It is well documented that patients with rheumatoid arthritis (RA) are at a higher risk for comorbidities, including in early RA.1,2 Rheumatologists are just now beginning to address this field of comorbidities, including potential risks and suggested treatments.1
“Comorbidities appear to be of [the] utmost importance to consider, not only because of their high prevalence but also because of their potential involvement in RA outcomes,” wrote Camille Roubille, MD, of the Department of Internal Medicine at the University of Montpellier in France, and colleagues, in an editorial published in the Journal of Rheumatology.1 Researchers stressed the importance of a multidisciplinary care team in managing these comorbidities.
Currently, rheumatologists’ concerns about prescribing disease-modifying antirheumatic drugs (DMARDs) or other biologic agents in patients with comorbidities loom large: According to 1 cross-sectional, international study,3 biologic DMARD (bDMARD) use “decreases by 11% for each additional chronic morbid condition” in patients with multimorbidities.
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In another study, investigators found that patients with both RA and a high number of comorbidities often deprioritized rheumatological care. Although these patients may “attach less importance to RA management because of the burden of comorbidities,”1 rheumatologists may also delay treatment with bDMARDs due to potential comorbidity-related complications.4
In an article published in Joint Bone Spine,5 Laure Gossec, MD, PhD, of the Sorbonne University in Paris, France, and colleagues developed a set of management recommendations, based on European League of Against Rheumatism guidelines, for the collection and reporting of 6 selected patient comorbidities: ischemic cardiovascular diseases, malignancies, infections, diverticulitis, osteoporosis, and depression.6
Through a literature review and consensus process, researchers sought to collate both published and unpublished recommendations for comorbidity care management, including “prescribing, screening procedures, treatment introductions, and/or referrals to appropriate other health professionals.”5 Ultimately, recommendations for each comorbid condition were detailed, including steps recommended for individual treating rheumatologists.
Dr Gossec and colleagues were able to develop clear definitions of which aspects of comorbidity management were “potentially within the remit of rheumatologists.” Although these aspects vary by comorbidity, the overall outcome was a pragmatic, working document that can be used by both hospital rheumatology teams and rheumatologists in private practice. Dr Gossec and colleagues concluded that adding that this project would be “highly useful” to rheumatologists due to the proposal of screening and collection questions in addition to practical management recommendations.
According to a 2016 study published in Rheumatology,7 76% of a cohort of 2090 patients in the Canadian Early Arthritis Cohort reported the presence of at least 1 comorbid condition. Even after controlling for age, sex, and symptom duration, patients with comorbidities had worse baseline function compared with patients without comorbidities. At 1 year, these patients had a higher pain score and were less likely to achieve remission. “Addressing comorbidity may improve clinical outcomes in early RA,” the researchers concluded.7
More recently, researchers used a population-based cohort of patients with RA and matched controls to assess the relationship between the presence of comorbidities with patient-reported outcomes.7 The study included 96,921 patients with RA and 484,604 age- and sex-matched controls who completed a self-reported questionnaire.
“Compared [with] controls, all investigated comorbidities were more frequent in persons with RA,” the researchers wrote8 noting that the most common comorbid conditions were osteoarthritis, depression, and osteoporosis, in addition to cardiovascular risk factors.
“Patients with RA and multimorbidity are at risk [for] insufficient rheumatological care and poorer patient reported outcomes,” investigators concluded.8
Another risk associated with comorbidities includes potentially avoidable hospital admissions. Recently, investigators found that hospitalization proportion increases relative to the number of comorbid conditions — up to 55% among patients with ≥8 comorbidities.7
Although Dr Roubille and colleagues note that not all comorbidities are created equal, with severity playing a role, they suggest that the most relevant course of action for comorbidity management may be to “examine the effect of different associations of comorbidities to identify subsets of patients with RA who need to be tightly monitored, and who might best benefit from a multidisciplinary approach.”1
One way rheumatologists can thoughtfully consider the role of comorbidities in their daily management of patients with RA is to “prevent, screen for, and manage all comorbidities associated with RA.”1
However, despite this suggestion, Dr Roubille and colleagues acknowledge that this “insightful recommendation” is rife with practical issues—in particular, the time constraints associated with a 20-minute visit.1
Integrated care requires time, the authors noted, adding that despite best efforts, it can be difficult to incorporate comorbidity management into a “classical visit.”1 It is important for researchers to avoid creating an “RA paradox,” where specialized care modalities compete with a patient’s general plan of care.1
In addition to time-based considerations, cost-based considerations must also be taken into account. “Perhaps in the future … we will be able to select the most relevant comorbidities and then prioritize the management of [those] that require the most active care in patients with RA,” Dr Roubille and colleagues wrote.1
The final consideration is one of leadership: who is responsible for the screening and management of RA comorbidities?1,5 Some rheumatologists may not be comfortable providing this type of care, not considering themselves either qualified or experienced enough to manage conditions like hypertension, depression, or diabetes.1 One proposal, published in the Annals of the Rheumatic Diseases,8 suggests that clinicians undertake a dedicated visit focused on systematic screening, which may aid in identifying which patients should be referred to either other specialists or general practitioners.1,8
In order to best provide personalized and coordinated care, communication between all healthcare providers should be encouraged, and shared with every caregiver who works with the patient.1 Due to the high prevalence of polypharmacy among patients with RA, this care team should also include a pharmacist.
“[W]hatever the disease index, patients with comorbidities are heterogenous and a poor coordination of fragmented healthcare might be harmful,” Dr Roubille and colleagues concluded. “Patients with RA need personalized comorbidities management strategies to improve their quality of life and disability outcomes.”1
References
1. Roubille C, Fesler P, Combe B. Shifting from a rheumatologic point of view toward patient-centered care in rheumatoid arthritis with an integrated management of comorbidities. J Rheumatol. 2019;46(6):545-547.
2. Dougados M, Soubrier M, Antunez A, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA). Ann Rheum Dis. 2014;73(1):62-68.
3. Armagan B, Sari A, Erden A, et al. Starting of biological disease modifying antirheumatic drugs may be postponed in rheumatoid arthritis patients with multimorbidity: single center real life results. Medicine (Baltimore). 2018;97(13):e9930.
4. Radner H, Yoshida K, Hmamouchi I, Dougados M, Smolen JS, Solomon DH. Treatment patterns of multimorbid patients with rheumatoid arthritis: results from an international cross-sectional study. J Rheumatol. 2015;42(7):1099-1104.
5. Gossec L, Baillet A, Dadoun S, et al. Collection and management of selected comorbidities and their risk factors in chronic inflammatory rheumatic diseases in daily practice in France. Joint Bone Spine. 2016;83(5):501-509.
6. Baillet A, Gossec L, Carmona L, et al. Points to consider for reporting, screening for and preventing selected comorbidities in chronic inflammatory rheumatic diseases in daily practice: a EULAR initiative. Ann Rheum Dis. 2016;75(6):965-973.
7. Hitchon CA, Boire G, Haraoui B, et al; CATCH investigators. Self-reported comorbidity is common in early inflammatory arthritis and associated with poorer function and worse arthritis disease outcomes: results from the Canadian Early Arthritis Cohort. Rheumatology (Oxford). 2016;55(10):1751-1762.
8. Luque Ramos A, Redeker I, Hoffmann F, Callhoff J, Zink A, Albrecht K. Comorbidities in patients with rheumatoid arthritis and their association with patient-reported outcomes: results of claims data linked to questionnaire survey. J Rheumatol. 2019;46(6):564-571.
This article originally appeared on Rheumatology Advisor
