Category Archives: Rheumatoid Arthritis

An autoimmune, systemic form of arthritis and the most common inflammatory arthritis

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.

For more information on arthritis treatments and other arthritis problems,  go to:

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Don’t be a victim of arthritis myths… Arthritis treatment is effective!

Ashley Macha, writing in Health online, reported on four arthritis myths.  This was done as part of a May is Arthritis Awareness Month campaign, featuring Joe Montana, Hall of Fame quarterback.

1. Myth: Arthritis only affects the aging.  Reality: This is the most common misconception. Anyone, at any age can be affected, according to the Arthritis Foundation. The most common type is osteoarthritis, the kind due to wear and tear on the joints over time (which is what Montana has), but also rheumatoid arthritis, an autoimmune disease that can occur at any age, juvenile arthritis, an autoimmune disease in children, and other types.

2. Myth: Joint health is not a serious issue. Reality: The population of those with arthritis in the United States is increasing, with approximately 70 million Americans predicted to have arthritis by 2030. It is the number one cause of disability in the United States.

3. Myth: Patients with arthritis should avoid exercise. Reality: The Arthritis Foundation recommends starting out walking or doing water workouts. Montana lifts weights to keep his muscles in shape. “When muscles are strong, it takes pressure off them [joints].” Patience White, MD, and vice president of public health for the Arthritis Foundation says resistance training can provide numerous benefits for those who suffer from arthritis. Dr. White recommends simple exercises, including hamstring and calf stretches, or weightlifting with something as simple as 16-ounce soup cans.

4. Myth: There is no treatment for arthritis. Reality: “I always thought initially that there was nothing you could do to help to ease your everyday life,” Montana said. There are medication and treatments, as well yoga moves to help ease pain, natural remedies, and new treatments are in the pipeline. Treatment also varies with the type of arthritis. There are more than 100 different kinds of arthritis and each is treated differently.

There are many other myths but the key points to remember are that arthritis, when diagnosed early is very treatable and that newer treatments such as stem cell therapy for osteoarthritis look extremely promising.

For more information on arthritis treatments and other arthritis problems,  go to:

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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.

For more information on arthritis treatments and other arthritis problems,  go to:

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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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Methotrexate reduces risk of death from rheumatoid arthritis by 70%!

Methotrexate may reduce the risk of death in rheumatoid arthritis patients, according to study results published Arthritis and Rheumatism. Researchers assessed the association of mortality and treatment with methotrexate in 5,000 rheumatoid arthritis patients at 10 rheumatology practices in the U.S. The data methotrexate-tabletsused in the study was collected from 1981 to 2005.

Among patients taking methotrexate, there was up to a 70% lower risk of death compared to patients not taking methotrexate. This effect appeared to occur after patients took methotrexate for more than one year. The effect did not continue to increase with longer duration of use. According to researchers, it appears that methotrexate must be taken continuously on its prescribed schedule to maintain therapeutic effects.

For more information on arthritis treatments and other arthritis problems,  go to:

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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.

For more information on arthritis treatments and other arthritis problems,  go to:

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Long-Term Humira Use … Few Adverse Events

Nancy Walsh writing in MedPage Today reported, “Long-term immunosuppressive treatment with Humira,  a TNF inhibitor drug used in humiradiseases such as rheumatoid arthritis and psoriatic arthritis,  is associated with low rates of adverse events such as serious infections and malignancies, with differences being seen according to the underlying disease,” according to  a study published in the Annals of the Rheumatic Diseases.

Investigators found that “the most frequently reported serious adverse events across indications were infections.” The study indicated that “the most common infections among patients with rheumatoid arthritis were cellulitis – occurring at a rate of 0.3 per 100 patient-years – and pneumonia, seen at a rate of 0.7 per 100.”

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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.”

For more information on arthritis treatments and other arthritis problems,  go to:

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Flares in rheumatoid arthritis

What factors can cause flares of rheumatoid arthritis?

Here are some “suspects”:

rheumatoid-arthritis-handFlares with RA can occur as a result of:

  1. Going off medicines.  Sometimes patients need to hold their medicines if they’re sick or they’re having a surgical procedure.  It’s not uncommon for them to flare.
  2. Stress.  Emotional or physical stress can cause flares.
  3. Tapering of therapy.  Sometimes patients will have their medicines tapered either because they want to or because the doctor wants to.  An example might be tapering of prednisone.  That can cause a flare.
  4. Weather changes. This is controversial since studies have been conflicting.  All I can say is my patients tell me they feel worse with cold damp weather.
  5. While not a flare inducer, smoking is a risk factor for RA and smokers seem to do worse.
  6. Illness. Sometimes colds might be associated with flares but not as often as one might think.
  7. Changing therapies.  Sometimes when a treatment is undergoing transition, ie going from one biologic to another, the patient might flare.  Haven’t seen this often but it has occurred.

For more information on arthritis treatments and other arthritis problems,  go to:

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And don’t forget to sign up for  free weekly arthritis tips and a free copy of our special report “The Consumer’s Guide to Arthritis”

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