To the Editor:
We have read with great interest the recommendations for the management of comorbidities in rheumatoid arthritis (RA), psoriasis (PsO), and psoriatic arthritis (PsA) made by the Canadian Dermatology-Rheumatology Comorbidity Initiative1. The work is very interesting and comprehensive, and we congratulate the authors for combining more general recommendations for the management of the comorbidity of these 3 diseases. Indeed, it is sometimes difficult to distinguish between comorbidities, risk factors, medication adverse events, and extraarticular manifestations. But it holds clear that the presence of several different diseases aggravates the monitoring of these patients.
We have recently published a consensus statement for the management of comorbidity and extraarticular manifestations in RA2 and a practical derivation algorithm of patients with comorbidity associated with PsO in Spain3. In the mentioned manuscript, the Canadian experts selected 8 main topics regarding comorbidities in RA, PsA, and PsO1. The Spanish panel selected the 10 most relevant comorbidities and risk factors based on a ranking depending on incidence, mortality, and preventability. Interestingly, 8 out of the top 10 comorbidities agreed completely with the 8 selected by the Canadian Initiative1,2.
As in the Spanish recommendations (Table 1), most of the 19 recommendations from the Canadian Initiative received a grade C/D from the Oxford Centre for Evidence-based Medicine, with a level of agreement > 80% in all of them1,2. The overall assessment of the recommendations, according to the Centre for Evidence-based Medicine, is low (C/D, with A the highest and D the lowest) because they are based on expert opinion, although their influence is strong, which can be inferred by their wide applicability to clinical practice. Further, we would like to make some comments on this document.
Recommendations of the Madrilenian Society of Rheumatology for the management of comorbidities in rheumatoid arthritis. From Roubille C, et al. Rheumatol Int 2015;35:445–58.
First, despite substantial gaps in the current knowledge and management of cardiovascular (CV) risk in patients with chronic inflammatory rheumatic diseases (CIRD; recommendation 1), a recent work demonstrates that the prevalence of CV disease remains high even in subjects with CIRD periodically evaluated at rheumatology clinics4. This applies to almost half of the patients receiving biological therapy, even though most of them have low disease activity4.
Second, given the increased risk of infections in patients starting systemic therapy (recommendation 12), we believe it is important to remember the use of vaccinations as internationally accepted5. In relation to the patients with increased risk of skin cancer (recommendation 13), we support the recommendation, especially in patients with PsO/PsA who have received antitumor necrosis factor drugs, cyclosporine A, and psoralen ultraviolet A. Another interesting point that is unclear in these recommendations (recommendation 15) is the relation with bone loss and fractures, especially in patients with RA6. In fact, the presence of RA is currently considered an independent risk factor for incident fractures in the risk evaluation by the FRAX tool (www.shef.ac.uk/FRAX/tool.jsp?lang=sp).
Further, it is essential to highlight the frequent coexistence of depression and/or anxiety in these patients, because their presence worsens the outcome and modifies assessment scores and the response to therapies. In fact, depression was the most prevalent comorbidity in RA in the COMORA (Comorbidities in Rheumatoid Arthritis) study7. Strikingly, depression is the comorbidity more often disregarded in clinical practice by both rheumatologists and dermatologists. The Canadian Initiative includes 3 recommendations (recommendations 17–19) on the importance of this comorbidity. In our derivation algorithm of patients with PsO, we recommend, periodically, performing a simple scale such as the Goldberg’s scale, for early detection of mood disorders and an adequate referral to the psychologist or psychiatrist as soon as they are suspected3. Significantly, the Canadian document also reflects the effect of the recommendations on clinical practice. We observe that, while the presence of depression is rarely considered by rheumatologists and dermatologists, these 3 final recommendations have a greater effect (≥ 50%) on daily clinical practice1.
Both consensus documents agree on the importance of focusing on comorbidity in early diagnosis because it improves outcome globally and individually by each comorbidity. Moreover, it is difficult to treat patients when other rheumatic diseases are associated, especially osteoarthritis or fibromyalgia.
We draw special attention to 2 particular comorbidities that are not discussed at all in the Canadian document: oral health and sexual disorders. The importance of periodontal disease has gained tremendous interest in the last decade, especially in patients with RA, for its involvement in both pathogenicity and as a predictor of poor prognosis8. Also, accumulating evidence shows high prevalence of sexual disorders and erectile dysfunction in persons with PsO, PsA, and RA9,10. We think that recommendations on the management of comorbidities in CIRD should also include aspects of health promotion, especially in these key areas.
Finally, we believe that an integrated approach to these diseases must be multidisciplinary, as the authors of the initiative propose, where the rheumatologist or dermatologist or both should be involved as coordinators and managers of the comorbidity with other specialties, and where specialized nurses in rheumatology and dermatology must also be involved in its management.
