Course of radiographic damage over 10 years in a cohort with early rheumatoid arthritis

Aerobic capacity in patients with rheumatoid arthritis: a comparison of two submaximal test methods

BACKGROUND

In a clinical setting it is important to evaluate aerobic capacity in individuals with rheumatoid arthritis (RA) and to have a choice between tests, owing to disability of varying severity. Two submaximal tests, a bicycle ergometer test and a treadmill walking test, are commonly used. Despite expected differences in the results, these tests have been used interchangeably. The aim of the current study was to compare the results of the two tests, the size of the difference and factors expected to influence the results.

METHODS

Fifty-two outpatients with RA performed the two tests. Agreement and correlations between the results of the tests were calculated. Multivariate analysis was used to study the relationships between gender, weight, health assessment questionnaire, global health assessment and the difference between the tests.

RESULTS

Sixty per cent of the subjects exhibited a higher estimated value of maximum oxygen uptake (VO(2max)) in the treadmill test. The limits of agreement for the estimated VO(2max) values between the two methods ranged from -13.4 to +18.4 ml x min(-1) x kg(-1), and the intraclass correlation coefficient (ICC(Two-way mixed)) was 0.34 (95% confidence interval [CI] 0.07, 0.56). Body weight was independently associated with the difference between the two tests (regression coefficient 0.3; 95% CI 0.14, 0.42). A higher body weight had a greater impact on the results of the bicycle test (R(2) = 0.28; regression coefficient -0.3; 95% CI -0.47, -0.17) than on the treadmill walking test (R(2) = 0.02; regression coefficient -0.06; 95% CI -0.14, 0.03).

CONCLUSIONS

It is not advisable to use the two submaximal methods interchangeably. Weight influenced the difference between the two tests, and to a higher degree in the bicycle test than the treadmill walking test.

Long-term outcomes of rheumatoid arthritis

PURPOSE OF REVIEW

Rheumatoid arthritis (RA) is recognized as a disease with a natural history of severe long-term outcomes, which appear to be improving at this time, as reported from many clinics.

RECENT FINDINGS

Improved outcomes of many long-term consequences of inflammation such as joint deformity, functional declines, work disability, and early death have been reported in recent years.

SUMMARY

Therapies for RA are assessed in randomized clinical trials and in clinical care primarily according to measures of inflammatory activity, which may change considerably over days, weeks, and months. In usual clinical care, long-term consequences of the disease, which often require years of observation, can also be assessed. Data in published reports of both clinical trials and clinical care continue to include only a minority of all patients with RA. Further efforts are needed to promote collection of quantitative data in all patients with RA, at all visits in all clinical settings, to facilitate 'tight control' and better outcomes for all patients with RA.

The Value of HLA-DRB1 Shared Epitope, −308 Tumor Necrosis Factor-α Gene Promoter Polymorphism, Rheumatoid Factor, Anti-Citrullinated Peptide Antibodies, and Early Erosions for Predicting Radiological Outcome in Recent-Onset Rheumatoid Arthritis

Objective.

To study the value of HLA-DRB1 shared epitope (SE), −308 tumor necrosis factor-α (TNF-α) gene promoter polymorphism, rheumatoid factor (RF), anti-citrullinated peptide antibodies (anti-CCP), and baseline erosions for predicting radiological outcome at 1 year in patients with recent-onset rheumatoid arthritis (RA).

Methods.

Radiological damage was assessed by radiographs at baseline and at 1 year in an inception cohort of 134 RA patients with disease duration ≤ 1 year at study entry. Radiographs were scored with the modified Sharp/van der Heijde (SvdH) erosion score for hands, wrists, and feet. The predictive value of the variables was studied by multiple linear regression analysis, using immunogenetic factors, baseline SvdH erosion score, and type of treatment during the followup period as independent variables, and SvdH erosion score at 1 year as the dependent variable.

Results.

The SvdH erosion score increased from the baseline visit to the 1-year visit in 49 patients (36.6%). In multiple linear regression analysis, radiological outcome was significantly predicted by SE homozygosity (ß coefficient 1.75; 95% CI 1.54, 2.96; p = 0.005) and baseline SvdH erosion score (ß coefficient 1.56; 95% CI 1.4, 1.71; p < 0.001). This model explained 78% of the variability of the dependent variable (R2 = 0.779).

Conclusion.

Erosive damage at 1 year in patients with recent-onset RA is significantly influenced by SE homozygosity and the presence of baseline erosions, but not by RF status, anti-CCP status, or −308 TNF-α genotype.

Evidence of systemic inflammation and estimation of coronary artery disease risk: a population perspective

A growing body of evidence indicates that patients with immune-inflammatory diseases experience an increased risk for cardiovascular morbidity and mortality. However, patients with immune-inflammatory diseases do not exhibit a corresponding increase in traditional coronary artery disease (CAD) risk factors that could explain the observed increase in CAD. Chronic inflammation is now accepted as playing a potentially important role in the promotion of atherosclerosis, a main cause of CAD. Evidence is also accumulating to suggest that the chronic systemic inflammation associated with immune-inflammatory diseases results in elevated levels of nontraditional CAD risk factors, such as biomarkers of inflammation, in patients with these conditions. Evaluation of only traditional CAD risk factors in these patients, therefore, may result in the underestimation of their future overall CAD risk. Using the Framingham patient cohort, we found associations between markers of inflammation and CAD risk overall. The contribution of inflammatory biomarkers should be considered along with the status of traditional CAD risk factors to gain a complete picture of the CAD risk in patients with underlying conditions that increase inflammation such as rheumatoid arthritis or systemic lupus erythematosus.

Prognostic factors of 10-year radiographic outcome in early rheumatoid arthritis: a prospective study

INTRODUCTION

The objectives of this study were to determine the predictive factors of long-term radiographic outcome of rheumatoid arthritis (RA) and to describe the relationship between joint damage and disability over the course of the disease.

METHODS

A cohort of 191 patients with early RA referred from primary care physicians were prospectively followed for 10 years. To determine the predictive factors of radiographic outcome, univariate analysis of the relationship between baseline values and outcome measures was undertaken using a chi-squared or Fisher's exact test. Stepwise multiple logistic regression was also performed to select independent prognostic factors.

RESULTS

From data available for 112 patients, univariate analysis revealed a total Sharp score at 10 years that was significantly correlated with erythrocyte sedimentation rate (ESR), presence and level of IgA rheumatoid factor, presence of an anti-citrullinated protein antibody (ACPA), serum level of matrix metalloproteinase-3 and radiographic score at baseline. Logistic regression identified the baseline erosion score to be the most important baseline parameter as an independent prognostic factor of total radiographic score at 10 years (odds ratio = 5.64; 95% confidence interval = 1.78 to 17.86). After excluding radiographic scores from the entry parameters, the presence of ACPA and ESR were also predictive of the final total Sharp score. The Health Assessment Questionnaire (HAQ) score was strongly correlated with disease activity parameters, such as disease activity score and pain, at baseline and at three, five and 10 years. No correlation was found between total radiographic Sharp score and HAQ score throughout the study.

CONCLUSIONS

In this prospective study, baseline radiographic score, ESR and ACPA were the best predictive factors of 10-year radiographic outcome in early RA. HAQ disability was associated with disease activity throughout the 10-year follow-up but not with joint damage. This discrepancy with previous reports may be due in part to the early start of therapy with disease-modifying anti-rheumatic drugs.

Disease activity and the course of wrist joint deterioration over 10 years in the patients with early rheumatoid arthritis

The objectives of this study were to evaluate the course of radiographic deterioration of the wrist joint with rheumatoid arthritis (RA), and to determine the influence of disease activity on its deterioration. A retrospective study was performed on 122 wrists in 66 patients, who started treatment using disease-modifying antirheumatic drugs within the first year of the disease and followed for more than 10 years without surgical intervention. The mean disease activity score (DAS28-CRP[3]) was high during the first 2 years, followed by a decrease and a flattening of the curve of disease activity. Generally, carpal collapse progressed more in the early stage and decreased linearly over 10 years. Individually, continuous high disease activity and progression in radiographic damage were observed in carpal collapsed groups from early stage of the disease. The cut-off values of the mean DAS28-CRP(3) during year 0-2, which indicated progression to Larsen grade III or more and Schulthess type I (ankylosis) or III (disintegration) at year 10 were 3.34 (sensitivity: 70.9% and specificity: 72.1%) and 3.63 (sensitivity: 74.3% and specificity: 77.0%), respectively. In patients with RA, deterioration of the wrist joint was influenced by disease activity. Identifying this activity and the course of wrist progression may be useful in predicting wrist deterioration.

Hand bone densitometry: a more sensitive standard for the assessment of early bone damage in rheumatoid arthritis

OBJECTIVE

To examine the role of hand dual-energy x ray absorptiometry (DEXA) compared with radiography in the assessment of bone involvement in patients with early rheumatoid arthritis (RA) who have active disease.

METHODS

The study population (n = 79) had RA of <12 months' duration and were selected for poor prognostic features. Clinical data and bone mineral density (BMD) data were collected at baseline, 24 and 48 weeks. Hand radiographs were performed at baseline and 48 weeks. Bone damage analyses were performed for the group and individuals using the smallest detectable change (SDC) method.

RESULTS

At baseline, mean disease duration was 8.5 months, erythrocyte sedimentation rate was 34.3 mm/hour, C-reactive protein was 40.2 mg/l, Health Assessment Questionnaire score was 1.35 and 81% of patients were positive for rheumatoid factor. Mean (95% CI) hand BMD loss was 2.5% (-3.5 to -1.5) at 24 weeks and 2.6% (-3.8 to -1.5) at 48 weeks. Individual hand bone loss exceeding the SDC was seen in 46.8% at 24 weeks and in 58.2% at 48 weeks. In the subgroup of 58 patients who had undergone radiography, radiographic joint damage score evaluated by the Sharp-van der Heijde method increased from 4.8 to 10.6 (p = 0.001). Individual hand bone loss in this subgroup exceeding the SDC was seen in 50.0% at 24 weeks and in 56.9% at 48 weeks, whereas at 48 weeks only 22.4% had deteriorated in modified Sharp score.

CONCLUSION

The study results indicate that hand DEXA is a more sensitive tool than radiology (radiographic joint-damage scores), for measuring disease-related bone damage in early RA.

The course of established rheumatoid arthritis

Rheumatoid arthritis (RA) varies over time in individual patients and there are marked differences between patients in its impact and progression. The course of RA is therefore unique to each individual patient and is affected by the overall pattern of disease; many patients have classical polyarticular disease but there is also a range of subtypes, such as fibromyalgic and polymyalgic disease. Some patients with RA enter a period of sustained remission; this varies between 10% and 36% of cases; its frequency is mainly influenced by the different approaches to studying RA patients over time, and does not represent a true difference in disease outcome. Most patients have persisting synovial inflammation and disease activity scores average between 3 and 4; there is some evidence that inflammation is less marked in late RA. Persisting synovitis results in increasing disability - this worsens by an average of 0.6% each year - and in joint damage, which increases by an average of 2% each year. Comorbidities and extra-articular features are commonplace: about one-third of patients, respectively, have associated cardiovascular disease, lung disease or extra-articular features, although severe extra-articular problems like vasculitis affect only about 10% of patients. Some aspects of the course of RA are influenced by genetic risks; currently these are only weak predictors but it is anticipated their value will increase with time.

Comparison of in-office magnetic resonance imaging versus conventional radiography in detecting changes in erosions after one year of infliximab therapy in patients with rheumatoid arthritis

The objective of this study was to compare standard hand radiographs with in-office 0.2 T magnetic resonance imaging (MRI) in monitoring response to therapy in patients with rheumatoid arthritis (RA) who were receiving infliximab, to evaluate the frequency and location of erosions, and to determine if there were differences in outcome based on disease duration at baseline. Patients who satisfied the American College of Rheumatology criteria for RA and were receiving infliximab therapy were evaluated with a baseline and 1-year follow-up MRI. Magnetic resonance images were interpreted by two blinded, board-certified radiologists. Bone erosions were identified as well-defined defects extending through the cortical margin. The mean age of the 48 patients was 58.5 years. The median infliximab dosage was 4 mg/kg. Baseline data showed that 41 patients had abnormal MRIs. The mean time between the baseline and follow-up MRI examinations was 10.5 months. Follow-up MRI revealed regression in 11 patients. Thirty-one patients had both MRIs and radiographs. Magnetic resonance imaging was approximately twice as sensitive as radiography in detecting erosions at baseline. In-office MRI was useful in monitoring disease response after the initiation of infliximab treatment. Magnetic resonance imaging is potentially a very valuable diagnostic tool and prognostic indicator for use in patients with RA.

A retrospective analysis of low-field strength magnetic resonance imaging and the management of patients with rheumatoid arthritis

OBJECTIVE

To assess how in-office magnetic resonance imaging (MRI) scans of the hand/wrist or feet are utilized in a rheumatology practice to make clinical evaluations regarding therapeutic options for rheumatoid arthritis (RA) patients.

METHODS

In a large clinical practice, a retrospective review was conducted on the first 300 RA patients who had office-based MRI scans at baseline. Information was collected on demographics, baseline therapy, and whether any change in therapy occurred at the time of the MRI scans. MR images of the affected wrist were obtained with a low-field strength dedicated extremity unit.

RESULTS

Of the 300 patients, 99 patients (33%) had MRIs that exhibited signs of erosions, joint space narrowing, or bone edema. These patients were classified as MRI-positive. The remaining 201 patients (67%) were classified as MRI-negative. A substantial majority (85%) of MRI-positive patients received a change in their therapeutic regimen, compared with only 9.5% of the MRI-negative patients (p < 0.001). In the 84 MRI-positive patients who had their therapy changed, 65% received a new prescription for a biologic or an increase in the dose of their existing biologic and 34% of the MRI-positive patients received a DMARD. In the 19 MRI-negative patients with a therapeutic change, 11% received a biologic agent and 88% received a DMARD. The major limitation of this study is that it was a retrospective analysis and the assessments of MRI findings were qualitative.

CONCLUSION

In this large population of RA patients, there was an association between MRI detection of joint space narrowing, erosions, and/or bone edema and change in therapeutic management.

Adalimumab for rheumatoid arthritis

In the last few years significant advances have been made in our understanding of the molecular mechanisms underlying rheumatoid arthritis pathogenesis. Pro-inflammatory cytokines, such as TNF-alpha, play a pivotal role in its pathogenesis. Anti-TNF-alpha biological agents are considered a major advance in the treatment of rheumatoid arthritis. Adalimumab is a fully human monoclonal antibody that binds specifically to TNF-alpha, thereby neutralising its activity. It had significant efficacy in well-designed, placebo-controlled trials in patients suffering from rheumatoid arthritis, both as monotherapy and in combination with various disease-modifying antirheumatic drugs, including methotrexate. Adalimumab was generally well tolerated during both concomitant therapy with methotrexate or standard antirheumatic therapy and monotherapy. In addition, the radiographic progression of structural joint damage was significantly inhibited by adalimumab and improved quality of life. This review summarises the recent available data.

Insights to clinical use of serial determination in titers of cyclic citrullinated peptide autoantibodies

Anti-cyclic citrullinated peptide (CCP) antibody is a useful marker for the diagnosis and prognosis of rheumatoid arthritis (RA). Recently, clinical significance of follow-up in anti-CCP antibody titer has been pointed out. Thus, we investigated the serial determination in anti-CCP antibodies titer in RA patients. Six patients with RA, who were followed up for longer than 5 years, were assessed in anti-CCP antibodies and radiographs (Larsen score). Anti-CCP antibodies in frozen sera were measured using ELISA. As a result, 6 patients with RA were divided into two groups: one possessed high titers without variation, and the other was without high titers. Joint damage progressed during observation in 2 out of 3 patients with high anti-CCP titers in a retrospective assessment. In contrast, the RA patient, whose anti-CCP titer decreases although it had been high titer at baseline, did not show increase in the Larsen score. These findings suggest that it might be necessary to analyze changes in anti-CCP to predict the prognosis of joint destruction.

Biomarkers predict radiographic progression in early rheumatoid arthritis and perform well compared with traditional markers

OBJECTIVE

To evaluate the performance of biochemical and traditional markers in predicting radiographic progression in rheumatoid arthritis (RA).

METHODS

One hundred thirty-two patients with early RA were treated with nonbiologic therapies for 2 years and studied longitudinally. Genomic DNA was analyzed for presence of the shared epitope. Levels of matrix metalloproteinases (matrix metalloproteinase 1 [MMP-1], MMP-13, and MMP-3), tissue inhibitor of metalloproteinases 1 (TIMP-1), and cartilage oligomeric matrix protein (COMP) were assessed in serially obtained serum samples. The presence of pyridinoline (Pyr), deoxypyridinoline, glycosylated Pyr (Glc-Gal-Pyr), and C-telopeptide of type II collagen (CTX-II) was assessed in urine samples. Radiographs obtained at entry and at 2 years were evaluated using the modified Larsen score.

RESULTS

Baseline and 2-year radiographs were available from 118 patients. Larsen scores worsened during the 2 years in 50 patients, while 68 patients had no radiographic progression. Levels of a variety of biochemical markers, i.e., MMP-3, CTX-II, COMP, TIMP-1, Pyr, and Glc-Gal-Pyr, correlated significantly with radiographic progression at entry and longitudinally as assessed by area under the curve (AUC). By multivariate analysis, a model including MMP-3 and CTX-II was identified as providing the best prediction of radiographic progression at entry (predictive accuracy by receiver operating characteristic [ROC] AUC = 0.76 [95% confidence interval 0.66-0.85]), while a combination of MMP-3, CTX-II, and swollen joint count formed the best longitudinal AUC model (predictive accuracy by ROC AUC = 0.81 [95% confidence interval 0.73-0.89]). Patient-reported measures (Health Assessment Questionnaire, pain scores) were of limited use. In a subset of 50 patients who were treated with methotrexate (MTX) during the followup period, median serum MMP-3 levels decreased after the initiation of MTX therapy (P = 0.0003).

CONCLUSION

These results indicate that biochemical markers are useful predictors of radiographic progression in RA and that serum MMP-3 levels decrease significantly with MTX therapy. Multivariate models that include MMP-3 and CTX-II perform better than existing traditional markers in predicting radiographic outcome in RA.

Measuring Process of Arthritis Care: The Arthritis Foundation’s Quality Indicator Set for Rheumatoid Arthritis

OBJECTIVE

To describe the scientific evidence that supports each of the explicit process measures in the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis.

METHODS

For each of the 27 measures in the Arthritis Foundation's Quality Indicator set, a comprehensive literature review was performed for evidence that linked the process of care defined in the indicator with relevant clinical outcomes and to summarize practice guidelines relevant to the indicators.

RESULTS

Over 7500 titles were identified and reviewed. For each of the indicators the scientific evidence to support or refute the quality indicator was summarized. We found direct evidence that supported a process-outcome link for 15 of the indicators, an indirect link for 7 of the indicators, and no evidence to support or refute a link for 5. The processes of care described in the indicators for which no supporting/refuting data were found have been assumed to be so essential to care that clinical trails assessing their importance have not, and probably never will be, performed. The process of care described in all but 2 of the indicators is recommended in 1 or more practice guidelines.

CONCLUSION

There are sufficient scientific evidence and expert consensus to support the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis, which defines a minimal standard of care that can be used to assess health care quality for patients with rheumatoid arthritis.

Occupational therapy during the first 10 years of rheumatoid arthritis

OBJECTIVE

To describe disease development and occupational therapy during the first 10 years of rheumatoid arthritis (RA), and to assess patients' experiences of occupational therapy and comprehensive care.

METHODS

A total of 168 early RA patients with variable disease severity were followed up with regular team visits. The occupational therapist evaluated hand function and activity and performed the necessary interventions. These were recorded and the number of visits generating interventions was calculated. Semi-structured interview of 11 patients regarding their views of occupational therapy and team contact was performed.

RESULTS

Impairments of hand function were in general mild to moderate and remained fairly unchanged over time. Activity limitations increased slowly. Half of the follow-up visits generated interventions. Most common were prescriptions of assistive devices and orthoses, hand-training instructions and patient education. The patients interviewed were positive regarding occupational therapy and felt safe with comprehensive care.

CONCLUSION

RA patients in all stages of the disease benefit from regular contact with an occupational therapist and team care.

Remission, a Therapeutic Goal in Inflammatory Arthropathies?

In recent years, there have been major advances in the management of rheumatoid arthritis (RA), leading to the development of tumour necrosis factor (TNF) antagonists. With these agents, it is possible to arrest joint damage and, by treating early in the disease course, to prevent joint damage. It is also now thought that early treatment can achieve clinical remission in a substantial proportion of patients. With these increased expectations, a change is required in the way clinical improvement and drug efficacy is measured. The existing standard endpoint commonly used in RA clinical trials, the American College of Rheumatology (ACR) 20% response measure, is inadequate for the new goals of therapy that should be based on clinical remission and radiographic assessment.Adalimumab, a fully human anti-TNF monoclonal antibody, has been shown to be effective in achieving remission and preventing radiographic progression of joint damage in patients with RA and other inflammatory arthropathies, including psoriatic arthritis and ankylosing spondylitis. In a placebo-controlled trial in patients with early RA, combination treatment with adalimumab plus methotrexate (MTX) has been shown to be superior to either treatment alone in inducing significant clinical remission while being generally well tolerated. Compared with monotherapy, combination therapy resulted in significantly more patients (49% vs 25%; p < 0.001) remaining in clinical remission after 2 years. Suppression of joint damage assessed by the degree of inhibition of radiographic progression was also significantly higher for patients treated with adalimumab plus MTX (and with adalimumab alone) at 6 months, 1 and 2 years than for those treated with MTX alone. These data support the notion that clinical remission is a realistic therapeutic goal in patients with RA.

Antibodies to citrullinated proteins in rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic autoimmune disease of unknown etiology, characterized by chronic joint inflammation that often leads to joint destruction. Diagnosis of RA is currently based on the revised classification criteria of the American College of Rheumatology (ACR); however, it remains imprecise, especially early in the course of disease. Rheumatoid factor (RF) has been widely used in clinical practice as a useful serological marker for diagnosis of RA. Although RF is the only serological test in the criteria of the ACR, its specificity is limited since RF can be also detected in other rheumatic diseases. Because the current therapeutic strategies in RA employ increasingly aggressive regimens from early stage of the disease, more specific serological markers than RF are desirable. Recently, anti-cyclic citrullinated peptide (anti-CCP) antibodies have attracted attention as a useful marker for the diagnosis of RA with high specificity. In addition to the diagnostic properties, anti-CCP antibodies showed to be a good prognostic marker for joint destructions. In this review, we will explain about the clinical usefulness of anti-CCP antibodies for the daily practice of RA.

Association of tumor necrosis factor α polymorphism, but not the shared epitope, with increased radiographic progression in a seropositive rheumatoid arthritis inception cohort

OBJECTIVE

To determine whether the tumor necrosis factor alpha (TNFA) -308 guanine-to-adenosine polymorphism and/or the shared epitope (SE) is associated with radiographic damage in patients with early rheumatoid arthritis (RA).

METHODS

The cohort consisted of 189 patients with early seropositive RA (median 5.6 months since symptom onset) who had active disease, no previous disease-modifying antirheumatic drug treatment, and >or=2 sets of scored radiographs of the hands/wrists and forefeet. TNFA -308 polymorphism was analyzed by polymerase chain reaction pyrosequencing. The SE was defined as presence of any 1 of the following HLA-DRB1 alleles: *0101, *0102, *0401, *0404, *0405, *0408, *0410, *1001, *1402, or *1406. Radiographic progression was assessed by the total Sharp score.

RESULTS

Using a weighted least-squares regression analysis, patients with the -308 TNFA AA plus AG genotypes (n=49) had significantly higher rates of progression in erosion scores (median 0.84 versus 0.48 units/year), joint space narrowing (JSN) scores (0.42 versus 0.04), and total Sharp scores (1.70 versus 0.61) compared with patients with the TNFA GG genotype (n=140). Presence of the SE (n=137) was associated with significantly lower progression rates (per year) for total Sharp scores (median 0.9 versus 1.25 units/year) and JSN scores (0.04 versus 0.41), but not for erosion scores (0.50 versus 0.61) compared with patients without the SE (n=52). In a least-squares multiple linear regression model, the presence of the AA plus AG genotypes was associated with a significantly higher progression rate after adjusting for the presence of the SE, interaction between the SE and the AA plus AG genotypes, baseline log C-reactive protein level, Health Assessment Questionnaire Disability Index, total Sharp score, swollen joint count, and presence of osteophytes (osteoarthritis). There was a strong linkage disequilibrium between DRB1*0301 and TNFA polymorphism (D'=0.84, r2=0.45, P<0.001).

CONCLUSION

This study showed an association between the TNFA -308 polymorphism and progression of radiographic damage in patients with early seropositive RA. This association appeared to be independent of the SE, but might be dependent on other genetic variants in linkage disequilibrium with the -308 TNFA A allele and DRB1*0301. Further studies should be conducted to validate these results in both longitudinal observational cohorts and randomized clinical trials.

Conventional Disease-Modifying Antirheumatic Drugs in Early Arthritis

This article reviews the use of conventional disease-modifying antirheumatic drugs (DMARDs) in the treatment of early rheumatoid arthritis (RA). The Finnish early RA cohorts are used as examples of how early and active treatment strategies have improved over time with increasing variety of available DMARDs. Therapy goals of early RA include remission to prevent severe long-term outcomes of RA. Remission can be achieved in a third of patients with early RA using a combination of conventional DMARDs, including methotrexate, sulfasalazine, hydroxychloroquine, and prednisolone. Of patients with early RA, 20% to 30% do not improve enough with conventional treatments and should be identified at early phases to consider institution of biologic agents.

Nonsteroidal antiinflammatory drugs reduce radiographic progression in patients with ankylosing spondylitis: a randomized clinical trial

OBJECTIVE

A 2-year randomized controlled trial was performed to test the hypothesis that long-term, continuous treatment with nonsteroidal antiinflammatory drugs (NSAIDs), in comparison with NSAID treatment on demand only, influences radiographic progression in patients with ankylosing spondylitis (AS).

METHODS

Patients with AS (n = 215), who had previously participated in a 6-week, randomized, double-blind clinical trial that compared celecoxib, ketoprofen, and placebo, were randomly allocated to receive either continuous treatment with NSAIDs or on-demand treatment with NSAIDs for a period of 2 years. All patients began treatment with celecoxib, at a starting dosage of 100 mg twice daily; patients could increase this dosage to 200 mg twice daily or could switch to another NSAID while maintaining the same treatment strategy. Structural changes were assessed by radiographs of the lumbar and cervical spine and scored according to the modified Stoke Ankylosing Spondylitis Spine Score by one observer who was blinded to the treatment strategy and temporal order of the radiographs. Statistical analyses included a between-group comparison of 1) radiographic progression scores (by Mann-Whitney U test), 2) time-averaged values of variables reflecting signs and symptoms of AS (by linear regression analysis), and 3) the frequency of reported site-specific adverse events (by chi-square test or Fisher's exact test, as appropriate).

RESULTS

Complete sets of radiographs were available for 76 of the 111 patients in the continuous-treatment group and for 74 of the 104 patients in the on-demand group. The mean +/- SD scores for radiographic progression were 0.4 +/- 1.7 in the continuous-treatment group and 1.5 +/- 2.5 in the on-demand treatment group (P = 0.002). Parameters reflecting signs and symptoms were not statistically significantly different between groups. The between-group difference in radiographic progression did not disappear after adjusting for baseline values of radiographic damage or disease activity variables and for time-averaged values of disease activity variables, nor after input of missing data. Relevant adverse events tended to occur more frequently in the continuous-treatment group than in the on-demand group (for hypertension, 9% versus 3%; for abdominal pain, 11% versus 6%; for dyspepsia, 41% versus 38%), but the differences were not statistically significant.

CONCLUSION

A strategy of continuous use of NSAIDs reduces radiographic progression in symptomatic patients with AS, without increasing toxicity substantially.

Selecting criteria for monitoring patients with rheumatoid arthritis

Four treatment objectives govern the management of rheumatoid arthritis (RA): to control the clinical manifestations, to prevent structural damage, to prevent functional impairments, and to reduce excess mortality. Disease activity determines the extent of structural damage, the severity of functional impairments, and in part the excess mortality related to cardiovascular disease. In established RA, the functional impairments depend also on the extent of the structural damage. Methods for assessing disease activity, treatment responses, structural damage, and functional impairments are reviewed herein. A standardized follow-up protocol is suggested as a means of achieving greater uniformity in clinical practice.

Asymmetry of small joint involvement in rheumatoid arthritis: prevalence and tendency towards symmetry over time

OBJECTIVES

To quantify asymmetry of radiological joint damage in rheumatoid arthritis (RA), to determine whether asymmetrical damage to joints in RA becomes symmetrical over time, and to identify factors predictive of symmetrization.

METHODS

In phase 1, initial, mid-term (mean follow-up: 3 years) and late (mean follow-up: 8 years) radiographs of 48 patients with definite RA (English population) were graded by the Modified Larsen (ML) system. In phase 2, 27 subjects (Canadian population) with at least one asymmetrical pair of joints in the hands or feet were identified. Two successive radiographs of 77 asymmetrical joints, separated by at least 2 years, were compared. Clinical and biological factors were assessed for their ability to predict symmetrization, defined as a reduction in side-to-side difference over time of two or more ML grades.

RESULTS

In phase 1, the overall rate of asymmetry was 12.9% (95% CI: 11.2-14.5%), increasing from 9.7% (first visit) to 13.8% (mid-term) and 14.4% (last visit). Metacarpophalangeal (MCP) joints were more frequently asymmetrical than thumb (MCP and interphalangeal) joints (P = 0.0064) and proximal interphalangeal (PIP) joints (P < 0.0001); wrist quadrants were more frequently asymmetrical than PIP joints (P < 0.0001). In phase 2, two groups were identified and compared: symmetrizers (22 joints) and non-symmetrizers (55 joints). The overall probability of small joints in the hand and foot symmetrizing was 28.5%. Rheumatoid factor (RF) was predictive of symmetrization. The risk of symmetrization was significantly increased in RF-positive patients with asymmetric joints (P = 0.01). The prevalence of asymmetry did not decrease with disease duration, despite symmetrization.

CONCLUSIONS

Prevalence of asymmetry in joint damage in RA was 13-16%. Symmetry was more evident in PIP joints than in MCP and wrist joints. Seropositive patients are more than twice as likely to symmetrize than seronegative patients. Data regarding the tendency for symmetrization may have value in the clinical management of RA patients with asymmetrical joint damage.

Structural evaluation in the management of patients with rheumatoid arthritis: development of recommendations for clinical practice based on published evidence and expert opinion

OBJECTIVES

To develop French evidence-based recommendations for the structural evaluation of rheumatoid arthritis (RA) in everyday practice.

METHODS

A scientific committee selected 10 questions using the Delphi consensus procedure. Evidence-based responses to each question were sought by searching the PubMed and Ovid databases and the abstract databases for the 2002, 2003, and 2004 annual meetings of the French Society for Rheumatology, the EULAR, and the American College of Rheumatology. The following indexing terms were used: rheumatoid arthritis, arthritis, patient, diagnostic imaging, radiography, joint, erosion, and joint space width. All articles published in French or English prior to May 2004 were identified. The evidence from these articles was reported to a panel of 77 rheumatologists working in hospital or office practice. The panel developed detailed recommendations, filling gaps in evidence with their expert opinion. The strength of each recommendation was determined.

RESULTS

The 10 questions probed the structural evaluation of RA by plain radiography, magnetic resonance imaging (MRI), and ultrasonography, both for diagnostic and monitoring purposes. The literature search retrieved 673 publications, of which 166 were selected and reviewed. The panel developed 10 recommendations, one for each question, which were accepted by consensus.

CONCLUSION

Recommendations relative to the diagnosis or monitoring of structural involvement in patients with RA in everyday practice were developed. They should help to improve practice uniformity and, ultimately, to improve the management of RA.

Raised granzyme B levels are associated with erosions in patients with early rheumatoid factor positive rheumatoid arthritis

BACKGROUND

Raised granzyme B in serum and synovium of patients with rheumatoid arthritis suggests a role for cytotoxic T cells and natural killer cells in the pathogenesis of this disease.

OBJECTIVE

To evaluate serum granzyme B in patients with early arthritis and correlate it with specific diagnosis and clinical indices of disease severity.

METHODS

257 patients with inflammatory arthritis for less than one year (46% rheumatoid arthritis, 17% spondyloarthropathy, 37% undifferentiated arthritis) had a prospective clinical, serological, and radiographic evaluation. Granzyme B was measured in initial sera by ELISA. Patients were HLA typed for DR alleles using sequence specific primers. A logistic regression model was used to evaluate the potential prognostic value of serum granzyme B in predicting radiographic erosions after one year of follow up.

RESULTS

Granzyme B values were similar in rheumatoid arthritis, spondyloarthropathy, and undifferentiated arthritis. Concentrations were higher in rheumatoid factor (RF) positive patients than in RF negative patients (mean (SD): 3.15 (0.92) v 2.89 (0.71) pg/ml; p<0.05). After one year, erosions were present in 30% of patients in the overall cohort, and in 44% of patients with rheumatoid arthritis. In the entire cohort, serum granzyme B did not predict erosions independently. However, high granzyme B was an independent predictor of early erosions in patients with RF positive rheumatoid arthritis (odds ratio = 4.83 (95% confidence interval, 1.13 to 20.59)) (p<0.05).

CONCLUSIONS

Granzyme B may be a useful prognostic marker in early rheumatoid arthritis and may provide important clues to the pathogenesis of this disease.

Effect of sinomenine on cytokine expression of macrophages and synoviocytes in adjuvant arthritis rats

For exploring the mechanism of the anti-inflammatory and anti-rheumatic effect of sinomenine (SN), the actions of different dosage of SN were observed in vitro on the expression of cytokines, tumor necrosis factor (TNF-alpha) and interleukin-1beta (IL-1beta), as well as the activity of nuclear factor-kappaB (NF-kappaB) and the inhibitory kappaB-alpha (IkappaB-alpha) protein level of peritoneal macrophages (PMs) and synoviocytes in adjuvant arthritis (AA) rats. In this study, the experimental rat model of AA was used and PMs and synoviocytes were collected. The mRNAs of TNF-alpha and IL-1beta were detected with reverse transcription-polymerase chain reaction (RT-PCR) and NF-kappaB activity was measured by electrophoretic mobility shift assay (EMSA). The IkappaB-alpha protein level in the cytoplasma was detected by Western blot. Our results showed that expression of mRNAs of TNF-alpha and IL-1beta and NF-kappaB activity by PMs and synoviocytes were markedly increased compared to control group (P<0.05). In a definite concentration ranging from 30 to 120 microg/ml, SN showed inhibiting effect on the NF-kappaB activity and the expression of the mRNAs of TNF-alpha and IL-1beta in AA rats in a concentration-dependent manner (P<0.05). Positive correlations were found between changes of NF-kappaB activity and expression of TNF-alpha mRNA and IL-1beta mRNA (P<0.01). IkappaB-alpha protein level was increased by various dosages of SN in comparison with control group (P<0.01). In conclusion, SN decreases the mRNA expression of TNF-alpha and IL-1beta by inhibiting the NF-kappaB binding activity, which is mediated through up-regulating the IkappaB-alpha expression of PMs and synoviocytes in AA rats.

Imaging in early arthritis

Imaging can play a vital role in the evaluation of patients with early arthritis. Various imaging methods can be utilized to aid with diagnosis, predict prognosis and follow disease progression and treatment response. Previously, conventional radiography was the principal method used to evaluate and follow bone damage in patients with inflammatory arthritis. More recently the use of magnetic resonance imaging and ultrasonography has gained wider acceptance and popularity due to the ability of these multiplanar techniques to image both bone changes and soft tissue abnormalities, including synovitis. This chapter discusses the current imaging modalities used in the evaluation of patients with early arthritis, as well as the use of imaging in establishing the extent of disease, in prognosis and in monitoring disease course. Current data on imaging of patients with early arthritis due to rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis is reviewed.

Prognostic laboratory markers of joint damage in rheumatoid arthritis

OBJECTIVE

To investigate whether determination of a set of laboratory markers at baseline provides prognostic information on joint damage in hands and feet in rheumatoid arthritis.

METHODS

183 patients with early rheumatoid arthritis included in a prospective study were examined. Radiographic changes in hands and feet at 5 and 10 years after inclusion were evaluated (Larsen). The markers analysed were: erythrocyte sedimentation rate (ESR); HLA-DRB alleles typed by restriction fragment length polymorphism; and C reactive protein, cartilage oligomeric matrix protein (COMP), rheumatoid factor (RF) (IgG, IgA, and IgM subtypes), antibodies against cyclic citrullinated peptide (anti-CCP), and antibodies against interleukin 1alpha (anti-IL1alpha), analysed by immunoassays. Multiple linear regression with backward elimination was used to determine the prognostic value of the variables.

RESULTS

117/176 patients were positive for IgG RF, 138/176 for IgA RF, 139/176 for IgM RF, 140/176 for anti-CCP, and 40/182 for anti-IL1alpha. After five years, ESR, the presence of IgA RF, serum COMP, and the presence of anti-CCP were significantly associated with more severe joint damage, and the presence of anti-IL1alpha with less severe joint damage. Baseline C reactive protein and anti-CCP predicted radiographic outcome after 10 years. A stronger prediction was obtained by combining the prognostic factors.

CONCLUSIONS

Early determination of anti-CCP, IgA RF, anti-IL-1alpha, ESR, C reactive protein, and COMP predicted the development of joint damage in hands and feet in this cohort. A combination of these measures reflecting different aspects of the disease process should be useful for evaluating prognosis in individual patients with early rheumatoid arthritis.

Association of early radiographic damage with impaired physical function in rheumatoid arthritis: A ten-year, longitudinal observational study in 238 patients

OBJECTIVE

To investigate the longitudinal relationship between physical disability, disease activity, and radiographic damage over 10 years in patients with rheumatoid arthritis (RA).

METHODS

A cohort of 238 consecutively enrolled RA patients from the European Research on Incapacitating Disease and Social Support study (age range 20-70 years, mean disease duration 2.3 years, 68% rheumatoid factor [RF] positive) was followed up longitudinally for 10 years. Assessments at baseline and at years 1, 2, 5, and 10 comprised review of demographic variables, measurement of disease activity with the erythrocyte sedimentation rate (ESR), functional evaluations using the Health Assessment Questionnaire (HAQ) and grip strength (average value of the right and left hand), and radiographs of the hands scored by the van der Heijde modification of the Sharp method. Marginal modeling by generalized estimating equations was used to study the longitudinal relationship between the ESR and modified Sharp radiographic damage score with respect to explaining the HAQ score and grip strength. Age, sex, RF status, and disease duration were entered as covariates.

RESULTS

The HAQ score and grip strength were longitudinally associated with the momentary modified Sharp/van der Heijde score as well as with progression in this score, independent of the ESR. Therefore, an increase of 10 units in the modified Sharp/van der Heijde score will result in a 0.03-unit increase in HAQ score and a 0.95-kg decrease in grip strength, after adjustment for the ESR.

CONCLUSION

This 10-year observational study provides evidence that both radiographic damage and disease activity are independent contributors to impaired physical function in RA, both early and late in the disease process.

The PREMIER study: A multicenter, randomized, double-blind clinical trial of combination therapy with adalimumab plus methotrexate versus methotrexate alone or adalimumab alone in patients with early, aggressive rheumatoid arthritis who had not had previous methotrexate treatment

OBJECTIVE

To compare the efficacy and safety of adalimumab plus methotrexate (MTX) versus MTX monotherapy or adalimumab monotherapy in patients with early, aggressive rheumatoid arthritis (RA) who had not previously received MTX treatment.

METHODS

This was a 2-year, multicenter, double-blind, active comparator-controlled study of 799 RA patients with active disease of < 3 years' duration who had never been treated with MTX. Treatments included adalimumab 40 mg subcutaneously every other week plus oral MTX, adalimumab 40 mg subcutaneously every other week, or weekly oral MTX. Co-primary end points at year 1 were American College of Rheumatology 50% improvement (ACR50) and mean change from baseline in the modified total Sharp score.

RESULTS

Combination therapy was superior to both MTX and adalimumab monotherapy in all outcomes measured. At year 1, more patients receiving combination therapy exhibited an ACR50 response (62%) than did patients who received MTX or adalimumab monotherapy (46% and 41%, respectively; both P < 0.001). Similar superiority of combination therapy was seen in ACR20, ACR70, and ACR90 response rates at 1 and 2 years. There was significantly less radiographic progression (P < or = 0.002) among patients in the combination treatment arm at both year 1 and year 2 (1.3 and 1.9 Sharp units, respectively) than in patients in the MTX arm (5.7 and 10.4 Sharp units) or the adalimumab arm (3.0 and 5.5 Sharp units). After 2 years of treatment, 49% of patients receiving combination therapy exhibited disease remission (28-joint Disease Activity Score <2.6), and 49% exhibited a major clinical response (ACR70 response for at least 6 continuous months), rates approximately twice those found among patients receiving either monotherapy. The adverse event profiles were comparable in all 3 groups.

CONCLUSION

In this population of patients with early, aggressive RA, combination therapy with adalimumab plus MTX was significantly superior to either MTX alone or adalimumab alone in improving signs and symptoms of disease, inhibiting radiographic progression, and effecting clinical remission.

Interpreting radiographic data in rheumatoid arthritis

Plain film radiography is the preferred method for evaluating disease progression in rheumatoid arthritis and for establishing the efficacy of new disease modifying antirheumatic agents. However, the relative efficacy of these agents cannot be determined by comparing radiographic data from different studies, and a standardised system is needed.