Autoimmune Disease and Cardiometabolic Risk

QUEST WEBINAR TRANSCRIPT:

Autoimmune disease and cardiometabolic risk—Diagnosing and managing patients with autoimmune disease and their lifelong cardiometabolic risk in primary care

Presenter: Kenneth French, Sr Clinical consultant, Quest Diagnostics

French, Kenneth W   0:04
Today, we're going to be discussing the importance of understanding autoimmune diseases and how they actually contribute to one's future and long term cardiometabolic risk.

My name is Kenneth French. I'm a senior clinical consultant at Quest Diagnostics and I'm going to spend time talking about these important two categories and their relationship to each other, in particular in primary care.

The first thing we want to talk about is a panel of tests or grouping of tests that were put together at Quest Diagnostics and it's called ANAlyzeR. This particular panel of tests was designed for primary care to help them understand which patients have certain autoimmune disorders.

French, Kenneth W   0:43
So why is this important? Well, if we think about it currently, primary care has testing modalities and solutions for understanding who's at risk for diabetes, chronic kidney disease, and even metabolic associated steatotic liver disease. In the same way, primary care now has a tool called ANAlyzeR to help them understand which patients likely have an autoimmune disease.

Now what's important is just like diabetes, CKD, and MASLD, autoimmune disorders also represent an increased risk for cardiovascular disease.

So if we're concerned about patients’ risk for and who had diabetes, CKD, or MASLD, we need to be concerned about those patients who have been diagnosed with an autoimmune disease.

Now this is important. Primary care is playing a vital role in this particular area in medicine. Why? There're becoming fewer and fewer you know, rheumatologists, and it can take anywhere from up to six months to actually see these rheumatology appointments.

Well, having access to something like ANAlyzeR can actually cut down the time that's spent for that patient waiting for the rheumatologist. And we can actually reach a more to definitive diagnosis by using this type of tool. And of course now with prevalence of autoimmune disease now increasing, this is the time where ANAlyzeR solves a significant problem.

French, Kenneth W   2:03
Now this is important when we talk about screening for, you know, autoimmune diseases. Often times patients present with very vague symptoms. And once we've ruled out the traditional risk factors for whatever symptoms they may be emerging, then it's time to think about could this patient be suffering from an autoimmune disorder. While ANA or any nuclear antibodies are probably the most popular test that's used to assess the likelihood or the presence of an autoimmune condition, the problem is often times for several different autoimmune diseases, ANAs may not be positive, so by using ANAlyzeR developed by Quest, which is a profile of different antibodies, now we can actually empower primary care to reach a faster diagnosis or help identify patients with multiple autoimmune conditions.

French, Kenneth W   2:52
So what is ANAlyzeR?
Well, it requires one blood draw and it looks at 25 different analytes to see if the presence of one of 8 diseases is at play.

Now what's nice about this ANAlyzeR, of course, is it's very accessible in primary care. Currently approximately only 71% of insured patients will not receive a bill. And of course, Quest is in network with over 90% of the insured lives making ANAlyzeR the go-to test for assessing autoimmune disease.

French, Kenneth W   3:37
So let's talk about interpreting the results. It's important to recognize in this particular space that there's a lot of autoantibodies that are at play.

So Quest developed a tool to help primary care providers understand exactly what's being measured and what disease states are we looking for with the different analytes that are available.

French, Kenneth W   3:49
So let's look at a chart. What ANAlyzeR is actually doing on the left hand side are the different autoantibodies that are being analyzed in the ANAlyzeR panel and across the top are the 8 different disease states. Now within the chart you see a variety of numbers. These numbers correspond to the prevalence that those autoantibodies are seeing in that disease state.

Now it's important to recognize that while ANA is sort of the go-to test for assessing autoimmune disorders, there are instances where ANA may not be positive, but another autoantibody would be present, indicating that that patient could be, or likely has that particular autoimmune disorder.

So let's look at that as an example. Let's look at Sjogren's disease. Only 50 to 60% of the time do we see ANAs are positive in these types of individuals. However, if we go down to SSA or the Ro antibody, we can see that it's present 60 to 90% of the time.

If we look at another example like polymyositis, what we see again it too shares similar to Sjogren's only 50% of the to 60% of the time is the ANA positive.
But when we look for the Jo-1 autoantibody, it's presence would indicate that this patient likely has polymyositis.

Now it's important to also recognize that in healthy individuals, ANA can be positive if there are no presence of any other autoantibodies in these individuals.
But they have a mildly elevated ANA. These patients may not need to be sent to rheumatology, in particular if they have a very low titer, such as one in 40 or one in 80.

So you can see how using the analyzer we can begin to explore what are the issues that we're seeing with this patient and are we seeing the positive or the you know, the presence of certain autoantibodies that's consistent with the symptom we see in these patients.

French, Kenneth W   5:41
So what do these results mean? Quest will provide each and every primary care provider access to information about what each of these results mean.

French, Kenneth W   5:52

With regards to what was detected. What's the clinical significance of that? And this information actually helps the primary care provider direct the patient to the care that they need to help resolve their symptoms.

French, Kenneth W   6:02

So now that we've made that jump, we've understood what ANAlyzeR is and we understand the opportunities that ANAlyzeR gives us as far as understanding who's at risk or who has the condition. What does that mean for the patient in primary care for the rest of their life because once with an autoimmune condition, you're living with a condition that's long term. Well, certainly one of the common threads that we need to make sure we're abreast of is the idea that these are lifelong risk.

French, Kenneth W   6:33
So what does that mean? So the presence of an autoimmune disorder means now they're at risk for other disorders that are not necessarily autoimmune by nature. For example, atherosclerosis, heart disease, kidney disease, just to name a few conditions that are enhanced as a result of having this autoimmune disorder.

French, Kenneth W   6:52

Now what does this mean though?

Well, primary care providers are accustomed to thinking about chronic kidney disease as a disease that increases one's cardiovascular risk. They know that metabolic associated steatotic liver disease increases one's cardiovascular risk, Type 2 diabetes, even polycystic ovarian syndrome. All of these conditions, if they're diagnosed in a patient that means that patient has a lifelong risk for cardiovascular mortality that’s higher than the patient without these diseases.

Well, we need to add autoimmune disorders to this list by virtue of the fact that you have an autoimmune disorder, you have an increased cardiovascular risk that's higher than the average population without that disorder.

French, Kenneth W   7:37
So to give you some kind of feel for how serious some of these autoimmune disorders are and how much risk they pose to our patient population for cardiovascular disease, just take a look at rheumatoid arthritis.

Excess mortality in person with RA is mainly attributed to the cardiovascular disease because RA is a hugely inflammatory disease process. Of course, rheumatoid arthritis patients have a significantly higher risk of having a hospital MI and almost a nearly sixfold risk for having a silent MI.

Now what's remarkable is even in in something like lupus, the prevalence of metabolic syndrome is a significant risk as well as insulin resistance.

Now here's what's interesting. We always talk about risk equivalents.
So we know, for example, diabetes patients with Type 2 diabetes, they are at risk of equivalent for cardiovascular disease, their risks or their hazard ratio if you have diabetes is about twofold for having a heart attack. Well, let's look at autoimmune diseases. If you have one disease you have a hazard ratio of 1.4. By the time you reach 2 autoimmune diseases, you actually have a hazard ratio, a risk for future cardiovascular mortality that's greater than a patient with Type 2 diabetes.
And when we ask the question, well, what diseases have really high risk?
You know, systemic sclerosis has the highest hazard ratio and on this list of four, Type 1 diabetes comes in with a hazard ratio of 2.3.

So you can see the presence of an autoimmune disorder increases the overall.
CVD risk for these individuals tremendously, and therefore we need to be managing these patients significantly and more aggressively.

French, Kenneth W   9:20
So what does this mean? So similarly, when we diagnose patient with autoimmune disorders, this gives us an opportunity to recognize, well now we need to check your hypertension more frequently. We need to check your kidney function. We need to look for dyslipidemia. We need to understand incorrect sleep issues, smoking cessation, weight loss, all the things that we’d do globally to reduce someone's CVD risk, patients with autoimmune disorders get this heightened increased awareness of their condition and global control to reduce their cardiovascular risk.

French, Kenneth W   9:52
Now one of the ways at Quest we can help understand long term CVD risk in patients with autoimmune disorders is to perform the metabolic risk panel. The Metabolic Risk Panel is a profile that includes the lipid profile along with A1C, but it includes ApoB and Insulin Resistance Panel with Score. Why? Heart attacks track with ApoB, not LDL cholesterol. So now by adding the ApoB to the lipid profile, we can find patients who are at risk for cardiovascular mortality that's not identified with a lipid profile.

And similarly, patients with normal looking A1Cs, we tend to think well, we don't need to worry about these individuals, not if they’re insulin resistant. So the presence of insulin resistance tells us that these individuals are heading in the wrong direction and we need to intervene on their behalf before they develop pre diabetes and or diabetes.

French, Kenneth W   10:40
So you can appreciate now at this time the wealth of information that ANAlyzeR brings to help us understand who has certain immunological conditions or autoimmune disorders that we need to be concerned about. And at the same time, once we've identified those patients who have an autoimmune disease, we need to start thinking about their long-term cardiovascular risk.

So by using ANAlyzeR and the Metabolic Risk Panel, you have really good tools to triage the population that's most at risk.

French, Kenneth W   11:12

If you want to find out more information, you can certainly go to DiagnoseAutoimmune.com or QuestMetabolicRisk.com and if you have any specific questions about the information that was provided here, please feel free to e-mail us at IDI@questdiagnostics.com.

French, Kenneth W   11:31

One postscript note, any of the information that you saw in a panel, whether it be the ANAlyzeR or the Metabolic Risk Panel. Any component of those panels can be ordered separately and not in the panel format.

Thank you.