Hospitalists Can Get Help for Rheumatology Cases

Larry Beresford

October 26, 2022

SAN FRANCISCO — Few of the hospitalists attending a presentation by rheumatologist Sarah Goglin, MD, at the 26th annual Management of the Hospitalized Patient conference in San Francisco said they can get easy access to rheumatologist consultations when needed for their hospitalized patients.

Dr Sarah Goglin

Goglin, associate program director of the Rheumatology Fellowship and Internal Medicine Residency at the University of California San Francisco (UCSF), said the documented shortage of rheumatologists nationwide is worsening. Those with active outpatient practices are very busy and reluctant to take the time away from their practice to visit the hospital in person. "It's a challenging place for hospitalists to be. I don't envy them," she said in a follow-up interview to her presentation, "Interesting Cases in Hospital Rheumatology."

Rheumatologic diseases, broadly defined, are uncommon and unlikely to be seen by hospitalists on a routine basis. It definitely happens, she said, but not often enough for them to feel confident in their knowledge base to take care of these patients. They don't have someone to ask when they're not feeling confident. And lack of confidence can lead to over-testing.

But hospitalists may be able to call the rheumatologic specialist on call at the closest academic medical center. "That's why we're here. We are happy to talk about these cases with you," Goglin said. The rheumatological consult service at UCSF is busy caring for very complicated patients, some transferred from other hospitals. There is a rheumatologist on the floor every day and fellows who share call after hours.

"We can try to provide some guidance, even though it's a balancing act when you're not looking at the data yourself, firsthand. So, we can't make specific care recommendations, but we can help get a general sense of the case."

She also recommended that hospitalists take the time to communicate with a hospitalized patient's outpatient rheumatologist. "It can be extremely helpful in terms of understanding what to do about the patient's rheumatologic medications." Patients, too, can also be savvy about their medications and when these might need to be stopped during a hospitalization so that the hospitalist can treat their infections or cardiac conditions.

Although rheumatic and autoimmune diseases are not common, there are a variety of them. "Definitely, you'll see gout and pseudogout (calcium pyrophosphate deposition, or CPPD). You don't need a rheumatologist to take care of patients with gout or CPPD." Goglin said the rheumatoid arthritis drug anakinra (Kineret), an antagonist of the cytokine interleukin-1 — a major contributor to gout inflammation — should be part of the hospitalist's toolkit for acute gout management. Although it is not Food and Drug Administration-approved for gout, it can be used off label in the hospital and is often used for this purpose at UCSF, she said.

Other Rheumatologic Conditions Seen by Hospitalists

Three other broad, common categories of rheumatologic conditions seen in the hospital are antinuclear antibody-positive connective tissue diseases, vasculitis, and inflammatory arthritis, which includes rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.

Lupus is a special concern in hospitalized patients, she said. While there are only about 250,000 Americans with systemic lupus erythematosus (SLE), it is a serious diagnosis with significant morbidity for patients, especially when a diagnosis is missed early on. Life-threatening complications include a variety of infections. "Half of patients with SLE experience severe infections, and these account for 25%-50% of its overall mortality," Goglin said.

In most cases, patients with rheumatologic conditions will be okay if their rheumatologic medications need to be held for a short period of time to allow them to recover from the infection. "It's important to fully treat serious infections and to thoroughly consider and evaluate for infections in patients with rheumatologic diseases," she said. When the patient is immunologically suppressed, infections may present differently, and there may be unusual infections. "You just have to have a high level of suspicion for infections in our patients."

More often, the rheumatology patient comes into the hospital with a pre-existing condition and is already on a treatment regimen, so the hospitalist needs a general understanding of the major complications in the most common rheumatologic diseases. "With basic tests, you can quickly assess for morbidities like kidney disease." But for patients who come to the hospital with a suspected connective tissue disorder, a new rheumatic diagnosis involves another set of tests, starting with an antinuclear antibody test.

Goglin said she is working on a curriculum development project to create bite-sized, fun, interactive online modules on the key principles of rheumatology treatment, with the aim of broadly disseminating this kind of education. "These are geared for the internal medicine resident but will also be appropriate to hospitalists."

The project is still in its early stages, she told Medscape Medical News. "If somebody wants to give me more time to work on them, they will come more quickly."

Goglin has disclosed no relevant financial relationships.

Management of the Hospitalized Patient 2022: Interesting Cases in Hospital Rheumatology. Presented October 13, 2022.

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