A study published online in the Journal of Rheumatology adds new insight to the well-known link between rheumatoid arthritis, or RA, and gastrointestinal, or GI, problems, such as bleeding and ulcers.

It found that the incidence of upper-GI tract problems – occurring between the mouth and the end of the stomach – declined over the 28-year study period in people with RA. On the other hand, the incidence of lower-GI tract problems in people with RA – affecting the large and small intestines – held steady over the same time period.

Upper-GI problems in RA patients have been partly attributed to the use of nonsteroidal anti-inflammatory drugs, or NSAIDs. “An increased awareness of the [side effects of] NSAIDs, wiser use of NSAIDs when they are needed … and use of proton pump inhibitors to control upper-GI symptoms have helped to reduce the incidence of upper-GI problems associated with RA,” says study co-author Eric Matteson, MD, chair of rheumatology at the Mayo Clinic in Rochester, Minn.

Although less research has focused on the link between lower-GI problems and RA – this study identified factors associated with a higher risk of developing those problems. Factors include smoking, use of corticosteroids (i.e., prednisone, cortisone), prior upper-GI disease and abdominal surgery. “We are still seeing about a 50 percent increase in lower-GI problems in people with RA compared with those without it. More attention is needed to address lower-GI problems,” says Dr. Matteson. “Doctors and patients should be aware of the increased risk of lower-GI problems that can be related to RA and/or its treatments, and of the risk factors that can lead to lower-GI problems. Stopping smoking and avoiding corticosteroids can reduce the risk.”

The study confirms that, overall, people with RA have more upper- and lower-GI problems and are more likely to die of GI problems than people who do not have the disease. Experts suspect impaired immunity due to the disease plays a role.

The study compared 813 people diagnosed with RA with 813 age- and sex-matched people who did not have RA, all from the same county in Minnesota, and followed them for about 10 years. Upper-GI events included bleeding, GI perforation (a hole in the wall of the stomach or the small or large intestine), ulcers, obstruction and esophagitis (inflammation, irritation or swelling of the esophagus). Lower-GI events included bleeding, perforation, ulcers, obstruction, diverticulitis (infection or inflammation of the small sacs in the lining of the intestine) and colitis (swelling of the large intestine).
 

The risk of developing any GI event was 70 percent higher in those with RA than in those without RA (162 GI events among RA patients vs. 124 GI events among those without RA). When broken down into upper- and lower-GI events, the risks for someone with RA were 70 percent and 50 percent higher, respectively (154 upper- and 129 lower-GI events among RA patients vs. 110 upper- and 99 lower-GI events among controls).

In particular, people with RA had an increased risk of infectious colitis (inflammation of the colon caused by infection) and drug-induced colitis, as well as lower-GI bleeding, perforation and diverticulitis, compared with non-RA patients. And when GI events occurred, they were more likely to be serious and require hospitalization in people with RA than in those without RA.

The researchers also found that the incidence of any upper-GI event among RA patients fell significantly – from more than 4.5 per 100 person-years to fewer than 2 per 100 person-years – during the study period. (“Person-years” is a measurement of how often an event occurs. In the last example, if you were to follow 100 people for one year, statistically fewer than 2 would develop an upper-GI issue.)

But, the authors write, “there has been no significant improvement in incidence of lower-GI events, particularly in RA,” and suggest that better strategies and treatment approaches are needed to address lower-GI problems in people with RA. Such strategies include timely treatment of upper-GI disease, minimizing exposure to glucocorticoids (such as cortisone and prednisone), avoiding smoking, and screening for lower-GI disease, all of which may help reduce the incidence or seriousness of lower-GI issues.

“We know that people with RA have an increased risk of GI events and deaths due to those events,” says Gregg Silverman, MD, professor of medicine and pathology and co-director of the Center of Excellence on Musculoskeletal Disease at NYU School of Medicine in New York City. He was not involved in the study. “The take-home message of this study is that, although the impact of the disease and its treatments on the GI tract is changing, GI problems are not going away in patients with RA.”

“Patients should be aware that RA can have complications involving the lower-GI tract that can lead to serious complications, and that the medications for RA may cause or amplify related adverse events. To minimize this risk, patients should quit smoking and be vigilant for any GI symptoms, such as black, tarry stool, and seek medical attention if this occurs,” says Dr. Silverman.