What types of vasculitis are associated with Rheumatoid Arthritis (RA)?

From the Guidelines

Rheumatoid arthritis is associated with aortitis, which is a type of vasculitis that affects large vessels, as well as other forms of vasculitis such as rheumatoid vasculitis, leukocytoclastic vasculitis, polyarteritis nodosa-like vasculitis, and giant cell arteritis. According to the study published in the European Heart Journal 1, aortitis associated with rheumatoid disease is one of the types of vasculitis that predominately involves large and medium-sized vessels. The study published in the Mayo Clinic Proceedings 1 also mentions that rheumatoid arthritis can lead to vasculitis, which is a marker of severe disease. However, the most recent study published in the BMJ 1 does not provide specific information on the types of vasculitis associated with rheumatoid arthritis, but it discusses the treatment of ANCA-associated vasculitis, which may be relevant to some patients with rheumatoid arthritis. Some key points to consider when evaluating vasculitis in patients with rheumatoid arthritis include:

• The size of the vessels affected, which can range from small to large vessels
• The severity of the disease, which can manifest as skin ulcers, digital infarcts, mononeuritis multiplex, and occasionally visceral organ involvement
• The presence of extra-articular disease manifestations, such as interstitial lung disease and inflammatory eye disease
• The treatment options, which can range from topical therapies for mild cutaneous disease to systemic corticosteroids and immunosuppressants for more severe manifestations. It is essential to note that the treatment of vasculitis in patients with rheumatoid arthritis depends on the severity and organ involvement, and it is crucial to consider the potential side effects of treatment, such as infections and gastrointestinal toxicity. In terms of specific treatment options, the study published in the BMJ 1 suggests that a reduced dose regimen of glucocorticoid may reduce serious infections at 1 year compared with the standard dose regimen group. Overall, the association between rheumatoid arthritis and vasculitis is complex, and it is crucial to consider the individual patient's disease severity, organ involvement, and treatment options to provide the best possible care.

From the Research

Types of Vasculitis Associated with Rheumatoid Arthritis

• Rheumatoid vasculitis (RV) is a manifestation of "extra-articular" rheumatoid arthritis and involves the small- and medium-sized arteries in the body 2
• Leukocytoclastic vasculitis is also associated with rheumatoid arthritis, as seen in a case study where a patient presented with leukocytoclastic vasculitis along with rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies 2
• Polyarteritis nodosa (PAN) is not typically associated with rheumatoid arthritis, as a pan-CT angiography of the whole body was negative for any vascular changes ruling out PAN in a case study 2

Clinical Presentation of Rheumatoid Vasculitis

• Rheumatoid vasculitis has a heterogeneous clinical presentation that includes skin disorders, neuropathy, eye symptoms, and systemic inflammation 3
• Classic cutaneous clinical manifestations include ischemic ulcers, digital gangrene, and palpable purpura 4
• Mononeuritis multiplex is another classic presentation of rheumatoid vasculitis 4
• Weight loss, pleuritis, pericarditis, ocular inflammation, splenomegaly, hepatomegaly, and Felty's syndrome have also been reported in association with rheumatoid vasculitis 4

Incidence and Treatment of Rheumatoid Vasculitis

• Rheumatoid vasculitis occurs in approximately 1%-5% of patients who have rheumatoid arthritis 2, 3
• The incidence of systemic rheumatoid vasculitis has declined significantly following the general early use of methotrexate in the 1990s 5
• Treatment of rheumatoid vasculitis is conventionally with glucocorticoids and cyclophosphamide, but there is an increasing role for rituximab similar to that in other types of vasculitis 5, 6
• Rituximab has been shown to be an effective induction therapy for systemic rheumatoid vasculitis, with complete remission achieved in nearly three-fourths of patients receiving rituximab in daily practice 6