RA and Infection Risk

Learn how you can minimize the frequency and severity of infections.

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Doctors have long known that people with rheumatoid arthritis (RA) have an increased risk for infections, which can range from mild to life threatening. Problems with your immune system (the body’s defense against infectious bacteria and viruses) are partly to blame. But other factors, such as your age, overall health, environment, certain lifestyle habits and being hospitalized, can make a person more susceptible to infection, too.

The medications that help control the immune system’s wayward behavior in RA can also weaken the body’s defenses. “It’s a fine line – we want to treat a patient’s illness, but we don’t want to cause complications,” says Leslie Harrold, MD, a board certified rheumatologist and epidemiologist at the University of Massachusetts Medical School in Worcester.

These factors can cause opportunistic infections to wreak havoc in people with RA. But careful medication management and commonsense habits can help reduce your risk or minimize the severity of infections.

How Big a Risk?

Research dating back to the 1950s indicates that RA patients have more infections than people who don’t have the disease. Dr. Harrold’s patients tend to get mild infections, such as the common cold. However, serious infections are associated with one in four deaths among people with RA, according to the Centers for Disease Control and Prevention. A serious infection is one that requires intravenous antibiotics or hospitalization, or proves fatal; a few examples include pneumonia, staph infections and sepsis.

The increased risk for infection in RA may be partly due to a drop in the number and activity of white blood cells available to attack invaders. Also, the immune system of an RA patient is weakened and less able to recognize germs. Some research suggests that RA patients may not mobilize important defenders called T cells as efficiently as non-patients.

Your infection risk also rises with the severity of your disease activity. If it’s mild, your risk increases almost 3-fold, according to a 2013 study in The Journal of Rheumatology, while severe RA raises the risk nearly 5-fold. Other personal characteristics also raise your risk. As you age, your immune system works less efficiently, and you’re more likely to have other medical conditions linked to infections, such as diabetes or chronic kidney disease. Smoking weakens your defense against infections. And if you work in certain environments, such as a hospital or school, you may be exposed to more germs.

Medications and Infection

There’s little question that suppressing the immune system with medicine – essential for controlling RA – is a significant cause of infections. For example, a 4-fold increased risk for serious infections is one of the downsides of corticosteroid use.

Disease-modifying drugs such as methotrexate make infections somewhat more likely, too, but “the risk substantially increases when you add a biologic to the equation,” says Ali Ajam, MD, an assistant professor in the division of rheumatology and immunology at Ohio State University Wexner Medical Center in Columbus.

Initially there was some question as to whether biologics increase infection risk. An analysis of 106 clinical trials published in The Lancet in 2015 found that, compared to older DMARDs such as methotrexate, biologics carry double the risk for serious infections. However, the authors of the analysis found that only moderate and high doses appear to be a concern; low doses of biologics had a similar risk for infections as older DMARDs. Earlier studies, including one by British researchers published in 2011 in the journal Rheumatology, found the risk is greatest during the first 6 months you’re on a biologic, then diminishes until it’s only somewhat higher than the risk associated with DMARDs, though no one is certain why.

While doubling the risk for serious infection sounds scary, Dr. Ajam points out that “most of these medications have less than a 5% incidence of major infections. If a patient starts a biologic and has frequent infections, lowering the dose or switching to another often solves the problem,” says Dr. Ajam.

Cut Your Infection Risk

“There are many ways you can decrease your risk for infection,” says Dr. Harrold. Some steps are common sense: Eat a balanced diet, wash your hands often, don’t smoke and get plenty of sleep. In addition, take the following critical steps.

  • Get vaccinated. An annual flu shot and the pneumococcal vaccine are musts. (Ask your doctor which type of the latter is right for you before getting it.) You should also get the herpes zoster (shingles) vaccine when you’re eligible; since it contains a live virus, you must receive this shot before starting a biologic.
  • Avoid sick people. If you will be exposed to others who may be ill, wear a surgical mask.
  • Consider supplements. Herbal supplements containing turmeric, garlic and cinnamon may give your immune system a boost, says Dr. Ajam.

If you use a biologic and develop a fever or any other sign of infection, call your doctor. While infections are an important concern for RA patients, good control of your symptoms should be foremost in your mind.

“Don’t be scared of your medications,” says Dr. Harrold. “Be proactive and manage the risk.”