Dr. Blazer specializes in the treatment of rheumatic diseases including undifferentiated connective tissue disease, Sjogren’s syndrome, inflammatory arthritis, and systemic lupus erythematous (SLE), particularly in patients of African ancestry. As a physician-scientist, she studies the interplay between genetic signatures commonly found in African ancestry backgrounds, environmental and social stressors, and SLE pathogenesis. Here, she talks about the subject of her lecture and her broader research.

In my experience, any rheumatologist who takes care of people with lupus has observed disparities in outcomes for African American patients compared to others. This is especially true when it comes to lupus nephritis, the type of kidney damage associated with lupus. The bulk of this disparity is related to access to care and the social determinants of health. For a subgroup of African Americans, however, aggressive kidney disease may be due to genetic risk.

Thanks to research looking at the connections between African American genomes and disease, we are beginning to answer some of those questions. Investigators have found that about 13% of people of recent African descent carry two copies of a particular version, or variant, of the gene Apolipoprotein L1, or APOL1. One copy of the variant protects against Trypanosoma brucei, the parasite that causes African sleeping sickness. This evolutionary advantage helps explain why the variant is so common. But having two copies is associated with a much higher risk of kidney disease, as well as cardiovascular disease.

Interestingly, about 80% of people with high-risk APOL1 genes don’t go on to develop end-stage kidney disease. It takes a “second hit,” usually chronic infection or chronic inflammation, to send people with this mutation down the path toward having these severe kidney problems. By studying the how the inflammation seen in lupus patients interacts with these APOL1 variants and leads to severe disease, we hope to develop ways to modify the factors that trigger that risk.

Part of my research is focused on clinical observations in patients who carry these APOL1 variants. When a lupus patient has protein in their urine, is it due only to lupus nephritis or is it a combination of autoimmune activity and the APOL1 phenotype? These differences could affect how patients are treated and which medications they are given, including the amount of steroids we use. By learning more about these clinical differences, we hope to ultimately reduce the number of lupus patients who end up on dialysis. And it’s very exciting to bring precision medicine to a patient population that is largely underserved.

The other part of my research is focused on understanding which immune pathways are active when the APOL1 variant is most highly expressed and whether the combination of APOL1 and immune activity is really producing these severe disease symptoms. We look at how the APOL1 gene is expressed in different cell types and how that affects the cell damage that we see. One thing I’ve been studying is how these variants affect mitochondria and their ability to produce energy for the cell. I’ve also been looking at how the variants affect autophagy, which is one way that cells recycle their damaged parts. Studying autophagy could explain not only the relationship between APOL1 and inflammation, but potentially how APOL1 causes cellular injury in people who carry the variants.

The field of rheumatology is in a golden age right now. We have all these new biologic drugs that can specifically modulate different pathways. It’s possible that by identifying the essential immune stimulus, we’ll be able to find ways to decrease the likelihood that someone with lupus suffers kidney injury — preventing the poor outcomes seen in so many of these patients. We may also be able to develop small molecules that could directly impact the protein product of APOL1.

I’m studying the connections between these gene variants and lupus outcomes not only in patients who are treated at HSS; but I’m also working with collaborators at two teaching hospitals in Africa, the University of Ghana and Lagos State University in Nigeria. These large patient populations help us to study the cellular damage caused by the APOL1 variant and why patients who have it are more likely to develop global damage to their kidneys. Studying patients who are being treated in resource-limited countries also helps us understand the interplay between lupus, social determinants of health, and genetic risk; and how these factors that contribute to poorer kidney outcomes

The findings about APO1 explain a reason why African American lupus patients with this particular genetic background don’t do as well, but we know there are many socioeconomic and societal factors that also influence the different in outcomes. Ultimately, we want to find ways to promote better health for all people with lupus, whether they carry these variants or not.

As a rheumatologist, I treat People of Color with psoriatic arthritis. Many of my patients receive late diagnoses, because People of Color are less likely to see a specialist early on who can make a proper diagnosis. This is a result of a variety of factors, including the fact that they’re less likely to be referred to a specialist by their primary care doctor. Despite the challenges, I want People of Color with psoriatic arthritis to feel empowered to overcome obstacles. 

People of Color who stay in primary care for the treatment of their rheumatic conditions may be prescribed medications that only treat the symptoms of psoriatic arthritis, without delaying the progression of the disease. They also may overly rely on steroids, which are not actually helpful for psoriatic arthritis. If you can, try to get a referral to see a rheumatologist, because they will be the doctor best suited to help you manage your condition.

In rheumatology, very few specialists are People of Color, but we do know that when patients see culturally congruent physicians, they feel more heard and receive more comprehensive care. Since diversity in the rheumatology workforce is limited, allyship is key. Look for a doctor who listens to you, who is aware of their own biases and makes an effort to stay open and empathetic to your unique experience.

When it comes to criteria for the “right” doctor, there are tangibles and intangibles. When you think about tangible criteria, ask yourself: am I getting appropriate screening? Are my X-rays being done on an annual basis? If I’ve been on steroids, is someone checking my bone density? Am I receiving a full physical exam every time I see the doctor? If I’m taking certain drugs, am I getting laboratory monitoring I need?

The intangibles are found in the doctor-patient relationship. Do you feel that your doctor has empathy for you? Do you feel like your doctor takes your concerns seriously? Do they spend enough time describing your condition and treatment choices? Do you have a good understanding of your disease and your treatment plan?

If you don’t feel like you’re being heard, you don’t fully understand your care, or you aren’t receiving the tools and education you need to take care of yourself at home, then you may not have the right doctor. 

Treatment success is important, as well. If you keep coming to your doctor’s appointments with the same concerns and no one is changing your medication despite the fact that you still have other options available, that might not be the right doctor for you. Receiving a disease-modifying medication is key; that means the drug is affecting how your disease progresses, not just easing symptoms. The more that your inflammation goes unchecked, the more your joints may be injured, and the more likely it is that you’ll experience a disability.

Read the full article at healthgrades.com. 

Although patients with lupus nephritis recently gained two new add-on treatment options in voclosporin and belimumab, there have been little data published with real-world experience in using these drugs.

Voclosporin, a calcineurin inhibitor, was approved by the Food and Drug Administration (FDA) in January 2021 to treat lupus nephritis in combination with immunosuppressive medication. Belimumab, a human monoclonal antibody and B-lymphocyte stimulator, was approved in December 2020 in the United States as an add-on treatment for lupus nephritis in adults and later in July 2022 for children who are already receiving standard therapy.

The lack of real-world data on either of these treatments can be attributed to lupus nephritis being a rare disease, and the approvals happening fairly recently, experts said. 

Dr. Blazer explained that rheumatologists “are a little bit hesitant” to use newer agents rather than existing therapies, and have existing guidance from the American College of Rheumatology (ACR) on treating the condition.

“I think when someone has something like lupus nephritis that’s so serious, rheumatologists pull for the tried-and-true drugs that we know will affect the inflammation quickly and get that patient to remission,” she said.

Another issue Dr. Blazer encounters is cost. “I tend to treat patients who can have some socioeconomic challenges, and so I think very long and hard before prescribing either of them,” she explained. "Certainly in the case of voclosporin, when there are older, cheaper calcineurin inhibitors and I think I need one, I’m more likely to reach for one of the others,” she added. 

Read the full article at MDedge.com.  

Career Development Award recipient, Ashira Blazer, MD, MSCI, rheumatologist at HSS, says, “This award is very important for me and also for the field. One of the things that’s been a big issue in rheumatology, and in medicine as a whole is that we don’t have enough investigators of color. They are less likely to get quality mentorship and less likely to have the ability to stay in the pipeline.”

Postdoctoral award to promote diversity in lupus research recipient, Ruth Fernandez Ruiz, MD, MS,  rheumatologist at HSS, is evaluating the impact of genetic variants in lupus progression. “I am thrilled and honored to be one of the inaugural recipients of the Diversity in Lupus Research Awards,” she says. This funding will be instrumental in continuing my contributions to SLE research and advancing my academic career. I believe that the Diversity in Lupus Research award program by the LRA is a great initiative to address the profound underrepresentation of minorities in biomedical research." 

Read the full article: https://www.the-rheumatologist.org/

According to Dr. Blazer, there are a few signs to tell typical back pain from arthritis pain including stiffness in the morning. “Most people who have everyday back pain don't have too much stiffness in the morning," said Dr. Blazer says. “People with typical back pain may feel slightly stiff for 20 to 30 minutes in the morning, but those with pain from arthritis may have pain that lasts more than an hour or two.” She continued “If you have back pain that's waking you up at nighttime, that might be suggestive [of arthritis].” Additionally, it's possible to just have arthritis in your back, however if you have a form of autoimmune arthritis like rheumatoid arthritis or psoriatic arthritis, you may also have a rash. "A lot of times our arthritis syndromes go along with more than just back pain," said Dr. Blazer.

In general, back pain is treated "holistically and with supportive care," noted Dr. Blazer, which include moving regularly, taking over the counter medicines like acetaminophen or ibuprofen and even acupuncture. Additionally, moving regularly and eating a healthy diet can help lower the risk of developing arthritis, added Dr. Blazer, as well as having injuries properly treated. "One of the biggest causes for osteoarthritis progression is injury," stated Dr. Blazer. "We can have injuries or some sort of accident, and that can upset the support tissue in our joints. And often we don't go to physical therapy, we just sort of keep moving." Not taking the time to heal properly after an injury or making sure that your joints are moving well can raise the risk of developing arthritis later in life, she concluded.

Read the full article at Yahoo.com.

Dr. Blazer explained her background and passion for lupus. “As an African American woman with a large, Texan family, I grew up with a ton of family around. When I learned that one of my cousins had lupus during medical school, I became intrigued and committed to helping patients like her. Over the years, I have seen my patients through the lens of family. Understanding how their wellness practices influence their overall well-being is near and dear to my heart.”

Dr. Blazer explained, “I would say the most transformative period of my career happened when I started to do research in West Africa. I’m interested in lupus as it affects people of African ancestry and started to study a genetic risk factor for kidney disease as a rheumatologist in training. I wanted to understand how this genetic risk impacted lupus outcomes throughout the African diaspora. One of my mentors helped train the only rheumatologist in all of Ghana and connected us.”

She continued, “As a scientist, learning and building pipelines of information about African ancestry lupus patients was fascinating. Learning with my Ghanian colleague with a unique perspective to mine was all the more gratifying. I learned that I am much bigger than my perceived limitations. I definitely broke barriers that I had no idea I was capable of breaking.”

Dr. Blazer advised practicing daily gratitude as a lifestyle tweak to support better wellbeing. She said, “As humans, our minds often fall on the loudest or most negative aspects of our lives. This coupled with the constant outside chatter can really contribute to stress. One of the best remedies is to practice gratitude every day. Keeping a gratitude journal to give thanks for what went right in your day, doing a short meditation, or even a nightly prayer can all be ways to center attention on your blessings. This can foster health and well-being.”

Read the full interview at Medium.com/authority-magazinblae.

Dr. Blazer explained, “Essentially, holistic medicine is caring for someone with regard to all of them. So, not just their physical health, their spiritual, emotional, psychosocial health.”

She said in many cases, “minoritized” patients face disparities regarding multiple social determinants, in addition to their health.

Read the full article at Healio.com.

According to Dr. Blazer, “Rheumatoid arthritis is a primarily inflammatory condition, so what I hear from my patients with rheumatoid arthritis is when they wake up in the morning, their joints feel very stiff, sometimes swollen. It improves with movement or putting the hands particularly under hot water, and this stiffness lasts for over 30 minutes, sometimes up to an hour or two or longer.”

Osteoarthritis (OA) is caused by degenerative wear and tear on the joints. Over time, the cartilage or meniscus becomes damaged, leading to joint injury and pain.

Dr. Blazer explained, “OA does more classically happen in older adults, but we're seeing it happen younger and younger for a couple reasons. Osteoarthritis is one of these conditions that goes along with overall difficulty with metabolism. So, the more that we see things like obesity, diabetes, hypertension, metabolic syndrome, we're also seeing OA.”

“Just as those conditions are happening in people younger and younger, OA is happening in younger and younger people,” she added.

Dr. Blazer underscored that if people suspect their pain could be rheumatoid arthritis, they should be seen by their physician as quickly as possible.

Watch the full segment at Cbsnews.com.

Dr. Blazer received the Career Development Award to Promote Diversity in Lupus Research. She will build upon her preliminary research, which successfully separated lupus nephritis patients from non-lupus nephritis patients through the analysis of the sediment found in the lupus patient urine. The potential clinical use of the non-invasive urine-based test will be confirmed using a larger multi-national SLE patient group with African ancestry, which will provide a new opportunity to learn more about lupus nephritis in a high-risk and understudied patient group.

Dr. Fernandez Ruiz received the Postdoctoral Award to Promote Diversity in Lupus Research. She will investigate how permanent changes in our genetic makeup, called gene variants, influence lupus development and progression. By studying how genetic variants in the PRKG1 gene affect lupus, the research team may identify new biological pathways that could be targeted to reduce the inflammation in lupus patients caused by high levels of interferon alpha.

Read the full press release at Lupusresearch.org.