'Interdisciplinary approach is key' to treating pulmonary complications in rheumatic disease
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Understanding the breadth of pulmonary complications among patients with rheumatic disease is critical to total patient care, according to a presenter at the 2020 Interdisciplinary Autoimmune Summit.
“There are many different manifestations and each one of them could have its own differential and difference in presentation,” Jeffrey A. Sparks, MD, MMSc, assistant professor of medicine in the division of rheumatology, inflammation and immunity at Brigham and Women’s Hospital Harvard Medical School, said in his presentation.
While patients with these conditions generally present with cough or chest pain, there is a broad array of characteristics that could predispose them to lung complications. Deconditioning or obesity may be involved, along with gastroesophageal reflux disease (GERD). “[GERD] can actually cause a chemical pneumonitis and be similar to interstitial lung disease,” Sparks said. “It can be particularly prevalent in our patients.”
Infections may also cause lung disease in individuals with rheumatic disease, and Sparks warned that smoking or inhalant-related comorbidities are frequent.
Digging deeper, silicosis or berylliosis can look like granulomatous lesions in the rheumatology patient population.
More conventional airway complications such as asthma or chronic obstructive pulmonary disorder (COPD) may present, and Sparks added that malignancies have also been associated with lung complications.
While other complications such as idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, clinically insignificant radiologic abnormality, venous thromboembolism, respiratory muscle weakness, heart failure or coronary artery disease may not necessarily be associated with underlying rheumatic conditions, rheumatologists should nonetheless be on the lookout for them. “Certainly, you should think about having a wide differential diagnosis,” he said.
A companion issue that Sparks said clinicians should consider is that in addition to the heterogeneity of type, pulmonary complications can also be marked by heterogeneous severity. “These patients really need screening and close monitoring,” he said.
Once a pulmonary diagnosis has been made, Sparks warned that the choice of rheumatologic disease therapy is as critical to mitigating severity and impact. But even treatment can come with challenges, Sparks said. Heterogeneity of both efficacy and safety have been reported for treatments ranging from glucocorticoids and azathioprine to methotrexate, mycophenolate mofetil and the broad range of biologics. “Some of these medications could be beneficial, but some could be detrimental,” Sparks said.
With this in mind, Sparks offered a method of reducing possible detrimental effects of treatment. “An interdisciplinary approach is key,” he said.
“These are complicated patients, so, hopefully, you have been convinced that this is important,” Sparks concluded.
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Sparks JA. Pulmonary Manifestations of Rheumatic Disease. Presented at: Interdisciplinary Autoimmune Summit; July 10-12, 2020 (virtual meeting).
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