Managing Biologics for RA Patients with Comorbidities

Although biologics have been shown to improve the quality of life for patients with rheumatoid arthritis, side effects remain a problem, especially for RA patients who suffer from co-morbidities, such as cardiovascular disease, cancer and infections - which are among the leading causes of death in RA patients. Considering the prevalence of comorbidities in patients is important, but there is little literature on the subject, according to review published in the August 17 issue of BMJ.

• Biological drugs could help patients with rheumatoid arthritis and comorbidities, but there is limited evidence to guide their use.
• Patients with comorbidities are typically excluded from randomized, controlled trials. 
• Patients should be involved in the decision to use biological drugs.

_{Source:  BMJ}

 “Randomized controlled trials of such drugs in rheumatoid arthritis typically exclude patients with comorbidities and are of short duration, so they do not provide data on adverse events in these people,” wrote John S. Richards of the Veterans Affairs Medical Center, Washington DC, and colleagues. Other data sources such as national registries are limited by the pre-selection of patients for both traditional and biological drugs, he wrote. Although these databases document comorbidity, they rarely report its severity. “This too limits definitive statements on the progression or resolution of pre-existing disease.”  [[{"type":"media","view_mode":"media_crop","fid":"40705","attributes":{"alt":"","class":"media-image media-image-left","id":"media_crop_8305724437814","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4208","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.0080003738403px; line-height: 1.538em; float: left;","title":" ","typeof":"foaf:Image"}}]]Biological anti-rheumatic drugs may not be contraindicated in patients with rheumatoid arthritis and comorbid diseases, although additional assessments or precautions are recommended. On the contrary, biological drugs may improve the comorbid disease, by controlling the rheumatoid arthritis and perhaps through direct mechanisms. For example, they may improve glycemic control in diabetes. In treating hepatitis C virus infection, etanercept doubled the response rate to interferon alfa 2b and ribavirin. Methotrexate is contraindicated in chronic kidney injury, so biological drugs are attractive, although the evidence is limited to one open label study of five patients on etanercept.  This review summarizes current data on the use of biological anti-rheumatic drugs in patients with rheumatoid arthritis and infections with hepatitis B virus, hepatitis C virus, hepatitis E virus, tuberculosis, and human immunodeficiency virus; cardiovascular disease, cancer, interstitial lung disease, chronic obstructive pulmonary disease, diabetes, chronic kidney injury, and pregnancy.  

Patient input

The authors argue that patients should play an important role in setting recommendations because patients will have to assess the risks and benefits with their doctors. The investigators summarized their recommendations for patients as follows:  

• There is concern about the use of biological disease-modifying anti-rheumatic drugs in interstitial lung disease
• Etanercept seems to be a good option for patients with hepatitis C
• Temporary exacerbations of diabetes or chronic obstructive pulmonary disease that are treatable and reversible may be acceptable
• Insufficient data are available on the use of disease-modifying anti-rheumatic drugs in cardiovascular disease and pregnancy to make informed decisions

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• Cardiovascular Risk in RA: What Counts?
• How Risky Conversations Fail for Rheumatologists
• HBV Reactivation: Basics of New Warnings From Hepatologists
• Good News for Pregnant Women on Biologics

References:

Richards JS, Dowell SM, Quinones ME, Kerr GS.Clinical Review: State of the Art Review: How to use biologic agents in patients with rheumatoid arthritis who have comorbid disease. BMJ. August 17, 2015. 351:h3658. doi: 10.1136/bmj.h3658