Podcast: Understanding Arthritis Comorbidities

Full Transcript:
Released 10/31/2023

PODCAST OPEN:           
You’re listening to the Live Yes! With Arthritis podcast, created by the Arthritis Foundation to help people with arthritis — and the people who love them — live their best lives. If you’re dealing with chronic pain, this podcast is for you. You may have arthritis, but it doesn’t have you. Here, learn how you can take control of arthritis with tips and ideas from our hosts and guest experts.

MUSIC BRIDGE

Bailey Cook:
Welcome to the Live Yes! With Arthritis podcast. I'm Bailey Cook, one of your guest co-hosts for today's episode. I was diagnosed with arthritis when I was 8 years old. You may have heard me on the “Words of Wisdom” or “Small Bites to Healthy Living” episodes. Today's episode, we're going to be talking about comorbidities, what they are, how they can affect you and what you can do about them. Joining me today, I have another voice I'm sure you've heard, Rick Phillips. Welcome back, Rick. Do you want to tell our listeners a little bit about yourself?

Rick Phillips:
I live in Central Indiana, and I deal with rheumatoid arthritis, ankylosing spondylitis and type 1 diabetes. And I was diagnosed first about 23 years ago.

Bailey Cook:
Thanks, Rick. In today's episode, we also want to welcome back Dr. Ashira Blazer. Dr. Blazer will explain what a comorbidity is and what conditions are likely to occur with some of the more common forms of arthritis, including osteoarthritis, rheumatoid and psoriatic arthritis, juvenile arthritis, ankylosing spondylitis and gout. She'll offer tips on what to watch for and when to tell your health care provider, and how comorbidities are treated.

Dr. Ashira Blazer is a rheumatologist at Hospital for Special Surgery, assistant attending physician and assistant professor of medicine at Weill Cornell Medical College. She specializes in the treatment of all rheumatic diseases, including undifferentiated connective tissue disease, Sjögren's syndrome, inflammatory arthritis and systemic lupus erythematosus (SLE), particularly in patients of African ancestry. Welcome back to the podcast, Dr. Blazer.

Ashira Blazer, MD, MSCI:
Thank you for having me.

Bailey Cook:
Let's just jump right in. Dr. Blazer, can you explain what a comorbidity is?

Ashira Blazer, MD, MSCI:
A comorbidity is a chronic illness that goes along with the arthritis that you may have. So, we know that people who have forms of arthritis or inflammatory conditions are also at higher risk for other conditions, like high blood pressure or high cholesterol or diabetes. These other health challenges are considered the comorbidities.

Rick Phillips:
So, Dr. Blazer, can you explain a little bit about the difference between a comorbidity and the disease itself? Also, perhaps you can tell us a little bit about the incidence of comorbidity when one has inflammatory arthritis.

Ashira Blazer, MD, MSCI:
When somebody has an inflammatory condition, they may be at higher risk for other chronic diseases. It may be that there's a shared risk factor between the two. Or it may be that the ways that you move and live, given that you have your primary arthritic condition, increase the risk. For example, people who have osteoarthritis are much more likely to also have diabetes. In the general population, about 27% of people have diabetes. But in this population of people with osteoarthritis, about 60% of people have diabetes, right?

Rick Phillips:
Wow.

Ashira Blazer, MD, MSCI:
Yeah, so it's a really big difference. And it's not that the arthritis is necessarily directly causing the diabetes, or that the inflammation that you're having is directly causing this. It's that as we age, we may develop osteoarthritis, and we also may develop diabetes. As we gain weight, we may develop osteoarthritis, and we also may develop diabetes.

Also, when you can't move very well, when you can't exercise very well, when you have pain in your joints with some of our rheumatoid arthritis or psoriatic arthritis, and you can't stand up and cook a healthy meal for yourself, now your life is changing in ways that promote other chronic illnesses. The risk factors start to pile up as you develop or live with your chronic arthritis.

Rick Phillips:
Once you have an autoimmune disorder, you are more likely to have a second autoimmune disorder. Do you see any particular autoimmune disorders that tend to travel together?

Ashira Blazer, MD, MSCI:
Yes, many of these autoimmune disorders tend to travel together. I think one of them that we see with others very often is Sjögren's syndrome. Sjögren's syndrome is an autoimmune condition where the immune system becomes active against the moisture-producing glands, like the glands that make saliva or the glands that make your tears, right? And we do find that people with rheumatoid arthritis, for example, can develop secondary Sjögren's syndrome. Or people with lupus often also have the Sjögren's antibodies and then the symptoms of Sjögren's. So, I think that's one that really likes to tag along quite a bit. I also see quite a bit of thyroid disease, autoimmune thyroid disease, and our inflammatory arthro disease.

When we think about inflammatory bowel disease… In the family of arthritis, like psoriatic arthritis or ankylosing spondylitis, there's also a kind of arthritis that's very similar to those that goes along with inflammatory bowel disease. So, we do see people have both inflammatory bowel disease and the pattern of arthritis that we see, we call the spondyloarthropathies.

Bailey Cook:
What are some of the most common comorbidities that you see in your patients?

Ashira Blazer, MD, MSCI:
I see lots of lupus patients. That’s what’s near and dear to my heart. It’s my research. And lupus patients, this is the case for all autoimmune patients, one to keep an eye out for when you have lupus or rheumatoid arthritis or psoriatic arthritis or osteoarthritis — people who have chronic inflammation are more likely to have early heart disease and severe heart disease.

Cardiovascular disease is number one, and it also is the number one cause of morbidity and mortality in our patients. So, it's important for us to know that, even if our chronic autoimmune diseases, you know, don't necessarily cause morbidity and mortality, the higher risk of cardiovascular disease can.

Rick Phillips:
Does treating the main disease… Does that usually solve the problem of the comorbidity?

Ashira Blazer, MD, MSCI:
It can make it better, right? People who are treated well for their autoimmune disease are less likely to have that increased risk, particularly of cardiovascular disease. But it's important to make a distinction between the ways that we treat it. Many of the patients who I have say, "Oh, I was feeling a little bad, and so I had some extra prednisone at home, and I decided to take it to make myself feel better." And while prednisone or other kinds of steroids can work really fast to decrease inflammation in some of our diseases, that drug also increases the risk of comorbidities.

In fact, many of the comorbidities that we see in our autoimmune conditions are directly impacted by taking steroids. Overtaking steroids can actually directly cause these comorbidities. So, we really try to educate our patients that the other medications we use, which are the disease-modifying medications, are going to be important for both controlling your disease, decreasing your inflammation and decreasing the likelihood that you develop these comorbidities.

Rick Phillips:
One of those medications would be methotrexate, is that correct?

Ashira Blazer, MD, MSCI:
Yes.

Rick Phillips:
I know people who are prescribed methotrexate who just won't take it. And some who won't take it and won't tell their doctor that they're not taking it. Is that something you've seen in your practice? And how do you combat it?

Ashira Blazer, MD, MSCI:
It's a strange thing. I feel like people think that your doctor’s like your mom. (laughs) Like we're mad at you when you don't want to take the things that we prescribed. But, you know, it's important to know that we're prescribing these medications so that you can feel better and do better and live better, right? If you aren't going to take a medication, or you feel bad when you take the medication, it's so important to have that conversation with your doctor.

I try to talk to my patient upfront, have like a good rapport with them, and then do shared decision making where I make it clear that, “If it doesn't work for you, it doesn't work, right? So, if it works for your life, great, we'll do it. If it can't work for your life, we need to do a different strategy.” Because the drug that works is the drug that you take, right?

Bailey Cook:
I feel like, since I was diagnosed so young, I'm always like, “Yeah, let's do whatever the doctor says.” I have never had that moment of, “Well, I don't know if that's good for me.” I never once thought like, “Oh, I wonder if I could take something different and feel differently.” That never crossed my mind. But for the people that do have a little bit harder time taking certain medications, are there any additional therapies that are out there to combat the comorbidities?

Ashira Blazer, MD, MSCI:
There are strategies that you can use, if you're having side effects, to improve the way you feel when you're taking those medications. That's a very important conversation to have with your doctor. And then also, you know, seeing a primary care doctor. Because you are at higher risk than other people for these other conditions, and your primary care is going to do that screening regularly.

Screening for blood pressure and cholesterol, and then being able to treat that after the fact. That being either a medication targeted at lowering the blood sugar or the cholesterol or whatever it may be. And then also holistic. We know diet is important. We know exercise is really important. Sleeping. Like half of my medical advice is, "Go to bed at night," right? (laughter) All of these things are going to help you live better with your arthritis.

PROMO:
Whenever you need help, the Arthritis Foundation’s Helpline is here for you. Whether it’s about insurance coverage, a provider you need help from or something else, get in touch with us by phone toll-free at 800-283-7800. Or send us a message at https://www.arthritis.org/helpline. 

Rick Phillips:
Could you talk a little bit about osteoarthritis and comorbidities?

Ashira Blazer, MD, MSCI:
Osteoarthritis is more common in people who have the so-called metabolic syndrome, right? That means that people who have high blood pressure, high cholesterol, higher blood sugars, and then also who have more weight, particularly around the abdominal area. That's what we call metabolic syndrome. And it's more common to go along with osteoarthritis. It's important to manage those comorbidities with osteoarthritis.

For a really long time, we just thought that osteoarthritis and diabetes didn't necessarily interact with each other. And there's more and more information coming out that they may. The cartilage is made up of various cells. And those cells have to regulate their energy, just like everything else. They have to take in sugar, be nourished. And it turns out that too much sugar in those cartilage cells causes them to break down. People who have higher blood sugar have more progression in their osteoarthritis and less healthy cartilage.

So, you know, it may be the case that, if you're not very well controlled with your diabetes, it directly contributes to worsening of your osteoarthritis. And the science is still developing there, but there's more and more studies that suggest that.

Rick Phillips:
Are there other instances like that?

Ashira Blazer, MD, MSCI:
For sure. I think the best studied is with obesity, and that is both mechanical and also inflammatory. It turns out that our fat cells actually produce inflammatory chemicals called cytokines that can contribute to the inflammation that we see in our joints. And then also, there's some indication that high blood pressure and diabetes together cause narrowing over time, or atherosclerosis, of key blood vessels that have to feed and nourish the cartilage and the joints. That also can contribute to worsening. 

We do find that not treating the primary arthritis very well produces these comorbidities. And not treating the comorbidities very well can worsen the primary arthritis. So, it's important that everything be addressed so that you can live as well as you need to with your arthritis.

It's very important that you have a primary care doctor. And then also, if you develop some of these comorbidities, you should see a doctor who specializes in that. For example, if you've developed diabetes, you should see an endocrinologist. If you develop cardiovascular disease, you should see a cardiologist. And kidney disease, they need to be seeing a nephrologist, right? So, we try to have comprehensive care with other doctors to make sure that we're treating the patient holistically.

Rick Phillips:
How do you try to forge a relationship with other specialties, so that a patient can be seen in a more holistic fashion?

Ashira Blazer, MD, MSCI:
Yeah, so you know, rheumatologists, we don't have an organ system. So, I think we think about the whole body a lot more than other doctors do, and we know that we have to work with our colleagues. We have a system for being able to contact each other that's just on our phones. You know, it makes it a lot easier for us to see the notes, the labs, reach out if we need to.

Just having a good dialogue. There are more and more academic meetings for us that include multiple specialties. And that allows us to really reach out, understand the priorities of the other doctors, and then get a good network so that we can treat our patients well.

Bailey Cook:
For those that maybe don't know what to look for in comorbidities, what are those signs and symptoms that people should be aware of? When should they tell their health care provider, whether that be primary care or their rheumatologist? And how treatable are the conditions that may go with each disease?

Ashira Blazer, MD, MSCI:
I think the most important thing is to have a primary care doctor who is screening you regularly. Many of these comorbidities will not have symptoms, particularly early on. Screening and prevention — really, really, really key. I cannot stress that enough. Cardiovascular disease: You may develop chest pain or chest pressure. Diabetes: Some people have blurry vision or dry mouth. These can be signs of high blood sugar. Headaches in people who have hypertension or blurred vision, right? So, early detection, super key, and that's when we can do the most to improve your health.

Rick Phillips:
What happens when inflammatory disease tends to mimic other inflammatory diseases?

Ashira Blazer, MD, MSCI:
That happens all the time. And that's one of the things that we do, as rheumatologists, is really talk to the patient. Get the symptoms, get the blood tests, get the X-rays that help us distinguish. Very often, patients are confused about what they actually have, and then also, they don't necessarily buy into the treatment because they're not really sure that they've got this clear diagnosis.

So, if I can say, “You know, I saw this symptom and that symptom. I did this blood test, it was positive,” or “negative.” “I did this X-ray. Here are the findings. I put it all together in this score. This means you definitely have this,” the patient can have a much clearer view.

Rick Phillips:
What about insurance? Does insurance need a clear view to authorize treatment of an individual?

Ashira Blazer, MD, MSCI:
So, insurance is very problematic, right? (laughter) I mean, we all need it, but yeah, and I think some of these tools can be a double-edged sword. Because, say you have someone who's on the border of one of these diagnoses, and clinically you feel that it's the best explanation and you want to treat early, right?

Rick Phillips:
Right.

Ashira Blazer, MD, MSCI:
Spondyloarthropathies, for some of them, we used to require changes on an X-ray in order to really clinch the diagnosis. By the time you have changes on your X-ray, this disease has already damaged your body and your bones, right? We don't want to wait until you have changes on your X-rays. And then the insurance company says, “Well, they don't have changes on the X-rays, then we can't authorize this therapy.” Sometimes, insurance companies want these rubrics to be filled out in order to authorize therapy, and then we have to go argue with them.

Bailey Cook:
(laughs) That sounds super fun for you.

Ashira Blazer, MD, MSCI:
That is not. (laughs)

PROMO:
The Arthritis Foundation’s Live Yes! Connect Groups are empowering support groups that bring people together for informative events and engaging activities. Peer-run and volunteer-led, they offer a place of understanding and encouragement and cover all kinds of topics. Find a group that matches your interests at https://connectgroups.arthritis.org. 

Bailey Cook:
What parts of the body are commonly affected by comorbidities?

Ashira Blazer, MD, MSCI:
The most common comorbidity is the cardiovascular disease, and that can affect the heart directly, but it can affect any of the blood vessels as well. Some people will get peripheral vascular disease, meaning the blood vessels that feed the legs and feet most often become narrow. And so, they'll say, "When I start to walk very far, I get cramping in my legs." They can also be stroke, right? That’s an example of cardiovascular disease.

Diabetes can affect, can increase, the risk of cardiovascular disease. It can increase the risk of eye disease like cataracts. Hypertension as well.

Bailey Cook:
Any comorbidities that impact the lungs, the skin?

Ashira Blazer, MD, MSCI:
People with psoriatic arthritis often have psoriasis that’s sort of more closely related, that’s part of the pathogenesis of disease. They’ll develop rashes, right? So, any part of the body. We do find that some of our patients with inflammatory arthritis can also develop scarring in the lungs. That can sometimes be directly related to their illness, but also can be related to the treatments for the illness.

Infections are more common in people who have inflammatory arthritis because we treat them with medications that decrease the immune system's ability to fight viruses and bacteria. So, those patients can develop, for example, upper respiratory illnesses or pneumonia, things like that.

Rick Phillips:
If you had a magic wand, what would you use your wand for in the arthritis world?

Ashira Blazer, MD, MSCI:
Oh, wow. (laughs) I would say health equity. We know that poverty, decreased access to health care, decreased access to good health information and less embeddedness with your health care team all greatly impact outcomes, greatly impact comorbidities, greatly impact arthritis. This is sort of a golden time in rheumatology where we have many different therapies that are coming out, and we understand mechanisms so much better.

Rick Phillips:
Do you think people are being left behind because of costs? Or do you think they're being left behind because of access? Or is it really a combination of both?

Ashira Blazer, MD, MSCI:
It's a combination of all of those things. These medications cost quite a bit. And if you don't have insurance, and a lot of times, even if you do have insurance, it's very hard to afford. We know that rheumatologists are concentrated in certain cities and in wealthier areas of those cities. People in rural areas, people in deep urban areas, aren't going to have as great access to rheumatologists and are less likely to be referred to those rheumatologists. Providers are less likely to educate minority populations and poorer populations, about all of their treatment options. So, you know, it really is multifactorial, and I think that that's the biggest driver of comorbidities in arthritis.

Those patients really do suffer. Our system is very backward in that, as you become disabled… So, say you have arthritis, and you develop disability due to the fact that your disease has been active, and it's affecting your life. Now, you could lose your job. And you lose your job, you lose your insurance, right? Now, your ability to see that specialist that could get you back on track is greatly impeded.

PROMO:
Over the past seven decades, the Arthritis Foundation has invested over $500 million into scientific research, advancing arthritis treatments while pursuing a cure. Progress is being made every day, thanks to the contributions of people like you. Learn more about our research initiatives at https://www.arthritis.org/science.

Bailey Cook:
Dr. Blazer, we did ask on social media: "What is one health condition related to your arthritis that has surprised you?" And I just wanted to read a couple of the responses that we have gotten and kind of get your opinion on what they had said.

One person says, "I was a teacher. RA caused me to lose my voice in a very short period of time when speaking." That's something that you've heard of?

Ashira Blazer, MD, MSCI:
I don't hear that often, but I suppose it could happen, because your vocal cords have to contract and loosen for you to speak well, and there are actually little joints there. There are little bones that govern that. So, you know, could someone develop some inflammation there? Or could there be some side effect of the medication? It's possible.

Bailey Cook:
Interesting. Another one says, "All of my conditions — plantar fasciitis, gastritis, possible AMPS, hypermobility, sensitive skin, TMJ, I also have migraines and anxiety. BTW, I'm 18, was diagnosed with arthritis at the age of 14, and in the span of four years, I've had over 10 diagnoses and multiple maybe diagnoses."

Ashira Blazer, MD, MSCI:
I see that all the time. Yeah, all the time. For example, in lupus, the majority of our patients will also develop fibromyalgia. I always explain it like, "Have you ever cut yourself, and you didn't notice it, and then you do notice it, and all of a sudden it really hurts, right?" (laughs) It's because it's not just what's happening to your body. Those pain signals go up to your brain. And your brain says, "How dangerous is this? How much does this hurt? Or how little does it hurt?"

Your brain can sort of dial up or dial down the pain. And as you have chronic pain from your arthritis, you can then develop this sort of feedback loop. Or you just have pain all the time, whether or not you're having inflammation in your joints. And that can be a really hard problem. You know, it makes people's lives very miserable. And it doesn't respond so well to our therapies, our anti-inflammatory therapies. So, we have to have a holistic approach: exercise, sleeping at nighttime, taking care of our anxiety and depression. All of those things can help reset that balance.

Bailey Cook:
And then the last one, they said, "Interstitial lung disease and tachycardia, it's frustrating."

Ashira Blazer, MD, MSCI:
Interstitial lung disease can definitely go along with our arthritic conditions. And then you can get tachycardia either directly related, or some of our patients actually develop Pott's syndrome, which is just an inability to really regulate the blood pressure and the heart rate as we change positions, like laying down to standing up.

Bailey Cook:
We always end our episodes with your top three takeaways of the episode. So, we'll start with Dr. Blazer. 

Ashira Blazer, MD, MSCI:
Top three… I would say certainly see your primary care doctor, as screening and prevention is really key. The second would be chronic illnesses travel together, and it's important for us to manage them in a holistic way. And then the third will be: Go to bed. Sleeping helps everything. Please go to bed.

Bailey Cook:
I love that. Rick, what are your top three takeaways?

Rick Phillips:
Health equity issues are very real and need everybody in the entire community to help address them. Comorbidities are also very real, and we cannot ignore them. It's not always related to the arthritis that we have. And third, I now think of my inflammatory diseases as traveling around in a school bus.

Bailey Cook:
(laughs) That's awesome.

Ashira Blazer, MD, MSCI:
I love that.

Rick Phillips:
"We'll move over here and stop for a few minutes." (laughter)

Bailey Cook:
Well, Dr. Blazer, actually, you totally touched on the two that I had written down, being that you need to see a PCP and that screening and prevention is key. And then I would also just say that one thing that I really took from this is that I need to be more cognizant of what other things might be going on that I probably don't even realize could be related to my arthritis. Probably another top takeaway would be to question things and wonder why something is happening now versus why it wasn't before. And I will also agree with you, go to sleep. That's a great top takeaway to take. (laughs)

Dr. Blazer and Rick, thank you so much for joining us today.

Ashira Blazer, MD, MSCI:
Thank you.

Rick Phillips:
What great fun.

PODCAST CLOSE:
This episode was brought to you in part by Boehringer Ingelheim. Our podcast is also made possible in part by individual supporters like you, whose generosity we much appreciate. The Live Yes! With Arthritis podcast is independently produced by the Arthritis Foundation. This podcast aims to help people living with arthritis and chronic pain live their best life. People like you. For a transcript and show notes, go to https://www.arthritis.org/liveyes/podcast. Subscribe and rate us wherever you get your podcasts. And stay in touch!