Recommendations for the management of comorbidities in RA, PsA, and PsO from the Canadian Dermatology-Rheumatology Comorbidity Initiative. Listed according to the levels of evidence and grades of recommendations of the Oxford Centre for Evidence-Based Medicine (www.cebm.net/?o=1025).
| Topic | Recommendation | Level of Evidence | Grade of Recommendation | Level of Agreement, % | |
|---|---|---|---|---|---|
| # | Description | ||||
| Risks of CVD | 1. | Individuals with RA, PsA, and PsO have a greater risk of CVD than the general population. The diseases themselves and traditional risk factors contribute to this risk. The risk of MI in RA is comparable to that in DM. This should be recognized by healthcare providers and patients. | 2b, 3b (RA), 2b, 5 (PsA), 2b (PsO) | C | 87.7 |
| 2. | Traditional modifiable risk factors should be screened for and managed appropriately to reduce the risk of CVD in RA, PsA, and PsO populations. | 5 | D | 95.8 | |
| Effect of treatment on CVD | 3. | CS use should be minimized in RA, especially in patients with CV risk factors. | 2b, 5 | C | 93.3 |
| 4. | In patients with RA or PsA, especially those with additional CV risk factors, the risk and benefits of NSAID use should be weighed. | 3b, 5 | C | 91.9 | |
| 5. | Healthcare providers and patients should be aware that MTX and/or TNFi use may decrease the risk of CVE in RA. Their use may help to reduce CS and NSAID use, especially in patients with CV risk factors. | 2b, 5 | C | 84.6 | |
| 6. | Healthcare providers and patients should be aware that MTX and/or TNFi use may decrease the risk of CVD in PsA/PsO. | 2b, 5 | C | 83.3 | |
| Smoking | 7. | Statement: Current smoking is associated with an increased prevalence and/or incidence and possibly a negative effect on disease severity in RA, PsA, and PsO. Recommendation: Smoking status should be determined in all patients with RA, PsA, and PsO and smoking cessation should be encouraged. | 2b, 5 5 | C D | 94.6 |
| Weight | 8. | Statement: PsO severity may be associated with increased BMI and obesity. Increased BMI may be associated with increased disease activity of RA and PsO. Recommendation: Healthcare providers should be aware that higher BMI is associated with a reduced treatment response in RA, PsA, and PsO. TNFi may be associated with a mild increase in weight in RA, PsA, and PsO, but the clinical relevance is unknown. | 4, 5 (RA), 3b, 4, 5 (PsA), 2b, 5 (PsO) | C | 82.2 |
| 9. | Statement: The effects of dietary manipulations on disease activity in RA, PsA, and PsO are still uncertain. Recommendation: BMI should be determined in all patients with RA, PsA, and PsO. | 5 | D | 80.9 | |
| 10. | Healthcare providers should encourage healthy BMI. | 5 | D | 93.8 | |
| Malignancies and infections | 11. | Patients and healthcare providers should be aware of increased risk of infection when initiating systemic therapies (biologics, DMARD, CS), especially in RA. | 2b, 5 | C (RA), D (PsA, PsO) | 94.5 |
| 12. | Risk of infection should be assessed (including relevant comorbidities) when initiating systemic therapy. | 2b, 5 | C (RA), D (PsA, PsO) | 90.4 | |
| 13. | Prior to initiating systemic therapy, additional cancer screening beyond the nationally recommended guidelines for age and sex is not required. Individuals at increased risk for skin cancer may require closer monitoring. | 2b, 5 | C | 89.2 | |
| Risk of cancer recurrence or new cancer | 14. | In the absence of sufficient data on recurrent cancer, patients with a prior cancer or new cancer should be informed about a potential risk of new or recurrent cancers when treated for RA, PsA, or PsO with TNFi or some of the DMARD. | 2b, 5 | C | 87.1 |
| Osteoporosis | 15. | Individual disease-specific risk factors and markers for increased disease severity in RA, PsA, and PsO do not appear to be associated with increased bone loss. Usual profiling with standardized methods should be used to assess risk of osteoporosis and fracture. | 4 | D | 86.3 |
| 16. | Systemic CS have a negative effect on BMD. Usual CS-induced osteoporosis guidelines for prevention and treatment should be followed. | 1b (RA), 5 (PsA, PsO) | A (RA), B (PsA, PsO) | 92.5 | |
| Depression | 17. | Healthcare providers should be aware of increased symptoms of depression in patients with RA, PsA, or PsO. Patients should be screened for these symptoms and managed appropriately. | 2b, 5 (RA), 3b, 5 (PsA, PsO) | C | 90 |
| 18. | Healthcare providers treating RA, PsA, and PsO should be aware that symptoms of depression may affect disease activity measures and that disease symptoms may affect depression scores. | 3b, 5 (RA), 5 (PsA, PsO) | D | 92.2 | |
| 19. | Healthcare providers should be aware that disease control may reduce symptoms of depression in patients with RA, PsA, and PsO. | 1b, 5 (PsO), 5 (RA, PsA) | B (PsO), D (RA, PsA) | 90 |
RA: rheumatoid arthritis; PsA: psoriatic arthritis; PsO: psoriasis; CVD: cardiovascular diseases; MI: myocardial infarction; DM: diabetes mellitus; CS: corticosteroids; CV: cardiovascular; NSAID: nonsteroidal antiinflammatory drugs; MTX: methotrexate; TNFi: tumor necrosis factor inhibitors; CVE: cardiovascular events; BMI: body mass index; DMARD: disease-modifying antirheumatic drugs; BMD: bone mineral density.