What is “comorbidity”? All other diseases that co-exist with a disease of interest, are called comorbidities. Comorbidities in inflammatory rheumatic diseases can be associated with persistent inflammatory activity or disease related organ damage, or may be related to medications. Life style such as smoking or physical inactivity contribute to comorbidity. Patients with rheumatic diseases meet health professionals regularly and are more often tested for osteoporosis or cholesterol levels than individuals without rheumatic disease which may contribute to a higher prevalence of some comorbidities. Comorbidities can also be unrelated to rheumatic diseases or their treatments.
How to measure comorbidities? Comorbidity indices that estimate the frequency and severity of comorbidities are used in clinical studies. In clinical care, comorbidities are reviewed and recorded by a health professional by indicating whether a medical condition exists or not. In surveys, patients select from a list comorbidities that apply and a plain number of comorbidities is calculated without an indication of severity.
Impact of comorbidities. The impact of comorbidities in rheumatic diseases is multidimensional. Some comorbidities such as cardiovascular disease, lymphoma, renal and pulmonary disease and infections are associated with preterm mortality. As inflammation is the common pathophysiology in rheumatic diseases and in many comorbidities, suppression of inflammatory activity is essential. This emphasizes early and active treatment of every patient with an inflammatory condition, to diminish the risk of comorbidities. Furthermore, careful monitoring of patients at high risk of comorbidities, in particular those with severe, treatment refractory disease, is necessary.
Cardiovascular disease. In addition to the risk that is caused by inflammation, patients with rheumatic diseases are at least as likely as general population to have traditional cardiovascular risk factors such as hypertension, diabetes, and hyperlipidemia. Furthermore, patients with rheumatoid arthritis are more likely to smoke and be physically inactive than general population. Therefore, traditional risk factors for cardiovascular disease need to be reviewed and addressed on a regular basis, and interventions against adverse life style factors and other important predictors should be initiated when indicated.
Depression and fibromyalgia are comorbidities that increase the risk of work disability. Review of patients’ psychological well-being should be routine practice at rheumatology visits. A multidisciplinary team including nurses, physiotherapists, social workers and psychologists facilitates the management of patients with these comorbidities.
Osteoporosis is a prevalent comorbidity in rheumatic diseases. Patients need to be screened and treated for osteoporosis. Preferably, patients at high risk, in particular those who are treated with long term corticosteroid treatment, should be started on preventive treatment before osteoporosis develops.
Other comorbidities. Some comorbidities are associated with the use of anti-rheumatic drugs e.g. gastrointestinal ulcers with perforation or bleeding, which in the past were often seen in patients with heavy use of NSAIDs. Serious infections and pulmonary diseases are rare but potentially life threatening side effects of current anti-rheumatic medications.
Comorbidities as “side effects” of rheumatic diseases, preventable by active care. “Side effects” of untreated or poorly treated rheumatoid arthritis overall are worse than side effects of current anti-rheumatic drugs. It can be anticipated that comorbidity of rheumatic diseases will become less prominent over years with active treatment strategies and routine evaluation and care of other risk factors for comorbidities. Signals indicating such a development are already available.
Disclosure of Interest None Declared
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