Co-Management

There are many autoimmune conditions which affect specific organ systems that other specialists often request consultation for co-management with the rheumatologist. This is typically for confirmation of a suspected diagnosis, request for specific treatment such as infusion, or management of musculoskeletal manifestations secondary to the primary disease. Alongside your other specialists, common co-managed autoimmune conditions are:

This is a common chronic condition which whereby skin cells multiply too fast causing cells to accumulate and form grayish or reddish scales and itchy, dry plaques and patches that come and go. Triggers for these plaques are stress, infections, and cold temperatures. The rash can occur anywhere on the body but is commonly found on the elbows, knees, scalp and hairline. Treatment aims to heal the plaques and stop skin cells from growing so quickly. Your dermatologist will treat with topical ointments and creams, light therapy, and certain oral medications, but if the psoriasis remains uncontrolled, consultation with the rheumatologist may be recommended to consider stronger oral medications, injections or infusions. If there is suspicion of also having psoriatic arthritis, that also warrants a referral to the rheumatologist.

Cutaneous lupus refers to skin rashes associated with lupus. There are many different forms such as the classic “butterfly rash” of acute cutaneous lupus on the face, discoid lupus which appears as coin shaped lesions, and lupus panniculitis where the subcutaneous fat can become inflamed. Lupus rashes photosensitive, which means they get worse with sun exposure. Cutaneous lupus can co-exist with systemic lupus or exist by itself. Initial treatment includes avoidance of sun exposure, avoiding stress, topical treatments, and injections of steroid under the skin. Your dermatologist will request consultation with the rheumatologist if systemic lupus is suspected, or additional treatment is needed for severe cutaneous lupus with oral medications or infusion.

When lupus causes inflammation of the kidneys, it is called lupus nephritis. It can present as the only manifestation of systemic lupus, or it can co-exist with lupus symptoms affecting other body parts. It requires a kidney biopsy to confirm the diagnosis and also classify what stage it is in. Left untreated, it can lead to kidney failure requiring dialysis. Mild stages are managed by your nephrologist with watchful waiting and blood pressure control. More severe stages require oral medications. If lupus nephritis remains uncontrolled the nephrologist will initiate stronger oral medications or infusion and frequently request input in conjunction with the rheumatologist.

Uveitis refers to inflammation of the middle layer of the eyeball. This can be due to infectious organisms which would be treated with antibiotics by your ophthalmologist. When it is not due to an infection, it could either be secondary to an underlying rheumatologic condition such as spondyloarthropathy or rheumatoid arthritis or others, or idiopathic meaning no clear underlying cause identified. The ophthalmologist will request consultation with the rheumatologist to help clarify if there might be an underlying cause. Uveitis can affect one or both of the eyes, and can come and go, but can become continues and chronic. If left untreated, uveitis can lead to blindness. If it remains uncontrolled despite local eyedrop treatments, your ophthalmologist will request consultation with the rheumatologist for oral medications, injections or infusion.

Interstitial lung disease (ILD) refers to when the lung tissue is inflamed, and if it progresses the inflammation will eventually turn into scar tissue that is stiff and damaged and oxygen does not pass through it very well. That end stage is called pulmonary fibrosis. ILD can be associated with an underlying rheumatologic condition such as rheumatoid arthritis, Sjogren’s syndrome, scleroderma, dermatomyositis, and mixed connective tissue disease. Your pulmonologist will treat breathing symptoms associated with ILD with steroids, inhalers, supplementary oxygen if needed, and use medications to prevent further progression of ILD into developing irreversible scar tissue. When an underlying rheumatologic condition is suspected, consultation with the rheumatologist is requested to confirm suspicion of the diagnosis.

Episodic or chronic inflammatory arthritis can be associated with Crohn’s Disease and Ulcerative Colitis, which are the most common types of inflammatory bowel disease (IBD). Sometimes the musculoskeletal manifestations can flare up even though the gut is in remission. Your gastroenterologist will request consultation from the rheumatologist if it is suspected to assist in getting symptoms under control. This may require adding an oral or injectable medication, or deciding to change the main IBD treatment in conjunction with your gastroenterologist.

Antiphospholipid Syndrome (APLS) is characterized by the presence of abnormal proteins in the bloodstream called antiphospholipid antibodies. These antibodies can make the blood more prone to clotting in veins and arteries. This can manifest as deep vein thrombosis or clots found in the deep veins of the extremities, pulmonary embolism or a sudden big clot blocking a major lung artery, stroke due to clots in the brain circulation, or recurrent pregnancy losses due to clots in the placenta’s circulation. APLS can occur by itself (primary APLS) or be caused by another underlying condition (secondary APLS), commonly associated with systemic lupus. This more commonly affects women more than men. Some people can have APLS antibodies present in their bloodstream transiently due to other sources of inflammation, and then they go away. Other people can have APLS antibodies present in their bloodstream but not have any manifestations of clots as described. The amount of risk of clotting and the decision to treat with blood thinners and consequent risk of bleeding is a careful decision weighed by your hematologist. When APLS antibodies are found, commonly by your OB/GYN or hematologist, consultation with the rheumatologist is requested to evaluate for the possibility of systemic lupus or other rheumatologic condition.

A form of small vessel vasculitis, this disease typically presents with a red painful, burning rash starting on the lower extremities, that spreads upward. Small pinpoint rash is called “petechiae” and when they coalesce into big patches of rash that is called “palpable purpura.” Leukocytoclastic vasculitis can be an adverse reaction to medications, due to infections or herald a malignancy, occur idiopathically, or be secondary to a systemic vasculitis or other rheumatologic condition. This is usually biopsied by the dermatologist to confirm the diagnosis. Treatment involves discontinuation of a drug if it is deemed to have caused the rash, or treatment the underlying cause if found. If the rash doesn’t go away on its own or respond to courses of steroids, and if workup of an underlying rheumatologic cause is needed, your dermatologist will request referral for further evaluation and treatment with oral medications, injections or infusion.