VUMC Leading in Research, Patient Advocacy
More than 24 million Americans suffer from autoimmune diseases: a collection of 80-plus diagnoses, most with no cure.
Kevin Byram, MD, assistant professor of Medicine in the Division of Rheumatology & Immunology at Vanderbilt University Medical Center (VUMC), said that as autoimmune diseases become more prevalent, it's more important than ever for providers to collaborate with specialists and listen closely to patient concerns. "We see all types of patients, but autoimmune diseases are most common in young women, which makes them different from any other chronic disease," Byram noted. "That said, autoimmune diseases know no bounds."
Many autoimmune disorders are difficult to diagnose with few offering a single test to confirm a specific condition. Byram added most patients referred to VUMC report joint pain and fatigue - symptoms that can suggest a myriad of diagnoses including osteoarthritis, gout, lupus and vasculitis.
Understanding the Immune System
"Sometimes our immune system, which fights everything from viruses to cancer, can get a mind of its own, become overactive and attack when and what it's not supposed to," Byram explained. "Rheumatoid arthritis attacks joints, while lupus attacks the heart, lung, skin and kidneys. The medications we use to treat these diseases also come with a risk because they calm down the good part of the system."
Researchers believe interplay of environment and genetics could induce autoimmunity. "It's still very early on, and we're trying to better define the effect of the environment on genetics," he said.
COVID-19 & Autoimmune Disease
Meeting the needs of patients through the COVID-19 pandemic has presented an unprecedented challenge for providers. That's because immunosuppressive medications put patients at greater risk of infection.
Kevin Byram, MD
"I have a lot of messages coming in through the patient portal from patients asking if they need to continue their meds, or stop them to protect themselves," Byram said. "Most are continuing theirs meds because the risk of a flare-up could affect their immune system, as well, putting them at additional risk of infections. But we do have some scenarios with milder diseases where the risk of meds outweighs the short-term risk of infection."
Providers also are encouraging stable patients to delay office visits to decrease risk of exposure on campus. They're also ramping up telehealth efforts to keep immunocompromised patients home.
Byram specializes in the treatment of vasculitis, or inflammation of blood vessels. In fact, he recently participated in the American College of Rheumatology's effort in developing new guidelines for diagnosis and treatment of vasculitis, to be released this year.
"These are rare diseases and can take a long time to diagnose, since blood vessels are in every organ of the body," Byram said, noting an improvement in both awareness and diagnosis in recent years. "Patients do sustain a lot of damage from the diseases, so we work to save lives, improve quality of life and decrease toxicity from medications."
VUMC is currently enrolling patients in multiple autoimmune trials. One drug repurposing trial called ClearMEMory, led by Leslie Crofford, MD, evaluates a common Alzheimer's medication for lupus "brain fog." VUMC physician-scientist April Barnado, MD, MSCI, recently collaborated with Duke University researchers to publish a paper on pregnancy outcomes in lupus. That's because young women with autoimmune conditions like lupus are more likely to suffer from miscarriage, preeclampsia and preterm birth - complications attributed to both the disease and treatment.
"Lupus patients tend to have worse pregnancies, and historically we, as providers, haven't done a great job at counseling them," Byram said. "We're learning better approaches."
In efforts to minimize pregnancy risks, the ACR recently published new guidelines for approaching pregnancy in rheumatic disease. Additional VUMC studies led by Michael Stein, MBChB, and Michelle Ormseth, MD, MSCI, are underway examining drug side effects and new ways to mitigate cardiovascular effects of treatment. "We look at diseases like diabetes as a risk factor for heart disease, but rheumatoid arthritis is also recognized as a risk and isn't captured in our usual means of risk assessment for younger patients," Byram said. "Normal young women have a low risk of heart blockage, but for women with lupus or RA that risk has to be considered highly by their primary care provider."
Challenges of Diagnosis
Rheumatology testing often requires expertise in interpretation, and Byram encourages providers to consult specialists before delivering a diagnosis. "If a test comes back abnormal, we ask providers to refrain from telling the patient they have lupus or RA, because it's the whole picture that's important," he said. "Labs are a small piece of the picture, and there are better ways to phrase results. We really need a greater degree of certainty, because there's a very gray area in rheumatology and that really frustrates patients."
Byram pointed out a simpler explanation like, "Your lab work raises some concerns, and we need a rheumatologist to help us sort that out," can help deflect anxiety. "When patients have that explanation, it's easier for them to approach us, but when they come in saying, 'I was diagnosed with this,' it creates a frustrating situation where they might get mixed messages," he continued, adding diseases could take months or years to fully develop, and diagnosis often requires ongoing evaluation.
Conditions like fibromyalgia, which can occur in 40 percent of patients with autoimmune disorders, also complicate a diagnosis. That's because fibromyalgia is not inflammatory in nature and requires a different approach to successfully treat. "Fibromyalgia syndrome doesn't respond to immunosuppression drugs, so we focus on optimization of exercise, mood, diet and sleep. It's a different mindset, because we're recommending things that are seemingly simple but we know are hard to actually do," Byram said.
He also cautioned against attributing every symptom to autoimmune disease. "Boil down the symptom and take it seriously," he said. "While it could be related to autoimmunity, other things need to be considered ... from heart disease to sleep apnea and lung disease. Common things also happen in these patients."
Byram also advocates for physical activity to improve pain, mood, sleep and energy in patients with autoimmune disease. He noted low and moderate exercise improves immune function and offsets effects of steroids, which can affect weight, mood and sleep.
"Exercise also improves overall heart health, so from that standpoint we're doing what we can to improve cardiac function," Byram said. "There is sometimes reticence in patients with joint pain, thinking that exercise will damage joints, but we know that's not true if done safely. It's more of a 'use-it-or-lose-it' scenario."