Living with rheumatoid arthritis (RA), a progressive autoimmune condition can be difficult. While there are ways to treat and manage RA, it can be hard to find which ones work best for you. To make things even more challenging, rheumatoid arthritis probably isn’t the only condition you’re trying to treat.
Studies show that patients with RA are more likely to develop other chronic conditions, like heart disease, diabetes, and depression, compared to people without RA. When more than one condition exists at the same it’s called a comorbidity. If left untreated, comorbidities can be fatal to people with RA.
Why Does RA Cause Other Conditions?
Rheumatoid arthritis is an autoimmune condition that affects 14 million people worldwide. Autoimmune disorders mistakenly attack the immune system’s healthy cells instead of protecting them. With RA, the immune system primarily attacks the lining of the joints, causing painful swelling that can eventually cause bone erosion and joint deformity. In severe cases, it can affect the heart and lungs.
Symptoms of rheumatoid arthritis include:
- Pain or aching in more than one joint
- Stiffness in more than one joint
- Swelling or tenderness in more than one joint
- Weakness
Widespread inflammation associated with RA is what causes damage to other parts of the body. Studies show that chronic inflammation, like that in rheumatoid arthritis, can lead to other chronic conditions.
Acute inflammation is good; it’s how the body fights infections and speeds up the healing process. But when inflammation gets too high and lingers for an extended period of time, the immune system sends too many white blood cells and chemical messengers despite the absence of injury and can cause more damage. This is called chronic inflammation.
The longer chronic inflammation exists, and RA is left untreated, the greater the risk of developing another chronic condition.
What Chronic Conditions are Associated with RA?
A study of comorbidities as risk factors for rheumatoid arthritis found that people who have RA are more likely to develop heart disease, sleep apnea, and blood clots. The study also found that people with inflammatory bowel disease, type 1 diabetes, or venous thromboembolism (VTE) may be at an increased risk of developing rheumatoid arthritis.
The study used data from the Mayo Clinic Biobank, which has data on 74 self-reported comorbidities and when they were diagnosed. Comorbidity means a person has more than one disease or condition at the same time. Comorbidities that developed in an age window before the date of RA diagnosis were categorized as “before RA.” Those that developed in an age window after the date of RA diagnosis were categorized as “after RA.”
Other studies found that people with RA are at a higher risk of developing depression, infections, and lung diseases, like COPD.
Heart Disease
People with rheumatoid arthritis are almost twice as likely to develop heart disease compared to people without RA. People with RA also have twice the rate of heart failure as people without the condition. More than half of premature deaths in RA patients can be attributed to heart disease.
Heart disease refers to many different types of heart conditions. Some of the most common types of heart conditions associated with RA are congenital heart disease, pericardial disease, and coronary artery disease (CAD). The trouble with heart disease is that many people don’t exhibit symptoms or signs are not caught until a major cardiac event has happened, like a heart attack or stroke.
Rheumatoid arthritis patients are sometimes unaware that their condition increases the risk of heart disease and may not know about other personal risk factors. Some major risk factors for heart disease include:
- High blood cholesterol
- Diabetes
- Smoking
- Physical inactivity
- Family history
Shared risk factors that can put people with RA at higher risk for heart disease include high blood pressure and obesity.
Inflammation is a hallmark of rheumatoid arthritis is inflammation, and chronic inflammation is a risk factor for heart disease. Inflammation causes plaque, abnormal clusters of protein fragments, to build-up in the arteries. When there is too much plaque in the arteries, blood vessels narrow and blocks blood flow. This can result in blood clots, which can lead to a heart attack or stroke.
Medications that are often used to help reduce inflammation and manage RA symptoms and reduce can also increase the risk of cardiac issues. This includes prednisone, a short-acting oral corticosteroid. Prednisone can cause plaque buildup in the artery walls and stiffer arteries. It can also raise blood pressure and cholesterol levels.
Non-steroidal anti-inflammatory drugs (NSAIDs) are also used to treat RA pain, inflammation, and swelling. Research shows that long-term NSAID use can contribute to a greater risk of heart attack, heart failure, stroke, and death from heart disease. The Food and Drug Administration (FDA) also warns that NSAIDs can cause heart attacks or strokes.
By working closely with your doctor, you can identify which medications are safest for you to use to manage RA pain and inflammation while keeping your risk of heart disease to a minimum.
Blood Clots
Venous thromboembolism (VTE) occurs when blood clots develop in the veins that carry blood to the heart. Previous studies have shown that RA is associated with an increased risk of VTE. The Mayo Clinic study found that VTE increased in frequency after RA diagnosis, compared to controls without RA. Other studies showed that VTE occurred more commonly in RA patients even before the onset of RA. This means systemic inflammation, which occurs when the immune system is constantly defending the body, may occur even before RA becomes clinically apparent.
Although the link between RA and VTE is not clearly understood, it is likely that chronic inflammation causes the association between the two. Patients with RA may have more risk factors for VTE, including physical inactivity, acute hospitalization, surgical procedures, and cardiovascular comorbidities.
It is also possible that disease-modifying anti-rheumatic drugs (DMARDs) use to treat RA cause VTE. Previous research has shown that starting RA patients on biologic DMARDs was associated with a 2.5-fold increased risk of VTE in the first 180 days. Researchers believe that starting biologic drugs may trigger a period of pro-coagulation.
A 2020 study analyzed data on more than 46,000 RA patients who visited a rheumatologist in Sweden at least once between 2006 and 2018. The study found that RA patients were more likely than the general population to experience deep vein thrombosis (DVT). Deep vein thrombosis occurs when a blood clot forms in one or more of the deep veins in your body, usually in the legs. It can cause leg pain or swelling, but it can also occur without symptoms. DVT can be dangerous because it can lead to a life-threatening pulmonary embolism, which is when a blood clot gets stuck in the lungs and blocks blood flow.
Chronic Obstructive Pulmonary Disease (COPD)
Chronic obstructive pulmonary disease (COPD) is a group of diseases that cause airflow blockage resulting in breathing difficulties that worsen over time. It includes conditions like emphysema and chronic bronchitis. Studies have found that people with RA have significant health risks for COPD compared to people without RA.
One study found that people with RA are nearly twice as likely to be hospitalized with COPD. Researchers in British Columbia reviewed information on cohorts of 24,625 RA patients who were diagnosed with the condition between 1996 and 2006. They compared that data with 25,396 controls (patients without RA). After adjusting the data to account for other factors that may increase the risk of lung disease, they found that the RA cases had a 47% greater risk of COPD hospitalization than the controls.
Another study found that COPD is a predictor of early mortality in patients with rheumatoid arthritis. The U.K. based study assessed the comorbidity burden in 6,591 RA patients at diagnosis and again at the three-year mark for the association with early mortality and joint destruction. They found that COPD was associated with a 3-fold increased risk for early mortality.
Researchers don’t know for certain why COPD has such implications for people with rheumatoid arthritis, but they believe chronic inflammation is the culprit. When you have COPD, less air can flow in and out of your lungs. This means less oxygen gets into your body and it’s harder to eliminate carbon dioxide. Systemic, chronic inflammation caused by RA makes this process even more difficult. Many of the same markers of inflammation found in RA are also elevated in COPD.
Type 1 Diabetes
People with type 1 diabetes are more likely to develop rheumatoid arthritis later. Nearly half of adults who have diabetes, also have arthritis.
Like RA, type 1 diabetes is an autoimmune disease. In type 1 diabetes, the body mistakenly identifies insulin-producing beta cells as foreign and destroys them. As a result, the pancreas can’t make enough or any insulin. Insulin is a hormone that helps blood sugar enter cells in the body to be used as energy. Without insulin, blood sugar can’t get into the cells and it builds up in the bloodstream. The absence of insulin is what causes a diagnosis of diabetes.
There may be a shared genetic risk between type 1 diabetes and RA, particularly caused by variants in the HLA DRB1 gene. HLA-DRB1 belongs to a class of genes known as the human leukocyte antigen (HLA) complex. The HLA complex helps the immune system distinguish the body’s own proteins from those made by foreign invaders.
HLA-DRB1 is the strongest known genetic risk factor for rheumatoid arthritis, and it also has one of the strongest associations with type 1 diabetes. Combinations of variations in the HLA-DRB1 gene and other HLA genes can increase the risk of type 1 diabetes, particularly HLA-DQA1 and HLA-DQB1.
Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) refers to conditions that involve long-term gut inflammation. Crohn’s disease and ulcerative colitis are two of the most common inflammatory bowel diseases. Ulcerative colitis is an autoimmune disorder of the colon that is characterized by chronic inflammation.
Although a genetic risk has not been identified, some studies have suggested that ulcerative colitis and rheumatoid arthritis are both associated with HLA-B27. Studies found that patients with ulcerative colitis developed RA within a few years of their diagnosis. While rheumatoid arthritis symptoms can begin during IBD at any time, the odds were nearly four times higher in the time period after an IBD diagnosis.
Sleep Apnea
Obstructive sleep apnea (OSA) is a sleep disorder that occurs when something blocks part of or all of the upper airway during sleep. This can cause your breathing to become shallow or you may stop breathing briefly. You may not know it’s happening at the time but you may feel symptoms like daytime sleepiness when you wake up.
One study found that the incidence rate of sleep apnea was 75% greater in people with RA than in people without RA. This risk was greater in men than women, and in older people. This risk may be due to joint abnormalities that can occur in RA. In RA, the higher cervical vertebrae (vertebrae of the neck, immediately below the skull) can become misaligned. This misalignment can cause the upper airway to narrow and compress the brain stem, which can make sleep apnea worse.
The link may also be due to immune system features that are associated with both conditions. Both conditions are associated with elevated levels of pro-inflammatory cytokines, including tumor necrosis factors and interleukins. In RA, elevated levels are related to immune system dysfunction and inflammation. In OSA, some interleukins and tumor necrosis factors have been found to be involved with non-REM phases of sleep.
Researchers have also found that higher levels of pro-inflammatory cytokines, like those found in RA, are associated with more severe OSA.
Lupus
Lupus is a chronic autoimmune condition that can cause pain and inflammation in any part of your body. It can also affect the brain, heart, joints, kidneys, and skin. The most common type of lupus is systemic lupus erythematosus (SLE), and it can range from mild to severe.
Lupus and rheumatoid arthritis share several symptoms and can sometimes be confused for one another. Both conditions can cause joint pain and swelling, although these symptoms are more prominent in RA. Lupus can affect the joints, but more commonly affects the skin and internal organs. Severe cases of lupus can also lead to kidney failure, seizures, and issues with blood clotting.
Mutations in the STAT4 gene show the genetic link between lupus and rheumatoid arthritis. This gene provides instructions for a protein that attaches to specific regions of the DNA to control the activity of certain genes. The STAT4 protein is activated by cytokines and increases the activity of genes that help T-cells mature into specialized T-cells. Mature T-cells stimulate immune cells and produce specific cytokines.
People who have a mutated version of this gene have twice the risk of developing lupus, and a 60% higher risk of developing RA. It isn’t known what causes the STAT4 gene to mutate, but the risk of developing autoimmune conditions increases when the mutation occurs.
Rhupus Syndrome
Rhupus syndrome is a rare overlap of rheumatoid arthritis and systemic lupus erythematosus. It is characterized by the presence of erosive arthritis and the signs and symptoms of SLE.
One study of patients with rhupus syndrome found that each had symmetrical arthritis, joint swelling, and radiological abnormalities. Most patients with rhupus syndrome (83.9%) were diagnosed at the onset of RA and they usually developed lupus within 7 to 8 years. Patients who were diagnosed with rhupus at the onset of lupus usually developed RA within 16 years.
Find Your Community
Whether you have rheumatoid arthritis by itself or with another condition, life can be challenging. You may start to feel overwhelmed and alone in your illness. Remember, you are not alone. At PatientsLikeMe, there are over 300,000 patients m just like you who are also living with RA. Join them today to share experiences around your condition.
