By Bryant England, MD, PhD, as told to Stephanie Watson

Rheumatoid arthritis (RA) causes a lot of problems for my patients on its own. But people with RA often have a constellation of other chronic conditions. The ones that I often see are cardiovascular disease, obesity, diabetes, depression, and lung diseases like asthma, COPD, and interstitial lung disease.

There are a lot of reasons why people with RA get these other conditions. One of them is that the same processes that lead to RA also drive these diseases. For example, inflammation may contribute to cardiovascular disease. Having higher disease activity, meaning the RA isn't well-controlled with medications, can increase the risk of heart disease.

RA also shares risk factors with other diseases. Smoking is the strongest environmental one for RA. It's also the strongest one for developing lung diseases.

Once people get RA, some of the medications they receive can contribute to developing other conditions. Glucocorticoids bring down inflammation, but they also raise blood sugar levels, which can increase the risk for diabetes.

On top of that, living with RA makes it harder for people to do their routine activities and stay active. It might prevent them from working. That can put a lot of strain on their mental health.

How do these conditions affect the progression of RA?

We don't really understand that yet. But we do know that these diseases are bidirectional. In other words, RA may influence these other conditions, and the other conditions also influence RA.

For example, people who are anxious and depressed have higher measures of RA disease activity. They tend to not feel as well, and they often have more tender joints. When your mental health isn't good, you generally don't feel well. Inflammation from RA may also influence a person's mental health. The relationship goes both ways.

What are the challenges of managing several conditions at once?

During a typical office visit, it is challenging to cover everything. Just focusing on joint health can take a full visit.

The other challenge for rheumatologists is making sure that we're treating the whole person. We can get very focused on a treat-to-target strategy for their joints, with the goal of low disease activity or remission using disease-modifying therapies. When we treat people who have multiple other conditions, we need to have a more holistic view and think about how RA and these other conditions are affecting their overall health. 

We also need to consider how RA treatment might affect those conditions. If I'm discussing an RA medication with someone who also has severe diabetes and COPD, I recognize that they are more likely to get complications like pneumonia from treatment. I might have a different conversation with them than I would with someone who doesn't have those risks.

How can treating other conditions affect RA progression?

We don't know for certain that optimal control of other chronic diseases improves their joint disease. But we do know that people with multiple chronic conditions have a harder time achieving RA treatment targets.

I think what's more important is to ensure that the treatment of RA and these other conditions is optimal for the person. Controlling those other diseases will be better for their long-term health and quality of life.

Sometimes rheumatologists get focused on preventing swollen joints and putting people into remission. But we also need to pay attention to the broader aspects of their health in order to assist them in living the best possible life.

Which doctors should be involved in treating multiple conditions?

People with RA might see several different specialists. This can be challenging to coordinate in our current health care system. I stress to my patients that they need to have a good primary care provider.

The primary care provider is the quarterback of your team. They have the big-picture view of everything that's going on with your health. The primary care provider is going to coordinate with all of your specialists, including rheumatologists like myself.

What extra monitoring do people with RA need?

There aren't guidelines on screening for most other chronic conditions specifically in people with RA. People should visit their primary care doctor for regular health screenings.

One condition that we do have some guidance on is osteoporosis. RA inflammation can speed up bone loss, and glucocorticoid medications can lower bone mineral density. We can order DEXA scans at regular intervals to screen for osteoporosis, and recommend calcium, vitamin D, exercise, and other therapies to prevent bone loss.

Don't be afraid to tell your rheumatologist about symptoms you might not immediately connect to your joints. Do you get short of breath when you walk up stairs? Can you do the same amount of physical activity that you used to do before? Your doctor might be able to connect the symptom to your RA or refer you to another expert for testing.

When it comes to diagnosing other conditions, timing is important. I worked on a study where we found that people with RA started getting other conditions right around the time when they were diagnosed with RA. This indicates that we need to evaluate people for other conditions from the moment we're diagnosing them with RA.

We don't want to just manage these conditions. Our goal is to prevent these other conditions from developing in the first place. And we need to do that early on.

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SOURCE:

Bryant England, MD, PhD, assistant professor of medicine, University of Nebraska Medical Center, Omaha, NE.