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 Table of Contents  
Year : 2022  |  Volume : 17  |  Issue : 3  |  Page : 225-226

Comorbidities in rheumatic disorders: Time to tame the invisible gorilla

Army Hospital (Research and Referral), New Delhi, India

Date of Submission30-Aug-2022
Date of Acceptance05-Sep-2022
Date of Web Publication14-Sep-2022

Correspondence Address:
Dr. Subramanian Shankar
Army Hospital (Research and Referral), O/o DGAFMS, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_1000_22

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How to cite this article:
Shankar S. Comorbidities in rheumatic disorders: Time to tame the invisible gorilla. Indian J Rheumatol 2022;17:225-6

How to cite this URL:
Shankar S. Comorbidities in rheumatic disorders: Time to tame the invisible gorilla. Indian J Rheumatol [serial online] 2022 [cited 2023 Feb 5];17:225-6. Available from:

Increased life expectancy has led to a corresponding rise in chronic condition comorbidities. There was a substantial rise in comorbidities with age and absolute terms over the past few decades. In 2013, over 2.3 billion individuals worldwide had >5 comorbidities, with over 80% being under the age of 65 years.[1] Multimorbidity, a patient-centric concept, where all comorbidities are given equal importance, is a new reality. While the multimorbidity in the general population is 25%, it is three times higher (75%) in patients with chronic arthritis.[2] When treating patients with chronic inflammatory conditions, it is important to take multimorbidity into account due to their high prevalence and the potential interaction of coexisting diseases.

While certain comorbidities such as coronary artery disease, osteoporosis, malignancies, depression, infections, and gastrointestinal diseases have a higher prevalence in rheumatic diseases, many other conditions may simply coexist.[3] The presence of comorbidities has a significant impact on rheumatic diseases translating to excess mortality at worst or a diminished quality of life at best. During the COVID pandemic, the presence of comorbidities was found to be associated with higher mortality in patients with rheumatic disorders.[4] The presence of comorbidities makes it difficult to optimize medications and achieve treat-to-target goals, increases the risk of infections and drug interactions due to polypharmacy, and raises the cost of illness by increased investigations, hospital visits, and admissions.

There is an increasing emphasis on prevention, screening, and management of comorbidities by the treating rheumatologist to enable holistic care.[5] While there are over a dozen indices to assess the impact of comorbidities, the Charlson Comorbidity Index and the Elixhauser Comorbidity Score are excellent at predicting mortality and are most widely used. The Functional Comorbidity Index is good at predicting functional status, whereas the rheumatic disease comorbidity index is good for both mortality prediction and functional assessment.[6]

Chandrashekara et al., in this issue of Indian Journal of Rheumatology (IJR), have looked at comorbidities in autoimmune rheumatic diseases in the Indian context.[7] In a multicentric observational study across five centers of India, comorbidities in 1885 patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), seronegative spondyloarthropathy (SpA), psoriatic arthritis (PSA), and scleroderma were analyzed. The prevalence ranged from about 10% in SpA to >50% in systemic sclerosis (SSC), with the other conditions having around 30% comorbidities. Hypertension (in RA and PSA), thyroid disease (in SLE and SSc), and diabetes (SpA) were found to be the most common comorbidities. The study found a slightly lower prevalence of coronary artery disease and fibromyalgia and a higher prevalence of hypertension and thyroid disorders. These being interim results, a more comprehensive picture will become evident subsequently as the study aims to recruit 6000 patients in all.

The study represents an excellent initiative of pan-India collaborative effort. There is a need for many more such studies to explore various aspects of comorbidities in rheumatic diseases. This includes identification of other comorbidities and coexistent diseases, functional screening protocols (e.g. for malignancies and osteoporosis), and optimizing treatment protocols in a setting of polypharmacy and impaired organ functions. With multiple domains' needing assessment, there is an opportunity to study various indices in detail or develop newer ones. Newer dimensions such as fall prevention, post joint replacement scenarios with comorbidities, and various aspects of health economics need exploration. There is also a need and an opportunity to study the common pathogenetic mechanisms shared by these comorbidities as also the role of inflammation in their development.

In the iconic study on selective attention, Simons and Chabris demonstrated that when our attention is focused on counting the passes in a basketball game, a gorilla can walk through the court beating its chest and most people will miss noticing it.[8] Among patients with rheumatic diseases with comorbidities, rheumatologists usually focus their attention on the primary rheumatological disorder, while the comorbidities might get short shrift. There is a need to embrace the idea of multimorbidity in every patient with rheumatic disease.[9],[10]

The current study may be seen as an attempt to make the gorilla visible to everyone with a flashlight. Dealing effectively with the comorbidities will not only translate to improved patient care but also is likely to present multiple research opportunities in this direction.

  References Top

Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;386:743-800.  Back to cited text no. 1
Radner H, Yoshida K, Smolen JS, Solomon DH. Multimorbidity and rheumatic conditions-enhancing the concept of comorbidity. Nat Rev Rheumatol 2014;10:252-6.  Back to cited text no. 2
Baillet A, Gossec L, Carmona L, Wit Md, van Eijk-Hustings Y, Bertheussen H, et al. Points to consider for reporting, screening for and preventing selected comorbidities in chronic inflammatory rheumatic diseases in daily practice: A EULAR initiative. Ann Rheum Dis 2016;75:965-73.  Back to cited text no. 3
Ahmed S, Gasparyan AY, Zimba O. Comorbidities in rheumatic diseases need special consideration during the COVID-19 pandemic. Rheumatol Int 2021;41:243-56.  Back to cited text no. 4
Theis KA, Brady TJ, Helmick CG. No one dies of old age anymore: A coordinated approach to comorbidities and the rheumatic diseases. Arthritis Care Res (Hoboken) 2017;69:1-4.  Back to cited text no. 5
England BR, Sayles H, Mikuls TR, Johnson DS, Michaud K. Validation of the rheumatic disease comorbidity index. Arthritis Care Res (Hoboken) 2015;67:865-72.  Back to cited text no. 6
Chandrashekara S, Shenoy P, Kumar U, Pandya S, Ghosh A. Burden of associated comorbidities in autoimmune rheumatic diseases in indian population: An interim report based on the indian rheumatology association database. Indian J Rheumatol 2022;17:227-33.  Back to cited text no. 7
  [Full text]  
Simons DJ, Chabris CF. Gorillas in our midst: Sustained inattentional blindness for dynamic events. Perception 1999;28:1059-74.  Back to cited text no. 8
Daïen CI, Tubery A, Beurai-Weber M, du Cailar G, Picot MC, Jaussent A, et al. Relevance and feasibility of a systematic screening of multimorbidities in patients with chronic inflammatory rheumatic diseases. Joint Bone Spine 2019;86:49-54.  Back to cited text no. 9
Radner H. Multimorbidity in rheumatic conditions. Wien Klin Wochenschr 2016;128:786-90.  Back to cited text no. 10


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