COPD and Rheumatoid Arthritis: Results of Nurses’ Health Study

Increased Risk of COPD and Rheumatoid Arthritis

Background:

Rheumatoid arthritis is a chronic inflammatory condition that is considered an autoimmune disorder. This means that the body’s immune system mistakenly attacks the body’s own tissues. Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining of joints, causing a painful swelling that can eventually result in bone erosion and joint deformity.

Images of inflammed joints suggesting a relationship between COPD and rheumatoid arthritis

Images of a normal joint and of osteoarthritis and rheumatoid arthritis

In some people, rheumatoid arthritis can also damage the skin, eyes, lungs, heart and blood vessels. As both COPD and rheumatoid arthritis are inflammatory conditions, it is interesting to consider whether COPD is more common in those with rheumatoid arthritis.

Study:

Dr. Jeffrey Sparks and colleagues at Brigham and Women’s Hospital in Boston used information (medical records and results of questionnaires completed every two years) collected between 1976 and 2014 in 121,701 women as part of the Nurses’ Health Study. For every woman with rheumatoid arthritis, they found 10 other women who did not have this condition but the same age. The study was published online on September 5, 2017, in Seminars in Arthritis & Rheumatism.

Results:

There were 843 women with rheumatoid arthritis matched with 8,399 women without this condition. Average age was 60 years. Rheumatoid arthritis was associated with a 52% increased risk of COPD.

Conclusion:

Rheumatoid arthritis was associated with increased risk for COPD independent of cigarette smoking.

My Comments:

If you have rheumatoid arthritis and have shortness of breath with activities, you should mention this to your health care professional at your next appointment. You should ask that breathing tests be ordered.

Why? Based on the results of this study, it is possible that you have COPD even if you did not smoke. Another possibility is inflammation and scarring the lung tissue called interstitial lung disease – which can also occur in those with rheumatoid arthritis.

COPD involves the breathing tubes (airways) of the lungs while interstitial lung disease involves the supporting tissues, or walls, of the air sacs.

Nebulizer Therapy – Can It Help Me Breathe Easier?

When to Consider Nebulizer Therapy

Dear Dr. Mahler:

I have severe COPD and attend pulmonary rehab sessions at the nearby hospital.  I take Advair in the purple disk twice a day and Spiriva powder in the capsule each morning. One of the other patients at rehab told me that she uses medicines in a nebulizer machine and this helps her breathe much better than when she used different inhalers in the past. Do you think that nebulizer therapy might help me?

Tracy from Bellingham, WA

Dear Tracy,

There are four different delivery systems for inhaled medications to treat those with COPD: metered-dose inhalers (commonly called puffers); dry powder inhalers; soft mist inhalers; and nebulizers. Some examples are shown below. In general, pharmaceutical companies have mainly been developing new bronchodilator medications as dry powders.

Metered-dose Inhaler

Metered-dose Inhaler

Examples of dry-powder inhalers

Examples of dry-powder inhalers

With dry powder inhalers, you need to take a hard and fast breath in – in order to pull the powder out of the device and overcome its internal resistance. Some individuals, especially those with more advanced COPD, may not have enough strength to successfully break up the powder packet in the inhaler device and then inhale the powder particles deep into the lower parts of the lungs.

Nebulizer therapy is used frequently to deliver bronchodilator medications to those with COPD who are experiencing a flare-up (exacerbation) both in the Emergency Department and in the hospital. Many patients with COPD find that this approach works better because you just breathe in and out normally when inhaling the medications from the nebulizer, and you don’t have to have to hold your breath as you do with the other delivery systems.

Inhaler machine for nebulizer therapy

Hand held nebulizer

There are four major reasons why your health care provider might prescribe nebulizer therapy: you have difficulty using the other inhaler devices [because of arthritis of the hands and wrists or because of difficulty following instructions (dementia)]; you have difficulty coordinating the steps to release the medication from the device, inhaling correctly, and then holding your breath for as long as possible; you are not able to breathe easier with inhaler devices; AND you do not have adequate force when breathing in to pull the powder out of the inhaler.

I suggest that you ask your health care provider whether a trial of nebulizer medications is appropriate, especially since you don’t feel it is easier to breathe with your current inhalers. Both types of bronchodilators (beta-agonists and muscarinic antagonists) as well as an inhaled corticosteroid are available in solutions for use in a nebulizer. These three different types of medications are similar to the Advair and Spiriva dry powder inhalers that you are currently using.

Best wishes,

Donald A. Mahler, M.D.