Rheumatology and Primary Care: What is the 95% Confidence Interval of Scope of Practice?
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We as rheumatologists are blessed with a surfeit of remarkable therapies and capabilities for controlling disease that we only dreamed about a short generation ago. With these capabilities have come new responsibilities that have — in some ways — stretched our scope of practice. Allow me to discuss just a few examples.
Calabrese
Consider the pre-biologic era: With the exception of the rare patient on alkylators or high-dose steroids, the specter of opportunistic infections among our patients was remarkably low. For that matter, aside from glucocorticoid exposure (which was, unfortunately, formidable), patients with rheumatoid arthritis had little other risk for serious and/or opportunistic infections.
Over the past 20 years, we have become experts on tuberculosis prevention and recognition in patients on biologics. We have also had to learn the clinical biology of hepatitis B and C, as these infections pose formidable comorbidities in our patients on targeted therapies. Thus, the rheumatologist as a fledgling infectious disease practitioner is now a reality, which served as the rationale for the development of the first combined rheumatology-infectious disease fellowship in the country at Cleveland Clinic.
What about cardiovascular disease? A generation ago, we were just starting to learn — thanks to many fine investigators including Ted Pincus, MD, and others — that RA was a formidable risk factor for cardiovascular disease. At that time, the tool box for primary prevention was nearly empty; but now, not only do we have a bevy of lipid-lowering drugs, but we are also reducing CVD risk with effective anti-inflammatory therapy.
The question of the moment, however, is what exactly is our real role in CVD prevention? Do we merely identify patients at greater risk and refer them for primary prevention to their PCPs or cardiology? Or, alternatively, do we take a role in both prescribing lipid-lowering therapy and behavioral modification for those at palpably increased CVD risk? Regardless of which path we take, how good are we about appraising CVD risk in our patients?
Most studies which have assessed rheumatology performance in CVD prevention have been sobering with little evidence that we as a profession are doing a great job. Finally, we must also recognize that several of our targeted therapies (IL-6 and JAK inhibitors) explicitly inform us through the package labeling to monitor lipids, thus we each must have a plan.
The current issue of Healio Rheumatology features a roundtable on yet another internal medicine-related role for the rheumatologist, namely our role in vaccine practice. Our expert panel illuminates how we can overcome obstacles to ensure our patients are vaccinated against preventable infections. I was privileged to have given a major session at ACR 2019 to an overflow audience of more than 2,000 rheumatologists who were highly activated and engaged on this topic so there is little doubt regarding our interest.
In 2013, the Infectious Disease Society of America published a white paper entitled “Vaccination of the Immunocompromised Host” and their number one recommendation was “Specialists who care for immunocompromised patients share responsibility with the primary care provider for ensuring that appropriate vaccinations are administered to immunocompromised patients (strong).”
I agree with this and say the implications are clear: Rheumatologists need to get on board in the effort to protect our vulnerable patients, those around them and our society.
Let me close by asking what is the 95% confidence interval of internal medicine practice for those of us practicing rheumatology? Give me your take through Twitter at @LCalabreseDO or email me at calabrl@ccf.org.
- For more information:
- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
Disclosures: Calabrese reports consulting relationships with AbbVie, Centecor Biopharmaceutical, Crescendo Bioscience, GlaxoSmithKline, Horizon Pharma, Janssen Pharmaceuticals, Pfizer, Regeneron Pharmaceuticals and UCB.
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