June 15, 2015 • By
Although close collaboration with a variety of specialists outside of rheumatology is important, you could make the case for rheumatologists and pulmonologists having to work together even more closely. If lung symptoms are severe and not under control,
However, the question sometimes is when to refer—even when there are not any evident lung symptoms and the patient’s rheumatic disease is well controlled with therapy.
Rheumatologists and pulmonologists have a great deal of clinical crossover for conditions like interstitial lung disease, pulmonary arterial hypertension in scleroderma and vasculitides (see sidebar, below).
In some circumstances, the rheumatologist receives a referral from the pulmonologist. “When lung symptoms with lung radiographic findings are the presenting symptom, patients usually see the pulmonologist first,” says Petros Efthimiou, MD, FACR, associate chief of rheumatology, New York Methodist Hospital, and associate professor of clinical medicine and rheumatology, Weill Medical College of Cornell University, N.Y. “If it is more subtle or chronic, then it may be the rheumatologist who determines that the lungs are involved and refer to the pulmonologist for evaluation.”
For example, patients may mention feeling shortness of breath when climbing stairs, and that could lead to a pulmonologist referral, says rheumatologist Stanley Cohen, MD, Irving, Texas.
Stuart D. Kaplan, MD, chief of rheumatology at South Nassau Communities Hospital in Oceanside, N.Y., refers patients to a pulmonologist when they experience shortness of breath or if he suspects lung involvement, even if there are no obvious symptoms.
Although there are varying accounts regarding how often lung disease is present in patients with such conditions as rheumatoid arthritis (RA), the key point is that lung involvement can be serious. “On CT scans or tests, two-thirds of patients may have some lung involvement, and 10–20% may have lung disease that is symptomatic. That’s a small percent, but it’s debilitating,” Dr. Cohen says.
When pulmonologists evaluate patients with an underlying rheumatic disease for lung involvement, they typically perform a pulmonary function test and a chest X-ray. The use of a high-resolution CT scan provides more definitive information regarding lung involvement, says pulmonologist Gregory P. Cosgrove, MD, chief medical officer, Pulmonary Fibrosis Foundation, and associate professor of medicine, National Jewish Health and University of Colorado–Denver. “In specific instances, a surgical lung biopsy can be utilized to better understand how the lung is affected,” he says.
The Big Question
Specialists from both sides of the diagnostic and treatment fence would like to have a better understanding of the significance of lung abnormalities, says Dr. Cosgrove.
“Many patients may have abnormalities on a CT scan, but may not develop symptoms and/or significant impairment,” he says. “We don’t want to overscreen individuals, but we do want to identify those with progressive disease early to intervene in diseases, such as [RA], scleroderma or polymyositis, to institute the appropriate care and identify the therapies.” Lung symptoms are particularly crucial to evaluate because they can contribute to earlier mortality, he says.
One challenge is that lungs are not well studied in rheumatic conditions, says Aryeh Fischer, MD, chief, Division of Rheumatology, co-director, the Autoimmune Lung Center, and associate professor of medicine, National Jewish Health and University of Colorado–Denver. This is despite numerous trials related to conditions, such as RA. “We need to get more organized to study this across both specialties,” he says.
The questions regarding the effects of lung disease in RA and related conditions have only emerged in the past 10 to 15 years because treatment for RA was previously so difficult, Dr. Cosgrove says. “One of the advantages with new medications for arthritis is that patients are doing well and staying active, but then they can still have lung problems. That’s something we have to address.”
The situation can be complicated by the possible presence of coronary disease, in which specialists must tease out the presence of lung or heart conditions—or both.
The situation is also complicated by the lack of studies to define effective therapies in lung disease with an underlying rheumatic disease, Dr. Cosgrove says.
One day, it would be helpful to have an algorithm that calls for a pulmonary evaluation if a patient has had RA for a certain number of years—even if they don’t have lung symptoms—and they have a certain serological marker on a blood test, Dr. Cosgrove says. However, he realizes there is a need to avoid causing anxiety among patients by ordering screens that may not be necessary.
Patients should be referred to pulmonologists for any chronic lung-related symptoms—anything that is beyond a standard cold, Dr. Cosgrove says. “The harder question is when to look for potential problems that may be under the radar if patients don’t have symptoms and are well controlled on therapy,” he says.
One way that rheumatologists and pulmonologists can work together more closely to catch serious disease is by working under an organizational system that encourages cross-collaboration, says Dr. Fischer, who often collaborates with Dr. Cosgrove. “We try to break down interdisciplinary divisions at our institution. We’re not siloed. Sometimes, our patients don’t remember who is the rheumatologist and who is the pulmonologist,” he says.
Dr. Kaplan would like pulmonologists to keep systemic conditions in mind as they evaluate patients. “When they see problems such as interstitial lung disease or other inflammatory conditions of the lung, they may be part of the larger picture of an underlying connective tissue disease. They may want to send the patient to a rheumatologist for an evaluation,” he says.
Conversely, agents prescribed typically by rheumatologists can assist with blocking lung disease at times, Dr. Efthimiou says. “Often, systemic immunotherapy, expertly administered by experienced rheumatologists, may halt or reverse the lung pathologic process and lead to better outcomes in affected patients,” he says.