Bryant England, MD: Multimorbidity in Patients With Rheumatoid Arthritis

Rheumatology Network sat down with Bryant England, MD, to discuss his presentation entitled, “Epidemiology of Multimorbidity in Rheumatoid Arthritis (RA).” England is Assistant Professor of Internal Medicine, Division of Rheumatology, at the University of Nebraska Medical Center. He explains how multi-morbidity poses a threat to patients with rheumatic disease, the common chronic conditions that this patient population faces, and the study designs of Specific Aim 1 and Specific Aim 2, which emphasizes multi-morbidity risk surrounding the period of RA onset and establishes a foundation of knowledge regarding multi-morbidity in RA.

England’s research was funded by the Rheumatology Research Foundation through their Scientist Development Award.

Rheumatology Network: Hi, Dr. England. Thank you for joining me today. To begin, how does multimorbidity pose a threat to patients with rheumatic disease.

Bryant England, MD: I think we've realized over time that while we're taking care of these patients, there's more than just rheumatoid arthritis that's on their mind and also on their body. They, when they come to a visit, we're interacting. We realize how well a patient is doing or how well they may not be doing. It's not just because of the swelling that's in their joints, but also how rheumatoid arthritis and all their other diseases are, together, impacting their life. And so it's really brought to our attention this need that we need to go beyond just the joint swelling in rheumatoid arthritis. So, essentially think about how we're taking care of this patient more globally.

RN: Is multimorbidity more common in patients with rheumatic disease when compared with the general population?

BE: Yeah, absolutely it is. So, you know, in rheumatoid arthritis, we know that patients are much more likely to have multimorbidity compared to people without rheumatoid arthritis. And some of our work has shown that once patients develop RA, it seems to be this tipping point by which the rate that they gain other chronic and chronic conditions really seems to shoot off. So, it's right around those couple of years as patients are being diagnosed that something is happening. And if we start following those patients over time, you see things like diabetes, hypertension, other chronic diseases really just start being accumulated by patients with RA. Whereas the patients who don't have rheumatoid arthritis don't gain them near as quickly.

RN: You mentioned a few of the chronic conditions that patients with RA are more likely to develop. What are some of the other most common chronic conditions for this patient population?

BE: We know mental health and chronic pain disorders are very common in this population as well. The stress of living with a chronic disease is a lot to carry. We also know that having a source of pain and discomfort also kind of predisposes to having other chronic pain. We know Fibromyalgia is very common in patients with rheumatoid arthritis as well.

RN: What are some of the strategies you have found reduces multimorbidity development and progression in patients with rheumatoid arthritis?

BE: That's a great question. I wish I knew the answer to that. Unfortunately, a lot of my research right now is trying to get towards that point where we can understand how to intervene to really stop this. A few things we do know, though, is it's really hard to stop something if you aren't aware of it. And so, a big first step is just being in tune to the fact that these patients are at higher risk of having other chronic conditions. And that, again, as we take care of them, we be a little broader in how we look at these patients and not just about the swelling, but also thinking about, okay, well, do they have osteoporosis? Do they have lung disease? Do they have cardiovascular disease? Are they at high risk of cardiovascular disease? Thinking through these other chronic conditions that patients with RA may get and then thinking about the strategies we know of that can help prevent them. So, for example, if you're seeing a patient with rheumatoid arthritis, and they happen to be a smoker, we know that if we talk to this patient about smoking cessation, and help them stop smoking, that we can help prevent heart disease, lung disease, and cancers down the road.

RN: What are some of the significant knowledge gaps that limit the development of management approaches?

BE: So, there are several. One of them that's challenging though, is when a patient comes into clinic who's multimorbid and the next patient who walks into the clinic that may be multimorbid is completely different than in that patient. And that's because multimorbidity can be a lot of different things. You have a patient who has rheumatoid arthritis, and recently had coronary artery bypass grafting and difficult to control diabetes. That patient has a certain number of things we may need to target and address for the overall health. But that might be very different things than the next person who walks in who has severe depression and anxiety. Different strategies are needed for that patient who's multimorbid compared to the prior multimorbid patient. And so one of the things we really need is good ways to kind of think about multimorbidity; to think about it in a way that we can research it and figure out what are the best medications and the best treatment strategies, but also in a way we can categorize patients we see in the clinic according to the same groupings. It's really once you can harmonize a patient population clinically and research-wise that you can then use those to help each other. We can do better research to get better treatment strategies so that we can take better care of our patients.

RN: Can you tell me a bit about the study designs of the Specific Aim 1 and Specific Aim 2 studies?

BE: One of the first things we wanted to do is understand when multimorbidity starts. And at what rate is RA progressing? So, to do that, we used 2 large real-world databases and we created cohorts of patients with rheumatoid arthritis. We matched them to patients without arthritis, then we followed them over time. And what we showed is that these chronic conditions are very common, even at the time RA patients are getting RA. But really, the time they get RA is this tipping point where they really shoot off and develop all these chronic conditions much faster than patients without RA. But the second piece, what we did is, again, using these 2 large real-world data sets, we identified these patients with rheumatoid arthritis and match patients without RA. And then we assessed all of their different chronic conditions. And we tried to cluster these conditions into unique patterns of multimorbidity. And then after doing that, we looked at how frequent are these patterns in RA and non-RA. And then based on these patterns, can we then group RA patients into unique clusters of patients based on the patterns and multimorbidity that they have? And what does that tell us about what's going to happen down the road for them?

RN: Are there any strengths or limitations of the studies that you would like to discuss?

BE: Yeah, so 1 of the strengths is that these are real-world datasets. And I think that's crucial when we're studying multimorbidity because that's where you see multimorbidity. These aren't necessarily the patients that are going to be preferentially put into a clinical trial. So, if you really want to study this population, you have to go through a real-world dataset. The thing is that these datasets we have are very large. And so that allows us to study a very broad population, and to really evaluate even chronic conditions that might be fairly infrequent. Because of our sample size, we have the ability to study those. We also were within our willpower to look at some of these really important long-term outcomes that might be infrequent.

RN: What would be the clinical significance of these results?

BE: I think these are a step forward in really empowering providers to think about what it means when you're making a diagnosis of rheumatoid arthritis. I think we are all well versed. When we diagnose rheumatoid arthritis, we need to get these patients on disease-modifying drugs right away and we need to be thinking about getting them to a treatment target of low disease activity or preferentially remission. But I think now what we can see from this data is that in addition to that, it's thinking broadly. How can I prevent some of these chronic conditions that these patients might be at risk from? How can I work with their primary care provider to manage the chronic conditions that they may already have? I think the second important piece is that understanding that we're making progress in terms of how we can think about these patients. We probably aren't quite there yet, that these tools are helpful to be deployed in the clinics, but we're at least making progress that hopefully, in the not-too-distant future, we can have some tools that are really helpful to help identify patients who might be at risk of cardiometabolic conditions, which then kind of prompts you to really think about how to counsel on these types of things diet, lifestyle modification, smoking cessation, making screening or diabetes, those types of things.

RN: Does your team plan on doing any further research on this topic?

BE: Yeah, absolutely. We want to continue to refine some of these methods and tools that we've been developing. But we also want to take that next step forward. And I think we've recognized and shown this as a problem and a challenge for our patients. And that we really want to address that and figure out how to how to solve that and tackle that issue. We want to make our patients lives better in the long term. And we've clearly shown the major need for that is to help address all these other chronic conditions in the multimorbidity that our patients frequently have.