What are the associated disorders and management options for patients with rheumatoid arthritis (RA)?

Associated Disorders with Rheumatoid Arthritis and Their Management

Patients with rheumatoid arthritis (RA) have significantly increased risk for multiple comorbidities, particularly cardiovascular disease (CVD), which requires aggressive screening and management alongside the primary joint disease. 1

Cardiovascular Disease

• CVD risk in RA patients is significantly elevated compared to the general population, with the magnitude comparable to that seen in diabetes mellitus 1
• Rheumatologists are responsible for CVD risk management in RA patients 1
• CVD risk assessment should be performed at RA diagnosis, once every 5 years, and when changing DMARD therapy 2
• Standard risk prediction models should be multiplied by 1.5 when certain RA disease characteristics are present 1
• Use of NSAIDs and corticosteroids should be minimized as they may increase CVD risk 2
• Statins are preferred treatment options for dyslipidemia in RA patients 1
• Adequate control of RA disease activity is necessary to lower CVD risk, with best evidence for anti-TNF and methotrexate treatments 1

Osteoporosis

• RA patients have increased risk of osteoporosis and fragility fractures 2, 3
• Assessment should include dual-energy X-ray absorptiometry and fracture risk assessment (FRAX) 2
• A FRAX-based approach with intervention thresholds is recommended for managing osteoporosis in RA 2
• Corticosteroid use should be at the lowest possible dose to minimize bone loss 2

Interstitial Lung Disease (ILD)

• ILD is a serious extra-articular manifestation of RA 1, 2
• Assessment includes evaluation of risk factors, pulmonary function tests, and HRCT imaging 2
• A multidisciplinary approach is recommended to determine ILD severity and management 2

Infections

• RA patients have increased risk of serious infections 3, 4
• This risk is further increased by immunosuppressive therapies, particularly biologics 3
• For patients with concomitant HBV/HCV infection, biological or targeted synthetic DMARDs can be used with antiviral prophylaxis or treatment in collaboration with a hepatologist 1
• Live vaccines should be avoided in patients on biologic therapies 5

Malignancies

• RA is associated with increased risk of certain malignancies, particularly lymphomas and non-melanoma skin cancers 3
• The relationship between RA treatments and malignancy risk is complex - TNF inhibitors may increase risk of non-melanoma skin cancers but data on other malignancies is less clear 3

Other Associated Conditions

• Fatigue is a common symptom requiring specific management approaches 1
• Psychological distress, including depression and anxiety, is more common in RA patients 1
• Fibromyalgia and obesity can complicate assessment of RA disease activity 1

Management Approach for Comorbidities

Assessment and Monitoring

• Composite disease activity indices should be interpreted with caution in the presence of comorbidities, particularly obesity and fibromyalgia 1
• Ultrasonography may be useful when there is doubt about inflammatory activity 1
• Regular monitoring of lipid parameters is necessary, as RA treatments can affect lipid levels 6

Non-Pharmacological Interventions

• Exercise programs improve physical functioning and can help manage pain and fatigue 1
• Psychological interventions such as cognitive behavioral therapy can reduce pain and fatigue 1
• Patient education and self-management programs are essential components of care 7, 8
• Smoking cessation is critical as tobacco use predicts worse outcomes 7

Pharmacological Considerations

• Treat-to-target strategy with adequate disease control helps limit RA-related comorbidities 2
• Methotrexate remains the cornerstone of RA treatment and may have cardioprotective effects 8, 9
• TNF inhibitors may reduce cardiovascular risk by controlling inflammation 9
• JAK inhibitors like tofacitinib can cause lipid elevations requiring monitoring 6
• The use of NSAIDs and corticosteroids should follow treatment-specific recommendations due to potential adverse effects on comorbidities 1

Pitfalls and Caveats

• Standard CVD risk prediction models underestimate risk in RA patients 1
• Inflammation can alter lipid parameters, making interpretation challenging 1
• Disease activity measures may be falsely elevated in patients with comorbid fibromyalgia or obesity 1
• Multidisciplinary care involving rheumatologists, primary care physicians, and specialists is essential for optimal management of comorbidities 7, 8
• Treatment decisions must balance control of RA with potential impacts on comorbidities 3