Diabetes and Arthritis – Correlation Link and Treatment!

 
Mr. Anderson, a 65 year old man, has been taking corticosteroids as medication for his arthritis pain for over 10 years. Recently he was complaining about his increased fatigue and frequent urge of urination. His doctor has diagnosed him with Type II diabetes mellitus. He explained to Mr. Anderson that it is hard to explain why he got diabetes but suggested that a genetic factor may play a role here as Mr. Anderson’s mother had died with both Diabetes and Arthritis. However his doctor did not rule out the possibility that Mr. Anderson’s refusal to take exercise over the years can be a factor too. As advised by the doctor, Mr. Anderson is now taking medication, natural supplement with a strict diet and physiotherapy.

 

Introduction

Over the years researchers are debating over the correlations between Diabetes and Arthritis. However some studies are strongly suggestive of the fact that there may be a link between these two diseases. According to CDC (Center for Disease Control and Prevention, more than half (52 percent) of people with diabetes also have arthritis1. Therefore once being diagnosed with one of these, patient should be warned about the other one’s symptoms and preventive measures to avoid it.

Although there is can be an association between arthritis and diabetes, these two diseases are not directly related to each other. Arthritis refers to the joint inflammatory reactions mainly triggered by autoimmune attack whereas Diabetes is associated with high blood glucose level.

Several clinical studies are indicating that some factors like chronic inflammation, genetics or physical inactivity are correlating these two diseases (see Factors Responsible for Linking Arthritis with Diabetes), whereas, some practitioners and researchers are still casting doubts on the relationships between Arthritis and Diabetes. This article will focus on the correlations between these two diseases on basis of scientific studies; factors that are affecting these and some general treatment options.

Correlation between Rheumatoid Arthritis and Type 2 Diabetes

About 90% diabetes are type 2 diabetes; which is a metabolic disorder primarily induced by insulin resistance. Rheumatoid arthritis, on the other hand, is the painful inflammatory conditions of the joints of wrists, fingers, feet, ankles etc. Although these diseases are different, due to multiple reasons there can be a correlation growing between these over time. A research on the Taiwanese patients based on the population database is suggesting a strong occurrence of rheumatoid arthritis among type 2 diabetes patients, especially among the women.

According to that study, the risk of developing RA was 3.6 times higher in patients with type 2 diabetes compared with patients without type 2 diabetes.

type 2 diabetes
Table 1: Association between type 2 diabetes and incident rheumatoid arthritis in male and female patients (N = 8,496). doi:10.1371/journal.pone.0101528.t002

This study was based on the data available from the National Health Insurance Research Database (NHIRD) in Taiwan and involved a total of 8,496 patients (Five controls per case). Among them 22.6% was male and 77.4% was female. The study showed that the prevalence of type 2 diabetes was higher among RA cases (19.6%) compared with controls (15.4%). This higher rate among the cases than the controls is mostly contributed by women and therefore a further analysis was done on female patients. The result was a bit surprising as the young women aged 20-44 years with type 2 diabetes seemed to be more prone to develop RA (Rheumatoid arthritis) than other women.

Correlation between Psoriatic Arthritis and Diabetes

Psoriatic arthritis is a form of arthritis among patients who already have psoriasis; a condition with severe inflammation on skin. Scientists have found evidence of prevalence of diabetes in a population-based cross-sectional study by analyzing the medical database of Clalit, the largest healthcare provider organization in Israel.

The researchers studied 549 patients with psoriatic arthritis and 1,098 patients without this disease. The result showed significant increase of chances of getting diabetes among the patients with psoriatic arthritis (15.3%?versus 10.7%, value = 0.008), the risk is higher in women (18.7%?versus 10.3%). Researchers came to the conclusion that women with psoriatic arthritis should be monitored for diabetes as there is a possibility of a link between psoriatic arthritis and diabetes in women.

Psoriatic Arthritis and Diabetes
Table 2: The Statistical Report on the Relationship between Diabetes with Psoriatic Arthritis.

There have been more clinical studies and researches done on the association of Diabetes with Arthritis. However, not all studies found a clear answer and the debate on whether or not these two are related still persists. When researches conducted by Han, et al4 and del Rincon5 addressed a correlation among these diseases, Solomon and colleagues6, Simard and Mittleman7 could not find any significant relationship. So the debate remains and further clinical studies are required to draw a conclusion.

Factors Responsible of Linking Arthritis with Diabetes

Physical Inactivity
According to the Centers for Disease Control and Prevention, physical activity is found to be very difficult or avoided by the patients with arthritis or diabetes. Possible reasons for unwilling to exercise are:

  • Fear of inducing arthritis pain
  • Fear of causing further damage to the joints
  • Lack of motivation
  • Having other prioritized responsibilities.

Although it is thoroughly advised to the patients, lower physical activity in condition may aggravate the chance of occurrence of the other disease. This situation is even worse for patients with both diseases. In US, nearly 30% patients with DM and RA, 21% with diabetes and 17% with arthritis refuse to go through any physical exercise8.

Percentage of Patients with Physical Inactivity

Percentage of Patients with Physical Inactivity
Figure: Physical Inactivity Is Most Common Among Adults Who Have Both Diabetes And Arthritis.

About 1 in 5 patient with diabetes (21%) is physically inactive which makes them prone to obesity and glucose intolerance. This may lead to the other complications like arthritis.

Long Terms Steroid Intake for Patients with RA:
According to Caldwell and Furst, long term use of corticosteroids for patients with Rheumatoid Arthritis can cause insulin resistance and lead them to diabetes9. Patients with RA have about 50% risk of getting Diabetes10. The reason behind this is unclear but possibly associated with the insulin resistance due to prolonged persistent inflammation in RA.
The use of steroid to control inflammation is a traditional approach; however this may trigger our body to produce more and more glucose as well. This elevated blood glucose level may potentially lead to cause diabetes.

However, there is a controversial theory that steroids may not be a factor here. Based on a Canadian study using a population-based health insurance database, scientist are noting that it does not matter whether the dose of oral or topical glucocorticoids is adjusted or not, the incidents of occurring type 2 diabetes in patients with RA will remain the same11. Nevertheless, other evidences of decreasing insulin sensitivity outweigh that data and further investigations are required to come to a conclusion.

Genetic Inheritance of being Prone to Autoimmune Diseases
Type 1 diabetes and rheumatoid arthritis are both autoimmune diseases, therefore they are likely to occur together. In type 1 diabetes, Insulin producing cells in the pancreas and in Arthritis joints of the body get attacked by the immune system. Researchers have recently identified a gene named PTPN22 that can increase the risk for type 1 diabetes, RA, and other immune disorders.

However this tendency of attacking body’s own self can run into family. That means if someone’s father had both the type1 diabetes and RA, he or she has a higher risk of developing this condition too.

Obesity and Metabolic Syndrome
Patients with arthritis have a long term inflammation in their bodies which may aggravate the occurrence of metabolic syndrome. Metabolic syndrome is a disorder where the risk factors of heart diseases and diabetes are unusually high and is associated with body’s inability to use or store the excess energy a person consumes. This syndrome is characterized by five risk factors like

  • High triglyceride levels: over 150 mg/dl
  • Low high density lipoprotein (HDL) levels: for women- below 50 mg/dl and for men- below 40 mg/dl
  • High blood pressure: 130/85 or higher
  • Excess body fat especially around the waist: waist measurement for women- at least 35 inches and for men- at least 40 inches.
  • Insulin resistance that leads to high blood sugar or diabetes. In this case fasting blood sugar will be 100 mg/dl or higher.

Therefore if a person is obese and also has Rheumatoid arthritis, the likeliness of Diabetes to that person increases too.
Treatment Options for the patients with Diabetes and Arthritis:

Disease Modifying Anti-rheumatic Drugs (DMARDs)
According to a study in the June 22/29 issue of JAMA, usage of disease modifying anti-rheumatic drugs on patients with rheumatoid arthritis or psoriasis were found to significantly lower the risk of diabetes12. Around 14000 people with RA or Psoriasis across Canada and US were treated with the following drugs:

  • TNF inhibitors with or without other DMARDs;
  • methotrexate without TNF inhibitors or hydroxychloroquine;
  • hydroxychloroquine without TNF inhibitors or methotrexate; or
  • other nonbiologic DMARDs without TNF inhibitors, methotrexate, or hydroxychloroquine.

The study showed that RA patients who took TNF inhibitors.

The study was conducted from the year 1996, January to June, 2008 and the participants were nearly 14000 patients with RA. Within these years 267 newly diagnosed cases of DM were found by the researchers. The distributions of the cases are as follows:

  • 80 cases among 4,623 treatment episodes with TNF inhibitor users;
  • 50 cases among 5,682 treatment episodes with hydroxychloroquine users.
  • 82 cases among 8,195 treatment episodes with methotrexate users;
  • 55 cases among 3,993 treatment episodes with nonbiologic DMARD users;

The research was concluded with the notation, “The fully adjusted models suggest a reduced relative risk of DM for TNF inhibitor and hydroxychloroquine compared with other nonbiologic DMARDs.”

Inhibitors of the Tumor Necrosis Factors
Drugs like drugs etanercept and adalimumab are TNF-alpha inhibitors; therefore can alleviate the sufferings of patients with both Type-1 DM and Arthritis. Both these diseases are caused by body’s aggressive immune system and tumor necrosis factor is one of the substances that aggravate this autoimmune attack. However, according to a study published in the journal Arthritis Care and Research more than 1,500 people with RA, who were given the class of RA drugs known as TNF-alpha inhibitors (such as Etanarcept, Adalimumab) had a reduced diabetes risk10.

Taking Natural Supplements
As the popularity of using natural supplements with anti-inflammatory action is increasing, prescribers are weighing the benefits of advising these over their side effects and limitations. In fact people’s belief in the natural supplements led the National Center of the Complementary and Alternative Medicine (NCCAM) to study on the risks and the advantages of these supplements13. If the inflammatory condition can be alleviated, the likeliness of occurring diabetes due to insulin resistance will go down as well. The most common natural anti-inflammatory supplements are:

Omega-3 fatty acids: Anti-inflammatories found in products like fish oil derived from freshwater fish like salmon and tuna. Studies of fish oil in chronic inflammatory diseases show benefits such as decreased pain and morning joint stiffness and lowered use of non-steroidal anti-inflammatory drugs.

Borage oil: Borage oil has anti-inflammatory effects and can be used along with other anti-rheumatic medications. It lowers the necessity for a high dose of steroids thus help in reducing the risk of high blood sugar. Caution should be taken when it is given with NSAIDs or other anti-clotting medicine as it has anticoagulant property too.

Other effective natural anti-inflammatory supplements that can be used to prevent Diabetes among the arthritis patients are Green tea extract (EGCG), curcumin (turmeric), quercetin, ginger, white willow bark, boswellia etc.

Proper Diet
A healthy diet rich in fruits, vegetables, low-fat dairy, and whole grains can reduce the blood glucose level, protect the coronary arteries from atherosclerosis and therefore reduces the risk of triggering an inflammatory state. These food also have anti-oxidant and anti-inflammatory properties thereby can protect the joints and inflamed areas of the patient’s body.

Exercise tips for people with diabetes and arthritis

Physical Activity
People with rheumatoid arthritis usually tend to avoid exercise with the fear of aggravating arthritis pain, but this may lead to obesity and a chance of getting diabetes. For them self management education programs and physical activity programs may become very useful. These programs are designed to teach people how to get the best out of the physical capability without inducing joint pain.

Losing Extra Weight
By maintaining a healthy diet with some exercise people with Arthritis can keep their triglycerides and blood glucose levels under control. It will indirectly protect them from developing metabolic syndrome and eventually diabetes.

Although there is an ongoing debate on the relationship between arthritis and diabetes, it is mostly believed that there is a connection, especially among the women. The risk factors of inducing these diseases overlap each other and by controlling the prognosis of one disease, onset of the other one can be prevented too. An overall consensus is that proper physical exercise, a healthy diet with conscious effort to prevent obesity can improve a patient’s life standard and consequently lowers the association between these two diseases. However, the importance of proper medication combined with natural joint pain supplements with anti-inflammatory properties is also very crucial for the treatments of the patients.
 

References

  • Arthritis Foundation website. Are Arthritis and Diabetes related? http://www.arthritis.org/conditions-treatments/disease-center/arthritis-and-diabetes/.
  • Ming-Chi Lu, Shih-Tang Yan, Wen-Yao Yin, Malcolm Kool, Ning-Sheng Lai. Risk of Rheumatoid Arthritis in Patients with Type 2 Diabetes: A Nationwide Population-Based Case-Control Study. July 02, 2014, DOI: 10.1371/journal.pone.0101528.
  • Jacob Dreiher, Tamar Freud, Arnon D. Cohen. Psoriatic Arthritis and Diabetes: A Population-Based Cross-Sectional Study. Dermatology Research and Practice. Volume 2013 (2013), Article ID 580404, 7 pages.
  • Han C, Robinson DW Jr, Hackett MV, Paramore LC, Fraeman KH, Bala MV. Cardiovascular disease and risk factors in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. J Rheumatol 2006;33:2167-72.
  • del Rincon I, Williams K, Stern MP, Freeman GL, Escalante A. High incidence of cardiovascular events in a rheumatoid arthritis cohort not explained by traditional risk factors. Arthritis Rheum 2001;44:2737-45.
  • Solomon DH, Karlson EW, Rimm EB, et al. Cardiovascular morbidity and mortality in women diagnosed with rheumatoid arthritis. Circulation 2003;107:1303-7.
  • Simard JF, Mittleman MA. Prevalent rheumatoid arthritis and diabetes among NHANES III participants aged 60 and older. J Rheumatol 2007;34:469-73.
  • Bolen J, Hootman J, Helmick CG, Murphy L, Langmaid G, Caspersen CJ. Arthritis as a Potential Barrier to Physical Activity Among Adults with Diabetes — United States, 2005 and 2007. MMWR 2008;57(18):486–489.
  • Caldwell JR, Furst DE. The efficacy and safety of low-dose corticosteroids for rheumatoid arthritis. Semin Arthritis Rheum (1991) 21: 1–11. doi: 10.1016/0049-0172(91)90051-z. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0101528#pone.0101528-Caldwell1.
  • Jennifer Acosta Scott .The Link Between Rheumatoid Arthritis and Diabetes The inflammation that comes with rheumatoid arthritis may increase your risk for diabetes. Follow these smart health tips to protect yourself. http://www.everydayhealth.com/rheumatoid-arthritis/the-link-between-rheumatoid-arthritis-and-diabetes.aspx.
  • Risk of Rheumatoid Arthritis in Patients with Type 2 Diabetes: A Nationwide Population-Based Case-Control Study. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0101528#pone.0101528-Solomon1. Published: July 02, 2014.
  • D. H. Solomon, E. Massarotti, R. Garg, J. Liu, C. Canning, S. Schneeweiss.Association Between Disease-Modifying Antirheumatic Drugs and Diabetes Risk in Patients With Rheumatoid Arthritis and Psoriasis. JAMA: The Journal of the American Medical Association, 2011; 305 (24): 2525 DOI:10.1001/jama.2011.878.
  • Karen Springen. Rheumatoid Arthritis: Best and Worst Supplements and Herbs. http://www.webmd.com/rheumatoid-arthritis/guide/rheumatoid-arthritis-best-worst-supplements-herbs.

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Author

Expert Author : Dr. Ahmed Zayed (Consumer Health Digest)

Dr. Ahmed Zayed Helmy holds a baccalaureate of Medicine and Surgery. He has completed his degree in 2011 at the University of Alexandria, Egypt. Dr. Ahmed believes in providing knowledgeable information to readers. Other than his passion for writing, currently he is working as a Plastic surgeon and is doing his masters at Ain shams University.