A Clinician’s Perspective
Improving Rheumatology Patient Care Using the
In addition to being an associate professor in the UCLA Department of Medicine Rheumatology division, Dr. Solomon Forouzesh is a board-certified rheumatologist in private practice in Culver City, California. He began his solo practice in 1979 and his practice has become one of the leading rheumatology practices in Culver City.
His practice is ethnically diverse with patients from more than 50 countries. He typically sees 25-30 adult patients per day; most of which have rheumatoid arthritis and other rheumatoid diseases. In 2011, he started using the T-SPOT.TB test to screen his patients for TB before initiating biologic therapy and also to screen patients who are currently on therapy. He used to screen with the PPD every year or two while his patients were on therapy or when he switched them to a new therapy. Currently, the T-SPOT.TB test is his preferred method for screening patients for TB. Here, he describes his experience:
“TB is a serious matter. I grew up in Iran, a country of TB and oil. For any patient entering the hospital, their differential diagnosis included TB: in the neurological ward it was tuberculosis meningitis; in the GI ward it was TB of the peritoneum. It is an ancient condition, and it is probably not going away. And now, I am aware of active cases of TB in my city. We can’t eradicate this bacterium—the mycobacteria is here to stay—so, we have to treat the disease it causes. For these reasons, I am passionate about screening my patients for TB.
“When we were using PPD, we had several issues. First, I had about 12 patients who had adverse reactions to screening with PPD; they had overreactions that caused the tissue at the placement site to become necrotic. It took a very long time for those patients to heal. Second, we had scheduling issues with placing and reading the test. People are busy; it was hard to get my patients back into the office to read the test at the appropriate time. Third, induration results are very subjective. In addition to our testing, we relied on some primary care physicians to place and read the PPD results. Since the results are so subjective, it caused some concern when I was prescribing biologics. I don’t like relying on subjective tests, but it was out of our control.
“When I learned about the T-SPOT.TB test, I realized that it offered solutions to these issues. Since it is a blood test, we don’t have any issues with patients having adverse reactions. I have much more confidence in the T-SPOT.TB test results. For example, I had one patient for whom I initially screened with PPD and determined that the induration was negative. I switched TB testing methods while I was treating this patient and subsequently tested the patient using the IGRA. The T-SPOT.TB test result was positive, but I received more than just a positive categorical value; I received a numeric value that helped guide my management decisions about this patient.
“Using the T-SPOT.TB test has definitely cut down on our administration time. We no longer have the patient scheduling issues with reading test results. I can retrieve the T-SPOT.TB test results easily, and the results are ready about the same time as the other labs that I run. This allows me to put my patients on treatment sooner than when I was screening with TST. In some cases it is as much as several weeks sooner.
“We also can schedule patients throughout the week. Before, I could only schedule screenings on Mondays, Tuesdays and Wednesdays because I didn’t have staff available to read the PPD results on the weekends.
“In addition, using the T-SPOT.TB test has made it possible to screen patients regularly for TB. I always test patients before they are started on therapy and when I switch treatment to other agents. And then I try to screen patients annually beyond that. It depends on how frequently patients come into the office, and if they have extended foreign travel. It also depends which therapy the patient is on for RA. Patients who are taking a newer biologic drug for RA that inhibits granulation formation are at increased risk for contracting TB. Granuloma is the body’s main self-protecting response to foreign agents, including bacteria and mycobacteria. During the first years of these biologic drugs, there was a rapid rise in the number of TB cases, so that’s become a primary target and approach for prevention. The biologic drugs have changed the natural course of RA and will stay here. Therefore, we have to provide the safest approach for patient care. In my mind, that’s doing regular screening for TB.
“The service I have gotten from Oxford Diagnostic Laboratories has been 100% reliable and helpful, and the reports they provide are detailed, precise, comprehensive and reliable. I can’t find a better approach than providing specialized laboratory services for performing a TB blood test—their service is impeccable.
“I am very happy that this test is available for my patients and the community I serve. Using the T-SPOT.TB test has made my life as a medical practitioner easier and has improved my ability to provide my patients with the best medical care to manage their disease.”
Dr. Solomon Forouzesh is the Founder and Medical Director of the Arthritis Care and Treatment Center in Los Angeles, a faculty member of the UCLA Department of Medicine, and an Associate Professor of Medicine and Rheumatology at UCLA/Cedars-Sinai Medical Center. He is also Medical Director of the Rehabilitation Department at Brotman Medical Center in Los Angeles. In 2005, Dr. Forouzesh was voted the “Best All-Around Physician” at Brotman Medical Center by his peers in Los Angeles.
Dr. Forouzesh’s area of specialty is the treatment of rheumatoid arthritis. He was rated among the “Top Doctors” in the field of rheumatology from 2000-2003 by the Center for the Study of Services’ Consumer CHECKBOOK in Los Angeles, and was also recognized as the “Medical Director of the Year” nationwide in the Rehab Care Group. Dr. Forouzesh is also a distinguished Fellow of the American College of Physicians and Fellow of the American College of Rheumatology.
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