Presentation on theme: "Comorbidities in Rheumatoid Arthritis"— Presentation transcript:
1Comorbidities in Rheumatoid Arthritis Dr Barb Blumenauer MD FRCPC
2Comorbidity Associated With RA Comorbidity in RA can be due to the disease, due to its treatment or due to lack of exercise, increased incidence of smoking etcRA increases standardized mortality rates(SMR) 50-60% compared to age and sex matched general population.RA patients tend to die prematurely and estimates range from yearsDisease control may impact survival although SMR haven't changed with advances in treatment but this may reflect the increased life expectancy of the population as a wholeMethotrexate has been shown to decrease mortality and there is evidence as well for anti-TNF therapy
3MortalityMost of excess mortality due to premature cardiovascular deathsHigher incidence of smoking in RA patients versus general population which could impact survivalRA patients often less physically activePrednisone has been shown to increase risk of CVD and increases with increasing daily dose and total cumulative dose.
4Cardiovascular Comorbidity in RA RA patients have increased incidence of MI and this is present even before onset and diagnosis of RARA patients less likely to survive MI with increased mortality in the first 30 days post MIStandard CV risk assessment such as Framingham underestimates the risk.No clear tool to estimate risk but many feel RA should be stratified and treated as per a diabeticSome evidence multiplying Framingham by a factor of gives better estimate
5CVD Cardiovascular Disease in RA RA patients may get more small vessel disease not surgically treatableNSAIDS causing even 4-5 mm Hg elevation in blood pressure can increase MI risk as shown in Vioxx clinical trialsRA patients are used to pain and may mistake chest pain due to MI as being MSK in origin and not seek or delay in seeking treatment and vice-versa ER personnel may make same mistakeTarget LDL 1.9 or less in RA patientsTight BP control as well
6Neurologic Disease in RA Increased incidence of CVA in RA patientsRarely peripheral neuropathyArava and Plaquenil rarely cause neuropathy
7Infection in RASome treatments may increase risk of infection however RA is an independent risk for infectionInfection risk higher with longer disease duration or increased disease activityAlthough some drugs may increase risk of infection BC data ( Dr Diane Lacaille) shows that treatment of RA with DMARDs actually reduces risk of infection compared to RA patients not on treatmentPrednisone significantly increases infection riskBiologics may increase infection but generally patients who make it through the first 3 months without infection don't have increased risk thereafter
8Infection in RAIncreased risk of lung ( may be due to smoking, interstitial lung disease)Also increased risk of skin and joint infectionJoint infections occur in native and artificial jointsBeware a disconcordant joint it may be infected rather than a flareTo reduce infection stop smoking, ensure vaccinations including influenza, pneumovax and Twinrix UTD, reduce/avoid PDZ, control disease activityConsider shingles vaccination before DMARDs beyond Plaquenil and sulfasalazine are started
9Infection in RABeware TB reactivation as patients immunocompromise may be due to effects of treatment or RAPPD may be falsely negative when RA disease activity highIf PPD 5 or more need prophylactic treatment to use biologic therapyBe on the look out for atypical infections including MAIC – I have had 3 patients within a yearSnowbirds ( does half of everybody else's practice run away for the winter?) often in areas where histoplasmosis and coccidiomycosis endemic and they may not present in a typical fashionLeukopenia or neutropenia common which could increase infection ( Felty's syndrome etc.)
10Lymphoproliferative Disease Leukemia and lymphoma rates about double those of general populationMethotrexate, Imuran and anti-TNF agents increase risk of lymphoma as does longer RA duration and increased disease activitySmoking increase lymphoma risk as well
11Malignancy in RAAside from lymphoma and leukemia also increased risk of lung cancer and skin cancers in RAPatients should practice safe sun and check skin regularly for any abnormalitiesLiterature supports lower incidence of colon CA which may be secondary to NSAIDs – will colon CA rates rise with more judicious use of NSAIDS with CVD risk concerns?Anti-TNF agents may slightly increase risk of lymphomas and skin cancers and ?lung CA(data contradictory) but appear to decrease risk of colon and breast cancer
12Lung Disease in RARA patients at increased risk of lung disease and it is often subclinicalLikely increases risk of pulmonary infectionMay be secondary to drugs such as methotrexate, Arava, goldPatients with ILD have increased mortalityRegistry data suggests doubling of mortality rate in RA patients with ILD who take anti-TNF agents
13C1-C2 SubluxationSynovitis can lead to instability but usually in long standing diseasePatients with symptoms or after 10 or so years of disease should be screened periodically and pre-operatively with cervical flexion and extension views to exclude significant subluxationUsually if greater than mm surgical fixation requiredNEVER passively flex a rheumatoid neck because if they have this you can compromise the cord and paralyze or kill themRA patients shouldn't have neck manipulation from ANY practitioner and need to be specifically advised chiropractic neck manipulation could be unsafe
14Ocular ComorbiditiesEpiscleritis and scleritis most common eye involvement but rare with advent of better treatmentCan lead to ocular perforation if not controlledWatch for glaucoma if on high dose prednisoneCataracts with PDZ
15Osteoporosis RA independent risk factor for OP RA Automatically moves patient up one risk category for fracturePrednisone also automatically increases risk one category i.e. low, medium or high risk for fractureTherefore RA patient on PDZ high risk for fracture regardless of BMD valuesReduce/avoid PDZ, stop smoking and increase activity to reduce risk of OPStart OP prophylaxis if you start PDZ unless certain it will be a short course except in women of child bearing potential due to concern about fetal bone malformation in subsequent pregnancy
16DepressionRA patients have a higher incidence of depression and this can be compounded by dugs such as PrednisoneMany depressed patients feel it is the RA that is the problem but treating RA often improves function, pain and quality of life
17Rare RA ComorbiditiesVasculitis rare in RA but occurs and sometimes in association with methotrexateRenal disease rare from an RA perspective but chronic NSAIDS can cause issues as can gold and cyclosporine.
18ConclusionsRA is associated with significant co morbidities than can reflect disease severity, duration or treatmentGenerally controlling disease activity can reduce some of these issuesStratifying CV risk problematic with the tools available currently but they are high risk and should be treated as such due to their excess death from CV disease and increased rates of premature deathPatients should quit smokingAvoid/reduce PDZMethotrexate confers a survival advantage ( less dead is almost always better than more dead)
19ConclusionsEnsure immunizations are UTD but live vaccines contradicted with most DMARD agentsPromote fitness ( RA FIT website great)Maintain ideal body weight- being obese is a pro-inflammatory stateBe vigilant about BP controlWatch for infections including atypical onesDiagnose RA early and control disease to give patient best chance to avoid comorbidities!