A key takeaway from Dr. Muscal’s talk was the need for collaboration between rheumatologist and neurologists in caring for patients with inflammatory brain diseases, and understanding each other’s thought processes. For the neurologist, the MRI of the brain is a significant branch point in how they think about the most likely underlying condition. Myelin oligodendrocyte glycoprotein antibody disease and neuromyelitis optica may not immediately find their way onto the rheumatologist’s differential when evaluating patients, but neurologists commonly consider these conditions. Conversely, it may be up to the rheumatologist to do a thorough evaluation for SLE in a patient presenting with transverse myelitis given that this can be a manifestation of lupus-spectrum disorders. Dr. Muscal presented a particularly challenging case of encephalitis in a young woman that initially looked like it could be SLE, but was actually the result of N-methyl-D-aspartate (NMDA) receptor encephalitis, driving home the point that keeping an open diagnostic mind is essential when evaluating these types of patients.
Drug Management of Rheumatic Diseases
Dr. Chung
The third talk was given by Cecilia Chung, MD, MPH, professor of medicine and chief in the Division of Rheumatology of the Department of Medicine at University of Miami, Fla., who discussed pearls in drug management of rheumatic disease. Her talk was broken down into three sections with illustrative case examples. Pearl #1 was to employ the effects of drug pleiotropism to maximize the benefit provided by any single medication. This applies to losartan, which not only is an effective antihypertensive but also has uricosuric and promotes uricosuria. This is not a class effect among all angiotensin-receptor blockers (ARBs) and, in actuality, other ARBs may actually increase the risk for gout.11 Pleiotropism is also relevant to statins, which are used for hyperlipidemia but may also have anti-inflammatory properties relevant to patients with conditions like RA. In a seminal paper from Ridker et al. involving healthy persons without hyperlipidemia but with elevated high-sensitivity C-reactive protein (hsCRP) levels, rosuvastatin significantly reduced the incidence of major cardiovascular events as compared with placebo.12 Meta-analyses of randomized, controlled trials have been able to demonstrate that statins—atorvastatin in particular—can reduce DAS28 scores, CRP, erythrocyte sedimentation rate, tender and swollen joint counts, and circulating inflammatory cytokines in patients with RA, and this effect is most pronounced in patients with higher baseline disease activity.13 Dr. Chung also referred to work indicating that glucagon-like peptide-1 (GLP-1) receptor agonists may be able to improve pain in patients with osteoarthritis not only through helping these patients lose weight, but also through anti-inflammatory mechanisms that are still being explored.14
