Rheumatoid Arthritis Comorbidities/Co-Conditions
Living with a chronic disease like arthritis means that you may experience other conditions or diseases. Medical professionals call these comorbidities but we are going to refer to them as co-conditions. We believe that it is important to understand how arthritis might affect you and to find proactive strategies to deal with concurrent health issues.
According to the CDC here are the most commonly found co-conditions:
- chronic respiratory conditions
- heart disease
Frequently overlooked are co-conditions that impact mental health. There is research being done around arthritis and depression and arthritis and anxiety.
Chronic Respiratory Conditions
Other than the joints and heart, the lungs are the part of the body most commonly affected by rheumatoid arthritis (RA). The lung complications associated with RA can be serious and even fatal, yet often cause no symptoms. The diagnosis of lung disease in RA patients can be challenging because the symptoms of lung problems overlap with the symptoms of heart disease.
How RA may impact your respiratory system:
- Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is the most serious and most common lung complication in people with RA. An estimated one in 10 people with RA will develop RA-ILD. It refers to a group of lung disorders marked by inflammation and scarring of the lung tissue, which is caused by the immune system attacking the lungs. As scarring becomes more severe it can affect breathing and lead to breathlessness and dry cough. Unfortunately RA-ILD has a high mortality rate – it is as deadly among people with RA as congestive heart failure – as there is currently no effective treatment.
- Rheumatoid nodules can occur in the lungs of patients with RA
- Pulmonary fibrosis, permanent scarring of the lungs, is another lung condition caused by inflammation and is often linked with RA-ILD. As the healthy air sacs are replaced by scar tissue, breathing becomes difficult. Oxygen therapy may make breathing easier, but it cannot undo the damage caused by the scarring. Methotrexate can cause pulmonary fibrosis, so people who take this drug should be monitored closely for lung disease.
- Pleurisy is an inflammation of the lining of the lungs, called the pleura. It occurs in more than half of all people with RA and can make breathing painful.
It’s important to try to prevent RA-associated lung disease because of its high risk of complications.
The most important things you can do are to avoid smoking, or if you do smoke, ask your doctor for help quitting, and make sure you get regular checkups so that your doctor can listen to your lungs and monitor your breathing. If you have RA and are experiencing shortness of breath, coughing, or other respiratory symptoms, seek medical attention quickly.
Diabetes occurs when the body is unable to produce or use the hormone insulin sufficiently. Insulin converts the sugars we get from food into energy. Like rheumatoid arthritis (RA), diabetes is an autoimmune disease. In the case of diabetes, the body’s immune system attacks the cells of the pancreas that make insulin.
Of the 52 million adults with arthritis in the U.S., 16 percent have type 2 diabetes, and 47 percent of adults with diabetes have arthritis. We know that people with diabetes are nearly twice as likely to have arthritis, but why? Research suggests a link between diabetes and arthritis, though the specific nature of this connection is unclear.
One theory suggests that the ongoing inflammation that is a hallmark of RA may play a role in the development of diabetes. This is because of the known link between inflammation and an increased risk of insulin resistance. Indeed, insulin resistance does tend to be elevated in RA, and levels of inflammatory markers tend to be high both in people with RA and people with diabetes. Another theory is that people with RA and other forms of arthritis tend to be more sedentary (and a sedentary lifestyle leads to obesity, a known risk factor for diabetes). If true, this could explain the increased risk of diabetes among people with arthritis.
One of the medications often used for arthritis could also play a role, as it is well known that steroids can increase the risk of diabetes. However, studies show that other RA drugs may actually lower diabetes risk: the antimalarial drug hydroxychloroquine, which is typically used to treat mild RA, is associated with a lower risk of diabetes among people with RA, though it’s unclear why this is so. Other RA drugs known as TNF blockers and methotrexate have been shown to improve insulin resistance and lower diabetes risk, but more research is needed.
For people with RA who may be concerned about diabetes, it is important to maintain a healthy lifestyle. This includes exercise, eating a healthy diet that contains some protein, healthy fats, whole grains and non-starchy vegetables, maintaining a healthy weight, and not smoking. These choices not only help manage RA; they also are important to reduce your risk of diabetes.
Anxiety, Depression, and Other Mental Health Problems
Anxiety and depression are common among people with arthritis. One study showed that people with rheumatoid arthritis (RA) are twice as likely to suffer from depression as those without RA. We know that as many as 40 percent of people with RA have significant symptoms of depression, and according to the CDC, one in three adults with arthritis also has anxiety or depression. This is not surprising given the chronic pain and physical limitations that often come with RA; however, many people don’t realize that depression can actually worsen arthritis pain. One 2011 study showed that among people with osteoarthritis, depression can have as much of an impact on knee pain as physical joint damage.
One reason for the link between pain and depression has to do with lifestyle changes that may be caused by depression and that can increase pain. These include poor sleep, lack of exercise and reduced socializing. Another theory suggests that if you have depression, you are less able to cope with chronic pain and may perceive your condition more negatively than those who are not depressed. There are also biological factors shared by both depression and chronic pain – specifically, the neurotransmitters serotonin and norepinephrine – that can cause the brain to register more pain from certain stimuli, such as a stiff joint, in people with depression.
Anxiety can be just as big of an issue in arthritis as depression. In fact, a CDC study found that anxiety was even more common in RA patients than depression. People with arthritis may become anxious about their pain and disability or worry that they will be unable to work, take care of their families or perform other daily tasks in the future. People with arthritis may also be hesitant to go out and participate in activities like exercise or social functions, which can increase their sense of anxiety.
Anxiety and depression not only contribute to arthritis pain, but can also lead to poorer health outcomes and reduced treatment response. Research shows that people with RA who also have persistent anxiety or depression have reduced odds of achieving RA remission at two years.
Unfortunately, mental health problems in people with arthritis are underdiagnosed because many patients do not feel comfortable mentioning mental health symptoms to their doctor, and often doctors do not ask. If you are experiencing depression or anxiety, it’s important to talk to your doctor so that you can receive the best treatment for you.
Heart disease is a catch-all term that includes heart attack, irregular heartbeat, high blood pressure and atherosclerosis (the build-up of plaque in the arteries). Heart disease is the leading cause of death in rheumatoid arthritis (RA) patients, and if you have RA, you have a twofold increased risk for heart attack and stroke. For people who’ve had RA for 10 years or more, the risk rises to nearly threefold.
The risk is not limited to RA, however. One of the earliest findings of a link between heart disease and osteoarthritis (OA) came in 2003 when a study found that men with OA in just one finger joint were 42 percent more likely to die of heart disease versus men without OA.
The reason for the increased risk of heart disease in arthritis patients, as is the case with some other arthritis co-conditions, is inflammation. Inflammation, regardless of its source, is a known risk factor for heart disease. RA-related inflammation narrows blood vessels and leads to plaque formation inside of the arteries. If this plaque clogs blood vessels, heart attack or stroke may result. Inflammation can also reshape the blood vessel walls, making the plaque inside the vessels more prone to rupture, which can also trigger a heart attack. As for osteoarthritis, though the disease itself isn’t inflammatory, the damage it causes to joints can lead to inflammation.
The inflammation of arthritis does not act alone, however. There are other independent risk factors for heart disease that can be modified or controlled, such as smoking, high cholesterol, high blood pressure, inactivity, obesity and diabetes. Unfortunately, these risk factors tend to go hand in hand with arthritis: The CDC says that 52 percent of people with diabetes have arthritis, 53 percent with arthritis have high blood pressure, 66 percent with arthritis are overweight, and about one in five people with arthritis are smokers.
While we know that high cholesterol levels are associated with a higher risk of heart disease in everyone, cholesterol levels are more likely to be unstable in people with higher levels of inflammation and RA disease activity. This can lead to an even higher risk of heart attack for people with RA. In addition, some of the medications used for arthritis, such as prednisone, tocilizumab and NSAIDs, appear to increase heart disease risk, while other arthritis drugs offer heart protective benefits (including TNF inhibitors, methotrexate and hydroxychloroquine).
It can be challenging for doctors to assess heart disease risk in people with RA. For example, if someone has high levels of inflammation, cholesterol levels can drop as a result and the low cholesterol levels may lead the doctor to think the person isn’t at high risk for heart problems. However, experts say it’s crucial to get control of RA as early as possible after diagnosis, and to assess risk factors for heart disease when the patient is diagnosed with RA to prevent further cardiovascular damage. Exercise, eating a balanced diet and keeping inflammation in control throughout your body can lower your risk of developing heart disease.
Stroke is the fifth leading cause of death in the U.S., with 800,000 people having a new or recurrent stroke each year. Contrary to popular belief, stroke does not just happen to the elderly. Anyone can have a stroke, which happens when blood flow to an area of the brain is reduced or cut off, causing brain cells to die. This occurs either because a blood clot blocks the blood flow or a blood vessel leaks or bursts.
Symptoms of stroke can include slurring speech, confusion, paralysis or numbness of the face, arm or leg, a sudden severe headache, trouble seeing in one or both eyes and difficulty walking. Depending on how severe the stroke is, the person can have mild problems such as temporary weakness of one of their limbs, or more severe, permanent effects such as paralysis on one side of the body or loss of the ability to speak. More than two thirds of people who have a stroke have some form of permanent disability.
Along with heart attack, stroke is the cause of many premature deaths in people with rheumatoid arthritis (RA). One study found that people with RA had a 67 percent higher risk of stroke than those without, though it remains unclear to what extent arthritis is an independent risk factor for stroke. The connection appears to be inflammation. Similar to heart disease, some studies show that inflammation, including the type that is associated with arthritis and systemic lupus erythematous, increases a person’s risk for stroke.
Additional risk factors for stroke include high cholesterol, diabetes, obesity, smoking, high blood pressure and carotid artery disease (in which the carotid arteries in your neck, which supply the brain with blood, become narrowed due to the build-up of plaque). If someone with RA has any of these other conditions, the risk of stroke becomes even higher.
People with RA should take care to reduce their risk of stroke, along with all forms of heart disease, by addressing the risk factors they can control – not smoking, losing weight, working to achieve healthy cholesterol levels, eating a balanced diet and exercising.