It’s only recently that we’ve discovered that the same inflammatory processes that drive rheumatoid arthritis (RA) also are responsible for complications that affect other internal organs. For example, heart disease, which is a common complication in patients with rheumatoid arthritis is caused by inflammation.
Couple that with the fact that many patients with rheumatoid arthritis have other heart “unhealthy” risk factors such as corticosteroid use, diabetes, and high blood pressure. It’s no wonder the incidence of heart disease manifested by heart attacks and strokes are a significant cause of both morbidity as well as mortality.
We know that inflammation starts in the lining of an artery and sets up conditions favorable for the development of a plaque that eventually leads to narrowing of that artery.
It’s not only heart disease that’s a consequence of rheumatoid arthritis and chronic inflammation. Lymphoma, a malignancy condition affecting lymph nodes is a result of chronic inflammation as well.
With newer therapies that control RA better, it is evident that if the disease is controlled better, then there appears to be a decrease in heart disease and other comorbidities, because inflammation control is better.
So, as rheumatologists, it’s important to ensure that RA patients have their comorbidities dealt with. If the patient has a history of elevated cholesterol, it’s important for a rheumatologist to address that issue perhaps not as the primary care physician but as an advisor to the patient.
The same goes for hypertension, diabetes, and cigarette smoking.
There is little if any doubt that treating the primary joint disease with TNF inhibitors decreases some of the comorbidities. The evidence, while not overwhelming, is certainly suggestive. There is, as mentioned earlier, excellent data indicating that uncontrolled or poorly controlled inflammatory joint disease negatively affects morbidity and mortality.
Also, from the other studies, it is clear that there is a strong link between inflammatory joint disease and subsequent risk for heart disease.
So the question is this… are the newer therapies which carry risks of their own… do these risks justify their use in RA. The answer is straightforward. Every therapy has risks and also benefits. Every patient needs to understand that drugs have potential good effects… and potential bad ones as well.
During clinical trial development, close scrutiny of these drugs ensures that there is reasonable efficacy as well as safety.
Once a drug is approved by the FDA, then further surveillance of drug effects and side effects continues.
For example, currently, it is known that patients taking a TNF inhibitor plus a biologic have a slightly higher incidence of infection than patients just taking methotrexate. However, the benefit derived from combination therapy of methotrexate plus a biologic so far outweighs side effects. Patients just need to be monitored carefully.
Another drug pathway under study is blockage of IL 6. There is data indicating that inhibitors of IL 6 may raise cholesterol. But the “good” and “bad” cholesterol relationship we have always assumed may not necessarily be as cut and dried as we once assumed.
Also, changes in cholesterol property may be affected by the TNF inhibitors as well.
So… the bottom line is this: it’s important to recognize that all drugs have upsides as well as downsides. And that it’s important to monitor patients carefully.
Comorbidities are important factors to consider in patients who have rheumatoid arthritis.
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