Rheumatoid arthritis cause death

RA Patients Living a Decade Longer

LIVERPOOL — Life expectancy among patients with rheumatoid arthritis (RA) has increased dramatically over the past 25 years, a researcher reported here.

The average age at death for RA patients in a cohort that enrolled patients between 1986 and 1998 was 76.7 years (95% CI 75-78.1), while for a cohort that enrolled patients between 2002 and 2012, the average age of death was 86.7 (95% CI 84.1-89.5), according to Sam Norton, PhD, of King’s College in London.

This represented a 3.5% decrease in relative hazard ratio for all-cause mortality every year between 1986 and 2012, he said at the annual meeting of the British Society for Rheumatology.

Since the 1980s, there has been an increase of at least 5 years in life expectancy in the general population, but it’s been uncertain whether this has also been the case in RA. One recent report from the Norfolk Arthritis Register suggested that there had been no change in mortality rates over time.

To examine this in the national RA population in the U.K., Norton’s group analyzed data from the Early Rheumatoid Arthritis Study (ERAS, 1986-1998) and the Early Rheumatoid Arthritis Network (ERAN, 2002-2012).

None of the patients had received disease-modifying anti-rheumatic drugs at the time of enrollment.

ERAS included almost 1,500 patients, and during almost 25,000 patient-years of follow-up there were 698 deaths. In ERAN, with 1,252 patients and 9,000 patient-years, there were 124 deaths.

Average duration of symptoms at the time of enrollment was 2 years in ERAS and 3 years in ERAN, and age at onset was 53 and 57, respectively.

Two-thirds were female in both groups.

The mean baseline disease activity score was 5.01 in ERAS and 4.53 in ERAN, Norton said. A possible reason for this slight decrease in disease activity in the later cohort was the greater use of steroids by primary care physicians before referral, he suggested.

Overall, there was a 27% decrease in excess all-cause mortality, which was mainly seen in patients younger than 55, he noted.

Another difference was that in 1986, the average age at disease onset was 54.2 years, while in 2012, age at onset was 58.5, which was an increase of about 2 months each year (t=2.9, P=0.007).

“But to add a slightly negative note, it’s important to recognize that if people are living longer, we need to think about disability,” Norton said.

“A 10-year increase in life expectancy and a 5-year delay on onset suggests that on average, people are living 5 years longer with disability. So obviously there’s good news but it’s not all good,” he said.

Disclaimer

The authors disclosed no financial relationships.

Primary Source

British Society for Rheumatology

Source Reference: Norton S, et al “Excess mortality in rheumatoid arthritis: gains in life expectancy over 25 years” BSR 2014; Abstract O34.

Comment

Can people die from rheumatoid arthritis?

As RA progresses, long-lasting or frequently occurring inflammation in the joints can lead to permanent joint damage. This can affect the joints of the cervical spine in the neck, and it may cause nodules to form under the skin.

RA can also increase the risk of certain health conditions. The following sections discuss three of the main complications: heart disease, respiratory problems, and infections.

Heart disease

Share on PinterestRA can cause damage to the tissues surrounding the heart.

RA can cause inflammation and damage to the arteries, the heart muscles, or tissues surrounding the heart.

Pericarditis, which is inflammation of the pericardium, the pouch surrounding the heart, and fluid buildup in this pouch may be especially significant factors. Pericarditis may affect around one-third of the people with RA.

While pericarditis is rarely a serious complication, any symptoms affecting the pericardium can be life-threatening.

People with RA are also much more likely to develop atherosclerosis, which is a buildup of plaque in the arteries. In a person with RA, this plaque is more likely to be brittle and break away, leading to a much higher risk of heart attack and stroke.

The Arthritis Foundation note that RA increases the risk of a number of other complications involving the heart. They report that a person with RA may have:

  • a nearly doubled risk of ischemic stroke
  • a tripled risk of deep vein thrombosis, which refers to blood clots in the legs
  • a more than quadrupled risk of a life-threatening pulmonary embolism

Respiratory disease

According to the Arthritis Foundation, beyond complications that affect the joints, people with RA are most likely to experience complications involving the lungs.

RA increases the risk of respiratory issues such as:

  • nodules in the lungs
  • a buildup of fluid in the lung tissue, usually in the space between the lung and the chest wall lining, which is called pleural effusion
  • bronchiectasis
  • interstitial lung disease

Interstitial lung disease affects 1 in 10 people with RA. It occurs when excessive inflammation from an overactive immune system causes scarring in lung tissue. This can make breathing difficult or impossible, and a person could eventually need a lung transplant.

People with RA may also have a higher risk of developing blockages in the small airways of the lungs.

Infections

People with autoimmune conditions, such as RA, tend to be more susceptible to potentially serious or fatal infections.

In people with RA, it is still unclear whether this susceptibility results from the condition or a side effect of RA medications, including biologics and steroids.

Vaccinations, such as the flu and pneumococcal vaccines, can prevent some infections associated with RA.

Other complications

Other complications from RA include:

  • inflammation in the eye
  • osteoporosis
  • anemia
  • type 2 diabetes
  • rheumatoid vasculitis, which is inflammation in the blood vessels

Learn more about the effects of RA on the body here.

How is lifespan affected by RA

Introduction

This article explores the impact that RA can have on life expectancy and how this level of risk can be improved. Many factors can influence life expectancy, both for the general population and for those with rheumatoid arthritis (RA). Over the years, studies have shown that RA can shorten lifespan by an average of about ten years, the cause for this decrease is due to multiple factors and there is an increasing impetus of managing other factors aside from physical disability and improvement of quality of life. With the advent of earlier diagnosis and new therapies, recent data suggests an increase in lifespans and in particular newly diagnosed individuals may have equivalent lifespans to the general population. The underlying cause for mortality is being researched and further treatment approaches are being developed.

Will all RA patients have a shorter lifespan than people without RA?

Statistics will always be general, and there are certainly patients with RA that have lived into their 80s and 90s (and some even beyond that), so you can never be certain that your lifespan as an individual will be affected, but as with members of the general population, it makes sense to be aware of the risk factors and to look after your body as best you can, in order to minimise some of these risks.
Young age at onset, long disease duration, the presence of other health problems, and characteristics of severe RA (such as poor quality of life, a lot of joint damage on x-rays, involvement of organs other than the joints, more active disease early on and being positive for both types of rheumatoid arthritis associated antibody (rheumatoid factor and anti-CCP)) can have an impact on lifespan. However, patients who see a rheumatologist early in the course of their disease have a better outcome. Many of these factors may be linked and more research is needed to tease out the most important of them. Using this information, health professionals should eventually be able to identify early on which individual patients are at high risk of early death and intervene appropriately, if possible, to control the relevant risk factors. Encouragingly, a recent Dutch study compared death rates from 1997 to 2012 and found over these 15 years declining death rates on an annual basis, though compared to age and sex matched individuals it remained higher.

What health conditions can affect life expectancy among RA patients?

RA patients appear to have a higher risk overall of developing serious lung or heart problems as well as infections, cancers and stomach problems.
The reasons for RA patients being more susceptible to infections and cancers may be related to the altered function of the body’s defence system (the immune system). However, as many of the drugs used for treatment of RA also have an impact on the immune system these are also implicated.
The following paragraphs look at each of these risk factors in more detail.

Infection risk:

Most infections in patients with RA are not serious and in recent years studies have shown that the more commonly used drugs (such as methotrexate, sulphasalazine and hydroxychloroquine) do not significantly increase the risk of serious infections. However azathioprine, cyclophosphamide and corticosteroids do appear to increase the risk of infections.

The number of “biological” therapies has increased exponentially in recent years and although the agents are effective there is also a small, but important increased risk in serious infections. The risk of infection is largely determined by non-modifiable factors (age, co-morbidities) and modifiable factors (corticosteroid usage, functional status).
Anti-TNF drugs and some other biologics are linked with an increased risk for re-activation of tuberculosis (TB), in people who had been exposed to TB in the past (whether they were aware of it or not), so you are likely to be screened for TB before you are able to start on this type of treatment, and if positive will require treatment.

Lung problems:

Involvement of the lungs occurs in 30-40% of patients with RA. Lung conditions account for about 10% of deaths in people with RA. Patients with RA may develop inflammation or scarring in their lungs which causes gradually worsening breathlessness. Breathlessness can also be due to inflammation of the blood vessels supplying the lungs, or of the membrane that covers the lungs. Other causes include getting unusual chest infections or scarring of the lungs as a side-effect of certain medications.

Cancer:

Like anyone, patients with RA may develop cancer, although the rates of some cancers are higher in RA than in the general population. Patients with RA have a reduced risk of bowel and breast cancer, but have higher incidences of lung cancer and lymphoma (a cancer of the blood and lymph glands). On average the risk of lymphoma is twice that of the general population. These cancers are commonest in patients with the most aggressive arthritis, who are more likely to receive the most aggressive treatments; it is therefore still not clear if the increased risk of cancer is due to the RA, its treatment or both.

Specific to anti-TNF therapies there appears to be a slight increase in non melanoma skin cancer (a type of cancer that fortunately usually responds well to treatment), but there is no increased risk over conventional treatments for other cancers. To minimise this risk, preventative skin care and skin surveillance is advised alongside prompt reporting of any new lesions.

Rheumatologists remain cautious in prescribing “biologics” and often do not prescribe these drugs to patients who have a strong family history of cancer or have recently had cancer.

Stomach problems:

In the past there were a large number of deaths from stomach or bowel problems (usually bleeding or perforated ulcers) most probably due to side effects of non-steroidal anti-inflammatory drugs (NSAIDs) on the lining of the stomach. However development of other drugs that protect the stomach from the side effects of anti-inflammatories and improvements in other treatments for RA may have reduced mortality from such causes. Recent evidence suggests that anti-inflammatory drugs may also be associated with high blood pressure, kidney disease and ultimately with an increase in disease and death due to heart disease (see below).

Heart disease:

Heart disease accounts for around a third of deaths in RA, with death from heart disease occurring in patients with RA ten years earlier, on average, than in the general population. There are multiple causes for this, but arguably the most important is ischaemic heart disease (IHD), where the blood vessels supplying the heart get furred up, making it harder for blood to reach the heart and deliver necessary oxygen to the cells. Furring of the arteries can occur in anyone, not only patients with RA, and is due to several “risk factors” including old age, male sex, family history as well as smoking, high blood pressure, high cholesterol, diabetes, increased weight and reduced exercise. This can lead to angina and heart attacks, sudden death, or heart failure. This may be more severe in people with RA than in the general population, even if they have the same risk factors. RA patients sometimes experience less in the way of warning symptoms (such as chest pain on exertion), probably because they are limited by their physical disability, or pain being attributed to other causes such as their arthritis, so may not receive the most appropriate investigations and treatment.
The reasons for the increased frequency and earlier development of IHD in RA are not known but are being actively researched. Overall, patients with RA may have more of the traditional “risk factors” described above but there are also other very important explanations related to the RA itself. Changes in the function of blood vessels due to the inflammation of RA, inflammation of the blood vessels themselves (called vasculitis) to the type and levels of cholesterol and altered clotting mechanisms of the blood due to inflammation or genetic differences are likely contributors.
So, what should you be doing to help decrease this risk? Firstly, it is important to modify any traditional “risk factors”, for example by stopping smoking, controlling high blood pressure or lowering cholesterol. Secondly in treating the RA as effectively and early as possible, the level of inflammation should be minimised. Encouragingly there are some early signs to suggest patients more recently diagnosed with RA who receive consistent RA medication have no increased risk of dying from IHD compared to the general population, at least in the early years of the disease and that patients who respond well to anti-TNF medication are at lower risk of a future heart attack.

A strong correlation has been seen with increased physical activity and lower cardiovascular events in patients with RA, along with improvements in weight, cholesterol levels, blood pressure and improved diabetes control.

Conclusion

Rheumatologists anticipate that more effective control of RA will not only improve quality of life but also improve life expectancy in patients, and with databases such as the BSRBR, and similar registers across the world, the story is becoming clearer. In the meantime, here are some practical steps that can help to reduce the risks:

  • Both you and your doctor should look out for any new symptoms, such as excessive tiredness, sweats and fevers, weight loss, which could be due to RA but may also reflect chronic infection or cancer. Chest pain or breathlessness may also need to be investigated with special tests looking for heart or lung disease.
  • If you smoke, you should try to stop smoking. Each year of smoking cessation (each year of being a non-smoker) is associated with a reduced risk of dying from any cause.
  • You should also make efforts to control your weight and be as physically active as possible. Your doctor in turn should check your blood pressure and cholesterol periodically and control them if necessary.
  • Both you and your doctors should consider supporting any further research addressing this important problem.

Further reading

NRAS information on CV risk assessment
The British Heart Foundation website (for tips on keeping your heart healthy)
References available on request
Reviewed: 02/01/2020

People With Rheumatoid Arthritis Are More Likely to Die Prematurely

Mortality rates are higher for people with rheumatoid arthritis (RA) compared with the general population, according to a new analysis published today in the journal Arthritis Care and Research. Study authors say that people with RA are nearly twice as likely to die before the age of 75, particularly due to heart disease and respiratory conditions.

The study followed 87,114 people with rheumatoid arthritis in Canada, with an average age of 57, and nearly 350,000 people age 15 and older from the general population from 2000 to 2013. During the study period, 14 percent of the people with rheumatoid arthritis and 9 percent of those in the general population group died.

RELATED: Rheumatoid Arthritis Worsens Outlook After Heart Attack

“We knew that premature mortality, but previously there had not been large enough sample sizes in studies to see where the exact differences may be occurring,” says lead author Jessica Widdifield, PhD, of Sunnybrook Research Institute in Toronto, an adjunct scientist at the Institute for Clinical Evaluative Sciences and assistant professor at the Institute of Health Policy, Management, and Evaluation at the University of Toronto in Toronto.

A New Way of Looking at the Mortality Numbers

RA itself is not generally considered a lethal disease, and the rate of mortality attributed to it as the main underlying cause of death is on the decline. Deaths in people with RA had previously been seen as complications of RA and its treatment, so Widdifield and her team approached looking at RA mortality in a new way. They examined premature mortality and age at the time of death and the potential number of years of life lost. “That rate is double for people with RA,” says Widdifield. “This method puts more weight if you died at a younger age.” Of people with rheumatoid arthritis, 36 percent do not live to the age of 75, compared with 32 percent of people without the disease.

Cardiovascular and Respiratory Deaths in People With Rheumatoid Arthritis

While the causes of death were very similar among the two groups — the most frequent being circulatory system diseases, cancer, and respiratory infections — people with rheumatoid arthritis were more likely to succumb to those serious health problems at a younger age.

RELATED: How to Protect Your Lungs When You Have Rheumatoid Arthritis

“Our findings offer new insights into the importance of cardiovascular and respiratory contributions — including pneumonia — to shortening patient lives,” says Widdifield. Her analysis shows that a third of RA deaths can be chalked up to heart disease. “Both patients and physicians should be thinking about this connection earlier in the patient’s life. The heightened risk associated with respiratory diseases and respiratory infections should also be a cause for discussion,” she says.

Why Heart Disease Is More Deadly for Those With RA

Heart disease should be considered a serious cause for concern among people with RA, even those who’ve yet to reach middle age. The study authors found that people with RA under the age of 45 had almost a threefold increased risk of cardiovascular disease death compared with the general population, in large part because of the high-grade, systemic inflammation that goes along with RA. “It doesn’t only affect the joints, it’s throughout the body, and it attacks multiple organs,” says Widdifield.

RELATED: How Rheumatoid Arthritis Progresses

RA treatments themselves may also play a role in leading to premature death, particularly because they can leave people more susceptible to infections. “A lot of disease-modifying treatments have altering effects on the immune system, so people with RA should take mild infections seriously,” says Widdifield. “Talk to your doctor about the flu and shingles vaccines and about other preventive strategies. Even a mild infection can turn more deadly in ,” she says.

RELATED: Why You Don’t Want to Get the Flu When You Have Rheumatoid Arthritis

Some Causes of Death Are Lower in People With Rheumatoid Arthritis

While the mortality rate was higher in people with RA for several serious health conditions — diseases of the circulatory system (29 percent in the general population vs. 30 percent with RA), cancers (26 percent vs. 33 percent), and respiratory diseases, including respiratory infections (12 percent vs. 9 percent) — people with RA were less likely to die from nervous system disorders, such as Alzheimer’s disease, and mental health disorders like dementia.

And in other promising news, Widdifield says, mortality rates for people with RA are better than they were in previous decades. “That’s because of significant improvements in treatment for RA over the last decade,” she says. “Rheumatologists have better clinical practice. But the downside is that there aren’t enough rheumatologists in North America, and we have to be proactive about improving that.”

RELATED: Rheumatoid Arthritis: What New Blood Pressure Guidelines Mean

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