Rheumatoid Arthritis: a look outside the joints

by Dr Nachiket Kulkarni

Rheumatoid Arthritis has been known to mankind since early time of medical descriptions. Disease with joint pains and crippling deformities is how it has been described. This description is pretty much spot on! But is it a complete one? Not really!
Rheumatoid Arthritis is not just a disease of joints. It's a disease characterised by various systemic manifestations. These systemic features are receiving special importance in current research as these features have major impact on RA morbidity and mortality. These features are primarily of two types- extra-articular features and Co-morbidities. Extra-articular features of RA are those which occur as  a direct consequence of RA pathology. Eg Rheumatoid nodules, ulcers etc. They are discussed in other sections of this magazine. We would make ourselves familiar with 'Co-morbidities' in this articles. This term refers to diseases which occur commonly with RA but are not direct effect of RA pathology. More often than not the Co-morbidities decide the cause of death in patients of RA!
The list of Co-morbidities has been ever increasing in recent past. Their impact on treatment, costs and quality of life has been recognised. Its imperative hence to be aware of this problem to safeguard ourselves of the bad effects.
1. Cardiovascular Diseases : This may come as a surprise to many that patients of Rheumatoid Arthritis have double the risk of Heart Attack. It is believed that increased inflammation in RA makes a person susceptible to have atherosclerosis at a rate much higher than general population. This makes them prone to have heart attack, paralysis attacks or even limb ischemia at lesser age as compared to general population. Increased cardiovascular diseases are a major cause for decreased life span for a patient of RA. The treatment of these diseases is a costly affair. More ever the number of medicines increase. There is a risk of drug-drug interactions which can hamper treatment efficacy or worse cause complications.
There is increased occurrence of Hypertension in patients of RA. This further adds to burden of atherosclerosis, increased medication and drug related complications.Cardiovascular diseases hence have now been recognised as major co-mobidity with RA 'BUT' (here its used for a positive tense) this menace is under ambit of control. Your Rheumatologist makes assessment of this risk from the time of diagnosis itself – irrespective of your age. During your follow up visits monitoring is done for hypertension and lipid levels. Lifestyle measures of healthy eating habits and exercise are re-enforced by your Rheumatologist.
Please feel free and take up initiative for yourself to discuss diet and exercise with your doctor. In most cases these measures suffice and in others these go a long way to support general health. Some times specialists help is taken to either identify or treat these problems. Correct treatment of RA is also protective against these complication. It is a heartening thought that patients of RA on regular follow up and treatment are less prone to these problems as compared to those who don't.
• Infections: RA is an autoimmune disorder. The immune system starts attacking our own body cells. Though the activity of immune system increases it is actually a defective one. This affects the primary function of immune system- to safeguard against foreign insults like microorganisms. Coupled to this the medicines which are advised for RA further can increase risk of infections. This is most associated with Biologics. The highest risk is for respiratory infections. risk of other infections like urinary infections, gastrointestinal infections, skin infections, etc also increase. Risk is similar for bacterial, viral or parasitic infections. Most concerning are chronic infections like Tuberculosis and Hepatitis B. These are of special importance while dealing with biologics. It needs to be noted that infections in setting of RA might require an aggressive antibiotic therapy as compared to non RA individuals. BUT(again a positive sense) this co morbidity is under a measure of control. During your first assessment a thorough clinical and laboratory review is done by the Rheumatologist. Any therapeutic decision which your doctor takes is weighed thoroughly in risk versus benefit ratio. Screening of diseases are sometimes done in special situation like before starting Biologics. Vaccinations have revolutionised this fields. Vaccines against specific diseases can be administered as per your doctor. This decreases the morbidity and mortality due to those infections significantly. With widespread research in this field more and more vaccines are developed against various diseases.
•Nutritional Deficiency : This comorbidity gets under recognised and hence becomes a reason for untackled but common problems. By virtue of severe inflammation persons appetite is affected. The disease process itself can affect the digestive tract from mouth to colon. This adversely affects digestion. Medicines react with food causing vital nutritional deficiency. Some patients have severe gastrointestinal problems due to drugs which further increases the problem. BUT!! Your Rheumatologist keeps a keen eye out for this problem. Clinical and laboratory parameters are followed to keep a look out. The dietary recommendation  is to eat healthy. Nutritional supplements are used regularly and in emergency in intravenous form to meet the need.
•Depression: RA is a painful chronic disease. It's obvious to understand that if not rightly attended to a person can develop depression. It is being researched that depression is associated with RA  due to the pathophysiological mechanics. About 19% of patients of RA were found to have depression in a case series. This has a direct impact on treatment and medications. In view of taboo associated with the subject very few get identified. Many patients suffer for bereft of right treatment. Please feel free to talk with doctor on this issue. Your doctor can help you be happy.
•Others: As mentioned earlier apart from the main comorbidities associated with RA the list is ever-increasing. Prominent among them are Drug related side effects and cancer. Drugs are the best friend for a patient of RA. They are also a double edged sword with number of side-effects. The list sometimes is exhausting.BUT!! As may be the toxicities as efficient would be your Rheumatologists capacity to prevent them. The doctor decides the best suited medicine after analysing you and timely monitoring specific to the drug used are done to prevent them or identify early. Other major comorbidity is Cancer. Some cancer occur in higher frequency in RA like lung cancer and lymphoma while some have a lower risk like bowel and breast cancer. A timely diagnosis is key to successful treatment. Be aware and be regular.

Understanding of comorbidities have made management of RA more tougher. It requires anticipation and early diagnosis for able management. Anticipation comes from awareness. Hope this article has sensitised you to be aware of problems of RA outside the joint. The take home message is that effective treatment of RA and regular follow up will help probably prevent, identify early and adequately manage RA and comorbidities.