Comorbidities in Rheumatology: How I treat

Varun Dhir MBBS, MD, DM
Professor, Internal Medicine (Rheumatology Division), PGIMER, Chandigarh

Targets of hypertension and choice of antihypertensives.

Despite a lowering of blood pressure cut-off for treatment to 130/80 (ACC/AHA2017), I usually start treatment for hypertension only above 140/90 mm.  The one exception is lupus nephritis, where I start treatment above 130/80mm Hg. My go-to drug is a combination of amlodipine and telmisartan (5+40), and I step-wise add on thiazide diuretic or prazosin (significant postural symptoms). In lupus nephritis, I use ACEI, typically ramipril at a dose of 5mg once to twice a day. In accelerated hypertension (rapidly progressive renal failure), I prefer clonidine (0.1 mg to 0.3mg TDS) with loop diuretics. If hypertension is refractory to these, I add ACEI despite raised creatinine. I find this pretty effective and safe(in admitted patients with monitoring of K+).

Targets of cholesterol levels = When I start anti-lipid therapy

A major source of confusion has been primary vs secondary prevention in lipid lowering. In secondary prevention (prior history of CAD/CVA), I find little burden on myself as these patients are usually under the care of cardiologists/neurologists and already on moderate to high-intensity statins with usually LDL values less than 70 mg/dl.

I have to make decisions to start lipid loweringin the context of primary prevention, i.e., patients without prior CAD.I start lipid-lowering therapy in patients with diabetesor hypertensionif LDL > 130 (repeated twice over a few months) despite lifestyle modifications with low-intensity statins (atorvastatin 20 mgOD).In the case of patients with no risk factors, I start treatment only if LDL is above 160.I do not routinely calculate the 10-year risk of CAD using the atherosclerotic cardiovascular risk calculator(recommended to start lipid lower in gif risk > 7.5%.)(!/calulate/estimator/), .

LTBI screening and treatment

I make sure all patients get a chest radiograph before starting immunosuppression. However, I am selective in getting LTBI screening. I do it only before TNFi and NOT before Rituximab or Tofacitinib (despite recommendations). My reasons are the lower risk with the latter two agents and the high burden of LTBI (nearly 30-40%). For screening, I prefer Mantoux and rarely use QuantiFERON gold. If Mantoux is positive, I start dual therapy with Rifampicin and Isoniazid, and concurrently start TNFi within the first two weeks and do not wait for 1-2 months (recommended).

Screening and managing Hepatitis B/C with immunosuppressants.

I am not particular about documenting a negative hepatitis B or C before starting conventional DMARDs like methotrexate in RA (recommended), but document normal liver function tests. However, I document negative HBsAg and anti-HCV before Rituximab or TNFi. But, I do not routinely get anti-Hbc total, due to slow turn-around time and false positives (institutional issues).

If HBsAg or anti-HCV is positive, viral loads are done, and follow-up with a hepatologist is planned. Generally, immunosuppression can be started within a week of immunosuppressive therapy for latent hepatitis B. However, in actively replicating hepatitis B or C (viral load positive), I wait for the hepatologists to give the go-ahead, unless there is life or an organ-threatening rheumatic disease, when I rely on IVIG or plasmapheresis or sometimes rituximab (in active hepatitis C).

Disclaimer: These views are personal and do not in any way reflect the policy followed in our unit or institution.

Suggested reading

  1. Buelt A, Richards A, Jones AL. Hypertension: New Guidelines from the International Society of Hypertension. Am Fam Physician. 2021 Jun 15;103(12):763-765.
  2. Arnold MJ, O’Malley PG, Downs JR. Key Recommendations on Managing Dyslipidemia for Cardiovascular Risk Reduction: Stopping Where the Evidence Does. Am Fam Physician. 2021 Apr 15;103(8):455-458.
  3. Lau G, Yu ML, Wong G, Thompson A, Ghazinian H, Hou JL, et al. APASL clinical practice guideline on hepatitis B reactivation related to the use of immunosuppressive therapy. Hepatol Int. 2021 Oct;15(5):1031-1048.
  4. Deciding When to Treat Latent TB Infection.