Making Assessments in Clinic Settings
When systemic sclerosis patients with these identified risk factors and GI symptoms are evaluated in rheumatology clinics, doctors should consider earlier testing to evaluate for dysmotility, Dr. McMahan says. Such studies may more precisely guide therapy. Initial interventions are symptom focused and may include addressing acid reflux (such as with a wedge pillow at night, modifications in lifestyle and diet, and prescribing proton pump inhibitors or H2 receptor blockers) and treating constipation (through diet and lifestyle modifications and introducing over-the-counter medications). At this stage, opioids and other such drugs should be minimized because they have a negative impact on motility and an increased risk for GI complications.
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Explore This IssueMay 2019
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If patients are not responding to initial interventions, or if symptoms are more severe, the doctor should consider referral to a gastroenterologist, Dr. McMahan says. “The main point is to listen to your patients’ concerns. Pay attention to signs of early GI problems and try to treat them the best you can. And if the patient progresses more rapidly, consider earlier referral to the GI specialist for a workup—preferably one experienced with systemic sclerosis.”
When systemic sclerosis patients with identified risk factors & GI symptoms are evaluated in rheumatology clinics, doctors should consider earlier testing to evaluate for dysmotility.
Tracy M. Frech, MD, associate professor of internal medicine in the Division of Rheumatology, University of Utah, Salt Lake City, who has a research and clinical interest in systemic sclerosis, credits the Hopkins study for highlighting the challenges of GI disease in patients with systemic sclerosis. “We need to identify the systemic sclerosis patients at the highest risk for GI dysmotility, especially with regard to their clinical features,” she says.
“The article helps a clinician think more closely about how to treat a male scleroderma patient with myopathy. In this case, a questionnaire, such as the UCLA Scleroderma Clinical Trial Gastrointestinal Tract Instrument, Version 2.0, could be used to assess risk of severe GI involvement,” Dr. Frech notes.3 This 34-item questionnaire is available in multiple languages and can be used for online screening. “In our clinic, everyone with scleroderma fills out the questionnaire, so I can get a quick look at their gastrointestinal issues,” Dr. Frech says. Other questionnaires are available, as well.
The Bottom Line
“I think the key take-home message for rheumatologists is the importance of asking these GI questions. It can be hard in our day-to-day practice because we’re so focused on musculoskeletal concerns,” Dr. Frech says. “And when it comes to a physical exam, the abdomen is a bit of a black box. However, this new research supports the rheumatologist in asking routinely about GI issues and doing a better job of distinguishing between mild and moderate to severe complaints. It highlights that as rheumatologists we can do better.
“The important thing is to ask the questions,” Dr. Frech continues. “I just gave a talk in Boise, Idaho, at the Scleroderma Foundation Chapter, trying to make patients more aware of gastrointestinal issues and the information that is available online. If they are having worsening GI symptoms, I encourage them to talk to their doctor.”