Reumatología Clínica

Reumatología Clínica

Volume 15, Issue 2, March–April 2019, Pages 102-108
Reumatología Clínica

Original Article
Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring in clinical practice: the spanish cohort of the COMORA studyPrevalencia de comorbilidades en artritis reumatoide y evaluación de su manejo en la clínica diaria: cohorte española del estudio COMORA

https://doi.org/10.1016/j.reuma.2017.06.002Get rights and content

Abstract

Objectives

To describe the prevalence of comorbidities in patients with RA in Spain and discuss their management and implications using data from the Spanish cohort of the multinational study on COMOrbidities in Rheumatoid Arthritis (COMORA).

Methods

This is a national sub-analysis of the COMORA study. We studied the demographics and disease characteristics of 200 adults patients diagnosed with RA (1987 ACR), and routine practices for screening and preventing the following selected comorbidities: cardiovascular, infections, cancer, gastrointestinal, pulmonary, osteoporosis and depression.

Results

Patients had a mean age of 58 years and a mean RA duration of 10 years. Mean DAS28 score was 3.3 and approximately 25% of patients were in remission (DAS28 <2.6). Forty-four (22%) patients had ≥1 comorbidity, the most frequent being depression (27%) and obesity (26%). A history of myocardial infarction or stroke was observed in 5% and 1% of patients, respectively, and any solid tumor in 6%. Having a Framingham Risk Score >20% (51%), hypercholesterolemia (46%) or hypertension (41%) and smoking (25%) were the most common CV risk factors. For prostate, colon and skin cancers, only 9%, 10% and 18% of patients, respectively, were optimally monitored. Infections were also inadequately managed, with 7% and 17% of patients vaccinated against influenza and pneumococcal, respectively, as was osteoporosis, with 47% of patients supplemented with vitamin D and 56% with a bone densitometry performed.

Conclusions

In Spain, the prevalence of comorbidities and CV risk factors in RA patients with established and advanced disease is relatively high, and their management in clinical daily practice remains suboptimal.

Resumen

Objetivos

Describir la prevalencia de comorbilidades en pacientes con AR en España y discutir sobre su manejo en la clínica diaria utilizando los datos de la cohorte española del estudio internacional COMORA.

Métodos

Subanálisis nacional del estudio COMORA en el que se analizaron las características demográficas y clínicas de 200 pacientes con AR (1987 ACR) y las prácticas rutinarias para el cribado y la prevención de eventos cardiovasculares (CV), gastrointestinales y pulmonares, infecciones, cáncer, osteoporosis y depresión.

Resultados

Los pacientes tenían una edad media de 58 años, una duración media de la enfermedad de 10 años, un DAS28 de 3,3 y el 25% estaba en remisión (DAS28 <2,6). El 22% de los pacientes presentaba al menos una comorbilidad, principalmente depresión (27%) y obesidad (26%). El 5% tenía historia de infarto de miocardio, el 1% de ictus y el 6% de tumor sólido. Una puntuación de Framingham >20% (51%), tener hipercolesterolemia (46%), hipertensión (41%) y fumar (25%) fueron los factores de riesgo CV más comunes. En relación con el cáncer de próstata, colon y piel, solo el 9, 10 y el 18% de los pacientes, respectivamente, estaban óptimamente controlados. Las infecciones tampoco se manejaban de forma óptima, con solo el 7 y el 17% de los pacientes vacunados contra la influenza y neumococo, respectivamente, al igual que la osteoporosis, con el 47% suplementados con la vitamina D y el 56% con una densitometría realizada.

Conclusiones

En España, la prevalencia de comorbilidades y factores de riesgo CV en pacientes con AR establecida y avanzada es relativamente alta, y su manejo en la clínica diaria continúa siendo subóptimo.

Introduction

Rheumatoid arthritis (RA) is a chronic inflammatory disease that can lead to progressive joint deformity, disability and reduction of life expectancy. In addition to the consequences of the disease itself, patients with RA are at increased risk of developing comorbidities that contribute substantially to increased disability and worsened quality of life. Cardiovascular, lung and gastrointestinal diseases, malignancies, infections, psychiatric disorders, and osteoporosis are found to be more prevalent in patients with RA compared to the general population, mainly due to concomitant medication such as immunosuppressive drugs, immunomodulatory effects of the disease, and increased prevalence of cardiovascular (CV) risk factors.1, 2

The prognosis of RA has improved over years because of the considerable change in the treatment, which includes tight control, aiming for low disease activity or remission. However, comorbidities in RA are often underrecognized despite their impact on disease activity and treatment outcomes3, and the awareness of most rheumatologists about their responsibility in their management.4 Several studies, such as the international COMORA on prevalence of comorbidities in RA and their monitoring, reported that compliance with guidelines on how to detect and manage these comorbidities is far from optimal, and varies between countries.5 To address this issue, EULAR has just published recommendations for comorbidity risk management in patients with RA,4 which are expected to be easily implemented in daily practice and will be of interest to evaluate in future studies. In Spain, the Society of Rheumatology of the Community of Madrid (SORCOM) has also developed practical recommendations to guide rheumatologists on optimal diagnosis and management.6

How Spain could better follow and implement such guidelines will be determined by the findings of the present study by showing the gap between recommendations and routine practices existing in 2012 in the management of RA comorbidities.

Using data from the Spanish cohort of COMORA study, we describe the prevalence of comorbidities in patients with RA in Spain and discuss their management and implications in clinical practice. The rationale for a national sub-analysis of COMORA was the need to emphasize the mistakes that rheumatologists do in identifying and monitoring these conditions in RA and clarify the role they should have in this area.

Section snippets

Study Design and Patients

COMORA was a cross-sectional, observational, multicenter, international study to evaluate variability in the prevalence of comorbidities and their risk factors between participating countries.5

The study was conducted according to the ethical principles of the Declaration of Helsinki and was approved by all local ethics review committees, with written informed consent obtained from all patients.

Eligible patients in COMORA were at least 18 years old, fulfilled the 1987 American College of

Patient Characteristics

Patient characteristics are shown in Table 1. Mean age was 58.5 years and mean disease duration was 10.3 years. Disease activity was low, as shown by the mean DAS28 of 3.3, and approximately 25% of patients were in remission (DAS28 <2.6). At the time of the study, 94.5% of patients were taking DMARDs and 36.5% biological agents.

Prevalence of Comorbidities and Risk Factors

Of the 200 patients analyzed in the Spanish cohort, 44 (22%) had at least one comorbidity. This prevalence rate resulted from the exclusion of depression from the

Discussion

This study shows that prevalence of comorbidities and CV risk factors in patients with established and advanced RA is relatively high in Spain, and evaluation of their monitoring is suboptimal despite being a country with an effective and accessible health system. The rate of 22% of at least one comorbidity found is lower as in other studies,9 but precisely this possible underestimation reflects their inadequate screening in RA. Indeed, if adequate screening for depression had been included in

Protection of human and animal subjects

The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in

Source of Funding

This study was conducted with the support of an unrestricted grant from Roche Ltd.

Conflict of Interests

A.B. has received research grants from Roche, MSD, Pfizer, Abbvie, BMS and UCB. He is consultant and a member of speakers’ bureaus for Pfizer and has received speaker honoraria from Pfizer, Roche, MSD, Pfizer, Abbvie, BMS and UCB. L.L.O. has received grant for Roche and payment for lectures from Roche and Abbvie. M.A.L. has received payment for consultancy, lectures and board membership from Roche, Abbvie, BMS and MSD. C.O.C. has received grant from Roche and payment for lectures from UCB.

Acknowledgements

The authors would like to acknowledge the patients and doctors who participated in the study and the COMORA Committee for their support, especially Dr. Dougados, who was the principal investigator for the study. Medical writing assistance was provided by Isabel Caballero at Dynamic Science S.L. during the preparation of this article. Responsibility for opinions, conclusions and interpretation of data lies with the authors.

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