Impact of bariatric surgery on patients with rheumatoid arthritis

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Rheumatoid arthritis and gastric bypass surgery

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We investigated the effect of weight loss after bariatric surgery among patients with rheumatoid arthritis RA. Rheumatoid arthritis and gastric bypass surgery conducted a retrospective cohort study of RA patients who underwent bariatric surgery Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, or sleeve gastrectomy at two medical centers.

We obtained anthropometrics, laboratory values, RA disease activity, and medication use at baseline prior to surgeryat six and twelve months post-surgery, and at most recent follow-up visits. RA disease activity was determined by clinical or validated measures. At each post-surgical visit, characteristics were compared to baseline. We identified 53 RA patients who underwent bariatric surgery.

At baseline prior to surgery, mean body mass index was Twelve months post-surgery, subjects lost a mean of At most recent follow-up mean 5.

After substantial weight loss from bariatric surgery, RA patients had lower disease activity, decreased serum inflammatory markers, and less RA-related medication usage. Weight loss may be an important non-pharmacologic strategy to reduce RA disease activity.

However, other factors, such as improved efficacy of medications, improved physical activity, and metabolic changes, may also have contributed to these post-surgical improvements. Additionally, obesity causes a systemic inflammatory state due in part due to the secretion of adipokines by adipocytes and is associated with an elevation of serum inflammatory markers, such as C-reactive protein CRP and erythrocyte sedimentation rate ESR 23.

Overweight and obesity are associated with an increased risk of incident rheumatoid arthritis RA as well as increased RA disease severity and decreased treatment efficacy 4 - 8. Bariatric surgery causes substantial weight loss that has been associated with improvement, and sometimes remission, of chronic diseases such as diabetes mellitus and hypertension 9 Weight loss after bariatric surgery decreases serum uric rheumatoid arthritis and gastric bypass surgery levels in patients with diabetes and reduces serum inflammatory markers in the obese 11 - However, rheumatoid arthritis and gastric bypass surgery, the effect of substantial weight loss after bariatric surgery on systemic inflammatory rheumatic diseases has not been studied.

Non-pharmacologic treatments such as dietary changes, physical activity, and weight loss, typically play a secondary role in RA management; it is unclear whether these interventions modify RA disease activity In this retrospective cohort study, we aimed anti paxil determine the effect of weight loss after bariatric surgery on RA.

We hypothesized that weight loss after bariatric surgery would improve RA disease activity, decrease serum markers of inflammation, and reduce RA-related medication usage.

We conducted a retrospective cohort study of RA patients who underwent bariatric surgery using electronic medical record EMR data. Bariatric surgery was defined as Roux-en-Y gastric bypass current procedural terminology [CPT] codes, orsleeve gastrectomy CPT codelaparoscopic adjustable gastric banding CPT codes oror other absorption limiting gastric procedures CPT codes,or We reviewed EMR notes from three months prior to surgery to July among subjects with at least two billing codes for RA All subjects met the American College of Rheumatology RA classification criteria at time of bariatric surgery Subjects who had adequate clinical data available in the EMR before and after bariatric surgery were included in the study see Figure 1 for flow diagram defining the analyzed study sample.

The index date was defined as the date of bariatric surgery. We collected data at the following time points: Data were collected through routine medical care; medical records with assessments of joint signs, symptoms, and RA disease activity measures were prioritized for review. Data on demographics, comorbidities, rheumatoid arthritis and gastric bypass surgery, and RA characteristics serologic status, rheumatoid arthritis and gastric bypass surgery, bone erosions on radiography, and disease duration were evaluated as available at the index date.

BMI was calculated based on measured weight in kilograms divided by measured height in meters-squared Two board-certified rheumatologists JAS and BLB reviewed medical records to determine RA disease activity, the second of whom was blinded to timing of bariatric surgery and amount of weight lost. RA disease activity was categorized according to accepted criteria into high, moderate, low, or remission 21 We compared changes in anthropometrics, laboratory values, RA disease activity, and RA-related medication use between each post-surgical time point and baseline values for each subject using paired statistical tests, rheumatoid arthritis and gastric bypass surgery.

We compared measures at six and 12 months post-surgery and at most recent follow-up, to baseline measures. Rheumatoid arthritis and gastric bypass surgery identified 53 RA patients who underwent bariatric surgery at two large academic medical centers with EMR data before and after surgery.

Surgeries occurred between and for subjects in rheumatoid arthritis and gastric bypass surgery analyses. The mean age at bariatric surgery was At bariatric surgery, all subjects were obese: The mean duration of RA was 8.

After bariatric surgery, subjects lost substantial weight mean Mean most recent follow-up visit was 5. Mean BMI at six months post-surgery was CRP was significantly lower at six months post-surgery Similarly, rheumatoid arthritis and gastric bypass surgery, ESR was significantly lower at six months post-surgery However, similar frequencies of subjects were taking two or three DMARDs at every time point assessed.

Figure 3 shows study subjects stratified by RA disease activity categories assessed at baseline. RA disease activity improved after substantial weight loss from bariatric surgery in subjects classified with high, moderate, and low RA disease activity, and remained stable for subjects in remission at baseline. Mean values in subjects at baseline prior to bariatric surgerysix months post-surgery, 12 months post-surgery, and most recent follow-up: Rheumatoid arthritis disease activity in subjects after bariatric surgery stratified by RA disease activity classification at baseline prior to bariatric surgery.

Our study describes reduced serum inflammatory markers, decreased RA disease activity and less RA medication use after bariatric surgery in patients with RA. We also observed significantly decreased serum inflammatory markers at all post-operative time points compared to baseline. Only one prior study investigated the effect of weight loss on RA. No prior study has psoriasis and cipro the effects of more substantial weight loss on RA, the effects of bariatric surgery on RA, or examined changes in RA disease activity before and after bariatric surgery.

In that study, CRP levels at baseline prior to bariatric surgery were 3. Therefore, the reduction of CRP in the patients in our study was beyond what was expected from weight loss alone and thus may reflect an intrinsic reduction in systemic inflammation, rheumatoid arthritis and gastric bypass surgery.

Excess body weight has been associated with higher risk of developing RA 47 Others have suggested that adipocyte-derived pro-inflammatory cytokines such as leptin, resistin, and visfatin contribute to ongoing inflammation that may eventually manifest in clinical RA and increase RA disease activity In a high-risk population with arthralgias and positive RA-related antibodies, rheumatoid arthritis and gastric bypass surgery, those who smoked and had increased BMI were more likely to develop classifiable RA Obesity may also contribute to a more severe clinical course among those with RA.

Elevated BMI is associated with worse RA outcomes compared to those with normal BMI, including higher RA disease activity, poorer clinical response to treatment, worse quality of life, lower physical function, and more pain 530 - Among early RA patients however, obese patients are less likely to develop bone erosions compared to those with normal BMI, perhaps due to paradoxical anti-inflammatory effects of adiponectin on synoviocytes 33 - Therefore, the high RA disease activity we observed prior rheumatoid arthritis and gastric bypass surgery bariatric surgery may have been in part explained by decreased DMARD efficacy in those with more severe obesity.

In our study, we note that similar frequencies of patients were on two or more DMARDs both before and after bariatric surgery, but the frequency of patients on a single DMARD markedly decreased.

The overall markedly reduced need for DMARDs together with the increase in medication-free remission after bariatric surgery suggests that intrinsic changes in RA disease activity or response to DMARDs may have occurred. It is possible that the observed reduction in RA-related medication usage was in part due to perioperative medication adjustments as prior to bariatric surgery, patients are typically instructed to discontinue immunosuppressants, glucocorticoids, and NSAIDs due to the perioperative risk of gastrointestinal bleeding, poor wound healing, and infection.

Our results suggest that bariatric surgery might significantly reduce the need for RA-related medications and even induce long-term RA remission requiring no medications in some patients. This association may be due in part to metabolic, in addition to mechanical, factors, as osteoarthritis is more prevalent in persons with obesity not only in weight-bearing joints, but also in the hands Thus, it is possible that hand osteoarthritis contributed to some signs and symptoms of pain, tenderness, and swelling in our study, which might have also improved with weight loss However, in our study the majority of subjects were seropositive and many had bone erosions, characteristic of RA but not osteoarthritis.

Moreover, all subjects were assessed by experienced rheumatologists, who had expertise in differentiating between hand osteoarthritis and the findings of RA. Nonetheless, detecting synovitis in small joints in obese patients by physical examination rheumatoid arthritis and gastric bypass surgery is difficult even for experienced clinicians; therefore some of the reported improvements in joint examinations may have been due to reduced adiposity after bariatric surgery.

Some subjects in our study experienced serious adverse events after bariatric surgery, including re-operation, infection, pulmonary embolism, and death.

Due to the limited sample size of our study, we are unable to determine whether adverse events from bariatric surgery in RA patients differ compared to the general population of patients undergoing bariatric surgery Our study has several limitations. The study design was a retrospective uncontrolled, observational cohort without a comparison group that utilized data collected in routine medical care. Ascertainment of RA disease rheumatoid arthritis and gastric bypass surgery was performed by blinded chart review when validated measures were not available.

Since validated measures were not collected consistently, we were not able to analyze whether individual components of RA disease activity measures, such as tender or swollen joints, were also improved after bariatric surgery. A potential source of bias in our study was that patients and providers were aware of bariatric surgery status, weight lost, and improvements in ESR and CRP.

These factors might have influenced components of RA disease activity measures. We attempted to reduce this potential source of bias by blinded chart review to bariatric surgery status and weight loss. Since we relied on data collected during routine clinical practice, not all data were available.

For example, not all subjects had RF and anti-CCP tested at the institutions in this study as some had longstanding deforming RA diagnosed elsewhere and serologic markers were not routinely retested. Moreover, some subjects had longstanding RA diagnosed prior to the clinical availability of anti-CCP. This may explain a relatively low frequency of seropositive RA patients in this study. We note that obesity may have a stronger association with seronegative RA than seropositive RA, particularly in women 7.

In our study, some subjects were excluded due to inadequate data for analysis, raising the possibility stomach problems and diabetes our study sample may not be representative of patients with active RA see Figure 1.

However, given that both institutions included our study are large tertiary centers rheumatoid arthritis and gastric bypass surgery RA patients with severe or symptoms and signs of cancer disease are routinely referred, our study sample likely represents RA patients with longstanding and active RA. In addition, almost all subjects in our study were women, likely reflecting the female predominance in both RA prevalence and bariatric surgery seekers.

This raised the question of whether the effects of obesity in RA may be different for women and men 7 However, the impact of weight loss after bariatric surgery on RA disease activity in our study was substantial, so that even a modest effect in men may still have clinical benefit.

Decreased mechanical strain on joints, subjective improvements in overall health, increased efficacy of medications at reduced weight, improved diet, and increased physical activity, may all rheumatoid arthritis and gastric bypass surgery influenced RA disease activity measures without representing true changes in the underlying disease. While these factors may have played a role in the post-surgical improvements observed in our study, the substantial improvements in RA disease activity measures, reduced serum markers of inflammation, and decreased use of RA-related medications are all suggestive of reduced systemic inflammation.

Finally, we note that it is unclear whether the observed improvement in RA measures after bariatric surgery is related to the substantial weight loss itself, or to surgery-specific effects. Bariatric surgical procedures have profound metabolic effects, beyond those attributable to weight loss In patients with type 2 diabetes who undergo Roux-en-Y gastric bypass, the need for glucose-lowering medications is significantly reduced within days, well before significant weight loss The mechanisms responsible for these effects are only partially understood, and hypotheses include alterations in the microbiome, which may also influence RA 48 - Alterations in gut hormones after bariatric surgery, particularly glucagon-like peptide-1, may further modulate inflammation and metabolic factors involved in RA disease activity We were unable to investigate whether the specific surgical interventions, or the degree of weight lost, have differential effects on changes in RA measures in our study.

Prospective studies of RA patients undergoing bariatric surgery with consistent measurement of RA disease activity, metabolic factors, and tissue samples for microbiome and translational studies are necessary to clarify the exact mechanisms for the clinical improvement rheumatoid arthritis and gastric bypass surgery observed after bariatric surgery in RA patients.

 

Rheumatoid arthritis and gastric bypass surgery

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