More than RA
by Amanda Gardner
If you have rheumatoid arthritis (RA), be on the lookout for other health problems associated with the autoimmune disorder.
They may be caused by RA-related inflammation or RA treatments, or they may occur at higher rates for unknown reasons.
Regardless of the cause, most related conditions can be prevented or treated. Although it’s challenging to cope with the pain and fatigue of RA—much less other health problems—it makes sense to keep an eye out for the signs and symptoms of these conditions.
RA can cause bone thinning andosteoporosis (which increases the risk of bone fractures), as can the inflammation-fighting corticosteroids used to treat it.
In addition, people with RA often cut back on activity due to pain, which can accelerate loss of bone and muscle mass, says Guy Fiocco, MD, assistant professor of internal medicine at Texas A&M Health Science Center College of Medicine, in Temple.
Have regular bone-density scans and talk to your doctor about bone-strengthening medications and exercise. Also, get enough calcium and vitamin D, Dr. Fiocco says.
Heart disease and stroke
People with RA have about double the heart-disease risk as their same-age peers.
“Rheumatoid arthritis is considered equal to other [heart-disease] risk factors, such as diabetes, hypertension, increased lipids, smoking, and family history,” Dr. Fiocco says. “It’s at least as important as the other risk factors for premature heart disease and stroke.”
RA-related inflammation is thought to be the reason why, although some RA medications can contribute to the risk. People with RA should make an extra effort to eat heart-healthy food, manage other risk factors (like avoiding smoking), and monitor cholesterol and blood pressure.
Sjögren’s syndrome is an autoimmune disease that attacks the tear and salivary glands, causing dry eyes and mouth. It can arise on its own or as an added complication of rheumatoid arthritis.
Unfortunately, there’s no treatment for Sjögren’s, which can lead to vision problems and tooth decay because of the lack of saliva. Moisturizing eye drops, good dental hygiene, and drinking water can help prevent these problems.
Prescription drugs such as cevimeline (Evoxac) and pilocarpine (Salagen) can increase the production of saliva and tears. In severe cases, minor surgery can relieve dryness in the eyes.
“The one cancer that’s definitely been linked to RA is non-Hodgkin’s lymphoma,” Dr. Fiocco says.
RA patients have a two to four times higher risk than people without RA. Other blood cancers, such as leukemia and other forms of lymphoma, as well as lung cancer and melanoma, may also be a problem. Not only is the disease itself a culprit, but some drugs are too.
In fact, methotrexate (Trexall) and antitumor necrosis factor drugs such as adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) carry a warning about increased lymphoma risk. But the benefits may still outweigh the risk, given that the risk is low overall.
Some 8% of people with RA develop interstitial lung disease, or scarring of the lungs, compared with only 1% to 2% of the general population, says Eric L. Matteson, MD, chair of rheumatology at the Mayo Clinic, in Rochester, Minn.
In addition to the joints, RA can attack the lungs and cause scarring. Over time, this can make breathing difficult. RA treatments such as methotrexate and glucocorticosteroids can increase the risk of interstitial lung disease.
People with RA may also develop inflammation in the lining of the lungs, or pleurisy, which can make breathing painful, and lung nodules, which can be mistaken for cancer.
RA drugs such as methotrexate, adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) suppress the immune system, boosting the risk of infection. That’s on top of an already-increased risk due to the disease itself. “Just having rheumatoid arthritis approximately doubles your infection risk independent of treatment,” says Dr. Matteson.
One risk is tuberculosis (TB), although it is less common in the U.S. than in developing nations.
Still, doctors routinely perform a skin test to check for TB before starting a person on immune-suppressing drugs, Dr. Fiocco says. If the test is positive, the doctor will treat the infection first.
Not surprisingly, depression affects more people with RA—perhaps up to twice as many—than those who don’t have the condition. Having to cope with RA in addition to functional disability, loss of independence, and decrease in quality-of-life all contribute to depression, Dr. Fiocco says.
One small study showed that only 1 in 5 RA patients talk to their doctor about depression. If you have symptoms of depression, get help.
“With the newer [RA] medications, a lot more quality of life is being maintained these days,” says Dr. Fiocco.
RA can lead to anemia, which is a lack of red blood cells needed to transport oxygen in the body. RA inflammation can suppress the bone marrow that generates red blood cells.
“Anemia is directly related to the activity of the disease,” says Dr. Fiocco. “High levels of inflammation lead to greater degrees of anemia and these are closely correlated.”
Medication can also exacerbate the problem. If the anemia is due to inflammation, getting it under control will help, Dr. Matteson says. Drugs that spur red-blood-cell production can help too. And if you’re iron deficient, consider iron supplements, but keep in mind that highly active RA can inhibit iron absorption.
A rare but potentially serious RA complication is vasculitis, or an inflammation of the blood vessels, Dr. Matteson says. Vasculitis causes sores from poor blood circulation in the skin, particularly in the fingers or toes, and can sometimes cause nerve damage in the hands and feet as well as your organs.
It’s a serious side effect to watch for, although it doesn’t affect a lot of patients. “Probably less than 1%, but if it does occur, it’s a very serious problem,” Dr. Matteson says.
Another RA complication is gastrointestinal problems, primarily bleeding in the digestive tract and ulcers. This can be due to nonsteroidal anti-inflammatory drugs (NSAIDs), now available both over-the-counter (Advil or Aleve) and by prescription (Celebrex).
“The combination of NSAIDs plus steroids makes it even worse,” Dr. Fiocco says. GI bleeding can also cause or worsen anemia. If you’re taking a prescription NSAID, you should be monitored for this side effect.
If you’re taking an over-the-counter NSAID, stick to the recommended dosage and don’t take more than one NSAID, including aspirin, at a time.