Rheumatoid arthritis. For many, the term likely conjures up visions of swollen, disfigured, painful joints, and these are the hallmarks of untreated or poorly controlled disease.
However, RA is a chronic autoimmune disorder that does not just attack the joints. It causes widespread inflammation that can also lead to multiple serious problems — comorbidities — such as heart disease, high blood pressure, lung diseases and additional maladies. And some of these can start early.
“[Many of] the comorbidities that we see are present at the time of diagnosis of RA,” says Dr. Arundathi Jayatilleke, a rheumatologist and assistant professor of medicine at Drexel University College of Medicine in Philadelphia.
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“Patients with RA certainly have multiple comorbidities and [they] may start within the first few years of symptoms,” echoes Dr. Amish Dave, a rheumatologist at Virginia Mason Medical Center in Seattle.
“Different complications occur at various ages,” says Dr. Richard Lai, a rheumatologist and adjunct clinical assistant professor of medicine at the Pacific Northwest University of Health Sciences College of Osteopathic Medicine in Yakima, Washington. “Uveitis — inflammation in the eyes — leading to blindness may take place early in children with juvenile idiopathic arthritis,” he explains. “Adult-onset rheumatoid arthritis may cause other complications.”
Recent research has borne this out. A large, multinational study found that depression, asthma, heart attacks, stroke and chronic obstructive pulmonary disease are common in early RA. The participants in this 2014 study had been diagnosed for an average of 10 years, although some had been diagnosed for less than a year. “These associations between rheumatoid arthritis and medical comorbidities were seen across the countries studied,” Dave says.
A 2016 Swedish study found similar results. This study, which included 950 people who had been diagnosed with RA for a year or less, reported that 53 percent had one or more comorbidities at diagnosis. The most common were hypertension and COPD, which were present in 41 percent of the participants. Other early comorbidities included Type 2 diabetes and cancer. After five years, 41 percent had developed at least one new comorbidity, including hypertension, cancer, stroke or mini-stroke, heart attack and osteoporosis.
However, because many of these additional diseases are also common in the general population, “it can be difficult to determine whether they can be directly attributed to RA,” Jayatilleke cautions.
The inflammation that RA unleashes is a known risk factor for the development of cardiovascular disease. Another serious complication that is strongly correlated with RA is interstitial lung disease. According to Jayatilleke, the inflammation and nodules that are characteristic of ILD “can be present at [RA] diagnosis, and so [ILD] likely began even earlier.”
The Swedish study concluded that people with more active RA, as indicated by elevated blood levels of C-reactive protein and erthrocyte sedimentation rate — two markers of inflammation — and a higher RA disease activity score, were most likely to develop a new comorbidity, which indicates that the inflammation produced by RA plays an important role in the development of other concurrent diseases.
“More research is needed to determine when these comorbidities begin in relation to RA diagnosis,” Lai says.
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Three times as many women get RA as compared with men, but RA’s comorbidities don’t necessarily follow suit.
“Although RA is more common in women, the associated comorbidities are more common in men than women,” Jayatilleke says. “They are also more common in smokers, in people who have non-joint-related manifestations of RA, like skin nodules, and in people who were ever given corticosteroids such as prednisone,” she says.
Rheumatologists differ in their approach to screening newly diagnosed RA patients for other conditions.
“Because people with RA in the early stages of illness may not have ‘classic’ symptoms, it is difficult to come up with a ‘one-size-fits-all’ strategy for all patients,” Jayatilleke says.
Lai agrees. “There is unfortunately no standard recommendation to screen these comorbidities,” Lai says.
“The 2015 American College of Rheumatology Guideline for the Management of Rheumatoid Arthritis focuses on initiation and management of non-biologic and biologic disease-modifying anti-rheumatic drugs for RA,” Dave says. “Further guidance is needed to help rheumatologists determine how and when to screen for depression, cardiovascular disease, chronic obstructive pulmonary disease and other comorbidities,” he adds.
“Early and aggressive treatments at the time of diagnosis of RA are the current recommendation,” Lai says. “Overall, [this] seems to be the best approach to preventing complications, especially in people who have more severe arthritis or otherwise are at high risk,” he says.
“The topic of early RA is very important for the general public to be aware of,” stresses Dr. Amanda Sammut, who is the chief of rheumatology in the Department of Medicine at Harlem Hospital Center.
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“Unfortunately, I have seen people who have had swollen joints stay at home for months before seeking medical attention (they usually take over-the-counter medications),” says Sammut, who is also an assistant clinical professor of medicine at Columbia University College of Physicians and Surgeons in New York. “I have also seen patients wait months to see a specialist. During this wait, the RA does not care. It can be very aggressive,” she says.
“It’s very important to seek medical care early if you’re having signs and symptoms of RA,” she advises.
“The advances in treating RA using disease-modifying antirheumatic-drugs greatly improves the quality of life of patients,” Lai says. “In some studies, the use of newer biologics medications seems to decrease the risks for comorbidities.” Other preventive measures that should be emphasized are “cigarette-smoking cessation, lifestyle changes and dietary modifications,” he adds.
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Heart and Lung Disease and Other Complications Start Early in Rheumatoid Arthritis originally appeared on usnews.com
