a hospitalist at Saint Joseph’s Hospital in Tucson, Ariz., and one of some 400 attendees at a session called, Update in Rheumatology. “The next thing you know, the patient could be in septic shock,” she added.
Just six months on the job, Dr. Madike said she rarely sees patients with rheumatic disease and has yet to see any patient experiencing a gout flare-up. But she attended the course, presented by rheumatologist Brian Mandell, MD, to “see if anything had changed” and brush up on the latest evidence-based treatments, she said. “It’s different from the chest pain and pneumonias you see every day,” she noted.
Dr. Mandell, chair of medicine and senior staff physician in rheumatology and immunologic diseases at the Cleveland Clinic, reviewed the latest literature and provided treatment recommendations in a rapid-fire lecture during the session.
“If it’s elective surgery and you have the opportunity to hold the biologics in advance, for most patients, that is the most conservative approach to take,” Dr. Mandell said. “The data aren’t hard and fast, but that is reasonable practice. Think about holding at least one dosing interval.”
“The major take-home point, though: For patients who are on biologics and get admitted to the hospital for something, in those cases, hospitalists need to be very vigilant when a patient has general malaise, low-grade fever or nothing is really focal,” he added. “When patients are on biologics, physicians have to have a much higher suspicion for a deep-seated infection.”
Dr. Mandell also zeroed in on preoperative care of gout patients, encouraging hospitalists to think twice before stopping medications and to focus on managing the patients’ co-morbidities. “That’s what it’s all about,” he said. “For a hospitalist, manage the co-morbidities … and the drugs [because] they mix with the comorbidities.” (posted 6/6/14)
Richard Quinn is a freelance writer in New Jersey.