Chronic obstructive pulmonary disease and rheumatic diseases: A systematic review on a neglected comorbidity

Transcriptomics using lung resection material to advance our understanding of COPD and idiopathic pulmonary fibrosis pathogenesis

Genes involved in cell death, inflammation and viral infection are common to both COPD and IPF. A link to rheumatic disease is unique to COPD, and IPF-specific analyses showed increases in gene expression of keratins, collagens, mucins and MMPs. https://bit.ly/3JoW73H.

Thoracic manifestations and respiratory function alterations in axial spondyloarthritis and newest possibilities of ultrasound to detect changes in diaphragm-a narrative review

Background and Objective

Axial spondyloarthritis (axSpA) includes thoracic manifestations and changes in respiratory function that require a comprehensive understanding for effective treatment. This review aims to investigate these manifestations and evaluate the role of ultrasound in detecting diaphragmatic changes to provide insights for improved diagnosis and treatment strategies in axSpA patients.

Methods

A systematic search was conducted in Index Medicus and Scopus from 2003 to 2023. Inclusion criteria included primary and secondary publications, with a focus on high-quality evidence such as randomised controlled trials and systematic reviews with or without meta-analysis. Keywords spondyloarthritis, respiratory, chest, thoracic, diaphragm and ultrasound were used in the search. A total of 22 articles were identified after duplicates, and inadequate papers were removed.

Key Content and Findings

The review included the prevalence, classification and extra-articular manifestations of axSpA, highlighting the impact on respiratory function. Thoracic manifestations and the potential impact of pharmacological interventions were detailed, and various conditions affecting respiratory dynamics were discussed. In addition, the utility of ultrasonography in assessing diaphragmatic function was explained and the techniques, parameters and measurements used to assess diaphragmatic movement, muscle thickness and respiratory mobility were described. The results illustrate the changes in diaphragmatic function in axSpA patients and their correlation with disease activity.

Conclusions

This narrative review highlights the intricate relationship between axSpA and respiratory manifestations and emphasises the significant impact on thoracic function and diaphragmatic dynamics. The utility of ultrasound in assessing diaphragmatic function offers a promising avenue for objective evaluation that provides insight into disease activity and potential therapeutic responses. This review emphasises the critical role of early diagnosis and vigilant monitoring, and advocates a multidisciplinary approach that integrates non-pharmacological interventions, particularly tailored physical activity, to maintain and improve respiratory function in axSpA patients. Increased research initiatives and awareness of pulmonary complications in axSpA are essential to optimise medical care and improve treatment outcomes in this patient group.

The association between chronic obstructive pulmonary disease and autoimmune diseases: a bidirectional Mendelian randomization study

Objective

Observational studies have reported that chronic obstructive pulmonary disease (COPD) is often accompanied by autoimmune diseases, but the causal relationships between them remain uncertain. In this Mendelian study, we aimed to investigate the potential causal relationship between COPD and four common autoimmune diseases.

Methods

We conducted an analysis of summary data on COPD and autoimmune disease using publicly available genome-wide association studies (GWAS) summary data. We initially employed the inverse- variance weighted method as the primary approach to establish the causal impact of COPD on autoimmune diseases in the sample and conducted additional sensitivity analyses to examine the robustness of the results. Subsequently, we performed reverse Mendelian randomization (MR) analyses for the four autoimmune diseases. Finally, the potential for bidirectional causal relationships was assessed.

Results

Our MR analysis revealed no significant causal relationship between COPD and any of the studied autoimmune diseases. However, reverse MR results indicated a significant association between rheumatoid arthritis (RA), osteoarthritis (OA) and the risk of developing COPD, with respective odds ratios (OR) of 377.313 (95% CI, 6.625-21487.932, P = 0.004) for RA and 11.097 (95% CI, 1.583-77.796, P = 0.015) for OA. Sensitivity analyses confirmed the robustness of the results.

Conclusion

Our findings support a potential causal relationship between autoimmune diseases and COPD, highlighting the importance of considering comorbidities in clinical management of COPD.

More than a random association between chronic obstructive pulmonary disease and psoriatic arthritis: shared pathogenic features and implications for treatment

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic inflammatory condition characterized by skin and joints involvement, and with a great burden of comorbidity that could affect the choice of treatment. Chronic obstructive pulmonary disease (COPD) is one of the primary causes of morbidity and mortality. Medical therapy can improve symptoms and the frequency and severity of exacerbations. A variety of evidence showed an increasing association between COPD and PsA.

AREAS COVERED

Psoriatic disease and COPD appear to have a possible pathophysiologic link. The inhibition of intracellular molecules responsible for pro-inflammatory responses could be a therapeutic approach for both psoriatic diseases and COPD. Inhibitors of phosphodiesterase 4 (PDE-4) were developed to treat chronic inflammatory conditions such as psoriasis, PsA and COPD. Roflumilast has been used to treat COPD and asthma, while Apremilast to treat psoriasis and PsA. Given the efficacy and safety of these treatments, we can speculate that blocking PDE-4 might also provide clinical benefits in patients with co-existing COPD and PsA.

EXPERT OPINION

This hypothesis could offer the opportunity to screen patients for both diseases. Furthermore, this approach would increase the involvement of other specialists in the management of PsA, and it would improve the use of a tailored treatment for each patient.

Blood Cadmium Levels and Oxygen Desaturation during the 6-Minute Walk Test in Patients with Chronic Obstructive Pulmonary Disease

Background and Objectives: chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation and a history of exposure to noxious stimuli. Cigarette smoking is the most important causal factor for developing COPD. Cadmium, a minor metallic element, is one of the main inorganic components in tobacco smoke. Inhaled cadmium was associated with a decline in lung function, gas exchange impairment, and the development of obstructive lung disease. Patients with COPD who had oxygen desaturation during the 6-min walk test (6MWT) had a significantly worse prognosis than non-desaturation in COPD patients. Nonetheless, few studies have addressed the influence of blood cadmium levels on exercise-induced oxygen desaturation in COPD patients. Our objective was to assess the potential impact of blood cadmium levels on oxygen desaturation during the 6MWT among COPD patients. Materials and Methods: we performed a retrospective analysis of patients with COPD who were examined for blood cadmium levels in a tertiary care referral center in Taiwan, between March 2020 and May 2021. The 6-min walk test was performed. Normal control subjects who had no evidence of COPD were also enrolled. Results: a total of 73 COPD patients were analyzed and stratified into the high-blood cadmium group (13 patients) and low-blood cadmium group (60 patients). A total of 50 normal control subjects without a diagnosis of COPD were enrolled. The high-blood cadmium group had a significantly higher extent of desaturation than the low-blood cadmium group. The frequency of desaturation during 6MWT revealed a stepwise-increasing trend with an increase in blood cadmium levels. A multivariable logistic regression model revealed that blood cadmium levels were independently associated with desaturation during the 6MWT (odds ratio 12.849 [95% CI 1.168–141.329]; p = 0.037). Conclusions: our findings indicate that blood cadmium levels, within the normal range, were significantly associated with desaturation during 6MWT in patients with COPD.

Musculoskeletal Disorders in Chronic Obstructive Airway Diseases: A Neglected Clinical Entity

Chronic obstructive pulmonary disease (COPD) is a lung disease that can affect various extra-pulmonary organs; one being the musculoskeletal system. Skeletal muscle dysfunction and osteoporosis are two important musculoskeletal disorders that have an impact on the quality of life in COPD patients in terms of morbidity and mortality. Treatment related adverse effects of COPD such as steroid-induced myopathy and osteoporosis are well recognised. Other comorbidities like sarcopenia, cardiovascular disease, metabolic diseases (diabetes mellitus, obesity, and thyroid diseases), chronic kidney disease, sleep apnoea, anaemia, and depression are also noted, which can contribute to impaired health status, increased healthcare utilisation, and even mortality. As well, it has been shown that autoimmunity and autoimmune rheumatic diseases (AIRDs) are linked to COPD. In this mini-review, we intend to give an overview of different types of musculoskeletal disorders associated with COPD.

The use and context of the term 'multimorbidity' in rheumatoid arthritis: a systematic literature review

This systematic literature review aimed to analyse terms describing coexisting conditions in the RA literature, informing the need for an operationalized definition of multimorbidity. Articles discussing RA with multimorbidity, published 1946 until August 2020, were identified. The primary outcome was the use and/or definition of 'multimorbidity' in RA. Information extracted included terms defining coexisting conditions, the use of a comorbidity/multimorbidity score and the use of 'index disease' to describe RA (more applicable to comorbidity than multimorbidity). Thirty-nine articles were included. Eight articles used the term 'multimorbidity', 18 used 'comorbidity' and 12 used both terms, 7 synonymously. One used no term. Fourteen articles fully defined the term. The number of co-existing conditions described in included studies was one-121. Twelve articles used a comorbidity/multimorbidity score. Four articles described RA as the 'index disease'. Our results demonstrate inconsistent use of the term multimorbidity. Improved assessment of multimorbidity is indicated in RA patients, including an operationalized use and definition.

Common Mental Disorders, Functional Limitation and Diet Quality Trends and Related Factors among COPD Patients in Spain, 2006-2017: Evidence from Spanish National Health Surveys

Certain conditions such as common mental disorders (CMDs), functional limitation (FL) and poor diet quality may affect the lives of individuals who suffer from chronic obstructive pulmonary disease (COPD). This study sought to examine time trends in the prevalence of CMDs, FL and diet quality among male and female COPD patients living in Spain from 2006 to 2017 and to identify which factors were related to CMDs, FL and a poor/improvable diet quality in these patients. We performed a cross-sectional study among COPD patients aged ≥ 40 years old using data from the Spanish National Health Surveys conducted in 2006, 2011 and 2017, identifying a total of 2572 COPD patients. Binary logistic regressions were performed to determine the characteristics related to CMDs, FL and poor/improvable diet quality. Over the years of the study, the prevalence of FL among female COPD patients increased (p for trend <0.001). In addition, CMDs were associated to body mass index (BMI), educational level, physical activity, smoking status, occupation, chronic conditions and alcohol consumption; FL was related to age, living with a partner, educational level, physical activity and chronic conditions; and poor/improvable diet quality was associated to age, smoking status, BMI and physical activity.

Comorbidities in a Cohort of 66 Patients With Psoriatic Arthritis Mutilans-Results From the Nordic PAM Study

Objective: Psoriatic arthritis mutilans (PAM) is the most severe phenotype of psoriatic arthritis due to excessive bone erosion causing joint destruction and decreased functional capacity. The aim of this study was to investigate the prevalence of comorbidities among patients with PAM and the association between comorbidities and joint involvement. Methods: A total of 66 patients aged ≥18 years from the Nordic countries with past or present psoriasis along with at least one mutilated joint were included in the present study. Results: The median number of comorbid conditions per patient was 1 [interquartile range (IQR) 0-2] and 16.7% reported three or more comorbidities. The most frequent comorbidity was hypertension (36.4%). The median number of mutilated joints per patient was 3 (IQR 1-8.3; range 1-38). Conclusion: Two thirds of the patients with PAM reported comorbid conditions and the most frequent was hypertension which affected more than a third of the patients. However, this study was unable to detect any association between comorbidities and the severity of PAM.

Comparable or higher prevalence of comorbidities in antiphospholipid syndrome vs rheumatoid arthritis: a multicenter, case-control study

OBJECTIVES

Evidence on comorbidity prevalence in antiphospholipid syndrome (APS) and its difference from high comorbidity burden rheumatic diseases is limited. Herein, we compare multiple comorbidities between APS and RA.

METHODS

A total of 326 patients from the Greek APS registry [237 women, mean age 48.7 (13.4) years, 161 primary APS (PAPS), 165 SLE-APS] were age/sex matched (1:2 ratio) with 652 patients from a Greek multicentre RA cohort of 3115 patients. Prevalence of cardiovascular (CV) risk factors, stroke, coronary artery disease (CAD), osteoporosis, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), depression and neoplasms were compared between APS and RA patients using multivariate regression analysis.

RESULTS

Ηyperlipidemia and obesity (ΒΜΙ ≥ 30 kg/m2) were comparable while hypertension, smoking, stroke and CAD were more prevalent in APS compared with RA patients. Osteoporosis and depression were more frequent in APS, while DM, COPD and neoplasms did not differ between the two groups. Comparison of APS subgroups to 1:2 matched RA patients revealed that smoking and stroke were more prevalent in both PAPS and SLE-APS vs RA. Hypertension, CAD and osteoporosis were more frequent only in SLE-APS vs RA, whereas DM was less prevalent in PAPS vs RA. Hyperlipidaemia was independently associated with CV events (combined stroke and CAD) in PAPS and SLE-APS, while CS duration was associated with osteoporosis in SLE-APS.

CONCLUSION

Comorbidity burden in APS (PAPS and SLE-APS) is comparable or higher than that in RA, entailing a high level of diligence for CV risk prevention, awareness for depression and CS exposure minimization.

Perspective: The Lung, Particles, Fibers, Nanomaterials, and Autoimmunity

Studies have shown that a wide range of factors including drugs, chemicals, microbes, and other environmental agents can induce pre-clinical autoimmunity. However, only a few have been confidently linked to autoimmune diseases. Among these are exposures to inhaled particulates that are known to be associated with autoimmune diseases such as lupus and rheumatoid arthritis. In this article, the potential of particle, fiber, and nanomaterial exposures to induce autoimmunity is discussed. It is hypothesized that inhalation of particulate material known to be associated with human autoimmune diseases, such as cigarette smoke and crystalline silica, results in a complex interplay of a number of pathological processes, including, toxicity, oxidative stress, cell and tissue damage, chronic inflammation, post-translational modification of self-antigens, and the formation of lymphoid follicles that provide a milieu for the accumulation of autoreactive B and T cells necessary for the development and persistence of autoimmune responses, leading to disease. Although experimental studies show nanomaterials are capable of inducing several of the above features, there is no evidence that this matures to autoimmune disease. The procession of events hypothesized here provides a foundation from which to pursue experimental studies to determine the potential of other environmental exposures to induce autoimmunity and autoimmune disease.

C-reactive protein and implications in rheumatoid arthritis and associated comorbidities

C-reactive protein (CRP) is routinely assessed as a marker of systemic inflammation in rheumatoid arthritis (RA). However, it is also an immune regulator that plays an important role in inflammatory pathways associated with RA and promotes atherogenic effects. Comorbidities linked to systemic inflammation are common in RA, and CRP has been associated with the risk for cardiovascular disease, diabetes, metabolic syndrome, pulmonary diseases, and depression. The relationship between systemic inflammation, CRP, and comorbidities in RA is complex, and it is challenging to determine how changing CRP levels may affect the risk or progression of these comorbidities. We review the biological role of CRP in RA and its implications for disease activity and treatment response. We also discuss the impact of treatment on CRP levels and whether reducing systemic inflammation and inhibiting CRP-mediated inflammatory pathways may have an impact on conditions commonly comorbid with RA.

Mixed Airway and Pulmonary Parenchymal Disease in Patients With Primary Sjögren Syndrome: A 6-year Follow-up

OBJECTIVE

To assess pulmonary function and chronic obstructive pulmonary disease (COPD) development over time in patients with primary Sjögren syndrome (pSS), as well as the association between pulmonary function, radiographic findings, respiratory symptoms, and clinical features of pSS, taking cigarette consumption into account.

METHODS

Forty patients with pSS (mean age 66 yrs; range 42-81 yrs; 39 women), previously participating in a cross-sectional study on pulmonary involvement in pSS, were reassessed by pulmonary function tests after a mean follow-up time of 6 years. At follow-up, patients were also assessed by high-resolution computed tomography of the chest, as well as for pSS disease activity, respiratory symptoms, and cigarette consumption.

RESULTS

Patients with pSS showed significantly decreased percentages of predicted total lung capacity (TLC), residual volume (RV), RV/TLC ratio, and diffusing capacity of the lungs for carbon monoxide, as well as an increase in predicted forced expiratory volume in 1 second/vital capacity (FEV1/VC) ratio from baseline to follow-up. The proportion of COPD in patients with pSS did not change significantly from baseline to follow-up (38% vs 40%, respectively). Radiographic signs of bronchial involvement and interstitial lung disease were each found in 38% of the patients.

CONCLUSION

Both airway and pulmonary parenchymal disease were commonly found in patients with pSS, with a coexistence of both an obstructive and restrictive pulmonary function pattern, where the latter tended to deteriorate over time. COPD was a common finding. Airway and pulmonary involvement may be underdiagnosed in pSS, which is why special attention to clinical assessment of pulmonary involvement in patients with pSS is mandated.

Multimorbidity in COPD, does sleep matter?

A good night's sleep is a prerequisite for sustainable mental and physical health. Sleep disorders, including sleep disordered breathing, insomnia and sleep related motor dysfunction (e.g., restless legs syndrome), are common in patients with chronic obstructive pulmonary disease (COPD), especially in more severe disease. COPD is commonly associated with multimorbidity, and sleep disorders as a component of this multimorbidity spectrum have a further negative impact on COPD-related comorbidities. Indeed, concomitant diseases in COPD and in obstructive sleep apnea (OSA) are similar, suggesting that the combination of COPD and OSA, the so called OSA-COPD overlap syndrome (OVS), affects patient outcomes. Potential clinically important interactions of OVS exist in cardiovascular and metabolic disease, arthritis, anxiety, depression, neurocognitive disorder and the fatigue syndrome. Correct diagnosis for recognition and treatment of sleep-related disorders in COPD is recommended. However, surprisingly limited information is available and further research and improved diagnostic tools are needed. In the absence of clear evidence, we agree with the recommendation of the Global Initiative on Chronic Obstructive Lung Disease that sleep disorders should be actively searched for and treated in patients with COPD. We believe that both aspects are important components of the holistic approach required in patients with chronic multimorbid conditions.