Validation of the rheumatic disease comorbidity index

In early rheumatoid arthritis, comorbidities do not explain the increased risk of failure to reach remission in patients with obesity

OBJECTIVE

To examine whether obesity and/or overweight are independently associated with an increased risk of remission failure in patients with early rheumatoid arthritis (RA), treated with methotrexate as first disease-modifying antirheumatic drug, or if the previously reported associations could be explained by underlying comorbidities and lifestyle factors.

METHODS

For patients included in the Epidemiological Investigation of Rheumatoid Arthritis (EIRA) study 2006-2018 initiating methotrexate monotherapy (n=1285), we captured data on body mass index, comorbidities and disease activity from EIRA and through linkage to nationwide Swedish clinical and quality registers. The primary outcome was failure to reach 28-joint Disease Activity Score (DAS28) remission at 3 and 6 months. Secondary outcomes included Boolean, Simplified Disease Activity Index and Clinical Disease Activity Index remission and their individual components. We estimated the relative risk (RR) of remission failure in patients with obesity and overweight compared with normal weight using modified Poisson regression, adjusting for potential confounders.

RESULTS

After 6 months, 64% (n=98/153) of patients with obesity, 52% (n=171/326) with overweight and 48% (n=210/433) with normal weight failed to reach DAS28 remission, with an RR of 1.33 (95% CI 1.14 to 1.55) for patients with obesity after adjustment for age and sex. The increased risk of remission failure in patients with obesity remained after further adjustment for seropositivity, educational level, smoking, alcohol use, physical activity, calendar period, glucocorticoid treatment and comorbidities (RR=1.27, 95% CI 1.08 to 1.50). No significant association was observed for patients with overweight. The results were similar for the secondary outcomes and after 3 months.

CONCLUSION

Obesity is a risk factor for remission failure in early RA, independent of comorbid conditions.

Relapses and serious adverse events during rituximab maintenance therapy in ANCA-associated vasculitis: a multicentre retrospective study

OBJECTIVES

There are limited real-life data regarding the efficacy and safety of rituximab (RTX) as a remission maintenance agent in microscopic polyangiitis (MPA) and granulomatosis-with-polyangiitis (GPA). We aimed to estimate the incidence and risk factors for relapses, as well for serious adverse events (SAEs) in MPA/GPA patients during RTX maintenance.

METHODS

A retrospective cohort of newly diagnosed/relapsing GPA/MPA patients who received RTX maintenance (≥1 RTX cycle, ≥6 months follow-up) following complete remission (BVAS version-3 = 0 plus prednisolone ≤7.5 mg/day) with induction regimens. SAEs included serious infections, COronaVIrus-Disease 2019 (COVID-19)-associated hospitalizations, deaths, cardiovascular events, malignancies and hypogammaglobulinemia. The incidence rates (IRs) and relapse-free survival were estimated through Kaplan-Meier plots. Cox regression was conducted to investigate factors associated with the time-to-relapse.

RESULTS

A total of 101 patients were included: 48% females, 69% GPA, 53% newly diagnosed, median age 63 years. During follow-up (294.5 patient-years, median: 3 RTX cycles), 30 relapses (57% major) occurred among 24 patients (24%, IR 10.2/100 patient-years). Kidney involvement (adjusted hazard ratio/aHR: 0.20; 95% CI: 0.06-0.74, P = 0.016), prior induction with RTX plus CYC (vs RTX monotherapy: aHR = 0.02; 95% CI: 0.001-0.43, P = 0.012) and shorter time interval until complete remission (aHR = 1.07; 95% CI: 1.01-1.14, P = 0.023) were associated with decreased relapse risk. We recorded 17 serious infections (IR 5.8/100 patient-years), 11 COVID-19-associated hospitalizations (IR 3.7/100 patient-years), 4 malignancies (IR 1.4/100 patient-years), 6 cardiovascular events (IR 2/100 patient-years) and 10 deaths (IR 3.4/100 patient-years).

CONCLUSION

In this real-world study, relapses during RTX maintenance occurred in approximately 1 out of 4 patients. Kidney involvement, induction with RTX plus CYC, and earlier achievement of complete remission were associated with lower relapse risk. The serious infections rate was consistent with previous reports, whereas an increased rate of COVID-19-associated hospitalizations was observed.

Immunosenescence in autoimmune diseases

Autoimmune diseases (AIDs) are a group of disorders in which the immune system mistakenly attacks the body's own tissues, characterized by the loss of tolerance to self-antigens and destruction of tissues. Aging is a natural process of physiological decline that also alters the immune system, a condition known as immunosenescence. During immunosenescence, the immune system undergoes various changes, including modifications and antigenicity of self-antigens, abnormalities in the quantity, phenotype, and function of lymphocytes and antibodies, as well as a narrowing of the B and T cell receptor repertoire, changes that may increase susceptibility to AIDs. Additionally, senescent immune cells and the senescence-associated secretory phenotype (SASP) contribute to target organ involvement in AIDs, exacerbating chronic inflammation and tissue damage. Mitochondrial dysfunction and metabolic imbalances in AIDs lead to the accumulation of senescent cells, which act as upstream drivers of immunosenescence. In this review, we summarize the bidirectional relationship between AIDs and immunosenescence, as well as its potential mechanisms. Therapeutic approaches targeting immunosenescence in AIDs remain at an early stage. Strategies aimed at resetting or reversing the aging immune system are expected to become a novel direction in the future.

Prevalence of social frailty in patients with rheumatoid arthritis: Data from a multicentre observational study (T-FLAG study)

OBJECTIVES

The aim of this study was to investigate the prevalence of social frailty and associated factors.

METHODS

A total of 655 consecutive patients who were able to complete the Kihon Checklist (KCL) and the Questionnaire on Social Frailty between June and August 2022 were enrolled. Social frailty was assessed using the Makizako Social Frailty Index. Patient characteristics were analysed by analysis of variance. Factors associated with social frailty were analysed using multivariate logistic analysis. Spearman's rank correlation coefficients were used to examine correlations between each KCL domain and social frailty.

RESULTS

The mean age was 68 years, and the disease duration was 12 years; 73% of patients were female. Social frailty was present in 30.8% of patients, with 36.5% classified as social prefrailty. Multivariate analysis revealed age and Health Assessment Questionnaire-Disability Index to be independent factors associated with social frailty. The proportion of social frailty increased with increasing age and worsening Health Assessment Questionnaire-Disability Index scores. The KCL domain 'Isolation' was the most strongly associated with social frailty (r = .601, P < .001), with higher scores associated with a higher proportion of social frailty.

CONCLUSIONS

Social frailty in patients with rheumatoid arthritis is associated with age and physical impairment (Health Assessment Questionnaire-Disability Index). Moreover, the KCL domain 'Isolation' was strongly associated with social frailty.

Evaluation of comorbidity burden on disease progression and mortality in patients with interstitial pneumonia with autoimmune features: A retrospective cohort study

BACKGROUND

Interstitial pneumonia with autoimmune features (IPAF) is a subset of interstitial lung disease that manifests with features of autoimmunity while not meeting classification criteria for a defined rheumatic disease. Comorbidity burden is an important prognostic indicator in various rheumatic and interstitial lung diseases, but few studies have commented on comorbidities in this population. This study was conducted to evaluate the association of individual comorbidities, the Charlson Comorbidity Index (CCI), and the Rheumatic Disease Comorbidity Index (RDCI) with lung disease progression and transplant/mortality outcomes in patients with IPAF.

METHODS

In a retrospective study, we evaluated the prevalence and severity of comorbidities in an institutional cohort of patients with IPAF. Using Cox regression, we correlated the association of individual comorbidities and comorbidity indices with time to lung disease progression (relative forced vital capacity decline of 10% or more) and with time to lung transplant/death. We compared the performance of CCI and RDCI in predicting outcomes.

RESULTS

History of cerebrovascular accident (CVA) or cardiovascular disease (CVD), moderate-severe chronic kidney disease, and fracture was associated with a faster onset of lung disease progression, while a history of gastroesophageal reflux was protective. History of CVA/CVD, diabetes mellitus, and lymphoma were associated with a faster onset of lung transplant/death. Both CCI and RDCI were associated with shorter time to lung disease progression and lung transplant/death in unadjusted analyses. However, only CCI was associated with shorter time to lung transplant/death in analyses adjusted for age, sex, pulmonary function, and radiographic pattern of lung lesion.

CONCLUSIONS

CCI and RDCI may be useful tools in assessing prognosis in patients with IPAF in terms of both lung disease progression and mortality. Prospective studies are needed to further evaluate the performance of CCI and RDCI and the impact of optimizing comorbid conditions that may mitigate poor outcomes among patients with IPAF.

Outcome Assessments for the Rheumatoid Hand

Rheumatoid arthritis profoundly affects hand function and quality of life. Standardized outcome measures are lacking, hindering comparison between studies. Clinical assessment traditionally relies on performance-based tests like range of motion, grip, and the Jebsen-Taylor Hand Function Test, crucial for evaluating treatment effects, especially surgery. Patient-reported outcome measures have gained significance in assessing post-surgery results, with tools like Cochin Hand Disability Scale and Michigan Hand Outcomes Questionnaire proving effective. However, generic instruments and disease-specific ones also play roles in follow-up. Combining objective measures with patient-reported outcomes is essential for comprehensive evaluation and postoperative care in rheumatoid hand patients.

The Veterans Affairs Rheumatoid Arthritis Registry: A unique population in rheumatoid arthritis research

BACKGROUND

As the largest integrated healthcare system in the U.S., the Veterans Affairs (VA) provides a unique context for the conduct of clinical and clinical-translational research in rheumatoid arthritis (RA).

OBJECTIVES

To review attributes of the VA Rheumatoid Arthritis Registry (RA) and highlight its research contributions.

FINDINGS

With >3,600 participants enrolled from 19 VA medical centers across the U.S., VARA includes longitudinally collected clinical data and a central biorepository that includes serum, plasma, and DNA collected at enrollment. VARA research capacity is enhanced via active linkages with internal data including the VA's Corporate Data Warehouse and elements captured during oncology care. This capacity is further enabled via active linkages with the National Death Index and Centers for Medicare & Medicaid Services (CMS) data.

CONCLUSION

As a highly unique study population with comprehensive data annotation available to researchers, VARA is poised to continue address impactful questions in RA for years to come.

Perceived mistreatment in patients with rheumatic diseases: The impact of the underlying diagnosis

BACKGROUND

Mistreatment is a complex problem that impacts people's quality of life, morbidity, and mortality. In aged people, it has been associated with female sex, poor general health, depression, functional and cognitive decline, and increased dependence levels, all of which are well-recognized characteristics of patients with rheumatic diseases (RMDs). The objective was to describe the mistreatment phenomenon in Mexican patients with RMDs. We additionally report the adaptation and validation of the Geriatric Mistreatment Scale (GMS) in the target population.

PATIENTS AND METHODS

This cross-sectional study was developed in two phases (June 28, 2023-February 2, 2024), and three convenience samples were used: S-1 (n = 30), S-2 (n = 260), and S-3 (n = 372). Phase 1 consisted of adapting the GMS to RMDs (RMD-MS) (experts' agreement), followed by RMD-MS face validity (pilot testing, S-1), content validity (experts' agreement), concurrent criterion validity (family APGAR score ≤3, S-2), construct validity (exploratory factor analysis and convergent validity, S-2), reliability (internal consistency and temporal stability, S-2) and feasibility (in S-1). Phase 2 consisted of the mistreatment description in S-3.

RESULTS

Patients represented typical RMD outpatients with substantial disease duration. There were 187 (50.3%) patients with overall mistreatment, and psychological was the most frequent in 142 (75.9%) patients, followed by neglect mistreatment in 96 (51.3%), sexual in 30 (16%), physical in 23 (12.3%), and economic mistreatment in 20 (10.7%) patients. Patients' perceived mistreatment was related to the underlying RMD in 13.3% of sexual mistreatment and 53.3% of psychological mistreatment. The number of "I do not want to answer" responses raised to 21.7%-67.7% for abusers' sex and 40%-72.9% for the abusers' relationship with the participant. The RMD-MS was valid, reliable, and feasible.

CONCLUSIONS

Half of the Mexican patients with RMDs perceived some mistreatment, most frequently psychological mistreatment, which is also often perceived as related to the underlying RMD.

The Burden of Glucocorticoids: Patterns of Use, Adverse Health Conditions, and Health Care Use in Two Cohorts With Systemic Lupus Erythematosus

OBJECTIVE

Glucocorticoids (GCs) can be beneficial from both clinical and patient perspectives, but side effects are well documented. We examined patterns of GC use over 15 years (2006-2021) and occurrence of adverse health conditions (AHCs) and health care use by GC exposure in two longitudinal cohorts with systemic lupus erythematosus (SLE).

METHODS

Data from the Lupus Outcomes Study (LOS; 2003-2015) and FORWARD cohort (2015-2021) were used. AHCs examined were diabetes, osteoporosis, nontraumatic fractures, cataracts, and infections. Health care use measures examined were the number of rheumatology and other provider visits, hospitalizations, and specific diagnostic tests. Kaplan-Meier analyses examined time to occurrence of each AHC. Cox regression analyses estimated the risk of occurrence of AHCs, controlling for covariates by GC use and by GC dose (0, 1-5, 5-7.5, and ≥7.5 mg).

RESULTS

GC use was relatively consistent over time. At baseline, individuals who used GCs in the LOS were more likely to report osteoporosis (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.2-2.6) and cataracts (aOR 1.6, 95% CI 1.04-2.6); individuals who used GCs in the FORWARD cohort were more likely to report diabetes (aOR 5.1, 95% CI 2.2-12.0), osteoporosis (aOR 4.5, 95% CI 2.6-8.0), and fractures (aOR 6.5, 95% CI 3.8-11.1). Individuals who used high doses of GCs in the LOS had greater incidence of osteoporosis, fracture, and cataracts. In the FORWARD cohort, a significant difference in incidence was noted only for infections. In both cohorts, individuals who used GCs had more rheumatology and other physician visits, and greater risk of hospitalization.

CONCLUSION

Despite recommendations on steroid sparing, a large portion of people with SLE appear to remain on steroids. These analyses provide additional evidence of the potential health and health care burden of GC use, underscoring the need for other effective treatments for individuals with SLE.

The Risk of Lung Cancer in Rheumatoid Arthritis and Rheumatoid Arthritis-Associated Interstitial Lung Disease

OBJECTIVE

We aimed to evaluate lung cancer risk in patients with rheumatoid arthritis (RA) and RA-interstitial lung disease (ILD).

METHODS

We performed a retrospective, matched cohort study of RA and RA-ILD within the Veterans Health Administration (VA) between 2000 and 2019. Patients with RA and RA-ILD were identified with validated administrative-based algorithms, then matched (up to 1:10) on age, gender, and VA enrollment year to individuals without RA. Lung cancers were identified from a VA oncology database and the National Death Index. Conditional Cox regression models assessed lung cancer risk adjusting for race, ethnicity, smoking status, Agent Orange exposure, and comorbidity burden among matched individuals. Several sensitivity analyses were performed.

RESULTS

We matched 72,795 patients with RA with 633,937 patients without RA (mean age 63 years; 88% male). Over 4,481,323 patient-years, 17,099 incident lung cancers occurred. RA was independently associated with an increased lung cancer risk (adjusted hazard ratio [aHR] 1.58 [95% confidence interval (CI) 1.52-1.64]), which persisted in never smokers (aHR 1.65 [95% CI 1.22-2.24]) and in those with incident RA (aHR 1.54 [95% CI 1.44-1.65]). Compared to non-RA controls, prevalent RA-ILD (n = 757) was more strongly associated with lung cancer risk (aHR 3.25 [95% CI 2.13-4.95]) than RA without ILD (aHR 1.57 [95% CI 1.51-1.64]). Analyses of both prevalent and incident RA-ILD produced similar results (RA-ILD vs non-RA aHR 2.88 [95% CI 2.45-3.40]).

CONCLUSION

RA was associated with a >50% increased risk of lung cancer, and those with RA-ILD represented a particularly high-risk group with an approximate three-fold increased risk. Increased lung cancer surveillance in RA, and especially RA-ILD, may be a useful strategy for reducing the burden posed by the leading cause of cancer death.

Frailty and rheumatic diseases: evidence to date and lessons learned

Frailty represents a dynamic multisystem state of reduced physiological reserve that increases vulnerability to adverse health outcomes. Frailty occurs prematurely in adults with immune-mediated rheumatic diseases and is emerging as an important risk factor for adverse outcomes in these conditions. In this Series paper, we present a conceptual overview of frailty and its prevalence among patients with immune-mediated rheumatic diseases. We discuss putative mechanisms of frailty relevant to these diseases, tools for frailty measurement, and potential implications of frailty assessment for clinical care. We also explore the complex inter-relationship between frailty, inflammation, and disease activity in immune-mediated rheumatic diseases. As insight is gained into the epidemiology and mechanisms of frailty among patients with immune-mediated inflammatory rheumatic diseases, the possibility of targeting frailty with an intervention that could complement standard disease-modifying therapies to prevent adverse outcomes and improve health-related quality of life becomes closer to reality.

A comparison of comorbidities and their risk factors prevalence across rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis with focus on cardiovascular diseases: data from a single center real-world cohort

Management of comorbidities is essential to a patient-centered approach to the treatment of chronic inflammatory arthritis. The aim of this study was to compare the prevalence of comorbidities and their risk factors in rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (axSpA) in a single center outpatient cohort. This cross-sectional study included adult patients diagnosed with RA, PsA, and axSpA from a single rheumatology outpatient center. Comorbidities were documented by physicians, and patients were categorized into two age groups, younger (< 45 years) and older (≥ 45 years), with age- and gender-based comparisons. Disease activity, comorbidities, and cardiovascular (CV) risk factors were analyzed using chi-squared tests for categorical variables and independent samples t-tests for continuous variables, with p values < 0.05 considered statistically significant. Comorbidities were registered by physicians using GoTreatIt® Rheuma software. Among 508 RA, 267 PsA, and 285 axSpA patients, the four most common comorbidities were hypertension (36.4%, 25.1%, and 19.7%, respectively), dyslipidemia (19.5%, 15.4%, 14.7% respectively), obesity (16.9%, 22.5%, 14% respectively) and thyroid disease (21.5%, 13.9%, 11.2% respectively). Other comorbidities differed among the diseases and included osteoporosis, osteoarthritis, diabetes mellitus, arrhythmia, and asthma in RA, diabetes mellitus, depression and asthma in PsA, osteoporosis and serious infection in axSpA. RA patients, compared to axSpA had a higher prevalence of coronary artery disease (4.1% vs. 0.7%, p = 0.006), arrhythmia (6.9% vs. 2.5%, p = 0.008) and major adverse cardiac events (2.6% vs. 0.4%, p = 0.024) compared to axSpA. Osteoporosis was more frequent in RA (19.1%) and axSpA (8.4%) than in PsA (2.3%; p < 0.001) and was frequently diagnosed in patients aged < 45. Depression prevalence was surprisingly low (1.6%, 5.2%, and 1.8%, respectively). RA patients had the highest multimorbidity rate, with 26.6% reporting three or more comorbidities, compared to 16.8% in PsA and 10.6% in axSpA (p < 0.001). Health status was poorest in RA and worse in women compared to men for all diseases. RA, PsA, and axSpA share the same four most common comorbidities: hypertension, dyslipidemia, obesity, and thyroid disease but have different prevalence of other disorders and CV risk factors, indicating the need for an individual screening and prevention approach. The possible unrecognition of depression should be evaluated.

Towards a comprehensive approach to the management and prognosis of systemic sclerosis's patients: The role of comorbidities in the SPRING-SIR registry

OBJECTIVES

The current knowledge about the role of comorbidities in systemic sclerosis (SSc) is limited. Therefore, the aim of this study was to evaluate the prevalence of comorbidities and their impact on disease activity and prognosis in the Systemic sclerosis PRogression INvestiGation (SPRING) registry.

METHODS

SSc patients from the SPRING registry, fulfilling the ACR/EULAR 2013 classification criteria, with complete data on baseline comorbidities were enrolled. The Charlson comorbidity index (CCI) was used to quantify the overall comorbidity burden. The disease activity was calculated using the revised EUSTAR activity index (AI). The impact of SSc features on CCI, the effect of CCI on SSc disease activity and mortality were tested with multivariable regression models.

RESULTS

Among 1910 SSc patients enrolled, 67.3 % had at least one comorbidity at baseline. The most frequent comorbidities were systemic arterial hypertension (23.7 %), osteoporosis (12.9 %) and dyslipidemia (11 %). The mean value of CCI score was 2.0 ± 1.8. When patients were grouped according to increasing levels of CCI, a clear separation in the distribution of SSc-related clinical features could be observed. Among over 900 patients with available follow-up, no association between baseline CCI and changes in disease activity was observed. Conversely, the risk of death over time was independently predicted by both CCI and AI.

CONCLUSIONS

Comorbidities and disease activity independently impact on the prognosis of SSc patients. This suggests that the management of comorbidities, together with the reduction of disease activity, is fundamental to improve patient survival.

A quasi-experimental study about shared decision-making and motivational interviewing on patients with a recent fracture attending Fracture Liaison Services

Shared decision-making (SDM) aims to improve patients' experiences with care, treatment adherence, and health outcomes. However, the effectiveness of SDM in patients with a recent fracture who require anti-osteoporosis medication (AOM) is unclear. The objective of this study was to assess the effectiveness of a multicomponent adherence intervention (MCAI) including a patient decision aid (PDA) and motivational interviewing at Fracture Liaison Services (FLS) on multiple outcomes compared with usual care (UC). This pre-post superiority study included patients with a recent fracture attending FLS and with AOM treatment indication. The primary outcome was 1-year AOM persistence measured by pharmacy records. Secondary outcomes included treatment initiation, AOM adherence (measured by medication possession ratio [MPR]), decision quality (SDM process; 0-100, best), and decisional conflict (0-100, highest conflict), subsequent fractures, and mortality. Outcomes were tested in MCAI and UC groups at the first FLS visit and 4 and 12 months afterwards. Multiple imputation and uni- and multivariable analyses were performed. Post hoc analyses assessed the role of health literacy level. In total, 245 patients (MCAI: n = 136, UC: n = 109) were included. AOM persistence was 80.4% in the MCAI and 76.7% in the UC group (p=.626). SDM process scores were significantly better in MCAI (60.4 vs 55.1; p = .003). AOM initiation (97.8% vs 97.5%), MPR (90.9% vs 88.3%, p=.582), and decisional conflict (21.7 vs 23.0; p = .314) did not differ between groups. Results did not change importantly after adjustment. Stratified analyses by health literacy showed a better effect on MPR and SDM in those with adequate health literacy. This study showed no significant effect on AOM persistence; however, it demonstrated a significant positive effect of MCAI on SDM process in FLS attendees. (Netherlands Trial Registry, Trial NL7236 [NTR7435]; version 1.0; 26-11-2020 https://onderzoekmetmensen.nl/nl/trial/22858).

Associations Between Adiponectin and the Development of Diabetes in Rheumatoid Arthritis

PURPOSE

We evaluated associations between adiponectin and the risk of diabetes among patients with rheumatoid arthritis (RA), a systemic inflammatory disease associated with metabolic disturbance.

METHODS

This prospective cohort study included adults with RA from the Veterans Affairs Rheumatoid Arthritis Registry. Adiponectin and inflammatory cytokines/chemokines were measured at enrollment on stored serum samples. Adiponectin levels were categorized, and clinical variables were described across categories (<10 μg/mL; 10-40 μg/mL; >40 μg/mL). Multivariable Cox proportional hazard models evaluated associations between adiponectin and incident diabetes adjusting for age, sex, race, smoking status, body mass index (BMI), disease-modifying therapy use, calendar year, and comorbidity. Testing for modification of effect in the context of elevated cytokines/chemokines was performed.

RESULTS

Among 2595 patients included in the analysis, those with adiponectin levels >40 μg/mL (N = 379; 15%) were older and had lower BMI. There were 125 new cases of diabetes among 1689 patients without prevalent disease at enrollment. There was an inverse association between adiponectin and incident diabetes; however, the association was positive among patients with adiponectin levels >40 μg/mL. Patients with levels >40 μg/mL were at higher risk compared to those with levels 10-40 μg/mL (HR: 1.70 [1.34, 2.16] P < .001). Those with adiponectin levels >40 μg/mL had significantly higher levels of inflammatory cytokines with evidence of a modified effect of adiponectin on diabetes risk in the setting of inflammation.

CONCLUSION

The relationship between adiponectin and incident diabetes risk is U-shaped in RA. Patients with very high adiponectin levels have greater systemic inflammation and an altered relationship between adiponectin and diabetes risk.

Predictive factors of methotrexate monotherapy success in patients with rheumatoid arthritis in a national referral center: a cohort study

BACKGROUND

Methotrexate (MTX) remains the recommended first-line treatment for rheumatoid arthritis (RA); however, its response varies and is influenced by various factors. This study aimed to identify predictors of MTX monotherapy treatment success in an Indonesian cohort.

METHODS

This retrospective cohort study included newly diagnosed RA patients receiving MTX monotherapy. Treatment success was defined as achieving remission or low disease activity according to Disease Activity Score-28 with erythrocyte sedimentation rate (DAS28-ESR) after 12 months of MTX therapy. The association between demographic, clinical, and laboratory factors and achieving therapy targets was evaluated using multivariate logistic regression analysis.

RESULTS

Among 254 subjects, 59.4% achieved treatment success with MTX monotherapy, with remission attained in 33% and low disease activity in 26.4%. Most subjects were female (95.7%) with a mean age of 48 ± 11 years. Multivariate analysis revealed that lower disease activity (OR 1.97; 95% CI [1.04-3.72]), normal ESR (OR 2.58; 95% CI [1.05-6.34]), normoweight (OR 2.55, 95% CI [1.45-4.49]), and tender joint count ≤ 5 (OR 2.45, 95% CI [1.31-4.58]) were significant predictors of treatment success.

CONCLUSION

The rate of MTX monotherapy success in our study was 59.4%. Lower disease activity, normal ESR, normoweight, and fewer tender joints at baseline were significant predictors of treatment success.

Australian adaptation and external validation of Commissioning for Quality in Rheumatoid Arthritis-RA-Patient Reported Experience Measure (CQRA-RA-PREM)

Objectives

To evaluate the reliability and validity of an adapted Commissioning for Quality in Rheumatoid Arthritis-RA-Patient-Reported Experience Measure (CQRA-RA-PREM) for assessing care experience in an Australian rheumatology outpatient cohort.

Methods

Individual patient interviews were performed to check the language and completion time of the CQRA-RA-PREM before modification. Australian Rheumatology Association Database (ARAD) participants completed the CQRA-PREM-Australian version (CQRA-PREM-AU) (22 items, 5 domains), disease activity measure (RAPID-3, BASDAI) and Assessment of Quality of Life (AQOL-6D) index. Exploratory factor analysis (EFA) assessed item correlation. Cronbach's α assessed internal consistency.

Results

Individual patient interviews (n = 8, 62% male, mean age 50 years, mean disease duration 4.5 years) informed CQRA-RA-PREM modification. The ARAD survey response rate was 707/1124 (63%); 459 (65%) RA, 134 (19%) PsA, 114 (16%) AS; 67% female, mean age 62 years, mean disease duration 22 years. The median instrument completion time was 299 s (interquartile range 284-414). Scoring of responses allowed an averaged overall score. EFA extracted five factors: all items loading similarly onto factor 1, indicating validity of the overall score. The CQRA-PREM-AU score correlated with the AQOL-6D score (ρ = 0.23, P < 0.01); partial correlation with disease activity was not significant (ρ = 0.03, P = 0.45), indicating divergent validity. Reliability was comparable across disease subgroups (Cronbach's α >0.94). The mean overall score did not differ by disease subgroup [4.1 (s.d. 0.6, P = 0.73) and there was no floor/ceiling effect.

Conclusion

CQRA-PREM-AU is a valid and reliable instrument to measure self-reported care experience in Australian rheumatology patients and may be interpreted as an average overall numerical score.

Disease activity and widespread pain are main contributors to patient-reported global health in axial spondyloarthritis: an analysis of 6064 patients

Global health (GH) and health-related quality of life are patient priorities in axial spondyloarthritis (axSpA). Our objective was to assess the relative importance of disease-related factors including disease activity, and patient-related factors including comorbidities, to explain GH in axSpA. Post hoc cross-sectional analyses of 4 sets (COMOSPA, PERSPA, COMEDSPA, and DESIR) of patients fulfilling ASAS criteria for axSpA. GH was assessed through the ASAS Health Index (ASAS-HI) or the EuroQoL-5D-3L (EQ-5D). Disease-related factors included disease activity (ASDAS, psoriasis, arthritis, enthesitis, and CRP), disease duration, diagnostic delay, bamboo spine, and treatment. Non-disease-related factors included sociodemographic characteristics, comorbidities and chronic widespread pain. Multivariable logistic and linear regressions and partial variances (R2) were applied to identify independent determinants of GH. In 6064 patients (range 284-2756 across datasets), mean age ranged 38.9-45.8 years, 51-68% were male. GH was generally moderate: median ASAS-HI ranged 5.0-7.0. GH was explained by ASDAS (range of odds ratios, OR, 2.60-4.48) and chronic widespread pain (range of OR 2.19-8.39); other determinants included comorbidities and sociodemographic characteristics. Only 47-57% of the total variance in GH could be explained by the models; disease activity (partial variance, 16-26%) and chronic widespread pain (partial variance 12-15%) were the key contributing variables. A wide range of disease and non-disease-related variables usually collected in studies could only explain 47-57% of the variability in GH. Among these, disease activity and chronic widespread pain were most relevant and of similar magnitude of importance. These findings will be helpful for shared decision-making.

Current perspective on infections and mitigation strategies in primary systemic vasculitis

PURPOSE OF REVIEW

The purpose of this review is to summarize and evaluate most recent evidence on the epidemiology of infections and associated risk factors in patients with primary systemic vasculitides (PSV), as well as discuss mitigation strategies including the risk of antibiotic prophylaxis.

RECENT FINDINGS

Infections remain one of the leading causes of mortality in patients with PSV, with rates of severe infection ranging from 16 to 40% in different cohorts. Older age, frailty, renal and pulmonary involvement, and higher burden of comorbidities have been recognized as important patient-associated risk factors. Treatments including higher cumulative doses of glucocorticoids are associated with an increased risk of infections, and recent studies show the potential benefit of interventions such as reduced-dose glucocorticoid regimens. Existing mitigation strategies include screening, vaccination, and infection prophylaxis. The latter remains particularly important for Pneumocystis jirovecii pneumonia; however, the benefit-risk ratio seems to be less clear outside of induction phase (i.e., high dose of glucocorticoids) and optimal treatment duration remains less clear. Patients with PSV are at increased risk of infections, due to disease itself, comorbidities, and treatment side effects. Awareness of the timing and types of infection, as well as mitigation strategies are imperative to ensure treatment success and survival for patients.

What role do socioeconomic and clinical factors play in disease activity states in rheumatoid arthritis? Data from a large UK early inflammatory arthritis audit

BACKGROUND

Persistently active rheumatoid arthritis (pactiveRA) may be due to the interplay between biological and non-biological factors. The role of socioeconomic factors remains unclear.

OBJECTIVES

To explore which biological and non-biological factors associate with pactiveRA.

METHODS

Adults with early RA in the National Early Inflammatory Arthritis Audit, recruited from May 2018 to October 2022, were included if having pactiveRA or persistently low RA (plowRA). The pactiveRA was defined as three consecutive Disease Activity Score-28 joints (DAS28) of >3.2 at baseline, 3 and 12 months. The plowRA was defined as DAS28 ≤3.2 at 3 and 12 months. Stepwise forward logistic regression was used to explore associations with pactiveRA (outcome). Age and gender were included a priori, with socioeconomic factors and comorbidities as exposure variables.

RESULTS

682 patients with pactiveRA and 1026 plowRA were included. Compared with plowRA, patients with pactiveRA were younger (58, IQR: 49-67) versus (62, IQR: 52-72), and included more women (69% vs 59%). The pactiveRA was associated with worse scores in patient-reported outcomes at baseline, and anxiety and depression screens. Overall, there was clear social patterning in pactiveRA, with age-by-gender interaction. Logistic regression indicated age, gender, social deprivation and previous or current smoking, were independently associated with pactiveRA, after controlling for disease severity markers (seropositivity). Depression, lung disease, gastric ulcers and baseline corticosteroid use, were also associated with pactiveRA (p<0.05 for all).

CONCLUSION

Socioeconomic factors and deprivation were associated with pactiveRA, independent of clinical and disease characteristics. Identifying 'adverse' socioeconomic drivers of pactiveRA can help tailor interventions according to individual need.

Occupational impacts of early inflammatory arthritis: results from the National Early Inflammatory Arthritis Audit

OBJECTIVES

Inflammatory arthritis causes significant work disability. Studies regarding this frequently fail to report important contextual information such as employment type. Our objective was to explore work participation, by gender and occupation type, in early inflammatory arthritis.

METHODS

Data are from the National Early Inflammatory Arthritis Audit for 2018-2020. At diagnosis, clinicians collected information on demographics, inflammatory arthritis disease activity, and working status. Participants completed patient-reported outcomes at baseline, 3 months and 12 months, including occupation and Work Productivity and Activity Impairment (WPAI). Descriptive analyses of work participation and WPAI scores by occupational class at all time points were performed. Regression models were used to examine associations between WPAI score and occupation.

RESULTS

In all, 12 473 people received a diagnosis of inflammatory arthritis and reported employment status, among whom 5999 (47%) were in paid work for at least 20 hours/week. At diagnosis, the working cohort had statistically significant lower measures of disease activity (P < 0.001). Occupational data were available for 3694 individuals. At diagnosis, 2793 completed a WPAI; 200 (7.2%) had stopped work and 344 (12.3%) changed jobs because of inflammatory arthritis symptoms. There was a high burden of absenteeism (30%) and presenteeism (40%). Compared with managerial or professional workers, the burden of work disability was greater among those in routine (manual) occupations. During follow-up, 9.4% of WPAI completers stopped work and 14.6% changed roles. Work drop-out occurred almost entirely among people doing routine jobs.

CONCLUSION

It is easier to retain work in certain employment sectors. Participation in routine jobs is more affected, which may widen health inequalities.

Evaluation of serious infections, including Mycobacterium tuberculosis, during treatment with biologic disease-modifying anti-rheumatic drugs: does line of therapy matter?

OBJECTIVES

This study aimed to evaluate if and how the incidence of serious infection (SI) and active tuberculosis (TB) differ among seven biologic DMARDs (bDMARDs) in patients with RA considering the line of therapy.

METHODS

Patients with RA from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis (BSRBR-RA) cohort who initiated etanercept, certolizumab, infliximab, adalimumab, abatacept, rituximab or tocilizumab from the first to fifth line of therapy were included. Follow-up extended up to 3 years. The primary outcome was SI and the secondary outcome was TB. Event rates were calculated and compared using Cox proportional hazards models, controlling for confounding with inverse probability of treatment weights. Comparisons were made overall and stratified by line of therapy. Sensitivity analysis was restricted to all treatment courses from 2009 (tocilizumab availability) until the end of the study (2018).

RESULTS

Among 33 897 treatment courses (62 513 patient-years) the incidence of SI was 4.4/100 patient-years (95% CI 4.2, 4.5). After adjustment, hazards ratios (HRs) of SI were slightly higher with adalimumab and infliximab compared with etanercept. However, no clear pattern was observed when stratifying by line of therapy in terms of incidence rate or HR. Sensitivity analyses showed similar HRs among these treatments. Regarding TB, all 49 cases occurred during the first three lines of treatment and rarely since 2009.

CONCLUSION

The risk of serious infections does not appear to be influenced by the line of therapy in patients with RA. However, the risk of TB seems to be more frequent during the initial lines of treatment or prior to 2009.

Five-year follow-up of patients with difficult-to-treat rheumatoid arthritis

OBJECTIVES

To elucidate the long-term outcomes of patients with difficult-to-treat rheumatoid arthritis (D2T RA).

METHODS

We collected data on the clinical course of patients who had been identified as D2T RA in 2018 until 2023. We stratified the patients according to outcomes at the last visit: resolved D2T RA, persistent D2T RA, and mortality. We compared their clinical characteristics and investigated the predictive factors for the resolution of D2T RA or mortality. Furthermore, we investigated the impact of the causes of D2T RA identified in 2018, multidrug resistance, comorbidities, and socioeconomic factors on outcomes in 2023.

RESULTS

Of 173 patients identified as D2T RA in 2018, 150 were included in the analysis. Among them, D2T RA was resolved in 67 (45%), 75 (50%) remained as D2T RA, and 8 (5%) died. Patients with resolved D2T RA were significantly younger at the latest visit (p= 0.02), had a higher proportion of treatment changes during five years (p= 0.002), and had a higher proportion of interleukin-6 receptor inhibitors use in 2023 (p= 0.04) than those in patients with persistent D2T RA or those who died. D2T RA resolved in 38% of patients with multidrug resistance, mainly with treatment changes. Rheumatic disease comorbidity index and glucocorticoid dose escalation were independent risk factors for mortality (odds ratio [OR], 3.50; p= 0.02 and OR, 31.9; p= 0.002, respectively).

CONCLUSION

Further modifications in RA treatment are useful for resolving D2T RA. Multiple comorbidities and glucocorticoid use are associated with mortality.

Factors Associated With Distress Related to Perceived Dignity in Patients With Rheumatic Diseases

BACKGROUND

The loss of perceived dignity is an existential source of human suffering, described in patients with cancer and chronic diseases and hospitalized patients but rarely explored among patients with rheumatic diseases (RMDs). We recently observed that distress related to perceived dignity (DPD) was present in 26.9% of Mexican patients with different RMDs. The study aimed to investigate the factors associated with DPD.

METHODS

This cross-sectional study was performed between February and September 2022. Consecutive patients with RMDs completed patient-reported outcomes (to assess mental health, disease activity/severity, disability, fatigue, quality of life [QoL], satisfaction with medical care, and family function) and had a rheumatic evaluation to assess disease activity status and comorbidity. Sociodemographic variables and disease-related and treatment-related variables were retrieved with standardized formats. DPD was defined based on the Patient Dignity Inventory score. Multivariate regression analysis was used.

RESULTS

Four hundred patients were included and were representative of outpatients with RMDs, while 7.5% each were inpatients and patients from the emergency care unit. There were 107 patients (26.8%) with DPD. Past mental health-related comorbidity (Odds Ratio [OR]: 4.680 [95% Confidence Interval [CI]: 1.906-11.491]), the number of immunosuppressive drugs/patient (OR: 1.683 [95% CI: 1.015-2.791]), the physical health dimension score of the World Health Organization Quality of Life-Brief questionnaire (WHOQOL-BREF) (OR: 0.937 [95% CI: 0.907-0.967]), and the emotional health dimension score of the WHOQOL-BREF (OR: 0.895 [95% CI: 0.863-0.928]) were associated with DPD.

CONCLUSIONS

DPD was present in a substantial proportion of patients with RMDs and was associated with mental health-related comorbidity, disease activity/severity-related variables, and the patient QoL.

Prognostic modeling in early rheumatoid arthritis: reconsidering the predictive role of disease activity scores

OBJECTIVE

In this prospective cohort study, we provide several prognostic models to predict functional status as measured by the modified Health Assessment Questionnaire (mHAQ). The early adoption of the treat-to-target strategy in this cohort offered a unique opportunity to identify predictive factors using longitudinal data across 20 years.

METHODS

A cohort of 397 patients with early RA was used to develop statistical models to predict mHAQ score measured at baseline, 12 months, and 18 months post diagnosis, as well as serially measured mHAQ. Demographic data, clinical measures, autoantibodies, medication use, comorbid conditions, and baseline mHAQ were considered as predictors.

RESULTS

The discriminative performance of models was comparable to previous work, with an area under the receiver operator curve ranging from 0.64 to 0.88. The most consistent predictive variable was baseline mHAQ. Patient-reported outcomes including early morning stiffness, tender joint count (TJC), fatigue, pain, and patient global assessment were positively predictive of a higher mHAQ at baseline and longitudinally, as was the physician global assessment and C-reactive protein. When considering future function, a higher TJC predicted persistent disability while a higher swollen joint count predicted functional improvements with treatment.

CONCLUSION

In our study of mHAQ prediction in RA patients receiving treat-to-target therapy, patient-reported outcomes were most consistently predictive of function. Patients with high disease activity due predominantly to tenderness scores rather than swelling may benefit from less aggressive treatment escalation and an emphasis on non-pharmacological therapies, allowing for a more personalized approach to treatment. Key Points • Long-term use of the treat-to-target strategy in this patient cohort offers a unique opportunity to develop prognostic models for functional outcomes using extensive longitudinal data. • Patient reported outcomes were more consistent predictors of function than traditional prognostic markers. • Tender joint count and swollen joint count had discordant relationships with future function, adding weight to the possibility that disease activity may better guide treatment when the components are considered separately.

The Association of Rheumatologist Supply and Multidisciplinary Care With Timely Patient Access to Rheumatologists: Evidence From British Columbia, Canada

OBJECTIVE

The objective was to understand how the expansion of rheumatology supply and the introduction of multidisciplinary care was associated with access to rheumatology services.

METHODS

We accessed Population Data BC, a longitudinal database with de-identified individual-level health data on all residents of British Columbia, Canada, to analyze physician visits and prescribing from 2010-2011 to 2019-2020. We calculated access as the time from referral to first rheumatologist visit and, for people with rheumatoid arthritis (RA), time to first disease-modifying antirheumatic drug (DMARD). Associations between lag time, patient characteristics, and system variables were explored using quantile regression.

RESULTS

Over the study period, there were 149,902 new rheumatologist visits, with 31% more visits in 2019-2020 than in 2010-2011. The proportion of first visits for patients with inflammatory arthritis increased from 28% to 51%. The median time from referral to first visit decreased by 22 days (35%) from 63 days (interquartile range 21-120 days) in 2010-2011. For people with RA, time from referral to DMARD decreased by 4 days (6%) to 62 days. Male sex, living in metropolitan areas, and having a rheumatologist who used a multidisciplinary care assessment code were associated with shorter times from referral to first DMARD.

CONCLUSION

Access to rheumatology care improved, and the increased proportion of patients with IA in the first visits case-mix indicates that rheumatologist supply and incentives for multidisciplinary care may have improved referral patterns. However, time to DMARDs for people with RA remained long, and we found signals of unequal access for female patients and people living outside of metropolitan areas.

Classifying Multimorbidity Using Drug Concepts via the Rx-Risk Comorbidity Index: Methods and Comparative Cross-Sectional Study

OBJECTIVE

The study objective was to update a method to identify comorbid conditions using only medication information in circumstances in which diagnosis codes may be undercaptured, such as in single-specialty electronic health records (EHRs), and to compare the distribution of comorbidities across Rx-Risk versus other traditional comorbidity indices.

METHODS

Using First Databank, RxNorm, and its web-based clients, RxNav and RxClass, we mapped Drug Concept Unique Identifiers (RxCUIs), National Drug Codes (NDCs), and Anatomical Therapeutic Chemical (ATC) codes to Rx-Risk, a medication-focused comorbidity index. In established rheumatoid arthritis (RA) and osteoarthritis (OA) cohorts within the Rheumatology Informatics System for Effectiveness registry, we then compared Rx-Risk with other comorbidity indices, including the Charlson Comorbidity Index, Rheumatic Disease Comorbidity Index (RDCI), and Elixhauser.

RESULTS

We identified 965 unique ingredient RxCUIs representing the 46 Rx-Risk comorbidity categories. After excluding dosage form and ingredient related RxCUIs, 80,911 unique associated RxCUIs were mapped to the index. Additionally, 187,024 unique NDCs and 354 ATC codes were obtained and mapped to the index categories. When compared to traditional comorbidity indices in the RA cohort, the median score for Rx-Risk (median 6.00 [25th percentile 2, 75th percentile 9]) was much greater than for Charlson (median 0 [25th percentile 0, 75th percentile 0]), RDCI (median 0 [25th percentile 0, 75th percentile 0]), and Elixhauser (median 1 [25th percentile 1, 75th percentile 1]). Analyses of the OA cohort yielded similar results. For patients with a Charlson score of 0 (85% of total), both the RDCI and Elixhauser were close to 1, but the Rx-Risk score ranged from 0 to 16 or more.

CONCLUSION

The misclassification and under-ascertainment of comorbidities in single-specialty EHRs can largely be overcome by using a medication-focused comorbidity index.

A population-based analysis of rheumatology care patterns for inflammatory arthritis during COVID-19 in Alberta, Canada

OBJECTIVE

The aim of the study was to understand the impact of the COVID-19 pandemic on inflammatory arthritis (IA) rheumatology care in Alberta, Canada.

METHODS

We used linked provincial health administrative datasets to establish an incident cohort of individuals with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and Ankylosing Spondylitis (AS) seen at least once by a rheumatologist. We examined incidence rates (IR) per 100,000 population, and patterns of follow-up care between 2011 and 2022. In a subset of individuals diagnosed five years prior to the pandemic, we report on those lost to follow-up during the pandemic, and those with virtual care visits followed by in-person visit within 30 days. Multivariable logistic regression was used to examine patient characteristics associated with these patterns of care.

RESULTS

The IR for RA in 2020 declined compared to previous years (44.6), but not for AS (9.2) or PsA (9.1). In 2021 IRs rose (RA 49.5; AS 11.8; PsA 11.8). Among those diagnosed within 5 years of the pandemic, 632 (6.0 %) were lost to follow-up, with characteristics of those lost to follow-up differing between IA types. 1444 individuals had at least one virtual visit followed within 30 days by an in-person follow-up. This was less common in males (OR 0.69-0.79) and more common for those with a higher frequency of physician visits prior to the pandemic (OR 1.27-1.32).

CONCLUSION

Impacts of patterns of care during the pandemic should be further explored for healthcare planning to uphold optimal care access and promote effective use of virtual care.

Impact of multimorbidity on the first ts/bDMARD effectiveness and retention rate after two years of follow-up in patients with rheumatoid arthritis from the BIOBADASER registry

BACKGROUND

Patients with Rheumatoid Arthritis (RA) have a higher prevalence of comorbidities compared to the general population. However, the implications of multimorbidity on therapeutic response and treatment retention remain unexplored.

OBJECTIVES

(a) To evaluate the impact of multimorbidity on the effectiveness of the first targeted synthetic or biologic disease-modifying antirheumatic drug (ts/bDMARD), in patients with RA after 2-year follow-up; (b) to investigate the influence of multimorbidity on treatment retention rate.

METHODS

Patients with RA from the BIOBADASER registry exposed to a first ts/bDMARDs were included. Patients were categorized based on multimorbidity status at baseline, defined as a Charlson Comorbidity index (CCI) score ≥ 3. A linear regression model, adjusted for sex and age, was employed to compare the absolute DAS28 score over time after ts/bDMARD initiation between the two groups. The Log-Rank test and Kaplan-Meier curve were used to compare the retention rates of the first ts/bDMARD between the groups.

RESULTS

A total of 1128 patients initiating ts/bDMARD were included, with 107 (9.3%) exhibiting multimorbidity. The linear regression model showed significantly higher DAS28 (beta coefficient 0.33, 95%CI:0.07-0.58) over a two-year period in patients with multimorbidity, even after adjusting for age and sex. Finally, no differences in the ts/bDMARD retention rate were found between groups (median 6.94-6.96 years in CCI < 3 vs. 5.68-5.62 in CCI ≥ 3; p = 0.610).

CONCLUSIONS

Multimorbidity in patients with RA was associated with greater DAS28 scores within the first two years after ts/bDMARD initiation, in comparison with patients without multimorbidity. A slightly shorter retention rate was found in patients with multimorbidity, although the difference was non-significant.

Patterns of comorbidities differentially affect long-term functional evolution and disease activity in patients with 'difficult to treat' rheumatoid arthritis

BACKGROUND

Characterisation of the long-term outcome of patients with 'difficult to treat' (D2T) rheumatoid arthritis and factors contributing to its evolution are unknown. Herein, we explored the heterogeneity and contributing factors of D2T long-term outcome.

METHODS

Patients included from a prospective single centre cohort study. The EULAR definition of D2T was applied. Longitudinal clustering of functional status (modified Health Assessment Questionnaire (mHAQ)) and disease activity (Disease Activity Score-28 (DAS28)) were assessed using latent-class trajectory analysis. Multiple linear mixed models were used to examine the impact of comorbidities and their clusters on the long-term outcome.

RESULTS

251 out of 1264 patients (19.9%) were identified as D2T. Younger age, fibromyalgia, osteoarthritis, DAS28-erythrocyte sedimentation rate (ESR) at first biological or targeted synthetic disease-modifying antirheumatic drug (b/ts-DMARD) initiation and failure to reduce DAS28-ESR scores within the first 6 months of b/ts-DMARD therapy were significant predictors of patients becoming D2T. Long-term follow-up (total of 5872 person-years) revealed four groups of functional status evolution: 18.2% had stable, mildly compromised mHAQ (mean 0.41), 39.9% had gradual improvement (1.21-0.87) and two groups had either slow deterioration or stable significant functional impairment (HAQ>1). Similarly, four distinct groups of disease activity evolution were identified. Among the different clusters of comorbidities assessed, presence of 'mental-health and pain-related illnesses' or 'metabolic diseases' had significant contribution to mHAQ worsening (p<0.0001 for both) and DAS28 evolution (p<0.0001 and p=0.018, respectively).

CONCLUSION

D2T patients represent a heterogeneous group in terms of long-term disease course. Mental-health/pain-related illnesses as well as metabolic diseases contribute to long-term adverse outcomes and should be targeted in order to optimise the prognosis of this subset of rheumatoid arthritis.

Comorbidities and chance of remission in patients with early rheumatoid arthritis receiving methotrexate as first-line therapy: a Swedish observational nationwide study

OBJECTIVES

This study aims to examine whether comorbidities affect the likelihood of reaching primary remission on methotrexate monotherapy as the first disease-modifying antirheumatic drug (DMARD) in early rheumatoid arthritis (RA).

METHODS

We used nationwide Swedish clinical and quality registers to collect RA disease activity measures and comorbidity data for patients diagnosed with RA 2007-2020 (n=11 001). The primary outcome was failure to reach 28-joint Disease Activity Score (DAS28) remission at 3 months. Secondary outcomes included Boolean, Simplified Disease Activity Index/Clinical Disease Activity Index remission, European Alliance of Associations for Rheumatology response and no swollen joint count at 3 and 6 months. For each comorbidity, and for combinations thereof, we calculated adjusted relative risks (RRs) of failure to reach remission, using modified Poisson regression.

RESULTS

In total, 53% (n=4019/7643) failed to reach DAS28 remission after 3 months of methotrexate monotherapy, ranging from 66% (n=25/38) among patients with chronic kidney disease to 48% (n=154/319) in patients with previous cancer. The risk of not reaching DAS28 remission at 3 months (RR adjusted for sex and age) was increased among patients with endocrine (RR 1.08, 95% CI 1.01 to 1.15), gastrointestinal (RR 1.16, 95% CI 1.03 to 1.30), infectious (RR 1.21, 95% CI 1.06 to 1.38), psychiatric (RR 1.24, 95% CI 1.15 to 1.35) and respiratory comorbidities (RR 1.16, 95% CI 1.01 to 1.32). Having three or more comorbidity categories was associated with a 27% higher risk of DAS28 remission failure at 3 months. A similar pattern was observed for the secondary outcomes.

CONCLUSIONS

Comorbidities decrease the chance of reaching remission on methotrexate as DMARD monotherapy in patients with early RA and are important to consider when assessing treatment outcomes.

Major adverse cardiovascular events and mortality with opioids versus NSAIDs initiation in patients with rheumatoid arthritis

OBJECTIVE

Assess major adverse cardiovascular event (MACE) risk with opioids compared with non-steroidal anti-inflammatory drugs (NSAIDs) in patients with rheumatoid arthritis (RA) METHODS: We conducted a new-user active comparator cohort study among patients with RA within FORWARD, The National Databank for Rheumatic Diseases, with ≥1 year participation between 1998 and 2021. Each opioid initiator was matched to two NSAID initiators by propensity scores (PSs). Patients were followed until the occurrence of the composite endpoint of MACE (myocardial infarction, stroke, heart failure, cardiovascular disease (CVD) death, venous thromboembolism (VTE)) and all-cause mortality. The risk of outcomes was estimated using Cox proportional hazards with adjustment for PS weights and imbalanced covariables.

RESULTS

Among 6866 opioid initiators and 13 689 NSAID initiators, 212 vs 253 MACE (20.6/1000 person-years (PY) vs 18.9/1000 PY) and 144 vs 150 deaths (13.5/1000 PY vs 10.8/1000 PY) occurred, respectively. The risk of MACE with opioids was similar to NSAIDs (HR=1.02, 95% CI 0.85 to 1.22), whereas all-cause mortality with opioids was 33% higher than NSAIDs (HR=1.33, 95% CI 1.06 to 1.67) in PS-weighted models. Among the individual outcomes of MACE, VTE risk tended to be higher in opioid initiators than NSAID initiators (HR=1.41, 95% CI 0.84 to 2.35). Strong opioids had a higher risk for all-cause mortality and VTE than weak opioids compared with NSAIDs suggesting a dose-dependent association.

CONCLUSION

Opioids had similar MACE risk compared with NSAIDs in patients with RA with increased all-cause mortality and likely VTE, which suggests that opioids are not safer than NSAIDs, as clinicians have perceived.

Clinical Features Associated With Rate of Fractures in Patients With Systemic Sclerosis: A US Cohort Study

OBJECTIVE

Systemic sclerosis (SSc) is associated with several specific risk factors for fracture due to the complications of the disease and related medications. The present study was undertaken to examine the relationship between SSc-associated clinical features and fracture rate in a large US cohort.

METHODS

Participants with SSc in FORWARD, The National Databank for Rheumatic Diseases, were included (1998-2019). Age- and sex-matched individuals with osteoarthritis (OA) from the same database were included as comparators. The primary end point was self-reported major osteoporotic fracture. Cox proportional hazards models were used to study the associations between risk factors and fractures.

RESULTS

The study included 922 individuals (SSc patients, n = 154; OA patients, n = 768). Eighty-seven percent were female, with a mean age of 57.8 years. Fifty-one patients developed at least 1 fracture during a median of 4.2 years (0.5-22.0 years) of follow-up. Patients with SSc had more frequent fractures compared to OA comparators (hazard ratio [HR] 2.38 [95% confidence interval (95% CI) 1.47-3.83]). Among patients with SSc, a higher Rheumatic Disease Comorbidity Index score (HR 1.45 [95% CI 1.20-1.75]) and a higher Health Assessment Questionnaire disability index score (HR 3.83 [95% CI 2.12-6.93]) were associated with more fractures. Diabetes mellitus (HR 5.89 [95% CI 2.51-13.82]) and renal disease (HR 2.43 [95% CI 1.10-5.37]) were independently associated with fracture among SSc patients relative to SSc patients without these comorbidities.

CONCLUSION

Our findings highlight factors associated with fracture among patients with SSc. Disability as measured by the HAQ DI is a particularly strong indicator of fracture rate in SSc. Improving SSc patients' functional status, where possible, may lead to better long-term outcomes.

Viewpoint: how to measure comorbidities in patients with rheumatoid arthritis - clinical and academic value

Given the high prevalence and the enormous impact on key outcomes, comorbidities are important to consider, especially in patients with RA. Comorbidity indices are tools to quantify the impact of the overall burden of coexisting diseases on a specific outcome of interest. Until now, no gold standard exists on how to measure comorbidities. A large variety of indices have been developed using different settings and therefore leading to conceptual differences. Choosing the right tool clearly depends on the intention (clinical or research purpose) and the specific research question. The current article will address the purpose and challenge of measuring comorbidities in RA patients.

Multimorbidity in rheumatoid arthritis: common mechanistic links and impact and challenges in routine clinical practice

Early identification and management of multimorbidity in patients with rheumatic and musculoskeletal diseases (RMDs), such as RA, is an integral, but often neglected, aspect of care. The prevalence and incidence of conditions such as osteoporosis, cardiovascular disease, pulmonary disease and malignancies, often co-existing with RA, continues to have significant implications for the management of this patient group. Multimorbidity in RMDs can be associated with inflammatory disease activity and target organ damage. Lifestyle factors, such as smoking and inactivity, further contribute to the burden of disease. Inflammation is the underlying factor, not just in RA but also many comorbidities. The current framework of a treat-to-target approach focuses on achieving early remission and inflammatory activity suppression. We describe how the comorbidity burden in people with RMDs impacts on disease outcome and treatment response. The importance of addressing comorbidity at an early stage and adopting a patient centred approach is critical in modern practice.

The Multimorbidity Web in rheumatoid arthritis

Multimorbidity, the presence of multiple chronic conditions, is highly prevalent in people with RA. An essential characteristic of multimorbidity is the interrelatedness of the different conditions that may develop in a multimorbid person. Recent studies have begun to identify and describe the Multimorbidity Web by elucidating unique multimorbidity patterns in people with RA. The primary multimorbidity patterns in this web are cardiopulmonary, cardiometabolic, and mental health and chronic pain multimorbidity. Once caught in the Multimorbidity Web, the consequences can be devastating, with reduced quality of life, physical function, survival, and treatment responses observed in multimorbid RA persons. The development of effective management and preventive approaches for multimorbidity in people with RA is in its infancy. Determining how best to assess, intervene, and prevent multimorbidity in RA is crucial to optimize long-term outcomes in people with RA.

Updating and Validating the Rheumatic Disease Comorbidity Index to Incorporate ICD-10-CM Diagnostic Codes

OBJECTIVE

To update and validate the Rheumatic Disease Comorbidity Index (RDCI) utilizing International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes.

METHODS

We defined ICD-9-CM (n = 1,068) and ICD-10-CM (n = 1,425) era cohorts (n = 862 in both) spanning the ICD-9-CM to ICD-10-CM transition in a multicenter, prospective rheumatoid arthritis registry. Information regarding comorbidities was collected from linked administrative data over 2-year assessment periods. An ICD-10-CM code list was generated from crosswalks and clinical expertise. ICD-9- and ICD-10-derived RDCI scores were compared using intraclass correlation coefficients (ICC). The predictive ability of the RDCI for functional status and death during follow-up was assessed using multivariable regression models and goodness-of-fit statistics (Akaike's information criterion [AIC] and quasi information criterion [QIC]) in both cohorts.

RESULTS

Mean ± SD RDCI scores were 2.93 ± 1.72 in the ICD-9-CM cohort and 2.92 ± 1.74 in the ICD-10-CM cohort. RDCI scores had substantial agreement in individuals who were in both cohorts (ICC 0.71 [95% confidence interval 0.68-0.74]). Prevalence of comorbidities was similar between cohorts with absolute differences <6%. Higher RDCI scores were associated with a greater risk of death and poorer functional status during follow-up in both cohorts. Similarly, in both cohorts, models including the RDCI score had the lowest QIC (functional status) and AIC (death) values, indicating better model performance.

CONCLUSION

The newly proposed ICD-10-CM codes for the RDCI-generated comparable RDCI scores to those derived from ICD-9-CM codes and are highly predictive of functional status and death. The proposed ICD-10-CM codes for the RDCI can be used in rheumatic disease outcomes research spanning the ICD-10-CM era.

COVID-19 admissions and mortality in patients with early inflammatory arthritis: results from a UK national cohort

OBJECTIVE

To describe the risks and predictors of coronavirus disease 2019 (COVID-19) hospitalization and mortality among patients with early inflammatory arthritis (EIA), recruited to the National Early Inflammatory Arthritis Audit (NEIAA).

METHODS

NEIAA is an observational cohort. We included adults with EIA from Feb 2020 to May 2021. Outcomes of interest were hospitalization and death due to COVID-19, using NHS Digital linkage. Cox proportional hazards were used to calculate hazard ratios for outcomes according to initial treatment strategy, with adjustment for confounders.

RESULTS

From 14 127 patients with EIA, there were 143 hospitalizations and 47 deaths due to COVID-19, with incidence rates per 100 person-years of 0.93 (95% CI 0.79, 1.10) for hospitalization and 0.30 (95% CI 0.23, 0.40) for death. Increasing age, male gender, comorbidities and ex-smoking were associated with increased risk of worse COVID-19 outcomes. Higher baseline DAS28 was not associated with COVID-19 admissions [confounder adjusted hazard ratio (aHR) 1.10; 95% CI 0.97, 1.24] or mortality (aHR 1.11; 95% CI 0.90, 1.37). Seropositivity was not associated with either outcome. Higher symptom burden on patient-reported measures predicted worse COVID-19 outcomes. In unadjusted models, CS associated with COVID-19 death (HR 2.29; 95% CI 1.02, 5.13), and SSZ monotherapy associated with COVID-19 admission (HR 1.92; 95% CI 1.04, 3.56). In adjusted models, associations for CS and SSZ were not statistically significant.

CONCLUSION

Patient characteristics have stronger associations with COVID-19 than the initial treatment strategy in patients with EIA. An important limitation is that we have not looked at treatment changes over time.

Work limitations and associated factors in rheumatoid arthritis, axial spondyloarthritis, osteoarthritis and fibromyalgia

INTRODUCTION

Rheumatic and musculoskeletal diseases (RMD) impact on work participation. The aims of this study were to: examine work limitations of working people with: rheumatoid arthritis, axial spondyloarthritis (axSpA), osteoarthritis, or fibromyalgia using the Workplace Activity Limitations Scale (WALS, a measure of presenteeism); and identify personal, functioning and disability, and work contextual factors associated with presenteeism.

METHODS

Secondary analysis was conducted of a cross-sectional survey including work outcome measures (WORK-PROM study). A literature review identified variables (coded to ICF) to include in multivariable regressions examining factors associated with presenteeism.

RESULTS

Moderate to high WALS scores were identified in: 93.60% with FM; 69.90% OA; 65.20% RA; and 46.80% axSpA (n = 822). Similarities in work limitations were noted across conditions, although some more problematic in specific RMD. Participants received help with about a quarter of activities (27%RA; 25%FM; 23%OA; 17%axSpA) and work adaptations for less than a fifth causing difficulty (18%FM; 14%RA; 14%OA; 9%axSpA). Literature review identified 33 variables in the WORK-PROM dataset to include in multivariable regressions. Factors associated with higher WALS scores were worse: functional limitations, job strain, pain, difficulties with mental-interpersonal job demands, perceived health status, work-life balance, greater need for work accommodations and lack of perceived work support.

DISCUSSION

This study extends understanding of work limitations of working people with these four RMD, the extent of help and adaptations received, need for more work accommodation support, and focus on work support, work rehabilitation, and healthy workplace practices to help keep people working.

Online Patient-Reported Outcome Measure Engagement Is Dependent on Demographics and Locality: Findings From an Observational Cohort

OBJECTIVE

Online patient-reported outcome measures (PROMs) enable remote collection of perceptions of health status, function, and well-being. We aimed to explore patterns of PROM completion in patients with early inflammatory arthritis (EIA) recruited to the National Early Inflammatory Arthritis Audit (NEIAA).

METHODS

NEIAA is an observational cohort study design; we included adults from this cohort with a new diagnosis of EIA from May 2018 to March 2020. The primary outcome was PROM completion at baseline, 3 months, and 12 months. Mixed effects logistic regression and spatial regression models were used to identify associations between demographics (age, gender, ethnicity, deprivation, smoking, and comorbidity), clinical commissioning groups, and PROM completion.

RESULTS

Eleven thousand nine hundred eighty-six patients with EIA were included, of whom 5331 (44.5%) completed at least 1 PROM. Patients from ethnic minority backgrounds were less likely to return a PROM (adjusted odds ratio [aOR] 0.57, 95% CI 0.48-0.66). Greater deprivation (aOR 0.73, 95% CI 0.64-0.83), male gender (aOR 0.86, 95% CI 0.78-0.94), higher comorbidity burden (aOR 0.95, 95% CI 0.91-0.99), and current smoker status (aOR 0.73, 95% CI 0.64-0.82) also reduced odds of PROM completion. Spatial analysis identified 2 regions with high (North of England) and low (Southeast of England) PROM completion.

CONCLUSION

We define key patient characteristics (including ethnicity) that influence PROM engagement using a national clinical audit. We observed an association between locality and PROM completion, with varying response rates across regions of England. Completion rates could benefit from targeted education for these groups.

Perceived dignity is an unrecognized source of emotional distress in patients with rheumatic diseases: Results from the validation of the Mexican version of the Patient Dignity Inventory

INTRODUCTION

Dignity has rarely been explored in patients with rheumatic diseases (RMDs), which contrasts with patients´ observations that dignity is a relevant area for research focus. The study's primary objective was to adapt and validate the Mexican version of the Patient Dignity Inventory (PDI-Mx) in patients with RMDs, and to estimate the proportion of patients with distress related to perceived dignity (DPD) assessed with the PDI-Mx.

METHODS

This cross-sectional study was developed in 2 phases. Phase 1 consisted of pilot testing and questionnaire feasibility (n = 50 patients), PDI-Mx content validity (experts' agreement), construct validity (exploratory factor analysis), discriminant validity (Heterotrait-Monotrait correlations' rate [HTMT]), criterion validity (Spearman correlations) and PDI-Mx reliability with internal consistency (Cronbach's alpha) and test-retest (intra-class correlation coefficients [ICC]) in 220 additional outpatients (among whom 30 underwent test-retest). Phase 2 consisted of quantifying DPD (PDI-Mx cut-off ≥54.4) in 290 outpatients with RMDs.

RESULTS

Overall, patients were representative of typical outpatients with RMDs from a National tertiary care level center. The 25-item PDI-Mx was found feasible, valid (experts' agreement ≥82%; a 4-factor structure accounted for 68.7% of the total variance; HTMT = 0.608; the strength of the correlations was moderate to high between the PDI-Mx, the Depression, Anxiety, and Stress scale dimensions scores, and the Health Assessment Questionnaire Disability Index score) and reliable (Cronbach's ɑ = 0.962, ICC = 0.939 [95%CI = 0.913-0.961]). DPD was present in 78 patients (26.9%).

CONCLUSIONS

The PDI-Mx questionnaire showed good psychometric properties for assessing DPD in our population. Perceived dignity in patients with RMDs might be an unrecognized source of emotional distress.

Real-World Sarilumab Use and Rule Testing to Predict Treatment Response in Patients with Rheumatoid Arthritis: Findings from the RISE Registry

INTRODUCTION

Clinical trial findings may not be generalizable to routine practice. This study evaluated sarilumab effectiveness in patients with rheumatoid arthritis (RA) and tested the real-world applicability of a response prediction rule, derived from trial data using machine learning (based on C-reactive protein [CRP] > 12.3 mg/l and seropositivity [anticyclic citrullinated peptide antibodies, ACPA +]).

METHODS

Sarilumab initiators from the ACR-RISE Registry, with ≥ 1 prescription on/after its FDA approval (2017-2020), were divided into three cohorts based on progressively restrictive criteria: Cohort A (had active disease), Cohort B (met eligibility criteria of a phase 3 trial in RA patients with inadequate response/intolerance to tumor necrosis factor inhibitors [TNFi]), and Cohort C (characteristics matched to the phase 3 trial baseline). Mean changes in Clinical Disease Activity Index (CDAI) and Routine Assessment of Patient Index Data 3 (RAPID3) were evaluated at 6 and 12 months. In a separate cohort, predictive rule was tested based on CRP levels and seropositive status (ACPA and/or rheumatoid factor); patients were categorized into rule-positive (seropositive with CRP > 12.3 mg/l) and rule-negative groups to compare the odds of achieving CDAI low disease activity (LDA)/remission and minimal clinically important difference (MCID) over 24 weeks.

RESULTS

Among sarilumab initiators (N = 2949), treatment effectiveness was noted across cohorts, with greater improvement noted for Cohort C at 6 and 12 months. Among the predictive rule cohort (N = 205), rule-positive (vs. rule-negative) patients were more likely to reach LDA (odds ratio: 1.5 [0.7, 3.2]) and MCID (1.1 [0.5, 2.4]). Sensitivity analyses (CRP > 5 mg/l) showed better response to sarilumab in rule-positive patients.

CONCLUSIONS

In real-world setting, sarilumab demonstrated treatment effectiveness, with greater improvements in the most selective population, mirroring phase 3 TNFi-refractory and rule-positive RA patients. Seropositivity appeared a stronger driver for treatment response than CRP, although optimization of the rule in routine practice requires further data.

A Narrowing Mortality Gap: Temporal Trends of Cause-Specific Mortality in a National Matched Cohort Study in US Veterans With Rheumatoid Arthritis

OBJECTIVE

To examine temporal trends in all-cause and cause-specific mortality in patients with rheumatoid arthritis (RA) in the Veterans Health Administration (VHA).

METHODS

We conducted a matched cohort study in the VHA from January 1, 2000 to December 31, 2017. Incident RA patients were matched up to 1:10 on age, sex, and VHA enrollment year to non-RA patients, then followed until death or end of study period. Cause of death was obtained from the National Death Index. Multivariable Cox regression models stratified by RA diagnosis years were used to examine trends in RA-related risk of all-cause and cause-specific mortality.

RESULTS

Among 29,779 incident RA patients (matched to 245,226 non-RA patients), 9,565 deaths occurred. RA patients were at increased risk of all-cause (adjusted hazard ratio [HRadj ] 1.23 [95% confidence interval (95% CI) 1.20-1.26]), cardiovascular (HRadj 1.19 [95% CI 1.14-1.23]), cancer (HRadj 1.19 [95% CI 1.14-1.24]), respiratory (HRadj 1.46 [95% CI 1.38-1.55]), and infection-related mortality (HRadj 1.59 [95% CI 1.41-1.80]). Interstitial lung disease was the cause of death most strongly associated with RA (HRadj 3.39 [95% CI 2.88-3.99]). Nearly 70% of excess deaths in RA were attributable to cardiopulmonary disease. All-cause mortality risk related to RA was lower among those diagnosed during 2012-2017 (HRadj 1.10 [95% CI 1.05-1.15]) compared to 2000-2005 (HRadj 1.31 [95% CI 1.26-1.36]), but still higher than for non-RA controls (P < 0.001). Cause-specific mortality trends were similar.

CONCLUSION

Excess RA-related mortality was driven by cardiovascular, cancer, respiratory, and infectious causes, particularly cardiopulmonary diseases. Although our findings support that RA-related mortality risk is decreasing over time, a mortality gap remains for all-cause and cause-specific mortality in RA.

Associations of Cost Sharing With Rheumatoid Arthritis Disease Burden

OBJECTIVE

To evaluate the regional variation of cost sharing and associations with rheumatoid arthritis (RA) disease burden in the US.

METHODS

Patients with RA from rheumatology practices in Northeast, South, and West US regions were evaluated. Sociodemographics, RA disease status, and comorbidities were collected, and Rheumatic Disease Comorbidity Index (RDCI) score was calculated. Primary insurance types and copay for office visits (OVs) and medications were documented. Univariable pairwise differences between regions were conducted, and multivariable regression models were estimated to evaluate associations of RDCI with insurance, geographical region, and race.

RESULTS

In a cohort of 402 predominantly female, White patients with RA, most received government versus private sponsored primary insurance (40% vs. 27.9%). Disease activity and RDCI were highest for patients in the South region, where copays for OVs were more frequently more than $25. Copays for OVs and medications were less than $10 in 45% and 31.8% of observations, respectively, and more prevalent in the Northeast and West patient subsets than in the South subset. Overall, RDCI score was significantly higher for OV copays less than $10 as well as for medication copays less than $25, both independent of region or race. Additionally, RDCI was significantly lower for privately insured than Medicare individuals (RDCI -0.78, 95% CI [-0.41 to -1.15], P < 0.001) and Medicaid (RDCI -0.83, 95% CI [-0.13 to -1.54], P = 0.020), independent of region and race.

CONCLUSION

Cost sharing may not facilitate optimum care for patients with RA, especially in the Southern regions. More support may be required of government insurance plans to accommodate patients with RA with a high disease burden.

Aortic Stenosis Risk in Rheumatoid Arthritis

Importance

Although an increased risk of ischemic cardiovascular disease has been associated with rheumatoid arthritis (RA), the risk of aortic stenosis (AS) is unknown.

Objective

To examine the risk of incident AS, aortic valve intervention, AS-related death, and risk factors for AS development in patients with RA.

Design, Setting, and Participants

This cohort study linked data from the Veterans Health Administration (VHA) and Centers for Medicare & Medicaid Services from 2000 to 2019. Patients with RA were matched by age, sex, and VHA enrollment year with up to 10 patients without RA. The cohort was followed until incident AS, aortic valve intervention, or death. Data were analyzed from August 23, 2022, to March 3, 2023.

Exposures

the primary exposure was the presence of RA, defined using validated RA algorithms.

Main Outcomes and Measures

Aortic stenosis was defined as a composite of inpatient or outpatient diagnoses, surgical or transcatheter aortic valve replacement, or AS-related death using diagnostic and procedural codes. Risk of AS development was assessed with multivariable Cox proportional hazards models adjusted for race, ethnicity, smoking status, body mass index, rurality, comorbidities, and health care use.

Results

The cohort included 73 070 patients with RA (64 008 [87.6%] males; mean [SD] age, 63.0 [11.9] years) matched with 639 268 patients without RA (554 182 [86.7%] males; mean [SD] age, 61.9 [11.7] years) and 16 109 composite AS outcomes that occurred over 6 223 150 person-years. The AS incidence rate was 3.97 (95% CI, 3.81-4.13) per 1000 person-years in patients with RA and 2.45 (95% CI, 2.41-2.49) per 1000 person-years in the control patients (absolute difference, 1.52 per 1000 person-years). Rheumatoid arthritis was associated with an increased risk of composite AS (adjusted hazard ratio [AHR], 1.48; 95% CI, 1.41-1.55), aortic valve intervention (AHR, 1.34; 95% CI, 1.22-1.48), and AS-related death (AHR, 1.26; 95% CI, 1.04-1.54).

Conclusions and Relevance

In this cohort study, RA was associated with a higher risk of developing AS and the subsequent risks of undergoing aortic valve intervention and suffering from AS-related death. Future studies are needed to confirm whether valvular heart disease, specifically AS, may be an overlooked cardiovascular disease complication in RA.

Trajectories of self-reported pain-related health outcomes and longitudinal effects on medication use in rheumatoid arthritis: a prospective cohort analysis using the Australian Rheumatology Association Database (ARAD)

OBJECTIVE

To determine distinct trajectories of self-reported pain-related health status in rheumatoid arthritis (RA), their relationship with sociodemographic factors and medication use.

METHODS

988 Australian Rheumatology Association Database participants with RA (71% female, mean age 54 years, mean disease duration 2.3 years) were included. Distinct multi-trajectories over 15-year follow-up for five different self-reported pain-related health outcome measures (Health Assessment Questionnaire Disability Index, visual analogue scores for pain, arthritis, global health and the Assessment of Quality of Life utility index) were identified using latent variable discrete mixture modelling. Random effects models were used to determine associations with medication use and biologic therapy modification during follow-up.

RESULTS

Four, approximately equally sized, pain/health status groups were identified, ranging from 'better' to 'poorer', within which changes over time were relatively small. Important determinants of those with poorer pain/health status included female gender, obesity, smoking, socioeconomic indicators and comorbidities. While biologic therapy use was similar between groups during follow-up, biologic therapy modifications (p_linear<0.001) and greater tendency of non-tumour necrosis factor inhibitor use (p_linear<0.001) were observed in those with poorer pain/health status. Similarly, greater use of opioids, prednisolone and non-steroidal anti-inflammatory drugs was seen in those with poorer pain/health status.

CONCLUSION

In the absence of disease activity information, distinct trajectories of varying pain/health status were seen from the outset and throughout the disease course in this RA cohort. More biologic therapy modifications and greater use in anti-inflammatories, opioids and prednisolone were seen in those with poorer pain/health status, reflecting undesirable lived experience of persistent pain in RA.

Discontinuation rate of sulfasalazine, leflunomide and methotrexate due to adverse events in a real-life setting (NOR-DMARD)

Objectives

MTX, LEF and SSZ are conventional synthetic DMARDs (csDMARDs) with a well-established role in the treatment of RA. We aimed to estimate and compare the relative risks for adverse events (AEs) and the discontinuation of these drugs owing to AEs.

Methods

We included all 3339 patients from the NOR-DMARD study treated with MTX, LEF or SSZ in monotherapy. All reported AEs were compared between treatment groups using quasi-Poisson regression. In addition, drug retention rates were analysed using Kaplan-Meier estimates with Cox regression to control for possible confounders. We analysed drug retention rates and cumulative risk of discontinuation attributable to AEs using the Kaplan-Meier estimator. We assessed age, sex, baseline DAS in 28 joints with ESR (DAS28-ESR), seropositivity, prednisolone use, previous DMARD use, year of inclusion and co-morbidity as possible cofounders.

Results

We found that the discontinuation rate attributable to AEs was significantly higher for LEF and SSZ than for MTX. After the first year, it was 13.7% (95% CI 12.2, 15.2), 39.6% (95% CI 34.8, 44) and 43.4% (95% CI 38.2, 48.1) for MTX, SSZ and LEF, respectively. Similar results were found when adjusting for confounders. The overall AEs were comparable across the treatment groups. The AE profile was as expected for each drug.

Conclusion

Our work has shown a similar AE profile of csDMARDs to previous data. However, higher discontinuation rates for SSZ and LEF cannot be explained easily from AE profiles.

Examining Rehabilitation Dose in Adults With Rheumatoid Arthritis: Association With Baseline Factors and Change in Clinical Outcomes

OBJECTIVE

To evaluate the association of baseline factors with rehabilitation dose and the association of rehabilitation dose with meaningful change in physical function, pain, and fatigue over 6 months among adults with rheumatoid arthritis (RA).

METHODS

Using data from the National Databank for Rheumatic Diseases registry, we extracted baseline characteristics and self-reported physical function (Health Assessment Questionnaire), pain (visual analog scale [VAS]), fatigue (VAS), rehabilitation dose (low: 1-2 visits, medium: 3-8 visits, high: >8 visits), and follow-up outcomes 6 months later. Changes in clinical outcomes were categorized as improved, no change, or worsened. We calculated odds ratios (ORs) and 95% confidence intervals (95% CIs) using proportional odds logistic regression models to examine the association of the baseline factors with rehabilitation dose and the association of rehabilitation dose with changes in clinical outcomes, adjusting for potential confounders.

RESULTS

The sample included 1,381 adults with a new episode of rehabilitation (dose: low 27%, medium 42%, high 31%). Worse baseline physical function (adjusted OR 1.29 [95% CI 1.04-1.60]), but not pain (adjusted OR 1.04 [95% CI 0.99-1.10]) or fatigue (adjusted OR 0.98 [95% CI 0.93-1.03]), were associated with a higher rehabilitation dose. A high rehabilitation dose was associated with a favorable change in physical function (OR 1.51 [95% CI 1.14-1.98]), pain (OR 1.44 [95% CI 1.06-1.96]), and fatigue (OR 1.45 [95% CI 1.06-1.99]) compared to a low dose; only the association with physical function change persisted in adjusted models (adjusted OR 1.41 [95% CI 1.03-1.92]).

CONCLUSION

Using real-world data, this study supports a higher rehabilitation dose to improve physical function in adults with RA.

Smoking cessation patterns, usefulness of quitting methods, and tobacco cessation motivators and barriers to quit in patients with rheumatoid arthritis

OBJECTIVE

Tobacco use is highly discouraged in patients with rheumatoid arthritis (RA) due to related short and long-term health implications. We aimed to evaluate smoking cessation patterns in patients with RA. In addition, we ascertained perceptions on the usefulness of quitting methods, and perceived motivators and barriers to quit.

METHODS

We surveyed adults with RA enrolled in the FORWARD Databank who self-identified as former or current tobacco users.

RESULTS

Three hundred forty-eight participants completed the survey and responded to the question "do you currently smoke" (former use = 319; current use = 29). Nicotine replacement therapy (NRT) was perceived as extremely/somewhat useful by 31%, followed by individual 27% and group counseling 21%. Experiencing a major health event was the most common motivator to quit. Current users on average smoked 17 cigarettes per day. Six of the 29 current users had used electronic cigarettes in the past 30 days. The most frequent methods used to quit were "cold turkey quitting," NRT, and prescription medicines. Only 8 of the 23 current users had plans to quit or expressed being ready to make changes to quit. Reasons most frequently listed to not quit were using smoking to manage negative emotions, as a pleasurable habit, to manage other addictions, and to provide a sense of control (e.g., to cope with RA).

CONCLUSIONS

Current users expressed several negative emotions including coping with the disease and "being a pleasurable habit" when trying to quit. Future cessation programs should address these barriers to support patients with RA. Key Points • First study characterizing the smoking behavior of patients with RA in the USA. Current users were younger, had a shorter disease duration, and worse disease outcomes compared to former smokers. • Former and current users reported similar motivators to quit, with experiencing a major health event being most common. Only about a third of participants who quit or who were still smoking received advice from a health professional. • The most common reasons for not quitting were that smoking help to manage negative emotions and was a pleasurable habit. Future studies should focus on cessation programs that support participants with RA by addressing the unique perceptions about smoking in this population.