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Title: Increased Incidence of Infection, Cardiovascular Disease, and Malignancy in Patients with Rheumatic Diseases

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Curr Opin Rheumatol 2004 Mar;16:2:109-13.
02/25/2004 10:26:00 AM
By Deanna M Green, PhD

Infection, cardiovascular events and cancer and lymphoma rates are significantly higher in patients with rheumatic disease, particularly those with rheumatoid arthritis, according to an American review. An association between these co-morbidities and the underlying disease and its related medications has yet to be observed. Survival rates for patients with chronic autoimmune diseases have steadily improved due to the increased use of more effective, well-tolerated treatment options. With longer life and increased age, these patients are more likely to accumulate co-morbid conditions. Mary Chester M. Wasko, MD, MSc, at the University of Pittsburgh, Pennsylvania, United States, reviewed recent findings on the risk of infection, cardiovascular disease, and malignancy in patients with rheumatic disease. Recent studies have demonstrated an increased risk of infection in patients with rheumatoid arthritis (RA). Specifically, RA patients have a hazard ratio of 1.7 for objectively confirmed infections and 1.83 for infections requiring hospitalisation when compared to population controls without inflammatory arthritis. Further analysis has determined that the risk factors for predicting infection in RA patients include increasing age, the presence of extra-articular disease manifestations, leucopoenia, corticosteroid use, and concomitant co-morbidities such as chronic lung disease, alcoholism, organic brain disease, and diabetes. Importantly, treatment with disease-modifying agents was not associated with increased infection risk, after adjusting for these factors. Previous studies have shown an increased risk for atherosclerotic cardiovascular events for patients with systemic lupus erythematosus. Despite this knowledge, a recent study determined that risk factor screening in this group is highly inconsistent. The risk conferred by RA is still unclear. A recent study showed a 60-70% excess all-cause mortality in RA when compared to patients with osteoarthritis and no arthritis, and a 30% to 60% excess incidence of cardiovascular events. Moreover, an analysis of the Nurses' Health Study found that women with RA had a significantly increased risk of myocardial infarction, but not stroke, and that the risk was greater for women with longer-standing disease. Interestingly, the increased risk of atherosclerotic events was not observed in patients with juvenile idiopathic arthritis. The US Food and Drug Administration has reported that patients with rheumatoid arthritis have a 2-fold increased incidence of lymphoma, with an even greater risk seen in patients with higher disease activity. Moreover, subsequent analysis has not observed an increased cancer risk with anti-TNF treatment. Dr. Wasko adds that "the relative contributions of underlying chronic inflammatory diseases and the medications to treat those rheumatic conditions are uncertain, but will be a challenging topic for future investigation."

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