How is lifespan affected by RA
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, but until recently this received much less attention by the medical and scientific communities than control of physical disability and improvement of quality of life. However, with increased interest in this area, RA mortality studies have been performed in most parts of the developed world, including the United Kingdom, USA, Canada, Holland, Scandinavia, Australia and Japan and ongoing research is continuously adding important pieces to the puzzle.
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.
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.
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.
There is also some concern about the “biologic” therapies and risk of infection. The British Society for Rheumatology Biologics Register (BSRBR), and other similar registers across the world are monitoring this very carefully. Thus far, the Register has shown that people on anti-TNF therapies (one of the most common types of biologic drug) have a small but significantly increased risk of serious infections during the first 6 months of treatment.
Anti-TNF drugs and some other biologics are linked with an increased risk for re-activation of tuberculosis, 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.
Lung conditions account for about 10-20% 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.
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 skin cancer (a type of cancer that fortunately usually responds well to treatment). Until more is known, rheumatologists will remain cautious in prescribing anti-TNF treatment, and often do not prescribe these drugs to patients who have a strong family history of cancer, or have had cancer themselves within the last 10 years.
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 accounts for almost half of all deaths in RA, with death from heart disease occurring in patients with RA ten years earlier, on average, than in the general population. The exact reasons for this are still unclear. What we do know, however, is that the most likely cause 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), changes 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 or lowering cholesterol (initial research in patients with RA suggests that cholesterol-lowering tablets may lower the chance of having a heart attack). Secondly in treating the RA as effectively 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.
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, in future years this story will no doubt become 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.
NRAS information on CV risk assessment
The British Heart Foundation website (for tips on keeping your heart healthy)
References available on request
Dr Holly John BM BS MRCP PhD, Consultant Rheumatologist, Dr Karen Douglas MBChB, MRCP, MD Consultant Rheumatologist, Prof George Kitas MD, PhD, FRCP, Consultant Rheumatologist, The Dudley Group NHS Foundation Trust
Original article: 14/08/2001
Next review due: 07/04/2019