Eric L. Matteson, MD, MPH, professor of medicine at Mayo Clinic School of Medicine, and chairman of the Division of Rheumatology at Mayo Clinic, Rochester, Minnesota, sat down with Rheumatology Advisor at the American College of Rheumatology annual meeting in Washington, DC, to discuss the morbidity associated with interstitial lung disease (ILD) in rheumatoid arthritis(RA) and other rheumatic diseases.
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I’m Eric Matteson and I am a professor of medicine at the Mayo Clinic in Rochester, Minnesota. I am a clinician scientist there and I have a particular interest in lung diseases in the rheumatic diseases. We know that in rheumatoid arthritis, lupus, scleroderma, Sjögren’s syndrome, and sarcoidosis that the lung disease is often the determinant of the patient’s outcome. What we have really underappreciated is the contribution of the lung disease to the morbidity and mortality of these diseases.
In an effort to understand this better we have undertaken a number of studies that look at the progression of the decline in pulmonary function, for example, in rheumatoid arthritis. This is something that heretofore has not been studied in these patients over long periods of time. In rheumatoid arthritis, about 10% or so of patients have significant lung disease and that interstitial lung disease increases the mortality or the death experience, the chances of dying at any given point, by threefold through the disease career. What we do not know is what kind of lung diseases are more likely to increase this risk of dying.
So what we have investigated are the two major forms of interstitial lung disease: NSIP [nonspecific interstitial pneumonitis] and UIP [usual interstitial pneumonitis]. What we have found is that UIP is more common in rheumatoid arthritis, but the impact of UIP on long-term mortality in rheumatoid arthritis is not different from NSIP, which is in contrast to idiopathic interstitial lung disease.
We also learned that there is a subset of patients who have rapidly progressive disease. These patients tend to be patients who are male, who are smokers, and who have a sharp decline in their DLCO, which is a measure of oxygenation and carbon monoxide exchange, and in their FVC [ forced vital capacity], which is a measure of lung volume, early on in the disease course. We are now starting to be able to identify who these patients are, and identifying this is really important to understanding which patients we need to focus on treatment for in the future as we develop better therapies for managing this part of the disease of rheumatoid arthritis.
In sarcoidosis much of the same is true, as well, and the extent of lung disease very much affects the mortality experience of patients with sarcoidosis. But we know it’s not just the lung disease that affects mortality and morbidity in sarcoidosis. We have traditionally connected sarcoidosis with lung disease, but we have found out now that patients who have sarcoidosis—like patients with other rheumatic diseases—have more cardiovascular disease. The risk of developing cardiovascular disease in sarcoidosis is about twofold compared to people who don’t have sarcoidosis. The risk of developing osteoporosis and osteoporotic fractures is increased, and their risk of developing peripheral vascular disease is also markedly increased.
So these are things that really have not been understood in populations of patients with sarcoidosis but things that providers who take care of these patients need now to pay more attention to and understand in order to better manage these conditions.
We [also] know that patients with rheumatoid arthritis, as patients with other rheumatic diseases, are at higher risk for cardiovascular diseases. We know that traditional risk factors for cardiovascular disease such as smoking, hypertension, obesity, and hyperlipidemia are factors that affect patients with rheumatoid arthritis, just as they affect people who don’t have rheumatoid arthritis. Above and beyond that, however, patients with rheumatoid arthritis are also at higher risk of cardiovascular disease simply based on the fact that they have rheumatoid arthritis, probably because of the inflammatory component of the disease. This is little recognized and is something that we are working to build into risk assessment for cardiovascular diseases among our patients who have rheumatic disease.
Traditionally, what we have done is to assess for risk factors like smoking, obesity, and so on, as I’ve mentioned. But now what we are trying to do is to further identify these patients for interventions. One thing that has become really clear through our population-based studies is that patients with rheumatoid arthritis don’t even receive statin therapies when they should be receiving them, so 50% of patients with rheumatoid arthritis who should be on a statin for managing their hyperlipidemia are not on statin therapy.
Further, the fact that the disease, rheumatoid arthritis, and the inflammatory condition that affects the joints also affects blood vessels and coronary arteries is a contributor toward this risk for cardiovascular disease means that we need to develop better risk assessment tools. The finding that we have so far is that the risk assessment tools that are available—the Framingham risk assessment tool or even the multiplication factor that EULAR uses (1.5-times the Framingham score after 10 years of disease)—are inadequate for predicting cardiovascular disease risk in these patients. So we are working very hard to find better assessment algorithms and better assessment tools so that we can identify these patients.
Zamora-Legoff A, Krause M, Crowson CS, Ryu JH, Matteson EL. Progressive decline of lung function in rheumatoid arthritis associated interstitial lung disease. Presented at: 2016 ACR/ARHP Annual Meeting. November 11-16, 2016; Washington, DC. Abstract 1497