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RheumThoughts: Multimorbidity in RA


Hi, I'm Bryant England. rheumatologist at the University of Nebraska. We're going to talk today about multi-morbidity and rheumatoid arthritis.

So, I'd like to start with you thinking about the last few patients with rheumatoid arthritis that you saw in your clinic. Do those patients have any other medical conditions besides rheumatoid arthritis? Now what about the last few patients that you made a new diagnosis of rheumatoid arthritis: do those patients have medical conditions besides rheumatoid arthritis? I suspect that you answered yes to both of those questions because when we look at large epidemiologic studies we see that most people with rheumatoid arthritis have multi-morbidity or multiple chronic conditions.

Multimorbidity is a little bit different than comorbidity, which may be a term that you're more familiar with. In comorbidity, we put rheumatoid arthritis as our focus, whereas in multimorbidity, we put the patient at the center of our focus.

On the outside of the patient are all the different conditions that they may experience, including rheumatoid arthritis. Separating those is important because multimorbidity is patient-centric and it also allows us to really see how those other conditions can interact together and cause poor long-term outcomes.

Multimorbidity is something that happens early in the RA disease course. We see again in epidemiologic studies that at the time that people are being diagnosed with rheumatoid arthritis, multimorbidity is already starting and it's already progressing. As it progresses, it leads to poor long-term health outcomes. These include things such as reduced quality of life, reduced survival. We've recently shown that this also affects RA-related outcomes. People with multi-morbidity tend to have poor functional status and higher disease activity over time.

it also affects how we treat our patients with multimorbidity.

Now, it's not clear in the literature whether having multimorbidity tends to affect which type of medicines we will use in patients who are multimorbid, but what is very clearly and consistently demonstrated is that when multimorbid persons initiated new medicine, they're less likely to reach our target disease activity thresholds of remission or low disease activity.

But probably the biggest wake-up call in terms of multi-morbidity and RA treatment came from ORAL surveillance, where we saw that in a multi-morbid population there was a differential safety risk with JAK Inhibitors versus TNF inhibitors.

This is really important for us  - learning that the risk to benefit ratio of some of our disease modifying therapies might be different in multi-morbit populations.

We clearly then need to address multi-morbidity in rheumatoid arthritis.

The first step is just simply recognizing that multimorbidity is an important concept that we need to bring into our discussions with our patients

in the clinic. We can talk with them about how this may alter the risk to benefit ratio of treatment decisions that we're implementing as part of shared decision-making. It's also important for us to engage other members of the healthcare team. Patients made a look to us as the quarterback of their care because rheumatoid arthritis is a chronic disease, but we need to remind them the importance of having a good primary care provider and engaging other subspecials as needed.

The real goal, though, is not to manage multi-morbidity but to prevent it in the first place. We can do that through regular chronic disease screenings, discussing healthy life behaviors with our patients such as exercise, diet modification, smoking cessation. And then as rheumatologists, doing our job well: treating rheumatoid arthritis the best that we can, early initiation of disease modifying therapies, treating to a target. And as we learned from ORAL surveillance, ultimately we need to generate comparative evidence of our therapies and therapy therapeutic approaches in multimorbid populations, so the data that we're applying the population matches the data that we generate.

In conclusion, we talked how multimorbidity is very common. In fact, most people with rheumatoid arthritis are multi-morbid. That multimorbidity was starting early in the disease course and predisposed them to poor long-term outcomes. In fact this even alters the risk to benefit ratio of some of our medications. What we have to do is we have to appropriately treat rheumatoid arthritis, but we also have to help them optimize their general health outcomes as part of their health care team. As we do these things, we must remember that multimorbidity is not something happening late in the process but targeting multimorbidity is something we need to do early on as a rheumatologist to help our patients prevent the progression of multimorbidity.

I'd like to thank you for tuning in. I'll see you next time.


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Dr. England is a clinician-investigator focused on improving long-term outcomes in rheumatoid arthritis. He conducts clinical and epidemiologic research in RA-associated lung disease, cardiovascular disease, cancer, and multimorbidity using several large observational datasets. He also leads prospective studies in RA-associated lung disease and connective tissue disease-interstitial lung disease.

Clinically, Dr. England is a rheumatologist focused on the care of patients with inflammatory arthritis (including RA and gout) and incorporates the use of musculoskeletal ultrasound into the diagnosis and management of rheumatic diseases. He also directs the University of Nebraska Medical Center Autoimmune Lung Disease Clinic, a multi-specialty clinic that specializes in treating autoimmune lung diseases (e.g. RA-interstitial lung disease and other connective tissue disease-interstitial lung disease). Dr. England is actively involved in several American College of Rheumatology projects and committees. He teaches medical students, residents, and fellows in the areas of rheumatology, musculoskeletal ultrasound, and clinical research as well as serves as a research mentor to students, residents, and fellows.