Category Archives: complications

Can rheumatoid arthritis kill you?

Here is an email question I received recently…

“I have been in search of a very important question, can you die from RA?  It is listed on a death certificate of a person I know that did not have an autopsy and there were no doctors present when this person died. The person had RA but I am not convinced that this is true and heard you can NOT die from RA alone.  I would appreciate any information you could offer.”

Actually, this is a very interesting question because it brings up an important issue.

Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis, affecting more than 2 million Americans.  It is a systemic autoimmune disease that can affect virtually any organ system.

What is not appreciated by many people, including physicians, is that RA has been associated with a significant mortality risk.

It has been estimated from a number of studies that uncontrolled or poorly controlled RA can shorten life span by ten to fifteen years. Despite the many treatment advances made in recent years, early mortality from rheumatoid arthritis remains a significant concern.

So why is that?

The answer lies in the chronic inflammation caused by the RA. The inflammation sets up an autoimmune situation that is perpetually turned on.  Essentially there is no “off-switch.”

Elegant studies done by Dr. Gerald Weissman and colleagues at the New York University School of Medicine implicate chronic gingival inflammation as the underlying trigger.

In any event, this chronic inflammation leads to early atherosclerotic cardiovascular disease. Heart attacks and strokes are the end result.  While this affects all patients, the effect seems to be most pronounced in women.

Some investigations have provided evidence that aggressive intervention with disease modifying anti-rheumatic drugs (DMARDS) and biologic agents may reverse the tendency to early heart attack and stroke.

Another cause of early death can be lung involvement leading to fibrosis and destruction of lung tissue.

Early crippling and disability is rarely seen nowadays.  However, in the past, this too was a significant cause of early death.

Rheumatoid vasculitis is a devastating complication of RA.  This problem occurs as a result of inflammation of blood vessel walls.  The inflammation causes closure of blood vessels to major organs and that obviously can cause major problems.  Immunosuppressive therapy has had mixed results as far as resolution of the problem.  Occasionally, high dose steroids and biologics have been used with some modicum of success.

This discussion would not be complete without a mention of early death related to treatment.  Non-steroidal anti-inflammatory drugs (NSAIDS) used to treat pain and inflammation can cause stomach ulcers, gastrointestinal bleeding, as well as liver and kidney damage.

Disease-modifying drugs such as methotrexate used to slow disease progression may also present problems.  And biologic therapies, even though they have revolutionized our approach to RA, because of their profound effects on the immune system, can also cause complications leading to death.

Nonetheless, when RA is treated appropriately, the benefits of therapy, I think, outweigh the negatives.

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Rheumatoid arthritis drugs… which ones are friendly to the heart and which ones aren’t!

Rheumatoid arthritis (RA) is a chronic, autoimmune systemic disease which affects approximately two million Americans. While the symptoms that bring the patient to the doctor are the joint swelling and pain, the area of most concern may not be the joints.  It is well established that cardiovascular risk is markedly increased in RA and in fact it is this complication that shortens lifespan by between ten to fifteen years.

A number of clinical studies have retrospectively examined the relationship between certain medications and the risk of cardiovascular events.  The report card has provided some real surprises.heart-attack_0

For example, methotrexate, the workhorse disease modifying anti-rheumatic drug (DMARD) of choice reduces cardiovascular mortality by almost 70 per cent. The mechanism is felt to be due to a reduction of atherosclerotic plaque formation as well as increased clearance of foam cells (Solomon DH, et al. Circulation 2003; 11: 1303-1307).

The other major player in the treatment of RA is the TNF inhibitor group.  These are used in more than 50 per cent of RA patients in the US. These drugs apparently reduce the risk of cardiovascular events by almost 50 per cent (Gonzalaz A, et al. Ann Rheum Dis. 2008; 67: 64-69). Why this occurs is still not clearly understood.

Steroids have been used to treat RA since the early 1950’s.  Steroids have been shown to worsen cardiovascular risk because of their effects on both blood pressure as well as blood glucose.  Steroid use in RA has been associated with increased carotid plaque formation as well as increased arterial stiffness.  So what dose is a safe dose?  The answer is still unknown.

Non-steroidal anti-inflammatory drugs (NSAIDS) raise blood pressure.  Randomized clinical trials have shown that cardiovascular risk is associated with COX-2 inhibitors but also with non-selective COX drugs also.  The upshot? All NSAIDS regardless of class, are associated with increased cardiovascular risk.

Hydroxychloroquine, a drug often used to treat mild RA, is associated with a decrease in diabetes and may also improve lipid status.  Actemra increases lipid profile but the long term effects are still unknown.  Leflunomide (Arava) increases blood pressure.  The eventual effects are still a subject of conjecture.

So what about aspirin?  This medication is used for cardiovascular prophylaxis.  In higher doses it also has anti-inflammatory effects although these are limited by the potential gastrointestinal side effects known to be caused by high dose aspirin. It is well known that other NSAIDS should not be used in patients taking aspirin for cardiovascular prophylaxis since they blunt that effect.

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Patients over 70 do well after minimally invasive spinal stenosis surgery

Rosemary Frei writing in Pain Management News reported on a study led by Raja Rampersand, MD at the Spinal Program of the Toronto Western Hospital and the University of Toronto. Analysis of data from 2008 to 2011 compared patients aged 40 to 69 with patients past the age of 70 who underwent surgical decompression for lumbar spinal stenosis.  There were no differences in adverse events between the two groups, although patients in both groups took longer to recover if a fusion accompanied the decompression. lumbar-spinal-stenosis-old-man

Comment: Spinal stenosis is one of the most common low back syndromes seen in rheumatology practice.  Although epidural steroid injections and physical therapy can be effective for many patients, many people with this malady go on to have surgery. This study provides encouraging news for patients with spinal stenosis.

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How to protect your back when you lift… another lesson in arthritis treatment

While arthritis is a frequent cause of low back pain and can be treated medically, most low back pain comes from simple daily activities such as lifting. In this case, prevention is the best treatment.low-back-pain-2

Lifting things the wrong way can cause severe low back problems including sprain, strain, and disc herniation.

Here are nine tips to help you prevent a problem:

  1. Plan ahead. Avoid sudden movements by clearing the path and ensuring you have a plan in mind.
  2. Stand with your feet shoulder width apart.
  3. Bend from your hips and knees, keeping your back straight.
  4. Use your core. Focus on trying to make your belly button meet your spine.
  5. Bring what you’re lifting as close to your body as possible both before and during lifting.
  6. Lift using your legs.  Push up from the heels.
  7. Ask for assistance if the object is heavy.
  8. Avoid twisting at the waist.  Keep the nose aligned with the toes. Move the feet.
  9. If pain does follow lifting and continues for more than 24 hours, see a physician.

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Conventional Medication Combo May Be As Effective As Anti-TNF Agents In RA

Nancy Walsh writing in Medpage Today reported, “Among patients with established rheumatoid arthritis, a combination of conventional disease-modifying drugs was as effective as early use of anti-tumor necrosis factor (TNF) agents,” according to a study presented at the annual meeting of the British Society for Rheumatology. Investigators found that individuals “who received disease-modifying anti-rheumatic drugs (DMARDs) had a change over 12 months on the Health Assessment Questionnaire (HAQ) of 0.45 points compared with 0.30 points for those given anti-TNF therapy.

I disagree with the findings of this study.  Conventional combination DMARDS are touted as being as effective as anti-TNFs by a few rheumatologists.  Personally, I don’t think they work as well and have their own share of potential side effects.

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What’s a safe dose of prednisone? Is there such a thing?

A spirited debate was published in the Rheumatologist, a magazine I get. The topic was the use of prednisone in rheumatoid arthritis.  Recent guidelines produced by the American College of Rheumatology regarding treatment of rheumatoid arthritis omitted the use of prednisone.

prednisone-5Dr. John Kirwan, a professor at the University of Bristol, who wrote several papers showing that prednisone had disease-modifying effects and held back the destructive processes of rheumatoid arthritis (RA) made his pitch. He advocated the use of prednisone in combination therapy for this condition.

Dr. Theodore Pincus, a professor at NYU, advocated the use of low dose prednisone (less than or equal to 5 mgs a day). He provided evidence that it was safe and effective at that dose.

Dr. Anthony S. Russell, a professor at the University of Alberta issued the counterpoint. He provided historical data showing that prednisone had long term toxicity without significant benefit (in his opinion.)

With all due respect to Dr. Russell, much of the data he cited was old data when higher doses of prednisone were used.  He also contended that primary care doctors would be tempted to use prednisone if they saw rheumatologists using it.

My opinion is this.  I use low dose prednisone a lot in my practice.  By low dose, I mean 5 mgs or less. I think it is effective as an add- on therapy.  It is also a great “bridge” if the patient is transitioning therapies. I have seen very little long term toxicity associated with this low dose approach.  And I think the benefits derived from improved activities of daily living far outweigh the negatives. I do think that doses higher than 5 mgs should be avoided if possible. I also don’t think the primary care issue is that big a deal although I admit… I have seen some indiscriminate use in my community.

 

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The Agony of Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis or frozen shoulder syndrome, is a common painful disorder characterized by a relatively long duration and limited range of motion in the shoulder.  The length of time the frozen stage of the disease can last is anywhere from 1 to 3.5 years with a mean of 30 months.

frozen-shoulderIncreased capsular collagen thickening and capsular contraction in the shoulder joint causes restriction in both active and passive range of motion in the shoulder.   Adhesions also develop that tether the joint surfaces. As the condition gets worse, pain can become more severe and is accompanied by stiffness and decreased range of motion. The stiffening may increase to the point where even the natural arm swing that goes along with normal walking is lost.   Pain at night is often unbearable.

The diagnosis is made using a combination of history and physical diagnosis.  Confirmation can be made using magnetic resonance imaging or diagnostic ultrasound.

The most common treatments for frozen shoulder currently are long-term intensive and aggressive physical therapy, corticosteroids administered by injection, manipulation under anesthesia and arthroscopic surgery.  Depending on the series and studies cited, the results of the different treatment modalities vary widely. Also, each treatment has associated risks.

Drugs are often used to manage the pain, but none have been demonstrated to have an impact on the course of frozen shoulder.

Frozen shoulder is estimated to affect approximately two to five percent of the general adult population.  Certain conditions are associated with an increased occurrence of frozen shoulder.  These include diabetes, Dupuytren’s contracture, trauma, a previous history of frozen shoulder, and thyroid disease.

The condition tends to occur in a patient’s fourth to sixth decade of life.   Frozen shoulder occurs slightly more often in women than in men and often presents bilaterally.  Unfortunately, it may affect the opposite side years after onset of symptoms in the first shoulder; however, it does not typically affect the same shoulder twice.

Recently the use of an injectable drug called collagenase clostridium histolyticum has been studied in clinical trials.  This is the same drug used to treat Depuytren’s contracture. The theory is that this drug may digest the excess collagen that accounts for the adhesions that are the ostensible perpetrators of the frozen shoulder. However, there is concern that this substance may also affect the normal cartilage of the shoulder.

Spontaneous remission is the usual course for many patients. However, this remission may take several months or years to take place.

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TNF Inhibitors and the Placenta… Which Should You Worry About During Pregnancy?

Mary Ann Moon writing in Rheumatology News reported on the conclusions of two studies. One concern rheumatologists have had is what to do about pregnant patients who are on TNF inhibitors.  Two observational studies (one from University California San Francisco and the other from Erasmus Medical Center, pregnant-womanRotterdam) provide some information.

The upshot is that stopping Remicade and Humira at the end of the second trimester reduces the amount of antibody transferred to the infant and shortens the time for the infant to clear the antibody. Cimzia doesn’t need to be stopped since it doesn’t cross the placenta.

Comment: This is important since it reduces the likelihood of opportunistic infection in the infant.

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More deaths from painkillers

Scott Glover and Lisa Girion writing in the Los Angeles Times reported that despite efforts “by law enforcement and public health officials to curb prescription drug abuse, drug-related deaths in the United States have continued oxycontinto rise, the latest data show.”

CDC data “reveal that drug fatalities increased 3% in 2010, the most recent year for which complete data are available. Preliminary data for 2011 indicate the trend has continued. The figures reflect all drug deaths, but the increase was propelled largely by prescription painkillers such as OxyContin and Vicodin, according to just-released analyses by CDC researchers.”

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Tipoffs to need for repeat joint surgery

Nancy Walsh writing in MedPage Today reported “Specific patient characteristics, such as depression and renal disease, can help predict which patients with knee or hip replacements are most likely to need repeat surgery joint-replacement-surgerywithin a year, a researcher reported” at an American Academy of Orthopaedic Surgeon meeting.

Investigators found that “in Medicare patients, one of the most significant independent risk factors for total knee arthroplasty revision within a year was chronic pulmonary disease, while depression was a main reason for revision total hip arthroplasty within 12 months.”

Several “factors influence outcomes in joint replacement surgery, including physician, health system, and device factors, but patient characteristics, particularly in older patients, have not been studied much, according to” Kevin Bozic, MD, “who presented results from two studies.”

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