Rheumatoid Arthritis and Infection Risk

When you live with rheumatoid arthritis (RA), you are often dealing with symptoms of pain, stiffness, and swelling. In addition, you face a higher risk of infection. Infections associated with RA can range from mild to life-threatening.

The increased risk for infection is related to a number of disease factors, including the disease itself, the medications to take it, your overall health, and your lifestyle. Read on to learn about your infection risk with RA, why that risk exists, and how you can stay healthy and reduce your risk for a serious infection.

What's the Risk?

An infection occurs when another organism enters the body and causes it to be sick. Organisms that cause infections are many and include things like viruses, bacteria, parasites, and fungi.

You can acquire an infection in a variety of ways, such as with contact from an infected person or by consuming contaminated food or water. An increased risk for infection with RA means you may experience more mild infections, such as the common cold or a sinus infection.

Additionally, RA puts you at risk for profoundly serious infections, like pneumonia (an infection that inflames the air sacs of one or both lungs) and sepsis (a life-threatening infection complication). Infections in people with RA can cause a person living with the disease to become hospitalized and need intravenous antibiotics.

According to a study from the Mayo Clinic reported in 2012, your risk for developing a severe infection is related to disease impact, corticosteroid use, age, and RA comorbidities like heart failure, chronic lung disease, and peripheral vascular disease.

These findings came from 584 people living with RA observed over a 12-year period. Almost half of the patients needed hospitalization and/or intravenous antibiotics because they had more than one serious infection. Among all the patients, there were 646 infections.

The Mayo Clinic had put together a risk score based on risk factors in the RA patients studied. By investigating the risk score, the researchers were able to determine how high a person’s risk was for serious infection. They further added that patients, based on that score, would need more frequent follow-ups, more infection prevention measures, and changes in treatments that could add to the risk.

According to the Johns Hopkins Arthritis Center, RA-related infections account for one-quarter of the deaths in people with RA. And research reported by in Rheumatology International finds infection as a cause of death is higher in people with RA compared to others in the general population. This risk of death includes respiratory infections.

Causes

There are several likely causes for the increased risk of infection for people with RA, including the disease itself, drug therapies used to treat the condition, overall health status, including comorbid conditions, and negative lifestyle habits.

The Disease Itself

An overactive immune system that is persistently fighting against healthy tissues can impair the ability to fight infection.

People with RA have an elevated risk for serious infection in comparison with other people living with non-inflammatory arthritis or musculoskeletal diseases, according to a study reported in 2019 in the journal RMD Open. This cohort study also found RA disease activity levels were connected to infections.

Here, researchers aimed to identify the risk of serious infection in people with RA over a five-year period. In comparison to the group of study subjects who had non-inflammatory arthritis or musculoskeletal condition, the people with RA had higher incidences for all types of infections assessed, including bacterial and respiratory.

They also had a 2 to 3 times higher risk for herpes zoster and other serious infections because of their compromised immune systems. Fungi-like serious infections were also more frequent in people with RA.

When researchers looked at disease activity, they found the people with RA who were in remission or had low disease activity had lower infection incidences. The risk for people with moderate to severe RA was much higher and in some cases meant very serious and life-threatening infections.

Medications

The medications used to treat RA are designed to suppress your overactive immune system. They can also suppress your body’s ability to fight infection.

In the previously noted RMD Open cohort study, study participants treated with conventional synthetic disease-modifying antirheumatic drugs (DMARDs) like methotrexate had a higher risk for serious infections compared to those treated with biologic therapies, such as Humira or Actemra, and Janus kinase (JAK) inhibitors, like Xeljanz. The risk for serious infection further increased in all people with RA were treating with glucocorticoids.

While the risk for infection is reduced with some types of RA drug therapies, the risk is still there. For example, even low doses of glucocorticoids are associated with a “small but significant” risk, according to a 2020 report in the Annals of Internal Medicine. The researchers note the importance of balancing the use of low dose glucocorticoids against the risk of infection.

While the infection risk with traditional DMARDs is higher, biologic drugs can also increase your risk for infection for RA and other types of inflammatory arthritis, according to a 2019 report in the Journal of Advanced Research. This report looked at a total of 5,596 patients using biologic DMARDs over an 11-year period.

Overall, 289 patients (4.2%) were hospitalized in that time period for infection and 55% of those hospitalizations were in people using biologics for the first time. The most common infections reported with biologic drug use for inflammatory arthritis were upper and lower respiratory infections­—infections that occur in the lungs, chest, sinuses, nose, or throat. 

Overall Health

Having other conditions­ called comorbid conditions­ with RA has been shown to increase infection risk. The term comorbidity is used to describe the presence of one or more health conditions in a person in addition to their primary disease.

A 2013 report in the journal Rheumatology shows the risk for RA is greater than two-fold for serious infections. The report’s authors point to older age and specific comorbid conditions to ask the elevated risk. They further note infections are higher in people with RA who may have chronic obstructive pulmonary disease and RA-related lung disease, chronic kidney disease, and diabetes.

Lifestyle

Unhealthy habits, such as smoking and excessive alcohol use, can also increase your risk for infections with RA. Smoking is considered a significant risk for the development of infections. It is also a risk factor for the development of RA and more severe disease in RA.

According to a 2013 report in The Journal Clinical & Cellular Immunology, cigarette smoking increases the risk for several types of infections, including viral, bacterial, and fungal. Cigarette smoking also promotes proinflammatory proteins associated with increased inflammation in RA. That means smoking with RA can be problematic, especially when it comes to serious and life-threatening infections.

Excessive alcohol consumption, over time, will result in a weakened immune system. A weak immune system increases your risk for bacterial and viral infections. It may also decrease the effects of vaccinations, including influenza and pneumonia vaccines.

Chronic alcohol use also increases inflammation throughout your body, which means more severe disease and increased vulnerability to infection for people with RA.

Cutting Your Infection Risk

As someone with RA who is vulnerable to infection, you will want to do what you can to reduce your risk for a serious infection. Some ways to decrease risk are common sense—like a healthy and balanced diet, getting plenty of sleep, and not smoking. In addition, you will want to take some more crucial steps.

Get Vaccinated

It is important for people with RA to stay current on vaccinations for respiratory infections like the flu and pneumonia. This is especially important if you are on an immunosuppressant drug to treat RA. Ask your healthcare provider what vaccinations you should be taking based on your age and overall health.

Wash Your Hands Often

Many infections can be simply avoided by washing your hands. According to the Centers for Disease Control and Prevention, you should scrub your hands for at least 20 seconds before, during, and after preparing food, before and after eating, after going to the bedroom or changing a diaper, and after blowing your nose, among other key times when you are likely to spread or get germs.

Avoid Sick People

It is important for everyone with RA to avoid contact with anyone who is sick. It is a good idea to explain to family and friends that you have a weakened immune system and that you need to be particularly careful. If you need to be around someone who is sick, wear a mask during the contact and discard the mask after you are away from the sick individual.

Review Your Treatment Plan

Because severe and uncontrolled RA are both associated with increased infection risk, it is important to keep symptoms managed. Ask your healthcare provider about whether you are taking the safest and lowest doses of RA medications in order to keep infection risk down. To keep a balance, your rheumatologist should regularly check disease activity and assess for signs of infection.

Manage Comorbid Conditions

The possibility of getting an infection with RA is even greater if you have another disease. It is, therefore, important to manage RA and the comorbid condition. By managing that second condition, taking medications as prescribed, and eating healthy and being active, you can further reduce the likelihood of an infection.

Pay Attention To How You Feel

It is important for people with RA to be aware of how they are feeling day to day and what infections are common with the medications you take. You should lookout for early signs of an infection—such as fever, chills and sweats, sore throat, cough, nasal congestion, or a stiff neck.

If you are feeling out of the ordinary or think you might need an antibiotic, you should get in touch with your healthcare provider right away. Your healthcare provider may want you to stop taking any medications that might interact with an antibiotic and make things worse. They will also want to monitor you for concerning symptoms and prescribe appropriate treatment right away.

Ask Your Healthcare Provider About Supplements

Some vitamins and supplements like vitamin C and zinc might give your immune system a boost and potentially reduce your risk for infection. You should always check with your healthcare provider before starting any supplement because some cause side effects or interact with medicines you might be taking.

RA and COVID-19 Infections

COVID-19 is caused by a coronavirus that can spread from person to person. People who have severe conditions like RA seem to have a higher risk for complications of COVID-19 like additional infections, pneumonia, breathing problems, organ failure, heart problems, and blood clots.

Because RA is a condition that weakens your immune system, you will need to be extra diligent to prevent a COVID-19 infection. In 2020, researchers from New Zealand and Australia conducted a study that found evidence people with RA may be at an increased risk for death from COVID-19.

That risk was mostly associated with a weakened immune system response from the use of immunosuppressive drug therapies although the researchers speculate that having certain gene mutations associated with RA might also play some part.

The researchers were also able to determine that RA did not increase the risk of being diagnosed with COVID-19. The researchers noted the risk of death in people with RA would need to be further investigated in order to work towards better treatment outcomes.

By now, the preventative steps towards COVID-19 are well-known and come down to basic infection prevention like regular hand washing, wearing a mask in public, and maintaining social distancing. For people with RA, it is also especially important to up-to-date on your vaccines, especially for influenza. Ask your healthcare provider if you need a pneumonia or shingles vaccine.

It is also a good idea to take advantage of telemedicine services. This way you stay in touch with your healthcare provider and are still prioritizing your health while reducing the number of times you leave your home.

A Word From Verywell

People with RA should be aware of their risk for infections and work with their healthcare providers to get ahead of any problems.

Make sure you visit your healthcare provider regularly and are doing all the follow-up lab work your healthcare provider has requested. Lab work can help your healthcare provider monitor how compromised your immune system is and what your risk for infection might be.

You will also want to discuss with your healthcare provider in advance what you should do if you start to experience signs of infection. Find out what to watch out for and what symptoms might feel like. Being both aware and prepared can go a long way in halting infections before they become serious and life-threatening.