| It's only recently that we've discovered that the | | | | excellent data indicating that uncontrolled- or |
| same inflammatory processes that drive | | | | poorly controlled inflammatory joint disease |
| rheumatoid arthritis (RA) also are responsible for | | | | negatively affects morbidity and mortality. |
| complications that affect other internal organs. For | | | | Also, from the other studies, it is clear that there |
| example, heart disease, which is a common | | | | is a strong link between inflammatory joint |
| complication in patients with rheumatoid arthritis is | | | | disease and subsequent risk for heart disease. |
| caused by inflammation. | | | | So the question is this... are the newer therapies |
| Couple that with the fact that many patients with | | | | which carry risks of their own... do these risks |
| rheumatoid arthritis have other heart "unhealthy" | | | | justify their use in RA. The answer is |
| risk factors such as corticosteroid use, diabetes, | | | | straightforward. Every therapy has risks and also |
| and high blood pressure. It's no wonder the | | | | benefits. Every patient needs to understand that |
| incidence of heart disease manifested by heart | | | | drugs have potential good effects... and potential |
| attacks and strokes are a significant cause of | | | | bad ones as well. |
| both morbidity as well as mortality. | | | | During clinical trial development, close scrutiny of |
| We know that inflammation starts in the lining of | | | | these drugs ensures that there is reasonable |
| an artery and sets up conditions favorable for the | | | | efficacy as well as safety. |
| development of a plaque that eventually leads to | | | | Once a drug is approved by the FDA, then |
| narrowing of that artery. | | | | further surveillance of drug effects and side |
| It's not only heart disease that's a consequence | | | | effects continues. |
| of rheumatoid arthritis and chronic inflammation. | | | | For example, currently, it is known that patients |
| Lymphoma, a malignancy condition affecting | | | | taking a TNF inhibitor plus a biologic have a slightly |
| lymph nodes is a result of chronic inflammation as | | | | higher incidence of infection than patients just |
| well. | | | | taking methotrexate. However, the benefit |
| With newer therapies that control RA better, it is | | | | derived from combination therapy of |
| evident that if the disease is controlled better, | | | | methotrexate plus a biologic so far outweighs side |
| then there appears to be a decrease in heart | | | | effects. Patients just need to be monitored |
| disease and other comorbidities, because | | | | carefully. |
| inflammation control is better. | | | | Another drug pathway under study is blockage of |
| So, as rheumatologists, it's important to ensure | | | | IL-6. There is data indicating that inhibitors of IL-6 |
| that RA patients have their comorbidities dealt | | | | may raise cholesterol. But the "good" and "bad" |
| with. If the patient has a history of elevated | | | | cholesterol relationship we have always assumed |
| cholesterol, it's important for a rheumatologist to | | | | may not necessarily be as cut and dried as we |
| address that issue- perhaps not as the primary | | | | once assumed. |
| care physician- but as an advisor to the patient. | | | | Also, changes in cholesterol property may be |
| The same goes for hypertension, diabetes, and | | | | affected by the TNF inhibitors as well. |
| cigarette smoking. | | | | So... the bottom line is this: it's important to |
| There is little if any doubt that treating the | | | | recognize that all drugs have upsides as well as |
| primary joint disease with TNF inhibitors | | | | downsides. And that it's important to monitor |
| decreases some of the comorbidities. The | | | | patients carefully. |
| evidence, while not overwhelming, is certainly | | | | Comorbidities are important factors to consider in |
| suggestive. There is, as mentioned earlier, | | | | patients who have rheumatoid arthritis. |