Dr. Mithu Maheswaranathan Discusses Rheumatology Challenges, Trends for 2024

The rheumatology space is ever shifting, and the start of a new year offers exciting and innovative changes for physicians and patients alike. DocWire News partner Mithu Maheswaranathan, MD, of Duke University Health, spoke about challenges, treatments, and trends in rheumatology and detailed what advancements he’s looking forward to in 2024.

About Dr. Mithu Maheswaranathan

I am a rheumatologist at Duke University Health. I completed my fellowship in 2018, and I’ve been working here since that time. I’m currently a member of the Duke Lupus Clinic, so I see patients with systemic lupus erythematosus (SLE) once a week and also general rheumatology clinics. My academic interests include patient-physician communication, health literacy, and medical education. I have some roles in the school of medicine and an interest in digital medical education as well.

You treat all rheumatic diseases but have a special focus on lupus. What are the biggest challenges of treating lupus, and are there any promising lupus therapies on the horizon?

That’s a good question. We definitely have some challenges in treating lupus in our clinics. First, there are some limited therapies within our treatment armamentarium at this time, especially when you think about steroids bearing medications to mitigate the effects of prednisone use that have a lot of long-term side effects. There are also social determinants that can negatively impact our patient and their ability to successfully manage their disease.

These can include things like socioeconomic inequities, challenges with access to care, medication adherence, and health literacy. All of these factors ultimately impact their disease activity and health outcomes. As rheumatologists, we’re becoming more aware of the impact of social determinants of health, the downstream consequences of systemic racism, and how that impacts racial disparities and outcomes in care. Going forward, we’re going to create more novel ways of trying to intervene regarding the social determinants of health.

There are also some ongoing clinical trials looking at new biologics in SLE with different mechanisms of action. Back in 2011, belimumab was the first therapy for SLE that had been approved by the US Food and Drug Administration (FDA) in 50 years. A few new studies have come out in the last couple of years. One was looking at a new indication for belimumab, specifically for lupus nephritis, so an approval for that indication, as well as the biologic anifrolumab. There’ve been a few new therapies, and this past year there was a post hoc analysis of the NOBILITY trial looking at obinutuzumab. So, a novel mechanism of anti-CD20 therapy in lupus, which was looked at in combination with standard of care for lupus nephritis. In the future, there’s hopefully going to be new therapeutics that target different pathways of the immune system that we can use in SLE. So, those are the 2 pathways I’m most looking forward to.

What have been the biggest general trends that you have observed in rheumatology in 2023?

One of the trends that we’ve seen is a further exploration of steroid-sparing therapies for a lot of our different rheumatic diseases. It’s a huge need. Some conditions have not had a lot of novel agents that have come out. In 2023, we saw the first FDA-approved therapy for polymyalgia rheumatica, which was sarilumab for refractory PMR. As we go forward, hopefully we’ll create novel mechanisms and novel drugs for different rheumatic diseases. That’s something that I think we’ll see more of in the future.

Another interesting trend that I think we saw in 2023 was the explosion of digital medical education. I think this really started in the pandemic especially, but it’s been further accelerated in rheumatology. I think there are a lot of novel people in this space. We saw a lot of conference coverage at ACR Convergence this year, the use of tutorials to summarize content from different talks, podcasts, video coverage like RheumNow, and then tremendous growth of some of the physician networks like the Q&A-based platform MedNet. I think it will be interesting to see where this goes in the future.

What impact have artificial intelligence (AI) and telemedicine had on the rheumatology space?

There’s been a very big interest, tremendous growth in exploration of telemedicine, especially in rheumatology. During the pandemic we saw, of course, a huge uptake in the use of telemedicine. There has been a telemedicine center that has really explored providing access to rheumatology care in more rural communities in a lot of different academic medical centers, including the University of Pittsburgh. That has really modeled that access to care through tele-rheumatology.

One of my colleagues at Duke, Dr. David Leverenz, has explored a model of trying to identify the patients who are best suited for telemedicine or most optimal for telemedicine by creating this model and having providers who see these patients rank how effective that particular visit was as in-person versus telemedicine. There have also been a lot of individuals who have explored how we can create telemedicine and telehealth curriculum for teaching ways of utilizing telemedicine more effectively in clinical care. So, we’re thinking about how we teach our fellows about rheumatology.

In terms of AI in rheumatology, I think there’s a big need for further exploration and a huge potential for it. When we think about using AI for diagnostic dilemmas, for creating some initial drafts of materials or automating our clinical tasks that we have to do every day in practice that are burdensome, these are all areas where I can see using AI. Hopefully there are people who are interested in exploring this in the rheumatology realm.

Are there any trials/therapies in the space that you have your eye on going into 2024?

I’m looking forward to seeing more exploration of the efficacy and safety of chimeric antigen receptor (CAR) T-cell therapy. There are CAR T-cell therapies that can target overactive immune system cells, help reestablish immune tolerance. And there was a study that was near the tail end of 2022 looking at CAR T-cell therapy in a few patients with refractory lupus. Now this has been explored in a few other conditions in rheumatology, including scleroderma and myositis with some mixed results.

I think it’s going to be interesting to see if we can identify some more targeted therapy to try to look at more specific target antigens in rheumatology with potentially fewer side effects than some of the current biologics. There’s a lot that we still don’t know about CAR T-cell therapy, but I’m looking forward to seeing the exploration in the future of CAR-T and potential other novel ways of targeting the immune system.