VIDEO: Common comorbid conditions with RA

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Yeah, there's a number of comorbid conditions that we observe in patients with rheumatoid arthritis or RA, some of those comorbid conditions rheumatologists consider extraarticular, outside of the joint manifestations of RA, and some of them are conditions that are commonly seen in patients with RA. And I would differentiate those two by saying extraarticular are likely caused by RA, and these other conditions might be caused by the systemic inflammation of RA, but we don't really know that. We know that they are commonly occur in the setting of RA, and so some of those extraarticular manifestations include rheumatoid-associated interstitial lung disease. And that's, we see that more and more, it happens in probably one to 5% of patients depending on how you screen for it. Another extraarticular manifestation is the anemia of rheumatoid arthritis, and this is typically an anemia of chronic inflammation or anemia of chronic disease. This is commonly seen in patients with RA, and usually improves with treatment.

There's many patients, there's some patients who develop large spleens, and drops in their platelet counts, Felty syndrome, this is something that we see less and less commonly as we treat rheumatoid arthritis more aggressively, other extraarticular manifestations include some eye complications, sometimes throat complications, and then very rarely is vascular inflammation, vasculitis. It's uncommon these days with rheumatoid arthritis, but we do see it occasionally. Those are the ones that I would describe as extraarticular manifestations, really things that are clearly known to be associated with severe RA, likely caused by RA, and then all the comorbid conditions that we worry about increasingly in rheumatoid arthritis are things like cardiovascular disease.

We see the risk of cardiovascular disease is about 50% higher in patients with rheumatoid arthritis than in age, gender matched people without RA or, you know, controls. We see that patients have a slightly higher risk of diabetes. And you know, there's a number of other cardio-metabolic complications that we see in many patients with RA, as well, depression, anxiety are commonly seen, and I think this is an area that people are continuing to research, and finally, I'll just mention chronic kidney disease, used to be that with poorly treated RA, we saw patients who had secondary amyloids, this is uncommon in today's, you know, well-treated rheumatoid population, but we still see that people with RA likely have a higher risk of chronic kidney disease, and worse glomerular filtration rates, GFRs over time. Is that related to the drugs or the disease? I think that's still to be determined.

There are some obvious ways that we think about using treatments in the setting of different comorbidities, and extraarticular manifestations. So I will say that, you know, an extraarticular manifestation like vasculitis, I think that many of, many rheumatologists would consider using medicines that might be depleting a B cells like rituximab. But in the setting of a typical patient with comorbid conditions like cardiovascular disease, under diabetes, or kidney disease, you know, we know that many of our medicines may have impacts on those organ systems. For example, kidney disease. We'd obviously be very careful about the use of non-steroidal anti-inflammatory drugs, NSAIDs in the setting of chronic kidney disease.

The use of drugs like methotrexate, we know the dosage needs to be adjusted in patients with reduced GFRs. So we need to think about the excretion, we need to think about potential toxicities in medicines. A common comorbidity that doesn't necessarily go along with RA, but is seen in a lot of older adults, diverticulitis, we know that certain drugs like IL-6 blockers cannot be used or should not be used in those patients.

So we know how to guide therapy based on some common and less common comorbid conditions, but this is really a focus with so many treatments for RA, I think many of us who do research are focusing on how to best tailor our treatments based on comorbidities. The second part of your question was about vaccinations, and vaccinations, I would say that I am increasingly vaccinating more frequently and more aggressively, you know, whether that be COVID or shingles vaccine, or pneumococcal Prevnar vaccine, I think more and more of us in clinic are setting up protocols where we have reminders, and nurses, and other people that help us to stay on top of patients to make sure they're getting their flu vaccine every year and all the other vaccines.

There are data that suggest that holding medicines like methotrexate around the time of vaccine may be beneficial, meaning that the immunogenicity, the antibody responses that are achieved are more robust when we hold certain DMARDs around the time of vaccines. This is an active area of research, so I don't think it's been determined, but guidelines now for COVID-19 vaccination are suggesting that we hold onto, we hold medicines for a week or two before and a week or two after to make sure patients who are able to hold their medicines get the full immunogenic benefits of a vaccine.