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Managing Comorbidities

If the last decade has been the one for successful adoption of treat-to-target algorithms for rheumatoid arthritis (RA) into our rheumatology practices, then, according to Prof Laure Gossec from UPMC Sorbonne, Paris, France, the way forward for the next decade is going to be incorporating management of comorbidities into the way we care for our RA patients.

What are RA-associated comorbidities? Clinicians working in health informatics have been known to say that a comorbidity is simply “another clinician’s diagnosis.” As rheumatologists, we may be very precise in our classification of the exact type of inflammatory arthritis and the RA subclassification because this is directly relevant to how we care for patients in our specialty. However, we tend to be more broad-brush in our recording of “other clinical diagnoses”, especially in the pre-centralized records days when we had to rely on the patient’s verbal history or trawl through thick paper files to find the relevant details (What type of myocardial infarction or stroke was it? How was it treated?). With the advent of electronic healthcare records and initiatives to link hospital and primary care data, it is now possible for us in rheumatology to access a wealth of high-quality clinical information about everyone else’s diagnoses. Our challenge now is to determine what to do about this.

Prof Ernest Choy from Cardiff University, UK reminds us that “RA is not just an arthritis.” RA is a systemic autoimmune disease, and inflammation of the joints is just one of its effects. He points out that the word “comorbidity” may be misleading, as so-called comorbidities are often not purely coincidental but are also related to the complexities of systemic inflammatory autoimmune disease. Uncontrolled systemic inflammation is, for example, a known risk factor for cardiovascular disease. Other organ systems may also be directly affected by the immunological disturbance itself: for example, the interstitial lung disease of RA highlighted by Prof Maya Buch from Leeds, UK, or the gut and skin manifestations of spondyloarthropathy mentioned by Prof Chris Buckley from Birmingham, UK.

Moreover, as Prof Choy points out, patients also want help from their rheumatologist in dealing with symptoms of RA “outside the joints”: fatigue and depression, for example. He points to data suggesting that good control of inflammation with biologic therapy may be associated with better outcomes in these “outside the joints” symptoms that impact on patients’ work, quality of life and ability to cope.

Thus, the benefits of good control of inflammation go beyond simple retardation of structural progression. Looking beyond the joints, inflammation interacts in a very complex way with other risk factors. For example, Prof Willem Lems at VUMC Netherlands points out that if inflammation is very well-controlled using an appropriate combination of therapies, the risk of glucocorticoid-induced osteoporosis may be substantially lower than we might think, at least at smaller glucocorticoid doses (<7.5 mg/d).

Prof Laure Gossec highlights data suggesting that we should not forget to look after the general health of patients with RA. Yearly visits to the dentist to assure control of periodontal disease, participation in national cancer screening programmes, and appropriate vaccinations to limit infections, for example, are even more important for our RA patients than in the healthy population and we should not forget about this. Smoking and obesity have been shown to influence responsiveness to prescribed therapies and so we should continue to support our patients to make the lifestyle changes. There is a lot to remember here and so perhaps checklists can be helpful in practice. The recently-published EULAR points to consider for reporting, screening for and preventing selected comorbidities in chronic inflammatory rheumatic diseases in daily practice suggests a standardized reporting form for use in clinical practice, while acknowledging that completing this form in its entirety may take up to an hour. How do we incorporate this into our routine clinical practice? Perhaps this is an area where rheumatology nurse specialists could help us. Or perhaps the next update of our electronic healthcare record will provide a “dashboard”-style overview of relevant comorbidities at every patient visit.

The way forward may be obvious, but the exact route we take will need to adapt to the local landscape. It will be interesting to see different models of implementation of comorbidity screening and management emerging over the next decade.


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