RA Burden Goes Far Beyond the Joints

Cutolo M, Kitas GD, van Riel PL. Burden of disease in treated rheumatoid arthritis patients: Going beyond the joint . Semin Arthritis Rheum (2013) doi: 10.1016/j.semarthrit.2013.08.004. First published online October 3, 2013.

As new biologic drugs and earlier use of disease modifying anti-rheumatic drugs (DMARDS) stave off joint damage in rheumatoid arthritis (RA), clinicians should now focus attention on alleviating the extra-articular burden of disease, a multinational literature review concludes.

The review of 118 studies details many systemic comorbidities, psychosocial issues, and impairments in health-related quality of life with RA that could be mediated by drugs with new mechanisms of action and current therapies. For example, inhibition of the pro-inflammatory cytokine IL-17A shows promising activity in early clinical trials that evaluate fatigue and other common extra-articular conditions.

RA patients have an approximately two-fold higher cardiovascular risk. the authors observe, so these risk factors require attention. They also note substantial evidence that conventional treatment with methotrexate reduces the risk of heart attack, stroke, and congestive heart failure, possibly by down-regulating proinflammatory cytokines.

Methotrexate is also associated with improvements in HRQOL in early-stage RA. Tumor necrosis factor inhibitors have similar effects.

Although proinflammatory cytokines may alter the hypothalamic–pituitary–adrenal axis and play a role in the depression that affects up to 40% of RA patients, the review finds little evidence that anti-inflammatory therapies help with depression.

The authors note that other comorbidities – such as osteoporosis, respiratory disease, infections, and malignancies – are often associated with treatments. They recommend prevention efforts, including prescribing bone-building drugs with corticosteroids.