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Weight-Loss Surgery Vastly Improves Rheumatoid Arthritis

Weight-Loss Surgery Vastly Improves Rheumatoid Arthritis

 If you're severely – or morbidly – obese and have rheumatoid arthritis, weight-loss surgery may greatly improve your symptoms, and there's even a good chance that it may cause the disease to go into remission.

These are the findings of a 2015 study published in the journal Arthritis Care & Research.

 A team of researchers at Harvard Medical School's Brigham and Women's Hospital in Boston reviewed the records of 53 patients with RA who had weight-loss – or bariatric – surgery in the 20 years between 1993 and 2013 and found that only 6 percent of patients were classified as having moderate to severe disease activity 12 months after surgery, compared with 57 percent before they underwent the operation.

 While this result is impressive, what's even more striking is that almost six years after surgery, 74 percent of the study's patients were classified as being in remission, compared with 24 percent who achieved remission with RA medications before they had surgery. And of these, more than one-quarter – 28 percent – did not need any medication at all.

 "This is a really exciting finding," says Dr. Jeffrey Sparks, the lead author of the study and a rheumatologist and associate physician in the Division of Rheumatology, Immunology and Allergy at Brigham and Women's Hospital. "Across the board, [surgery] vastly improved RA symptoms by every measure, including lower markers of inflammation, like C-reactive protein, disease activity and decreased medication use," he says.

This study is "the most recent and strongest available on this subject," according to Dr. Amanda Sammut, the chief of rheumatology at New York City Health and Hospitals in Harlem. However, she cautions that not much research has been done in this area.

 "We have limited information from studies regarding the effects of bariatric surgery in patients with RA," says Sammut, who is also an assistant clinical professor of medicine at Columbia University College of Physicians and Surgeons in New York. "The exact percentage of RA patients who experience improvement in their [disease] after bariatric surgery is not known," she adds.

"This number is difficult to estimate given that good studies are lacking regarding the effect of obesity surgery on RA," says Dr. Daniel El-Bogdadi.

Morbid obesity is defined as having a body mass index of 40 or more, or 35 or more in people who also have a high-risk condition like Type 2 diabetes or high blood pressure. (The Centers for Disease Control and Prevention says a BMI of 40 would apply to someone 5 foot, 9 inches tall weighing 271 pounds or more.) Another measure of morbid obesity is being 100 pounds or more over your ideal weight. According to the American Society of Metabolic and Bariatric Surgery, morbid obesity is an "epidemic within an epidemic," having quadrupled over the past 25 years to the point where it accounts for 20 percent of the obese population in the U.S., or more than eight million people.

The Arthritis Foundation states that about two-thirds of people with RA are either overweight or obese, which is roughly the same proportion as is seen in the general population.

More than a decade ago, the National Institutes of Health recommended bariatric surgery as the most effective means of losing weight and maintaining that loss long-term in people who are morbidly obese.

On average, people who have bariatric surgery lose between 19 and 23 percent of their total body weight. In this group of patients, surgery produced an average weight loss of 90 pounds or about 70 percent of the excess weight above normal body mass index.

Weight loss often reduces the incidence of obesity-related complications, such as diabetes, high blood pressure, heart disease, gastroesophageal reflux disease, obstructive sleep apnea and respiratory disease, depression, infertility and urinary stress incontinence or leakage of urine when laughing, coughing, sneezing and the like.

A diagnosis of RA in itself increases the risk of many of these same conditions, even in people who are not overweight. "RA patients have a 50 percent higher risk of death due to cardiovascular disease than the general population," says El-Bogdadi, who is also vice president of the DC Rheumatism Society.

"If you have rheumatoid arthritis it is important to maintain a healthy lifestyle and weight," Sammut says.

"Certainly losing weight can lower your triglyceride levels and possibly your cholesterol levels, decreasing this as a risk factor for cardiovascular disease," El-Bogdadi says. "Losing weight may also have an effect on lowering blood pressure and improving diabetes blood glucose control and further lowering cardiovascular risk."

But does bariatric surgery produce an even greater improvement in RA disease activity than losing weight through diet and exercise?

 "Obesity surgery may improve RA, at least indirectly, by altering factors that make up the disease activity score," El-Bogdadi says.

"Prospective controlled studies are needed to further evaluate the exact parameters that are improved with obesity surgery in patients with RA," he says.

Sparks agrees that more research is necessary.

"We've maxed out the knowledge we can gain from observational studies," he says, noting that future studies should also evaluate how nonsurgical and surgical weight loss affect RA disease activity. This may present a challenge, however, because people, in general, do not tend to lose as much weight by dieting as they do following bariatric surgery.

"You likely need quite a bit of weight loss to see the big effects that we saw in our study," Sparks notes.

El-Bogdadi also cautions that bariatric surgery can't cure RA. "Although it may improve the RA, it does not halt the disease process," he stresses. "Also, some of the improvements seen after bariatric surgery may even be temporary."

Bariatric surgery in RA patients may have other effects. For example, it may alter how the body processes medication. Gastric bypass surgery bypasses a large portion of the small intestine – the organ responsible for absorbing most of the nutrients and much of the medication we consume.

"Patients who undergo a Roux-en-Y gastric bypass, the most common procedure performed in the United States for weight loss, have physiologic changes in their gut that result in the malabsorption of many nutrients," El-Bogdadi explains, "and it is believed that there is decreased absorption of some medications [in people with RA]."

"Methotrexate, especially, may be absorbed differently," Sparks says.

"It may be wise to switch patients" from oral medications to drugs delivered under the skin or intravenously, El-Bogdadi says. "There is no data that suggests malabsorption of medications with gastric banding or sleeve gastrectomy," he adds, citing two of the other common forms of bariatric surgery.

Another effect of bariatric surgery may be an increase in osteoporosis.

"Weight loss, especially rapid weight loss, may actually cause osteoporosis to be worse, especially in post-menopausal women," El-Bogdadi says, noting that osteoporosis is one of the main complications of RA. "Malabsorption of vitamin D as a result of obesity surgery may also contribute to this bone loss," he adds.

If you are morbidly obese and have RA and decide to undergo bariatric surgery, "improvement in RA may be an added bonus," Sparks says, noting that "RA itself is not reason enough to consider the surgery."

And if you are thinking about having bariatric surgery, it's important to carefully consider your choices.

"There is no data to suggest that one type of obesity surgery procedure is more effective than another for improvement of RA," El-Bogdadi says.

"It is important for patients to know what their options are, as well as the potential risks of different procedures," Sammut stresses.




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