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I Have Rheumatoid Arthritis... Why Is My Rheumatologist So Concerned About My Lungs?

Nov 6, 2007
Rheumatoid arthritis (RA) is the most common inflammatory form of arthritis. It is a chronic, autoimmune disease that affects more than 2 million Americans. While the primary target for this disease is the musculoskeletal system, RA is also a systemic disease meaning that if affects internal organs. One of the most common organ systems affected is the respiratory system.

Upper airway symptoms are often caused by Sjogren's disease, an autoimmune condition that often accompanies RA. In Sjogren's disease, the glands that make secretions such as tears, saliva, and mucus are gradually destroyed. Since mucus is necessary for the neutralization and mobilization of bacteria, people with Sjogren's disease often develop recurrent respiratory infections.

The lungs themselves can be involved. People with RA can develop multiple problems including fibrosis (scarring of lung tissue), pleural effusion (water on the lung), pulmonary nodules (spots on the lung), and pneumonitis (inflammation of lung tissue.)

Finally, drugs used to treat rheumatoid arthritis such as methotrexate, gold, and newer biologic therapies can also adversely affect the lungs.

Also, acute lower respiratory tract infections are common in patients with rheumatoid arthritis, according to results of a study published in the September issue of the Journal of Rheumatology. Respiratory infections in this population carry a high mortality (risk of death).

"Rheumatoid arthritis...shortens life expectancy compared to a control population, and excess deaths are largely caused by accelerated vascular events and an increased propensity to infection, much of which is of respiratory origin," researchers from Queen Elizabeth Hospital, Gateshead, UK, write.

The researchers examined whether the development of lower respiratory tract infection in patients with rheumatoid arthritis (RA) is the result of their use of the drugs used to treat the RA or the inflammatory arthritis itself.

In a population of 1,522 RA patients seen over a 12-month period, 36 patients were admitted for 43 acute respiratory episodes. A detailed drug history and data on clinical outcome were collected for each case. The team collected and analyzed past medical history and admission data to evaluate the influence of oral steroids and disease modifying anti-rheumatic drugs (DMARDS) on outcome.

The overall annual incidence of lower respiratory tract infection in RA patients was 2.3%. Eight patients died from this problem, (mortality rate of 22.2%). Risk factors that predicted lower respiratory tract infection in this population included older age and male gender. An association was observed between oral steroid therapy and not taking DMARDs and an increased risk of hospital admission with lower respiratory tract infection. The authors report that there was a trend toward increased mortality in men and in those with duration of disease.

The researchers note that they have changed their clinical practice as a result of these findings. "In addition to initiating DMARDs early in all patients with RA, we actively recommend annual vaccination against influenza and pneumonia vaccination every 5 years in all patients, independent of their treatment," the authors write.

"Older patients with long disease duration are now actively encouraged to start DMARD therapy rather than oral steroids, although drug selection may be be altered by the presence of coexistent cardiac or pulmonary disease."
(J Rheumatol 2007;34:1832-1836).

Authors's note: This study underscores the severity of rheumatoid arthritis on the general health and mortality risk for patients with the disease. It is not a benign disease. It is not "just arthritis." As more data regarding the impact of RA on life expectancy is produced, it has become quite clear that RA must be diagnosed and treated aggressively.
About the Author
Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info: Arthritis Treatment
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