Michael Smith, MD (Host): Meaningful Medicine is a Novant Health podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Today, I'm sitting down with Dr. Dr. Pawan KC, and we're going to be talking about the treatment of autoimmune disorders.

But before we get started, Dr. KC, I always like to ask my guests, how did you get started in this field as a rheumatologist?

Pawan KC, MD: Yes. First of all, thank you for having me in the interview today and giving me this opportunity to help raise awareness in such an important topic. And regarding my interest in Rheumatology, and I'm probably biased because I'm a rheumatologist, but I think Rheumatology has one of the most interesting and rare pathologies. They are really intriguing, and I do love helping patients who have this rare diagnosis to help them make the diagnosis and navigating them through the treatment. And because most of these conditions are chronic, we follow them over a long period of time. So, that gives me a chance to build a long-term relationship with the patients. I know them better. Sometimes, you know, we even know their family. They know me better as well. So, that is fulfilling to me, that personal relationship.

I'm also a big proponent of physical exam in Medicine, and that is something ingrained in my clinical practice. I like to do a thorough history, physical exam, and come to a diagnosis and explain everything to the patient. I think Rheumatology is one of those specialties which still puts a lot of value in thorough history and physical exam. So, a mix of all of that kind of drove me into Rheumatology.

Host: Fantastic. So, let's begin with a very general question for the audience listening. And I know this is hard, but let's try our best to do it. What is an autoimmune disorder? In a quick, simple, like elevator pitch statement.

Pawan KC, MD: I'll try my best. So, one of the best analogies I read about, you know, autoimmune disease is think of your body as a castle and immune system as an army protecting that castle. Now, imagine your army getting confused and start destroying the castle. So, what happens in this autoimmune condition is that your immune system is getting confused and it just starts attacking your own body.

So, it sets up a reaction that can lead to a lot of different things, a lot of different signs and symptoms. So, the end result can be, you know, destruction of the organ, dysfunction, and even sometimes abnormal growth of the organ. So, it's basically an immune system that is getting confused. Immune system, which is supposed to fight infections like bacteria and viruses, it starts to fight your own body. So, that's, in simple terms, I understand autoimmune diseases.

Host: Great analogy there. It's like your own team starts fighting against you in a way. That definitely could cause problems because the immune system is powerful, right? Yeah, some powerful things it uses to kill bacteria, kill viruses. So when it turns on you, this could be harsh, right?

Pawan KC, MD: It can be powerful. Yeah, imagine getting sick with these viruses. But in this immune system, we don't even know what the trigger is. And the immune system produces these powerful reactions in your body, and it can make you feel miserable with all the signs and symptoms that it can produce.

Host: So, Dr. KC, who's more at risk? Or let me ask this, are there definitive risk factors, or is it hard to know that?

Pawan KC, MD: It is hard to know, and I like the fact that you're asking me the risk factors, not the cause itself, because we don't completely understand why someone develops autoimmune disease. It is considered to be, you know, a complex interplay of gene and certain things that you're exposed to during the life, environmental factors. But the fact is that we don't completely understand. However, there are certain factors that we know that have a strong link with development of autoimmune disease. And genetics is one of them. If you have a family member who has a history of autoimmune disease, your risk is going to be higher. That does not necessarily mean that you're always going to develop autoimmune disease, but your risk becomes higher.

Smoking is linked with a lot of different autoimmune diseases, including rheumatoid arthritis, where it has a strong link. Stress can play a role. Although, you know, the studies are not big, we know that stress plays a role in the development of autoimmune diseases. Being overweight or obese is a risk factor, maybe just because of the fact that it puts more stress on your joints. So, all of that can contribute. Certain medications, you know, some of the common medications that we use. Certain antibiotics, certain blood pressure medications can trigger autoimmune conditions like skin lupus. Sometimes really, really severe reactions like muscle inflammation, muscle weakness. That doesn't necessarily mean that you cannot take these medications. But if you develop something unusual, it's important to keep in mind that it could be a reaction to the medicine that they are on. So, these are some of the common risk factors. But like I said, you know, we don't completely understand, but these are some of the risk factors that we know for sure.

Host: Dr. KC, autoimmune diseases can often be misdiagnosed, and I know there must be a lot of reasons for that. And I was hoping you could share some insight into that. And also, are there some standard tests that can be ordered for patients who are dealing with these symptoms?

Pawan KC, MD: Yeah. You know, diagnosing someone with autoimmune disease, it can be really complex and a challenging process. And one of the common barriers is a lot of these symptoms have a lot of overlap with other conditions. If you think about symptoms like fatigue, joint pain, not feeling well, all of that can be part of chronic infection, certain nutritional deficiencies.

So, the autoimmune disease may not even come in mind in the initial part. So, that can create some delay in diagnosis. And most of these autoimmune diseases, you know, it can be on and off. So, we may be seeing patients may have symptoms and it goes away, they can come and go. So, you may be seeing a patient where they're not having any signs of joint swelling or anything like that.

So, recently, I saw a patient who had this intermittent joint swelling coming. And when I saw her in the clinic, she had nothing. However, she showed me some pictures where her joints were, you know, completely swollen up. So, that was pretty convincing. That can also, you know, create a confusion for the doctor, like, you know, they are not seeing anything on the exam or on that particular day. So, that mix of this can create a delay in the diagnosis.

Host: And then, what about the testing? Is there something that patients should ask for maybe if they feel like maybe they are being misdiagnosed? Is there something they could ask for?

Pawan KC, MD: Yeah. I think testing is completely reasonable. However, I would say that with word of caution that, you know, these tests are not perfect. There is no standard test. Now, there may be a scenario where you have a completely negative blood test, but you still have the disease. But there are situations you have a positive test, but you may not have the disease. So, by no means these are perfect tests, but they can support your diagnosis if you have certain signs and symptoms that fit with the diagnosis and a positive blood test can be really, really helpful in that scenario. But isolated blood tests may not always mean that you have the condition.

Host: Yeah. So, most patients are not going to see a rheumatologist at the get go, right? So, you know, if you're a patient, maybe somebody's listening to this podcast who kind of feels like we're talking to them, you know, they've had some symptoms, they're vague, maybe they've been worked up a little bit, at what point should this patient see a specialist?

Pawan KC, MD: I would say when your symptoms are unexplained and when they are happening in a recurrent fashion, let's say someone is having fevers, gland swelling, joint pain, that is you've been seeing your primary doctor, but you know, there is no conclusive answer and it has been happening in a repeated fashion. So in that scenario, it's always a good idea to talk to your primary doctor. "Hey, do I need to see a rheumatologist? Should we consider seeing a rheumatologist?"

Now, there are certain signs which highly suggest that you may have autoimmune disease. So, I would like patients to keep that in mind as well. Like, let's say they have joint swelling and stiffness that would last for more than 30 minutes, it takes some time to go away. Now, the skin rash can be a part of the initial manifestation of autoimmune disease. So if there is unexplained rash, it's again a good idea to consider Rheumatology referral. If you have an abnormal blood test, let's say you have certain symptoms and your primary care runs certain tests, your blood test is abnormal, especially if they are of high value, it is really important to see a rheumatologist in those conditions. But the key thing is if something is happening in a repeated fashion, no clear explanation for that, definitely consider Rheumatology.

Host: Great advice, Dr. KC. When somebody finally does come to see you, I know you have a huge workup and your physical exam's important to you, your history. And I'm so happy to hear that. That's kind of like old school medical school stuff, right? A lot of physicians don't do all that these day and age. That's great to hear. But when you actually talk to a patient, what are some of the most common questions they have for you of what's going on?

Pawan KC, MD: When I'm seeing a new patient for the first time, obviously, questions are kind of revolving around, "Do I have the autoimmune disease? If I have autoimmune disease, what kind of autoimmune disease is it?" So, a lot of times, the diagnosis may be clear on the first instance, however, it may take some time to run the blood test and everything to come back. And sometimes it's not uncommon, we have to see patients on the subsequent visits, and then we can come to a conclusive diagnosis. So, it may not be clear on the first instance when we are meeting the patient. So, it can take some time.

Some of the other questions, "What does this mean for my family members? Are my kids going to get it?" We talked about genetic risk. You know, it does not always necessarily mean that their family members are going to get it. "Will I ever be cured of this disease? How long do I have to take the medicines?" All of these things, we generally discuss during the first visit. And they also have questions about, "Do I have to limit something in my diet?" What are the lifestyle changes I can make? These are some of the common questions I get from the patients.

Host: Well, that brings up a couple of other additional questions real quick. I'm curious, Dr. KC, how many patients do you see initially where they've gone through a thorough workup and we still don't know what's going on. It's kind of like their symptoms are mysterious. What's like the percent of patients that you see in that position?

Pawan KC, MD: Rheumatology is one of those gray areas in Medicine, as you know. And things are not always black and white. So, that's why I said, you know, your diagnosis may not be clear when we see you for the first time, it can take some time. Things can evolve over time. You may just have a joint pain or swelling. But over time, you know, they may develop certain signs and symptoms that points to a certain diagnosis.

Now, I cannot put an exact number to those patients who cannot get a clear diagnosis on the first instance. But I would say, you know, somewhere around, for me, 20-30%. The number can vary, you know, based on the practice that they see, based on the doctors. But I would say this is definitely a gray area in the Medicine. It can take some time. Sometimes we do have to work in uncertainty. And I remember, you know, one of my mentors telling me while I was doing my fellowship that you have to feel comfortable in uncertainty to practice Rheumatology. So yeah, I mean, you know, that's common and we feel comfortable in uncertainty.

Host: So over the years, you know, given all of your experience, how has treatment for autoimmune diseases improved since you've been practicing?

Pawan KC, MD: So, I will say this is definitely an exciting time in Rheumatology. Back in the days, treatment was mainly focused on use of a lot of steroids. There were medications that caused broad immunosuppression, increasing risk of infections. However, in the past few decades, the introduction of this medicine called biologic medication, it has been a game-changer. So, biologic medications are basically the medicine that are, you know, synthesized from living cells compared to the other medicine that are synthesized from plant-based or chemicals. These medications have had a tremendous effect for the patient. So, some of these patients kind of hit the end of the road in the treatment path previously. These biologic medicines has opened box of options for these patients.

And I have seen, for some of these conditions like ankylosing spondylitis, there are not many treatment options nowadays with these medications. We don't see the outcomes the poor outcomes that we used to see in the past, like fused joints or deformed joints. So, it has definitely evolved and improved over the past few decades.

Host: So, can you explain how you try to personalize treatment plans with people with autoimmune disorders? What might that include?

Pawan KC, MD: Like I said earlier, you know, as rheumatologists, we like to ask a lot of questions, a thorough history, a thorough physical examination. I ask a lot of questions about their medical history, social history, occupation-wise, how these symptoms are affecting their quality of life, and what is important to them in the treatment.

Factoring all of that in, I come up with few treatment options for the patient, and work with them and see what best suits for them. So, let's say, for example, if someone has a history of heart disease, you obviously don't want to put them on a medicine that is going to increase their heart disease risk. Let's say you're seeing a young female with lupus and who is planning for pregnancy. So, you want to avoid medications or put them on medicine that is compatible with pregnancy. Let's say you have a patient who uses their hands a lot, as a part of this, like fine movement of their hands, even one single inflamed joint in one of the fingers can be debilitating for them, because they cannot perform at their job compared to someone who does not need to use their hands a lot as a part of the job. And they may, you know, the person who uses their hands a lot, may choose a more aggressive approach to the treatment compared to the other person. That's how I try to come up with a plan for the patient based on the individual factors.

Host: You know, you touched on the idea of diet and lifestyle. I want to go back to that quickly. There's a lot of trending diet plans out there. Is there any specific diet that you like your patients to follow when it comes to autoimmune disorders?

Pawan KC, MD: Yeah. I mean, there are indeed a lot of trending diets, exercise, you know, holistic medicine approaches, and some of these might add value to management of your autoimmune disease. Recently, I've seen, you know, patients going gluten-free, eating plant-based diet, Mediterranean diet.

Now, I will say about gluten-free diet, you know, there is an extreme form of sensitivity to gluten called celiac disease. And these patients have digestive symptoms and joint pain. Now, those are the patients who are going to tremendously benefit because if they eliminate gluten from their diet, they are going to feel better in terms of digestive symptoms and the joint pain. However, if you have a patient with arthritis, but they don't have gluten sensitivity and they want to see how they do if they eliminate gluten from their diet. So in those patient population, it is controversial.

However, I would say, you know, there is no harm in trying and see how you do with a gluten-free diet, but just make sure that you're meeting your nutritional requirements, you're not lacking in any nutritional or micronutrients, and you're meeting your calorie requirements and see how you do with that. I'm usually open to them trying that.

There are small studies that suggest that plant-based diet may be helpful, but these are small studies, hard to draw a conclusion from them, so it's difficult. Mediterranean diet is something I recommend generally for the patients because, traditionally, it has a lot of fruits, vegetables, fatty fish that's overall good for the cardiovascular health as well, which, you know, patients with rheumatic disease are at higher risk for.

So, I would recommend something like Mediterranean diet, and yoga. Tai chi is something I recommend because it helps to improve the balance, range of motion in the joints, and the strength. These are some of, you know, what we call a non-medication measures, which I generally recommend.

Host: Very nice. Yeah. I'm from the Mediterranean. So, I totally agree with you about the Mediterranean diet. I think it's fantastic. Great fruits, lots of good oils, colorful greens and veggies and lean proteins. It's fantastic. You know, Dr. KC, I always like to wrap up the interviews with, our guests. It's pretty straightforward. It's like what's your take home message? What's your biggest piece of advice for patients with an autoimmune disease?

Pawan KC, MD: Yeah. You know, getting diagnosed with autoimmune disease, it can be overwhelming. When you think about these conditions that it never goes away, it can be discouraging for the patients. However, with the treatment that we have currently, it can make a world of difference to how they feel and the quality of life.

And last month, September was a Rheumatic Disease Awareness Month and the theme of this year was self-management, which I completely agree with. So, I would say stay active with your care, regular followup with the doctors, take your medicine. If you forget medicine, you know, keep a reminder, stay healthy, stay active, exercise, yoga, meditation, avoiding stress. Those would be my biggest advice.

Host: Fantastic, Dr. KC. Thank you so much for joining us today. To find a physician, you can visit novanthealth.org. And for more health and wellness information from our experts, visit healthyheadlines.org I'm Dr. Mike. Thanks for listening.