Issue 9/2024
Popova, V.
Rheumatoid arthritis (RA) is a chronic inflammatory joint disease, symmetrically involving the small joints of both hands, but also with extra-articular manifestations and the presence of comorbid conditions, which are the cause of the premature death of patients and the difficult diagnosis and therapeutic impact.
The frequency of extra-articular manifestations is between 18-42% depending on the studied cohort. Initially, it was considered that they appear in the late stages of rheumatoid arthritis, associated with a severe course, but in recent years, extra-articular manifestations have been observed at the beginning of the disease, or before, which is an atypical presentation and makes diagnosis difficult in such cases. [1,2].
The main hallmark of rheumatoid arthritis (RA) is synovitis. Patient disability is a major consequence of joint involvement, but systemic manifestations and comorbidities are critical to patient prognosis. The most common cause of death in RA patients is CV comorbidities. Compared to the general population, patients with RA have a two-fold increased risk of myocardial infarction and up to a 50% increased risk of CV mortality. The second leading cause of death in patients with RA is respiratory disease, which occurs in 30-40% of patients – interstitial lung involvement, damage to the airways, pleura and pulmonary vessels is less common. Central and peripheral nervous system involvement is usually due to small vessel vasculitis, joint damage, or drug toxicity [1,2]. There is evidence that microvascular cerebral damage caused by systemic inflammation is associated with the development of Alzheimer‘s disease and vascular dementia [1,2]. Some studies have concluded that disease-modifying antirheumatic drugs and biologics can reduce the incidence of dementia, which is kind of revolutionary. Primary gastrointestinal and renal manifestations are rare, usually they are secondary, often associated with drug provocation and toxicity. Therefore, the goal of modern treatment of these patients is to achieve low disease activity or remission in order to minimize morbidity and mortality. The need for disease control, risk factors, and early and aggressive treatment are at the heart of this goal.
Modern RA treatment strategies support the thesis of early and aggressive treatment already at diagnosis, staging of patients and definition of high disease activity and high risk cohort with the goal of rapid remission or low disease activity [3]. However, there is a lack of studies on the incidence of ExA (non-articular manifestations) in patients receiving modern treatment. In this aspect, risk factors should also be taken into account, as well as potential predictors of ExA should be sought and evaluated. The most common risk factors for symptomatic manifestations are: smoking, joint erosions/destructive changes, early aggressive arthritis, positive antinuclear antibodies antibodies (ANA), high titers of rheumatoid factor (RF) or ACPA-Ab/antibodies/, HLA-shared epitope (SE), young age, high C-reactive protein (CRP) and high disease activity score assessed with DAS28 speed, systemic manifestations such as: fever, astheno-adynamia, consumptive syndrome. [1,4,5,6,7].
Аddress for correspondence:
Popova, V.
Medical University of Plovdiv Medical Faculty,
Department of Rheumatology
UMHAT ”Kaspela” - Plovidv
4001, Plovdiv
64, “Sofia”, Str.
e-mail: drvpopova@gmail.com