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Comorbidities in Rheumatoid Arthritis: My Top Studies From EULAR 2020

Paul Emery, MA, MD, FRCP

Versus Arthritis, Professor of Rheumatology 
Leeds Institute of Rheumatic & Musculoskeletal Medicine
University of Leeds
Consultant, Rheumatology
Leeds Teaching Hospitals NHS Trust
Leeds, West Yorkshire

Paul Emery, MA, MD, FRCP, has disclosed that he has received consulting fees from AbbVie, Gilead Sciences, Lilly, and Novartis.

View ClinicalThoughts from this Author

Released: August 24, 2020

The recent virtual revamp of the annual EULAR congress provided a wealth of new data to inform best practice in managing patients with rheumatoid arthritis (RA). In my previous commentary, I shared my take on the most important findings relevant to prevention and treatment. Here, I review new evidence on managing comorbidities in RA.

Interstitial Lung Disease (ILD)
ILD may be a bit of a Cinderella story in RA. We have historically been unable to do much about it, but the availability of antifibrotic drugs, such as nintedanib and pirfenidone, highlights the utility of earlier identification and intervention.

A number of abstracts at the EULAR 2020 E-Congress examined ILD in patients with RA. Zhuo and colleagues assessed factors associated with ILD in a large electronic medical record database and found that patients who developed ILD had a higher proportion of comorbidities and higher RA disease activity.

This reinforces the message that one way to avoid this complication may very well be better and earlier RA treatment.

Methotrexate use has been widely regarded as a possible cause of ILD. However, in a large, international study of more than 1200 patients with RA, Juge and colleagues found that patients with any methotrexate use were less likely to develop ILD vs never users, and methotrexate use was associated with a delayed onset of ILD.

Of course, this outcome could be due to channeling bias, but it suggests that ILD is not due to methotrexate use.

A similar outcome was reported among patients receiving non–anti-TNF biologic agents. Mena-Vázquez and colleagues found less progression of ILD among patients receiving these agents, whereas smoking and high RA disease activity were associated with more progression.

Possibly, these agents contribute to slowing ILD progression by reducing RA disease activity, a hypothesis that is supported by findings from additional studies showing that abatacept leads to stabilization of ILD in patients with RA.

To summarize, the message for rheumatologists regarding ILD is to be aware of it, as there is a potential for therapeutic intervention. It is unfortunately easy to miss in patients with RA, as they frequently have limited mobility and do not often complain of shortness of breath. I believe we may soon see risk scores developed for this common comorbidity.

Fatigue is a well-recognized comorbidity of rheumatic diseases. However, a study presented virtually at EULAR 2020 sheds new light on the potential for fatigue as an adverse reaction to biologic therapies.

In a database of nearly 1400 patients with immune-mediated inflammatory diseases, including RA, 100 patients reported experiencing fatigue associated with biologic therapy, and 48 patients reported a unique syndrome of recurring fatigue occurring directly after administration of biologic therapy. In a few of these cases, the patients discontinued the biologic therapy because of this syndrome.

This is certainly a surprise given that we have traditionally thought that many of these agents were capable of abolishing fatigue. Although rare in this database, the potential for biologic-associated fatigue—or at least patients’ perception of it—is worth being aware of so that we can intervene by changing therapy.

Cancer Risk
Little is known about the risk of new or recurring neoplasia in patients with a history of cancer who are receiving biologic DMARDs for RA. Wetzman and colleagues undertook systematic review with a meta-analysis of 12 observational cohort studies of patients treated with or without biologic DMARDs.

The take-home message is that they found no evidence of an increased risk of new or recurring cancers among patients receiving biologic DMARDs with a history of cancer, with one exception: an increased risk of skin cancers including melanoma.

It is important to point out the channeling bias in this analysis, as patients at very high risk for cancers probably were not initiated on a biologic DMARD. Nonetheless, these data are reassuring and suggest that we can safely administer biologic DMARDs for patients with a history of cancer, depending on the cancer. Indeed, in my experience, many patients would prefer to receive treatment for RA than be left with active disease.

Your Thoughts?
Which new data from EULAR 2020 will most influence your management of patients with RA? Join the discussion by posting a comment below. For more coverage of RA from the virtual meeting, download focused Capsule Summaries of key studies and reuse the slides in your own presentations. 

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