Anti-rheumatic therapy and comorbidity

Abstract

Anti-rheumatic medications have improved survival and quality of life for patients with rheumatic diseases. Published guidelines help physicians select the appropriate therapy from among the traditional immunosuppressants and disease-modifying agents to the newer small molecules and biologic drugs. However, given the paucity of data for patients with comorbidities, not surprisingly these evidenced-based guidelines do not address the use of anti-rheumatic medications for patients with many of the common chronic medical illnesses. Biologic and chronic disease registries although providing the long-term follow-up needed to evaluate the safety of specific anti-rheumatic drugs are susceptible to the channeling of patients to specific therapies based on the presumed risk of complications. In this chapter we review some of the published data of anti-rheumatic drugs in patients with chronic medical illnesses and provide recommendations. Rheumatic patients with chronic viral hepatitis are at risk of reactivation and hepatocellular injury with immunosuppressive therapy, but some biologic agents appear safe. Immunosuppression can enhance growth of certain malignancies complicating the selection of anti-rheumatic therapy for this group of patients, and specific surveillance may be required. Interstitial lung disease develops in many connective tissue diseases and may also be induced by certain anti-rheumatic drugs; however, these same medications may be used to treat the lung disease. Atherosclerosis is accelerated by the presence of chronic inflammation leading to an increased risk for cardiovascular disease in rheumatic patients. Certain anti-rheumatic medications can produce an atherogenic lipid profile, yet paradoxically the control of inflammation can reduce plaque and reduce cardiovascular events. The use of anti-rheumatic medications in diabetes mellitus, chronic kidney disease, and pregnancy is also discussed.