Cutting-Edge Medicine, Kaleidoscopic Disease

By: Jennifer Webster
Tuesday, September 3, 2013

Treating systemic lupus erythematosus is like taking a stethoscope to a whirlwind. Yet that’s just what physicians at Montefiore Medical Center Division of Rheumatology do every day.

A complex autoimmune disease, lupus can strike many organs and systems — including the joints, skin, heart, lungs, kidneys and brain — at once. The understanding of its molecular level is still obscure, and its real-world impact on patients’ lives is significant. Montefiore rheumatologists are experts in myriad fields, able to work with patients to best manage lupus symptoms and ease the disease’s progression.

Regular follow-up for lupus patients is a must, says Irene Blanco, MD, MS, rheumatologist at Montefiore and Assistant Professor at Albert Einstein College of Medicine.

“Patients typically need follow-up with a primary care physician or rheumatologist every three months, even when they are doing well,” Dr. Blanco says. “We collaborate with nephrologists and other professionals for screenings and specialist care.”

Regular care becomes especially important in the area of secondary disease. The inflammation caused by lupus, as well as medications used to treat the condition, accelerate conditions normally associated with aging, particularly cardiovascular disease.

“Patients are at risk for accelerated atherosclerosis both from lupus and from steroids prescribed to treat lupus,” Dr. Blanco says. “You don’t typically think of patients in their 30s having heart attacks, but it’s possible for a 30-year-old lupus patient to suffer a massive myocardial infarction.”

Patients with active lupus should be screened for cardiovascular disease as early as in their 20s, she adds.

Taking steroids over a long period of time also predisposes patients to developing osteoporosis, making bone density another concern for lupus patients and their providers, Dr. Blanco says.

“Providers should educate patients about bone health and the importance of calcium and vitamin D,” she says. “Any patient who has been taking steroids for more than six months should get a bone density test.”

Dr. Blanco also emphasizes that patients must learn to manage their conditions. For instance, skin care — including wearing sunblock of at least SPF 30, even for dark-skinned patients — is important.

Lupus Nephritis: A Case for Research and Collaboration

About 60 percent of people who have lupus will eventually develop lupus nephritis — inflammation of the kidneys. Of those, 10 to 30 percent will go on to experience renal failure and require dialysis or kidney transplantation.

Physician-scientists at Montefiore and Jacobi Medical Center work together on the complex task of predicting the onset of lupus nephritis before it occurs. Related research involves testing medications for efficacy in fighting the disease.

“We participate in Biogen’s TNF-like weak inducer of apoptosis [TWEAK] study, which examines a biomarker that may be elevated in the kidneys and urine of people with lupus nephritis,” Dr. Blanco says. “We are working with collaborators to see whether blocking TWEAK prevents renal fibrosis.”

Treating the Patient: Information Technology and Enduring Relationships

“A colleague once referred to lupus as a kaleidoscopic disease,” Dr. Blanco says. “It can take so many forms and strike in so many places; it’s a hard disease to manage.”

To that end, physicians at Montefiore rely on workflow technology combined with long-standing physician-patient relationships. Both help them map patients’ disease processes in the context of their individual lives.

“Within our electronic health record, we keep a flow sheet on each patient,” Dr. Blanco says. “That way, we can make sure we address every aspect of care. This includes considering each patient’s life circumstances and not unnecessarily overburdening them.”

Dr. Blanco uses the example of scheduling patients for regular health appointments and screenings for times when patients are known to experience less disease activity.

“At the same time, however, this is a chronic disease,” she says. “Our patients who have lupus are frequently very ill. They may have to deal with a lupus diagnosis, obtaining Medicaid and applying for SSI [Supplemental Security Income] all at the same time. We tell them that if they can ride this wave with us, things will eventually settle down. We treat the disease aggressively in the beginning so patients can return to living the lives they had before.”

To learn more, please visit