Rheumatoid Arthritis-Extra-Articular Involvement & Health Risks
by Dr.C.H. Weaver M.D. updated 1/2020
In addition to causing pain, swelling, and stiffness of joints RA can affect multiple organs and body systems. Extra-articular problems are caused by RA-related inflammation, associated with the autoimmune disorder itself or can be a consequence of treatment for RA. Most related conditions can be effectively prevented or managed and it’s important to keep an eye out for the early signs and symptoms of these conditions.
RA can lead to anemia (low red blood cell count) and, less commonly, to problems with the blood vessels, lungs, heart, and other organs. Individuals with RA need to be aware of the signs and symptoms that result from RA affecting areas of the body other than their joints.
Extra-Articular Involvement of RA
Heart & Lung Disease
Chest pain and shortness of breath are the key symptoms suggesting that RA may involve the heart or lungs. These symptoms should be taken seriously and immediately reported.
People with RA have almost twice the risk of heart-disease as their same-age peers. RA-related inflammation affecting the arteries is thought to be the reason. Rheumatoid arthritis is considered to be a risk factor for the development of heart disease, and of equal importance to other known risks including diabetes, high blood pressure, elevated cholesterol, smoking, and family history. For this reason, individuals with RA should make an extra effort to eat heart-healthy food, exercise regularly, and manage their other risk factors.
- Costochondritis is an inflammation of the cartilage that connects the ribs to the breastbone (sternum). Pain in the chest caused by costochondritis might mimic that of a heart attack or other heart conditions. Costochondritis may occur in RA, PsA and AS.
- Interstitial Lung Disease (RA-ILD) In addition to inflammation of the joints, RA can attack the lungs and cause scarring. Chest pain and shortness of breath are the most common symptoms. It is estimated that almost 8% of people with RA develop interstitial lung disease, or scarring of the lungs. RA associated inflammation can affect the lining of the lungs which can make breathing painful, produce lung nodules (which can be mistaken for cancer), or affect the lungs themselves leading to progressive scarring and shortness of breath.
- Acute Coronary Syndrome is one of the major causes of morbidity and mortality in RA.
The skin can also be impacted by RA because the same immune system problem that cause’s joint inflammation can also affect the skin and the blood vessels that supply the skin. Rheumatoid nodules, skin rash and Raynaud's all occur more commonly in individuals diagnosed with RA.
- Vasculitis or inflammation of blood vessels occurs in less than 5% of individuals with RA and most often involves the small blood vessels that supply blood to the skin on the fingertips. This may cause a blue or purplish rash near the fingernails. If the vasculitis involves larger arteries and veins, it can lead to a rash that’s red and painful most commonly on the legs. Treatment for rheumatic skin conditions must be personalized for each individual patient based on their condition and disease state. Therefore, any rash associated with RA requires a doctor’s supervision and treatment guidance.
- Rheumatoid nodules are firm lumps located just under the skin. The nodules most commonly grow close to the affected joints and can be as small as a pea and as large as a chestnut. Rheumatoid nodules are also often found at pressure points, including the hands, fingers, knuckles, or elbows; however, they may appear almost anywhere, including the lungs, heart, other internal organs, and even on the vocal cords, causing hoarseness. Nodules can be asymptomatic or quite painful, but they are typically not problematic unless they interfere with daily activities by putting pressure on nerves or by limiting joint movement.
- Rheumatoid vasculitis and blood vessel disease
- Kidney involvement
- Eye involvement
- Other organs: including spleen, liver, lymph system, gut
Osteoporosis or a “thinning of the bones” is a complication of RA that increases the risk of bone fractures. Osteoporosis can be worsened by steroids used to treat RA and by inactivity.
All individuals with RA and especially women should develop a plan with their doctor to reduce their risk of osteoporosis. Regular bone-density scans should be performed to evaluate both risk and the impact of treatment. Dietary calcium and vitamin D supplementation, a regular exercise program, and newer bone-strengthening medications such as Prolia (denosumab) are all part of a strategy to reduce the risk of osteoporosis.
Sjögren’s syndrome is an autoimmune disease that mainly attacks the tear and salivary glands, causing dry eyes and mouth. It can occur separately or as a complication of RA.
Although there is currently no treatment to reverse Sjögren’s, which can lead to vision problems and tooth decay because of the lack of saliva, using moisturizing eye drops and drinking water can help prevent Sjogren’s complications. In addition, prescription drugs such as Evoxac and Salagen can help increase the production of saliva and tears.
Individuals with dry eyes or dry mouth should bring these symptoms to the attention of their doctor.
Individuals with RA have a two to four times higher risk than people without RA of developing non-Hodgkin lymphoma (NHL), a cancer of the blood. The increased risk of developing NHL can also be increased as a result of certain medications used to treat RA. The RA medicines methotrexate, Humira (adalimumab), Enbrel (etanercept), and Remicade (infliximab) all have an FDA required warning about increased NHL risk. The risk is real but small and for many individuals with RA the benefits provided by these medicines still outweigh the risk of NHL.
Individuals with RA are already at increased risk of infection and several of the more effective drugs suppress the immune system to further increase this risk.
A history of previous infection, especially hepatitis, fungal infections, and tuberculosis, should always be brought to the attention of the treating physician so appropriate steps can be taken to ensure optimal management.
RA can lead to anemia, which is a lack of red blood cells needed to transport oxygen in the body. The main symptom of anemia is feeling tired or fatigue. Anemia can occur with RA because inflammation can decrease the bone marrow production of red blood cells.
Individuals with RA experiencing fatigue should always bring this to the attention of their doctor. Anemia can be effectively managed by controlling RA inflammation. Moreover, red blood cell production can be improved with iron supplements and the use of growth factors when necessary.
Bleeding of the gastrointestinal tract and ulcers can be a problem in individuals with RA. Bleeding is mainly due to the use of nonsteroidal anti-inflammatory drugs (NSAIDs), used by many RA patients to help control pain and inflammation. NSAIDSs are commonly purchased “over-the-counter” (Advil or Aleve) and by prescription (Celebrex).
Individuals with RA need to be aware that the combination of steroids (prednisone), which is often prescribed by their physician when combined with NSAIDs, increases their risk of ulcers and bleeding. Individuals need to be aware of this risk and make sure they communicate what medicines they are taking with their doctor.