Multiple studies have demonstrated that early aggressive management of rheumatoid arthritis (RA) is beneficial.

What many patients don't understand is why this is so important. Beyond the pain, stiffness, and inability to perform activities of daily living, moist patients aren't aware of the other insidious dangers that rheumatoid arthritis- if not optimally managed- poses.

The very substances- called cytokines- that promote the chronic inflammation of joints are also responsible for more serious problems affecting internal organs. Examples of some of these cytokines are TNF-alpha, interleukin-1 (IL-1), and IL-6.

These cytokines lead to insulin resistance, abnormal function of cells that line blood vessels, and abnormalities of cholesterol metabolism, causing increases in total cholesterol, low density lipoproteins (LDL- "bad cholesterol"), and triglycerides. The end result is a marked tendency to atherogenesis- "hardening of the arteries".

This hardening of the arteries is associated with cardiovascular disease leading to a marked tendency to stroke and heart attack. The insulin resistance also contributes to other metabolic disturbances. These metabolic problems can be aggravated by the natural tendency for patients with poorly controlled RA to be subject to stress, poor dietary habits, and less than sufficient exercise. The bottom line is that the life expectancy of a patient with rheumatoid arthritis is shortened by ten to fifteen years compared with age-matched controls.

One study demonstrated a two-fold higher risk for coronary heart disease in patients with rheumatoid arthritis compared with people who did not have rheumatoid arthritis (Satter N, McInnes IB. Curr Opin Rheumatol. 2005; 17: 286-292).

Another study showed that women with rheumatoid arthritis who had had rheumatoid arthritis for at least ten years were three times more likely to have had a heart attack compared to women without RA (Solomon DH, Karlson EW, Rimm EB, et al. Circulation. 2003; 107: 1303-1307).

So... it is this important but little emphasized complication of the disease that must be emphasized to patients.

Fortunately, most of the data that has been accumulated related to the cardiovascular issues from RA were collected before the advent of biologic therapy. There is increasing evidence that aggressive management of RA employing the newer biologic agents can help reduce the increased cardiovascular complications related to RA. One example is a study showing that female patients with RA treated with TNF-inhibitors had a reduced overall mortality rate. Unfortunately, the same was not true for men in this one example (Jacobsson LT, Turesson C, Nilsson JA, et al. Ann Rheum Dis. 2007; 66: 670-675).

However other studies have demonstrated a lower rate of cardiovascular problems such as heart attack, stroke, and congestive heart failure) in patients with RA treated with TNF-inhibitors (Dixon WG, Watson KD, Lunt M, et al. Arthritis Rheum. 2007; 56: 2905-2912).

So what should the approach be?

There is still a great deal of ignorance among patients with rheumatoid arthritis regarding the above mentioned complications. Currently, many patients are under the misimpression that natural remedies are good and that drugs are to be avoided, condemned, and are all-in-all, bad. What a mistake!

What rheumatologists must do is explain the reasoning behind the need for aggressive management. It should be explained that there is a narrow "window of opportunity" that makes treatment critical.

Patients should be educated as to the pathophysiology of RA and the terrible consequences that may arise as a result of less than optimal therapy.

While an open mind toward natural therapies is important, an open mind towards the value of proper medical therapies is just as critical.

It is particularly important that patients and physicians become strategic allies together to combat this medical scourge. The aim should be to induce complete remission.