Autoimmune Disease

Episode 4 - Autoimmune Disease

Dr. Eric Chehab:Welcome to IBJI OrthoInform where we talk all things ortho to help you ‘Move better. Live better.’  I'm your host, Dr. Eric Chehab, and our goal is to provide you with an in-depth resource about common orthopedic procedures and conditions that we see every day today.

It's my pleasure to welcome Dr. Ami Kothari, board-certified rheumatologist, who will be speaking about autoimmune diseases that affect our muscles and joints. As a brief introduction, Dr. Kothari graduated from the University of Illinois, Chicago in 1999. She then went on to complete her medical degree in 2003 at UIC and continued her medical training at UIC, where she completed her residency in internal medicine in 2006.  Staying in Chicago, Dr. Kothari began her fellowship training at Northwestern University in Rheumatology, which is the study of autoimmune diseases that affect the musculoskeletal system. And she completed that fellowship in 2009.

She has received numerous awards throughout her career, including induction into the Phi Peta Sigma, Phi Kappa Phi, and the Golden Key National Societies. She has conducted numerous research projects on autoimmune diseases, which have seen several incredible advances over the past two decades. In medicine. there are jokes that orthopedists are strong as an ox and twice as smart, but the rheumatologists are uniformly regarded as some of the smartest doctors in all of medicine. So, Dr. Kothari, welcome to OrthoInform and thank you for being here.

Dr. Ami Kothari:
Thank you so much for that lovely introduction. And it's my pleasure to be here today.

Dr. Eric Chehab:
So Ami, let's begin with the basics. What is an autoimmune disease?

Dr. Ami Kothari:
So I get asked that question quite a bit, and it's the core of what Rheumatology is. When your own immune system, which should be protecting you, turns around and it decides to attack your body. It can cause a wide array of symptoms including hair loss, fatigue, joint pain, joint swelling, rashes, eye redness as well. So, the disease spectrum is very broad– but that's the core of what an autoimmune disease is.

Dr. Eric Chehab:
What are some of the common manifestations of an autoimmune disease that patients will come to you for help?

Dr. Ami Kothari:
Typically, they come with joint pain. So, a lot of times they'll have a swollen knuckle, or all of their knuckles will be swollen, or they'll have one swollen wrist or an elbow or a knee. Oftentimes they've already seen the orthopedic surgeon. And the orthopedic surgeon has determined that it's not a surgical condition, and then they refer to us or we get a lot of referrals from the primary care physicians in the area as well. From there, it's trying to figure out why they're swollen, why they're in so much pain.

Dr. Eric Chehab:
The majority of the time that these patients come to you with a swollen joint that hasn't been injured, correct?

Dr. Ami Kothari:
Correct.

Dr. Eric Chehab:
And, and so it's their immune system that's gone after that joint?

Dr. Ami Kothari:
Right. So, it's your immune system that has attacked that joint and then decided to attack primarily the lining of that joint, and it causes synovitis– it causes inflammation. That in turn leads to swelling in the joints. So when the patient sees it, it looks boggy, it looks swollen, it feels warm and it's really, really tender. And it's painful as well. Oftentimes, they feel very stiff, especially in the morning, they could be stiff for anywhere between 20 minutes and two hours.

And then they start to feel very tired and they feel very achy. Initially they chalk it up to any number of things. They think that they’ve worked too hard or they maybe bumped their knee, or they bumped their hand. But after a few months or even weeks, then they bring it to our attention. When it's just not getting better with conservative measures.

Dr. Eric Chehab:
So you mentioned the swollen joint and then also the fatigue and achiness in general, what are some of the other associated manifestations of an autoimmune disease?

Dr. Ami Kothari:
Sometimes their hair starts to get a little bit thinner. Sometimes the white part of their eye, their sclera, starts to get inflamed or just very sensitive to the light as well. Sometimes, especially with lupus patients, they could get cold sores on their nose or their mouth, or they get what's called a butterfly rash on their cheeks.

Dr. Eric Chehab:
What does that look like?

Dr. Ami Kothari:
It looks like a butterfly around the cheek, and it goes all the way up around the eyebrow. It spares the folds around the bottom part of the cheek near the lips. So, it's a sort of a textbook rash.

Oftentimes people see the dermatologist first and then they refer it to us because of this rash. Um, the sunlight tends to make those rashes worse, but the rashes associated with lupus can be very non-specific. And so we see such a wide spectrum.

Dr. Eric Chehab:
So you mentioned fatigue and achiness. With all of these different presentations that patients can come to with, how do you diagnose an autoimmune disease?

Dr. Ami Kothari:
I always think of it is putting together pieces of a puzzle. And that's one of the reasons why I love rheumatology so much, because every patient is just so different–

Dr. Eric Chehab:
Yeah, putting all those pieces together is also one of the reasons why you guys are the smartest doctors in the hospitals!

Dr. Ami Kothari:
That's very kind of you to say, I appreciate that, but I think of rheumatology as like this gray zone. A patient comes in and it's not just always like a point A to point B– like we're trying to figure it out.

And, so a lot of times when I first see the patient, obviously we take their history and we find out what brings them in, where their pain is, how long they've had it. And then there's all the fun clues that go into it. So it's sometimes it's a travel history. Sometimes they've had a tick bite. Sometimes they've had a new pet and then they've gotten bitten by that pet.

A lot of times it has to do with a family history as well. Beause autoimmune diseases can cluster in families. Not necessarily the same disease, but it'll be different variations of similar diseases.

And then a smoking history is critical. Smoking has been shown to be one of the causes for rheumatoid arthritis, not the only one, but one of the causes. And then after that history, which does take the majority of the visit, then it's the physical exam.

So it's looking for all the swelling that I was talking about earlier to see how warm and how swollen the joints are and how many joints are swollen. And then beyond that, then it's the labs, it's all the blood work. And many times when they come in to see us, they get a lot of blood work drawn– especially their first visit

In their first visit, I'm looking for inflammation. I'm looking for the antibodies for the different autoimmune diseases.

Dr. Eric Chehab:
So what are some of those autoimmune diseases? What are some diagnoses that would count as an autoimmune disease that you would see most commonly?

Dr. Ami Kothari:
So number one would be rheumatoid arthritis. And that's when your own immune system attacks your joints. But it's not just the joints, it could cause internal organ involvement as well. So we obviously care so much about the patient's joints, we're protecting that as much as we can. And I also want to prevent any long-term complications, internally. So that would be rheumatoid arthritis.

Then there's psoriatic arthritis, which is a bit of a variant. So that also is an autoimmune condition attacking the joints, but then people have pretty severe psoriasis, like skin inflammation.

I also see ankylosing spondylitis, which is also very similar, but they primarily have back involvement.  They have eye involvement and sometimes tendonitis. Like they get like an Achilles tendonitis. So they're all across a broad spectrum, but they're all similar, but there are variations.

Dr. Eric Chehab:
And you mentioned tick bite. Are there some infectious diseases that will mimic an autoimmune disease or are those tick bites or infectious diseases considered autoimmune diseases?

Dr. Ami Kothari:
So those are our mimickers. So those are like the parts of the puzzle that kind of throw us off sometimes, but then sometimes those can mimic an autoimmune disease. So we have to rule that out. So part of what I do as a rheumatologist would be, it's like a diagnosis of exclusion. We rule out even some of the more common things first before we make that official diagnosis.

But oftentimes a tick bite or an infection can cause a reactive arthritis. So it looks just like rheumatoid arthritis, but it's not. And so it's really critical to make that differentiation so we stay on the right track in terms of treatment.

Dr. Eric Chehab:
So once you've evaluated a patient and have been able to diagnose them with an autoimmune disease, what sort of treatment options do they have in front of them?

Dr. Ami Kothari:
There has been a wide array of treatment options. Years ago, the treatment options were so limited. And now I've been at IBJI for about 11 years. And even in these 11 years, I've seen new advances, which is the fun part of being a doc here.

And so initially it's the anti-inflammatory– so acutely when I see someone, they're just miserable. They're inflamed. They're tired. A lot of times I'll give an anti-inflammatory like a Motrin or, a Naproxen, or steroids– that's when I'm figuring out what's going on.

Once I get all the test results; and let's say for instance, it's rheumatoid arthritis– It's initially treated with what's called a DMARD, which are tablets. A common one is called methotrexate–

Dr. Eric Chehab:
What, I'm so sorry to interrupt, but what does DMARD stand for?

Dr. Ami Kothari:
Yes, I should have clarified that. It's a disease modifying anti-rheumatic agent. And so it's the initial treatment for these autoimmune diseases.

Dr. Eric Chehab:
And when I was growing up, in medicine, we were taught about SMARDs and DMARDs– the DMARDs being the disease modifying anti-rheumatic drugs, and then the SMARDs being symptom modifying anti-rheumatic drugs.

Is that still even in use today or how do you classify these?

Dr. Ami Kothari:
Moreso now it's like the anti-inflammatories like the NSAIDs and the prednisone, then it's the DMARDs, which are the oral tablets, and then it's the biologics, which are the injections– which patients see advertised for all the time– and that's like injections that patients are getting once a week to every other week. And then after that, it's the infusions. It's the IV medications. So there's definitely a step-wise approach when we see patients.

Dr. Eric Chehab:
Are all patients going to require all of those treatments or are there some patients who may not have severe autoimmune disease? How does that work for their treatment?

Dr. Ami Kothari:
Some patients, we start with just a DMARD, like the tablets, and that's what they're on for their life– because these are chronic illnesses. So there's a subset that go into remission, but most do need long-term treatment.

And then there's those patients that we cycle through several medications to find the one that fits them the best. That's where all the research is– why ‘drug A’ works for this patient, and ‘drug B’ works for that one. And that's where all the research comes in, and I think we're going to get there at some point, so it won't be so much trial and error, but right now it's definitely a step wise approach based on the safety data.

Dr. Eric Chehab:
Let's take a typical, let's say, rheumatoid arthritis patient– who comes to you with the fatigue and the achiness, maybe the hair loss, the swollen joint(s)… is it one joint or many joints?

Dr. Ami Kothari:
Sometimes it's just one joint. Sometimes it's very classic and it's like ‘textbook’ and they'll be both hands right at all the perfect spots.

Dr. Eric Chehab:
So when you're taking this step wise approach, tell us what that would be like for that typical patient.

Dr. Ami Kothari:
Once I officially make the diagnosis with that patient, I'll start them on an anti-inflammatory initially, and then make sure all the blood work is updated.

If I have everything updated and the diagnosis of the RA is confirmed, then I would typically start with methotrexate, which is a DMARD, which are tablets that the patient takes once a week.

I give that a month and I see the patient back in a month, if they're doing well, I escalate the dosage. I give them a higher dosage– if they do well, we continue that.

Normally, I give that initial medication about a three month trial. If they're successful, they continue on and we keep watching them every couple of months. If it's not successful, and by successful, I mean less pain and less swelling, less fatigue. Then I move on to a biologic, which is one of the injectable medications.

With each drug, unless they're having a side effect, we typically give about a three-month trial, because it takes that long to notice if it's effective.

Dr. Eric Chehab:
Got it. So let's take a drug like methotrexate– a DMARD. What are some of the side effects that patients can experience from the medication?

Dr. Ami Kothari:
It goes one of two ways: some people do great with this medicine, others, they do feel tired. They feel achy. They could get cold sores. There is a cancer risk to these drugs as well, too. And we go over that at great length with the patients before starting. And the risk is incredibly low, but depending on the other conditions that they have, we have to tailor-make it for each patient.

Dr. Eric Chehab:
I can see why a patient would trade a very low risk of cancer from one of these medications, for the incredible relief that they can experience from their autoimmune disease.

Dr. Ami Kothari:
Absolutely. They get such improved quality of life. Plus, I always bring home the fact that it also prevents internal organ damage.  So it's their joints, plus their internal organs.

So their ability to live a very long productive life just exponentially improves.

Dr. Eric Chehab:
When you mentioned that low cancer risk, I thought– wow– that's actually something I wasn't aware of. But then when you think about the benefit of these medications, they so far outweigh that very small risk of the cancer development.

Dr. Ami Kothari:
Absolutely. And then also it's important to treat inflammation– cause you don't want a patient to be in this chronic state of inflammation cause that in itself is a cancer risk as well. So you need to treat appropriately.

Dr. Eric Chehab:
And so now let's move on to the next step. We were talking DMARDs, with methotrexate being your example, now give us some examples of the biologics.

Dr. Ami Kothari:
So typical biologics would be like Embrel or Humira, which the generic names are adalimumab and etanercept. And so those have both been on the market for over 20 years. So they're, they're considered like this new treatment, but they're actually standard of care at this point.

Dr. Eric Chehab:
But it is amazing since the introduction of the biologics, as an orthopedist, we used to see patients who were crippled by autoimmune disease. And I mean, physically disfigured and really having an incredibly hard time managing their day-to-day lives. And the number of patients that we see with that type of disability has decreased so dramatically.

The number of joint replacements that we're needing to do for patients with severe, crippling, rheumatoid arthritis. Has declined dramatically since the introduction of the biologics.

Dr. Ami Kothari:
I completely agree. So we have our subset of patients, that unfortunately, didn't receive these treatments because they were diagnosed at a time before these treatments became available.  But for patients, and even with those patients, with treatment now, it prevents the progression– so there's definitely hope there too.

But now patients that are getting diagnosed, we don't see that anymore. And I tell patients, if I see that, it means I don't have you on the right drug. And so it's really unheard of for me to see that, with all our new starts for these medications.

Dr. Eric Chehab:
So what are some of the side effects of these types of medications? The Enbrils and the Humiras…

Dr. Ami Kothari:
So some typical side effects include increased risk for infection, coughs and colds, there's also a cancer risk– again, very, very low. If someone has TB or hepatitis sitting quiet in their system, then it could get reactivated.

So we always check for that ahead of time, too. With all of these medications, we do labs at baseline, which means blood work at the baseline and then every couple months. So we are very, very diligent to make sure that we don't see any even minor abnormalities as well. And it's truly, it's unheard of.

Dr. Eric Chehab:
So obviously these medications, you mentioned colds and fevers and infection risk. That seems to make sense to me because these are autoimmune diseases, and these are medications that are affecting the immune system. But the biologics, what's so special about them?

Dr. Ami Kothari:
Their mechanism of action. So like the Enbrils and Humiras, they work in, what's called a ‘TNF pathway.’ There's oral biologics that work in what's called a ‘JAK pathway.’ So there's basically, it's different pathways inside your body that are trying to treat the autoimmune disease. So what it's doing is it's calming down the immune system. It's not wiping it out.  But it's, it's calming it down to bring it to pretty normal level, but people have to still be conscientious as well.

Dr. Eric Chehab:
So it's not eliminating their immune system. It's being very selective about the part of the immune system that's causing the problem.

Dr. Ami Kothari:
Exactly.

Dr. Eric Chehab:
And that's been the advance, correct? That the biologics have become much more specific in that line of the immune system?

Dr. Ami Kothari:
Right. It's like the more targeted therapy. And then, so let's say a TNF, which is like an Enbrel or Humira doesn't work. I would pick a medication that works in a different pathway– and then oftentimes changing the pathway, which is like the mechanism of action, it makes all the difference in treating the patient.

Dr. Eric Chehab:
Now let's take it to that final step of medications that you mentioned– that IV/Infusion medication.  So we've gone from the the anti-inflammatories to help people feel better, then the disease modifying drugs, like methotrexate, then the biologics like Humira and Embrel. And now we're going to go to this last class of medications, right?

Dr. Ami Kothari:
Right. So it's the infusion medication. So patients will hear it referred to as infusion or as IV therapy. So that's the next step. So just because someone's on an infusion, doesn't mean that they have more severe arthritis than someone that’s on the injection.

It's just which medicine works and it's how it's introduced into the body. But our infusion patients, it doesn't mean that they're our most severe patients– it's just how those certain drugs are introduced into the body.

But we have an infusion center at our Morton Grove office. And it's been fantastic.  Basically, it's our patients that are treated for our autoimmune diseases, and also osteoporosis as well. It’s a very happy, uplifting environment with patients going through similar issues. And we have two great nurses in there and there's always a rheumatologist in the office as well. But the infusions are IV medications that are given whether it's every month, every six weeks, every eight weeks, depending on the drug, it's a different interval.

And then there's some drugs that are given at our infusion center that are actually injections.

Dr. Eric Chehab:
What are some of those drugs in the Infusion Center?

Dr. Ami Kothari:
We have a vast array of drugs, but we typically give Remicade, Simponi Aria, or Orencia. We also give Cimzia injections in there.  We also treat osteoporosis in there, so it gives, Prolia and Evenity and Reclast infusions as well.

Dr. Eric Chehab:
And are these IV infusion medications things that have come out 40 years ago, 20 years ago, within the last five years?

Dr. Ami Kothari:
Some of the drugs are over 25-30 years old. Others are, newer as well. So I would say each year, there's been certain changes.

Especially every couple of years we notice different infusions and also different injections that people can self-administer too.

Dr. Eric Chehab:
And obviously the goal of each iteration of the medication, each new generation that comes out, is to be more selective and have less side effects.

Dr. Ami Kothari:
Absolutely. And I've seen that as well. So patients’ tolerance with these medications is quite good. We rarely have an injection site reaction. People are in and out of that infusion center. Some infusions are a couple hours, but many, are even just 30 minutes.

So it really has improved their quality of life. So they're able to work, especially now people are working from home, so they're able to pop in, get their infusion and then just go back home.

Dr. Eric Chehab:
You mentioned earlier that autoimmune diseases are typically chronic diseases, but some do go in remission.  Do you foresee a cure for auto immune diseases at any point?

Dr. Ami Kothari:
It would be every rheumatologist and patient's dream. And so that's what we're all working for. And then I would predict that that at some point, I don't know if in my career it will happen, but I do think at some point there will be medications like that.

Dr. Eric Chehab:
So when we have a patient coming in for surgery as an orthopedist, again since we're as strong as oxes and twice as smart, it's difficult for us to always know what medications will affect their immune system in such a way that it could affect the outcome of their procedure.

So how do you advise your patients who do have autoimmune diseases?  If they're approaching any type of surgery, whether it's orthopedic surgery or general surgery, or urologic surgeries, what's the advice you'd give them in general?

Dr. Ami Kothari:
In general, there are some standard guidelines, but I always tell patients, if you were to have any procedure done, just call me– because then based on their other health issues, what exactly the surgery is, and how much is going to go into it, then we can tell the patients how far in advance they need to stop the medication and then when they can resume the medication.

Typically, I have patients stop the medicine a week before– have surgery– and then start a week after. But every patient's so different that I always just prefer that they call me. And then it's nice for the surgeon, too. So I have that all set and then there's just no confusion.

Dr. Eric Chehab:
Well, you know as well as I do, that I call you every time I have a patient coming in for surgery on one of the DMARDs or biologics, in terms of how far in advance I should stop their medication. And then when they can resume that medication. And it obviously depends on the infection risk or the procedure, as you were saying, plus the type of medication that the patient is on.

Dr. Ami Kothari:
Totally agree. And we all, as rheumatologists, we know our patients so well. We see them every couple of months. So, we know if they've had this higher infection risk or if they've been generally okay. And so that's why I like to just know what they're doing and that way they do better overall.

Dr. Eric Chehab:
So there appears to be a growing trend. I don't know if it's within the rheumatologic literature– about diet– possibly triggering some of these autoimmune diseases. Give us some more insight into the role of diet in perhaps the triggering of autoimmune disease or maybe on a different front, as treatment for an autoimmune disease.

Dr. Ami Kothari:
It's the big picture. So it's what the physician–what the rheumatologist– is doing is helpful, because it's the medication and it's formalizing the diagnosis. But it's also what the patient is doing.

And so diet is very important. I don't necessarily know that diet alone can treat the disease, but I always tell patients to have just a very healthy, balanced diet. Not too much processed foods.  Just like anything in life, you want it all to be in moderation. So unless they have another health condition, like celiac disease, where they have to completely avoid gluten or they're lactose intolerant and they have to completely avoid dairy, they can have those, but just in moderation.

Although some people do notice triggers. So for some people, dairy is just not good for them. And then they notice inflammation. So then I have them avoid it. But unless that happens, I like all the major food groups, but in moderation.

Dr. Eric Chehab:
Is celiac disease an autoimmune disease triggered by the environmental introduction of gluten, or is it not quite that? In other words, is it a mimicker? So you'd mentioned at the beginning, mimicking autoimmune disease are actually autoimmune diseases. How do food types like gluten play into that?

Dr. Ami Kothari:
Yeah, celiac disease is definitely an autoimmune disease. People with celiac disease definitely have to at all costs, avoid gluten. Celiac is autoimmune, but it's treated primarily by the gastroenterologist.

So even though as rheumatologists, we treat autoimmune diseases, there are some that are given to the other sub-specialties.

Dr. Eric Chehab:
We see the manifestations as orthopedists of things like celiac disease because people don't absorb the vitamins that build their bones due to the gastrointestinal problems that celiac disease causes. So we see those manifestations in terms of fracture risk and poor bone health.

Dr. Ami Kothari:
Right. And that's a great point because then, you're right, when we see our patients with the thinner bones, like the osteoporosis, we always screen for celiac disease to make sure that that's not a cause.

Dr. Eric Chehab:
And we just mentioned diet. What other things can patients do for themselves to help them with their autoimmune disease?

Dr. Ami Kothari:
So, along with everything that you mentioned, exercise is a key factor as well. So patients think that when they're swollen and they're in a lot of pain, they can't move.

That makes it worse. They become stiffer. They become achier. And then it's just this vicious cycle. So in the beginning, I'm like, just do regular stretches. Don't even break a sweat, just stretch, just walk, just move, and then just build it up from there.

And the more you move, just like with any illness, the better. It’s good for the cardiac health, and it's also good for the joints. But patients just have to take it slow. I also oftentimes send patients to our physical therapists because then they help tailor-make a program for them so patients aren't as nervous about hurting themselves.

And then the nutritionists that we have here have also been helpful in guiding patients on an appropriate diet– especially patients that sort of need help with the moderation part of it.

Dr. Eric Chehab:
Does sleep play a role in any of the autoimmune diseases?

Dr. Ami Kothari:
Sleep definitely plays a role. People with poor sleep tend to be more tired in the morning, headaches, and a lot achier as well.  Sleep, whether it's with autoimmune diseases or cardiac diseases, is critical– especially with people that have sleep apnea.

We'll refer patients to get a sleep study. And then oftentimes when they have their C-PAP machines on, they sleep better, and they feel better. So it's the big picture.

Dr. Eric Chehab:
So if a family member gets diagnosed with an autoimmune disease, what is their prognosis for the long haul? What are they looking at as their outcome over a year, a decade, a lifetime?

Dr. Ami Kothari:
I think the prognosis is excellent. Anytime when I'm meeting a patient and then especially when I'm giving them that first diagnosis, it's a tough conversation. And I always start with, ‘you're going to be okay.’

And then I go into everything that we're going to do. But it's a step wise approach, along with the guidance for the diet, the exercise, taking time to rest– putting all of that together, patients’ prognosis is quite good, especially with all these advances in treatment.

Dr. Eric Chehab:
It's so great to hear, because again, when I was in training, in the early two thousands, these biologics were just being introduced. We didn't really see the impact of them. I rotated on what was called the surgical arthritis service, which basically was taking care of all of these patients with terrible, terrible, crippling, deforming, arthritis.

And again, it's just not something we see nearly as frequently. So these advances and have been unbelievably impactful, and the care that you're able to provide as this group of incredibly intelligent, smart, and awesome doctors has been terrific.

Dr. Ami Kothari:
And it's been fun just to watch patients. Because I see them a lot of times when they're young. And then you see them grow up, you see them get married, you see them have their children, and you see their quality of life. And it has been so rewarding.

Dr. Eric Chehab:
It must be very gratifying.

Dr. Ami Kothari:
Yeah, definitely.

Dr. Eric Chehab:
So are there any other pearls or insights that you'd like to share with us about autoimmune disease?

Dr. Ami Kothari:
I would say that if any patient is suspecting that they have an autoimmune disease, it's never too early just to get an evaluation. And the best-case scenario is you don't– and if you do, there's great treatment as well. But it's always good just to get that evaluation, because if it's present, you want to get treated early.

And then if it's not present, you have a good baseline set of labs and an evaluation. So if something changes years down the road, then I would have something to compare it to. So it's never too early.

Dr. Eric Chehab:
And that early intervention is so important because as orthopedists, we know that these autoimmune diseases that affect the joints and affect the cartilage– we haven't figured out a way to reverse that. We haven't really figured out a meaningful way to replace cartilage when it's been damaged. So that early intervention really is critical.

Dr. Ami Kothari:
It is critical. And then the relationship that we have between the rheumatologists and the orthopedic surgeons here, it's been phenomenal. And we’re able to toggle back and forth and just treat the patients well.

Dr. Eric Chehab:
So our guest today has been Dr. Ami Kothari. Ami, thank you so much for being here and shedding so much light on autoimmune diseases, the diagnosis, the treatment, and this excellent outlook for these patients.

Dr. Ami Kothari:
Thank you for having me. This has been such a pleasure.