A Need for Ototoxicity Monitoring in Adults with Rheumatoid Arthritis

Emamifer and Hansen1 offer an update on hearing impairment and rheumatoid arthritis (RA) that necessitates investigations into this disease and its primary, secondary, and iatrogenic effects on hearing function.2 RA is known to affect the bones and joints of people diagnosed with this disease.3 It is a progressive, inflammatory, chronic, autoimmune disease that is known to frequently affect the synovial joints with in-the-joint and outside-the-joint damage and pain.3 Because of its nature, RA has been linked to progressive and permanent disability with consequent quality of life impairment, including socioeconomic challenges for the individual and his or her family, as well as premature death.1-3 Guo et al. lists challenges that individuals with RA suffer from, including stiff, tender, and/or swollen joints, loss of appetite, fever, and fatigue, with an array of other potential difficulties or disorders which may be directly due to RA.3www.shutterstock.com. Ototoxicity, health, rheumatoid arthritis.OUR RESEARCH Khoza-Shangase and Riva conducted a scoping review on hearing function in adults with RA, as part of South Africa’s efforts to shift the ear and hearing care paradigm toward preventive care.2 The authors found significant paucity of evidence on the primary effects (from the disease itself) as well as potential tertiary effects (iatrogenic causes from the medications prescribed in this population). The review was conducted for the purposes of scoping available evidence for advocating for preventive audiology programs in low-and-middle-income countries (LMICs), such as South Africa. The review scoped published evidence on hearing function in adults with RA from January 2010 to August 2020 through Sage, ScienceDirect, PubMed, Scopus, Medline, ProQuest, and Google Scholar. Studies published in English that reported on the audiological function in adult individuals with RA were included. From 832 initial title records, 18 articles were included in the final scoping review. The small number of available studies, mostly from high-income countries, highlighted that hearing loss occurs in this population at a prevalence ranging between 21.3%4 and 66.6%5, although the cause remains uncertain. The published high prevalence of hearing loss in this population is higher than that recorded in healthy control groups.8 This hearing loss has no typical nature, degree, or configuration; however, high-frequency sensorineural hearing loss was the most prevalent—making differential diagnosis between the impact of ageing, noise exposure, as well as medications prescribed in this population challenging but required. The studies reviewed also revealed a need for systematic and standardized assessment battery in this population, for accurate diagnosis as well as comparative analysis of findings within and across populations. This assessment battery, to be sensitive and specific, while facilitating early detection, needs to include appropriate measures for this function.2 The above recorded prevalence rates were higher where advanced sensitive measures such as otoacoustic emissions and ultrahigh-frequency tools formed part of the assessment battery. The fact that the majority of the studies reviewed relied only on basic audiometry testing signals a likelihood of underestimation of hearing loss in this population, particularly ototoxic hearing loss, as this loss is insidious, but has potential to be prevented, unlike the primary causes of hearing loss (conductive hearing loss) in this population, which include involvement of the middle ear ossicular joints (the incudo-stapedial joint and the incudo-malleolar joint) in the RA disease process.6,7 There are other potential causes of sensorineural hearing loss in this population, other than ototoxicity, and these include neuritis, vasculitis, or immunological disorders.4,8,9 CLINICAL AND RESEARCH IMPLICATIONS With the focus on preventive audiology initiatives, prevention of potential ototoxicity as a cause of hearing loss in this population becomes priority. This is particularly so where evidence indicates that the most prescribed medications in this population, prescribed to avert additional damage and corrosion of the individual’s joints and not cure RA, are nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying anti-rheumatic drugs (DMARDs)3,10 such as sulfasalazine, methotrexate, and hydroxychloroquine, with evidence of ototoxicity linked to some of them.11-14 With this clearly established association between RA and hearing loss, particularly with preventable hearing loss in the form of ototoxicity, a need for further investigations in this population is highlighted, particularly studies into the potential influence of treatments on hearing and balance functions. Well-designed investigations that incorporate sensitive audiologic diagnostic measures in their test protocols and research designs that facilitate clear differential causal diagnosis are needed. Although RA does not form part of conditions/diseases that are normally prioritized in the burden of diseases ranking, it does affect between 0.5% and 1% of the global population15, and Safiri et al.16 argue that as a major global public health challenge, the age-standardized incidence and prevalence rates of RA are rising, particularly in low-and-middle-income countries such as Paraguay and Guatemala—however, high-income countries such as Canada are also not spared. These authors16, supported by Khoza-Shangase and Riva2 advocate for early detection and management of RA to mitigate against the morbidity associated with this condition—including prevention of hearing loss.

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