Jason Kolfenbach, MD: Top Secrets in Rheumatology

Rheumatology Network sat down with Jason Kolfenbach, MD, to discuss his CCR West presentations entitled “Common Eye Disorders in Rheumatology Clinic” and “Top Secrets in Rheumatology.” Kolfenbach is Associate Professor at the University of Colorado. He explains how eye disorders are related to rheumatic disease, trends in treatment, and he divulges a few secrets in the world of rheumatology.

Rheumatology Network: What are some of the common eye disorders in rheumatology?

Jason Kolfenbach, MD: We see a variety of inflammation around different areas of the eye, but I think probably the most common are spiritus, something called episcleritiss, this would be another one, and then probably like a little bit less commonly, we can see different forms of what's called the uveitis that can affect different areas within the eye itself.

RN: How are these eye disorders related to rheumatic disease?

JK: Yeah, it's a good question. So some patients can get kind of autoimmune or inflammatory diseases affecting the eyes on their own and a rheumatologist can be involved in those cases once for a couple of reasons. One to look for a systemic connection or a systemic autoimmune disease that's connected with it, or potentially to just to help manage some of the medications. But in our diseases, certain patients that we're already seeing in clinic with like rheumatoid arthritis, or let's say something called Wegener’s, those patients can get inflammatory disease commonly, and so then we need to kind of work with the ophthalmologist to kind of help manage those patients.

RN: And how do you go about treating these conditions?

JK: The treatment largely is similar to the medications that we use for the inflammatory disease outside of the eyes. And so, we'll use prednisone a lot of times as an acute management. But then we're always looking for something to replace that because the side effects of steroids and so we might use pill medications, like methotrexate or azathioprine or cellcept, or we could use injectable medications like Humira or even IV medications like rituximab.

RN: Do these conditions impact the way that you treat your patients rheumatic disease?

JK: Yes. Let's say if you use rheumatoid arthritis, for an example, we're obviously trying to control their joint symptoms, that's the biggest. And they're kind of the common denominator of someone's autoimmune illness. If they have RA it’s joint pain and swelling so we obviously want to control that. But if they have disease, like let's say if their joint disease is well controlled, but they're having manifestations somewhere else like in the lung or in the eyes, we change our management because we wouldn't be content to stay on the same immunosuppressive regimen, even if it's working for their joints. We'd want to be able to augment that with something else because untreated or undertreated inflammation in the eyes can be devastating in terms of loss of vision permanently. So, we might have to alter the regimen, even if it's doing fine for the joints. we might have to tweak it so that we can address this other area that's inflamed as well.

RN: What are some of the top secrets in rheumatology that you will be discussing in your upcoming presentation?

JK: So good question. I don't know if I want to divulge everything, though, because people won't go to the session otherwise, but so I'm going to be covering some tips on both the evaluation and management and some common conditions like rheumatoid arthritis and fibromyalgia. We have a couple of tips and pearls in there on lupus as well. I think that session, specifically, I always look forward to that because I try to include some practical stuff that I try to think about in the last hour in the back of my mind, that helps me kind of quickly go through some of the decisions that we make in terms of evaluating and then treating a patient with autoimmune disease in clinic. And so, I'm hopeful there's a couple of tips or tricks in there that can help clinicians as they're seeing patients. I have some information in there about patients with autoimmune disease, or are not immune or protected from having very common regional musculoskeletal conditions. So, an example of that would be if you have rheumatoid arthritis, you can get rotator cuff tendonitis from maybe playing volleyball on the weekend and being a kind of weekend warrior, so to speak, in terms of getting an overuse injury. And so, I highlighted through a couple of the secrets and pearls that that's important, because if you were seeing me in clinic, and you have rheumatoid, and then you have shoulder pain because you're playing softball or volleyball or something, we don't want to add more medications to treat your rheumatoid when it's really something totally different. And I think we forget that sometimes in rheumatology we develop a little bit of tunnel vision. And we think that everything that's sitting in front of us has to be their autoimmune disease, when you're just as likely to get osteoarthritis, or rotator cuff tendinitis, as anybody else. And so, there's a couple of pearls on that, that hopefully people will find helpful.

RN: Have you noticed any trends in rheumatology over the past year?

JK: I think there's 1 trend that we're seeing that I don't necessarily talk about in the things that are in my sessions, but I think there's this push to be able to get away with using less steroids, especially in the vasculitis conditions that we take care of. And so, there's lots of studies coming out saying that maybe we could use lower-dose prednisone approaches in some of these inflammatory conditions. And that's great, because I think we, for too long, rely upon steroids. And they're great medications for a lot of patients, but they have a lot of side effects. So then that's probably been 1 of the biggest trends was that I've seen. Multiple studies have shown that we can probably get away with less. It's probably safe and patients do just as well. And so we're going to limit the side effects that they're faced with.

RN: Is there anything else you'd like our audience to know before we wrap up?

JK Probably ending on the wellness aspect. I think what we do is really fun. And it's hugely important to patients in general because what we take care of. There are rare conditions that unfortunately, in medical school, when you look at all medical providers, when people go through medical school, or PA school, or nurse practitioner school, they don't get exposed to a lot of rheumatology. So not only is what we do fun, but it's vital because there's a segment of the population who really rely upon us because general practitioners might not have as much experience in recognizing the disease, knowing how to treat it, and knowing what complications arise. So, I think to some people that can seem like a burden, but to me, it's a huge privilege and it's really exciting to be able to be put in that position where we can really offer insight to people and to help out their quality of life.