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Taylor PC, Law ST. When the first visit to the rheumatologist is established rheumatoid arthritis. Best Pract Res Clin Rheumatol 2020; 33:101479. [PMID: 32001168 DOI: 10.1016/j.berh.2019.101479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The outlook for people living with rheumatoid arthritis (RA) has improved tremendously in a generation. Major contributions to this include recognition of the importance of early treatment initiation, improved understanding of the pathobiology, the identification of therapeutic targets and their subsequent validation in clinic trials and the realisation of the importance of 'tight control' of inflammatory responses. Despite these advances, many patients meeting classification criteria present for the first time to a rheumatologist with longstanding symptoms. There is no definition as to when RA becomes 'established'. But there is evidence that a 'window of opportunity' exists over about 12-16 weeks symptom duration, during which treatment intervention gives rise to the most optimal outcomes. This review addresses issues regarding the management of patients presenting outside the window of opportunity in terms of heterogeneity of presentation, assessment, therapeutic goals and treatment options as well as the importance of a multidisciplinary approach to holistic care.
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Ling SF, Viatte S, Lunt M, Van Sijl AM, Silva-Fernandez L, Symmons DPM, Young A, Macgregor AJ, Barton A. HLA-DRB1 Amino Acid Positions 11/13, 71, and 74 Are Associated With Inflammation Level, Disease Activity, and the Health Assessment Questionnaire Score in Patients With Inflammatory Polyarthritis. Arthritis Rheumatol 2017; 68:2618-2628. [PMID: 27274008 PMCID: PMC5244675 DOI: 10.1002/art.39780] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 06/01/2016] [Indexed: 02/01/2023]
Abstract
Objective Rheumatoid arthritis (RA) susceptibility HLA–DRB1 haplotypes based on amino acid positions 11/13, 71, and 74 predict radiographic damage. The mechanism of action is unknown, but it may be mediated by inflammation. We undertook this study to systematically investigate the effect of these amino acids on nonradiographic measures of disease activity/outcomes. Methods We tested the association of RA susceptibility HLA–DRB1 amino acids with the C‐reactive protein (CRP) level, the tender joint count (TJC), the swollen joint count (SJC), the Disease Activity Score in 28 joints (DAS28), and the Health Assessment Questionnaire (HAQ) score in the Norfolk Arthritis Register (NOAR) and Early Rheumatoid Arthritis Study (ERAS) cohorts. Longitudinal modeling of disease activity/outcomes was performed using generalized linear latent and mixed models. Mediation analysis was performed using directed acyclic graphs to investigate the paths from genetic factors to outcome. Results A total of 2,158 patients were available for analysis in the NOAR cohort. Valine at position 11 showed the strongest association with the CRP level (P = 2.21 × 10−6), the SJC (P = 7.51 × 10−6), and the DAS28 (P = 0.002); it was marginally associated with the HAQ score (P = 0.044) but not with the TJC. The same amino acid and haplotype risk hierarchy observed for susceptibility and radiographic severity was observed for the CRP level and nonradiographic measures of disease activity/outcome, apart from the TJC. The results were replicated in the ERAS cohort. The effect of valine at position 11 on the SJC was mainly mediated by anti–citrullinated protein antibody status, the effect of which was mainly mediated by inflammation; however, the effect of valine at position 11 was also independent of the CRP level (P = 1.6 × 10−4). Conclusion Genetic markers of RA susceptibility located within HLA–DRB1 determine the levels of clinical and systemic inflammation independently, and also determine all objective measures of disease activity and outcome.
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Affiliation(s)
| | | | - Mark Lunt
- University of Manchester, Manchester, UK
| | - Alper M Van Sijl
- University of Manchester, Manchester, UK, and Jan van Breemen Research Institute Reade, Amsterdam, The Netherlands
| | - Lucia Silva-Fernandez
- University of Manchester, Manchester, UK, and Complexo Hospitalario Universitario de Ferrol, A Coruña, Spain
| | - Deborah P M Symmons
- University of Manchester and Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Adam Young
- St. Albans City Hospital, St. Albans, UK, and University of Hertfordshire, Hatfield, UK
| | | | - Anne Barton
- University of Manchester and Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
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Issa SF, Duer A, Østergaard M, Hørslev-Petersen K, Hetland ML, Hansen MS, Junker K, Lindegaard HM, Møller JM, Junker P. Increased galectin-3 may serve as a serologic signature of pre-rheumatoid arthritis while markers of synovitis and cartilage do not differ between early undifferentiated arthritis subsets. Arthritis Res Ther 2017; 19:80. [PMID: 28446218 PMCID: PMC5407000 DOI: 10.1186/s13075-017-1282-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 03/24/2017] [Indexed: 01/01/2023] Open
Abstract
Background Undifferentiated arthritis (UA) is a label applied to patients with joint complaints which cannot be classified according to current criteria, which implies a need for precision diagnostic technologies. We studied serum galectin-3, a proinflammatory mediator, and seromarkers of structural joint elements in patients with early, UA and their associations with disease profile and biochemical and imaging findings. Methods One hundred and eleven UA patients were followed-up for at least 12 months and reclassified according to appropriate criteria (TUDAR). At baseline, demographics and laboratory and clinical disease measures, as well as wrist magnetic resonance imaging (MRI) synovitis, erosion, and bone marrow edema scorings, were recorded. Galectin-3, the type IIA collagen N-terminal propeptide (PIIANP), which is a marker of regenerative cartilage formation, and hyaluronan (HYA), which is prevalent in synovial tissue swellings, were measured by enzyme-linked immunosorbent assay (ELISA). Receiver operating characteristic (ROC) curve analysis was carried out to assess the discriminant capacity of galectin-3 against arthritis subsets. Results Galectin-3 was increased in pre-rheumatoid arthritis (RA) (4.6 μg/l, interquartile range (IQR) 3.8–5.5) versus non-RA (4.0 μg/l, IQR 3.1–4.9; p = 0.03) and controls (3.8 μg/l, IQR 3.0–4.8; p = 0.009). PIIANP was equally depressed in either subset (p < 0.01). Galectin-3 in non-RA and HYA in UA did not differ from healthy controls. In the entire UA cohort, galectin-3 correlated with the MRI bone marrow edema score, while PIIANP correlated with the MRI erosion score, and HYA with the synovitis and erosion scores. ROC curve analysis showed that baseline galectin-3 discriminated well between pre-RA and non-RA with univariate area under the curve (AUC) of 0.64 (95% confidence interval (CI) 0.53–0.76) while AUC for galectin-3 + anti-CCP increased to 0.71 (95% CI 0.59–0.83). Conclusions Galectin-3 in serum was increased in patients with early UA of pre-RA origin. Cartilage remodeling assessed by PIIANP was diminished in UA irrespective of subsequent clinical differentiation, while HYA did not differ from controls. ROC analysis showed a potential for galectin-3 to discriminate between pre-RA and non-RA. Trial registration KF 11 315829. Registered 25 July 2006.
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Affiliation(s)
- Saida Farah Issa
- Department of Rheumatology, Odense University Hospital and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Anne Duer
- Department of Radiology, Copenhagen University Hospital at Herlev, Herlev, Denmark
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kim Hørslev-Petersen
- Research Unit at King Christian X Hospital for Rheumatic Diseases, Graasten, Denmark
| | - Merete L Hetland
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Kirsten Junker
- The Institute of Molecular Medicine, Cancer and Inflammation, University of Southern Denmark, Odense, Denmark
| | - Hanne M Lindegaard
- Department of Rheumatology, Odense University Hospital and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jakob M Møller
- Department of Radiology, Copenhagen University Hospital at Herlev, Herlev, Denmark
| | - Peter Junker
- Department of Rheumatology, Odense University Hospital and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Lusa AL, Amigues I, Kramer HR, Dam TT, Giles JT. Indicators of walking speed in rheumatoid arthritis: relative influence of articular, psychosocial, and body composition characteristics. Arthritis Care Res (Hoboken) 2015; 67:21-31. [PMID: 25155859 DOI: 10.1002/acr.22433] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 08/05/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To explore the contributions from and interactions between articular swelling and damage, psychosocial factors, and body composition characteristics on walking speed in rheumatoid arthritis (RA). METHODS RA patients underwent the timed 400-meter long-corridor walk. Demographics, self-reported levels of depressive symptoms and fatigue, RA characteristics, and body composition (using whole-body dual X-ray absorptiometry, and abdominal and thigh computed tomography) were assessed and their associations with walking speed explored. RESULTS A total of 132 RA patients had data for the 400-meter walk, among whom 107 (81%) completed the full 400 meters. Significant multivariable indicators of slower walking speed were older age, higher depression scores, higher reported pain and fatigue, higher swollen and replaced joint counts, higher cumulative prednisone exposure, nontreatment with disease-modifying antirheumatic drugs, and worse body composition. These features accounted for 60% of the modeled variability in walking speed. Among specific articular features, slower walking speed was primarily correlated with large/medium lower-extremity joint involvement. However, these articular features accounted for only 21% of the explainable variability in walking speed. Having any relevant articular characteristic was associated with a 20% lower walking speed among those with worse body composition (P < 0.001), compared with only a 6% lower speed among those with better body composition (P = 0.010 for interaction). CONCLUSION Psychosocial factors and body composition are potentially reversible contributors to walking speed in RA. Relative to articular disease activity and damage, nonarticular indicators were collectively more potent indicators of an individual's mobility limitations.
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Affiliation(s)
- Amanda L Lusa
- Columbia University, College of Physicians and Surgeons, New York, New York
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Tavares R, Beattie KA, Bensen WG, Bobba RS, Cividino AA, Finlay K, Goeree R, Hart LE, Jurriaans E, Larche MJ, Parasu N, Tarride JE, Webber CE, Adachi JD. A double-blind, randomized controlled trial to compare the effect of biannual peripheral magnetic resonance imaging, radiography and standard of care disease progression monitoring on pharmacotherapeutic escalation in rheumatoid and undifferentiated inflammatory arthritis: study protocol for a randomized controlled trial. Trials 2014; 15:268. [PMID: 24997587 PMCID: PMC4227117 DOI: 10.1186/1745-6215-15-268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 06/05/2014] [Indexed: 11/28/2022] Open
Abstract
Background Permanent joint damage is a major consequence of rheumatoid arthritis (RA), the most common and destructive form of inflammatory arthritis. In aggressive disease, joint damage can occur within 6 months from symptom onset. Early, intensive treatment with conventional and biologic disease-modifying anti-rheumatic drugs (DMARDs) can delay the onset and progression of joint damage. The primary objective of the study is to investigate the value of magnetic resonance imaging (MRI) or radiography (X-ray) over standard of care as tools to guide DMARD treatment decision-making by rheumatologists for the care of RA. Methods A double-blind, randomized controlled trial has been designed. Rheumatoid and undifferentiated inflammatory arthritis patients will undergo an MRI and X-ray assessment every 6 months. Baseline adaptive randomization will be used to allocate participants to MRI, X-ray, or sham-intervention groups on a background of standard of care. Prognostic markers, treating physician, and baseline DMARD therapy will be used as intervention allocation parameters. The outcome measures in rheumatology RA MRI score and the van der Heijde-modified Sharp score will be used to evaluate the MRI and X-ray images, respectively. Radiologists will score anonymized images for all patients regardless of intervention allocation. Disease progression will be determined based on the study-specific, inter-rater smallest detectable difference. Allocation-dependent, intervention-concealed reports of positive or negative disease progression will be reported to the treating rheumatologist. Negative reports will be delivered for the sham-intervention group. Study-based radiology clinical reports will be provided to the treating rheumatologists for extra-study X-ray requisitions to limit patient radiation exposure as part of diagnostic imaging standard of care. DMARD treatment dose escalation and therapy changes will be measured to evaluate the primary objective. A sample size of 186 (62 per group) patients will be required to determine a 36% difference in pharmacological treatment escalation between the three groups with intermediate dispersion of data with 90% power at a 5% level of significance. Discussion This study will determine if monitoring RA and undifferentiated inflammatory arthritis patients using MRI and X-ray every 6 months over 2 years provides incremental evidence over standard of care to influence pharmacotherapeutic decision-making and ultimately hinder disease progression. Trial registration This trial has been registered at ClinicalTrials.gov: NCT00808496 (registered on 12 December 2008).
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Affiliation(s)
- Ruben Tavares
- UNCOVER Clinical Research Company, Milton, ON, Canada.
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Scott DL, Lempp H. Outcomes associated with early rheumatoid arthritis. Expert Rev Pharmacoecon Outcomes Res 2014; 6:495-508. [DOI: 10.1586/14737167.6.5.495] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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TAVARES RUBEN, POPE JANETE, TREMBLAY JEANLUC, THORNE CARTER, BYKERK VIVIANP, LAZOVSKIS JURIS, BLOCKA KENNETHL, BELL MARYJ, LACAILLE DIANE, HITCHON CAROLA, FITZGERALD AVRILA, FIDLER WESLEYK, BOOKMAN ARTHURA, HENDERSON JAMESM, MOSHER DIANNEP, SHOLTER DALTONE, KHRAISHI MAJED, HARAOUI BOULOS, CHEN HONG, LI XIUYING, LAUPACIS ANDREAS, BOIRE GILLES, TOMLINSON GEORGE, BOMBARDIER CLAIRE. Time to Disease-modifying Antirheumatic Drug Treatment in Rheumatoid Arthritis and Its Predictors: A National, Multicenter, Retrospective Cohort. J Rheumatol 2012; 39:2088-97. [DOI: 10.3899/jrheum.120100] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To determine the proportion of patients with rheumatoid arthritis (RA) under rheumatologic care treated with disease-modifying antirheumatic drugs (DMARD) within 6 months from symptom onset and the components of time to treatment and its predictors.Methods.A historical inception cohort of 339 patients with RA randomly selected from 18 rheumatology practices was audited. The proportion that initiated DMARD treatment within 6 months from symptom onset was estimated using Kaplan-Meier analysis. Time to each component of the care pathway was estimated. Multivariable modeling was used to determine predictors of early treatment using 12 preselected variables available in the clinical charts. Bootstrapping was used to validate the model.Results.Within 6 months from symptom onset, 41% (95% CI 36%−46%) of patients were treated with DMARD. The median time to treatment was 8.4 (interquartile range 3.8−24) months. Events preceding rheumatology referral accounted for 78.1% of the time to treatment. The most prominent predictor of increased time to treatment was a concomitant musculoskeletal condition, such as osteoarthritis or fibromyalgia. The significance of other variables was less consistent across the models investigated. Included variables accounted for 0.69 ± 0.03 of the variability in the model.Conclusion.Fewer than 50% of patients with RA are treated with DMARD within 6 months from symptom onset. Time to referral to rheumatology represents the greatest component delay to treatment. Concomitant musculoskeletal condition was the most prominent predictor of delayed initiation of DMARD. Implications of these and other findings warrant further investigation.
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[Influence of the physical therapy on the health and quality of life of the rheumatic patient]. ACTA ACUST UNITED AC 2011; 7:224-9. [PMID: 21794822 DOI: 10.1016/j.reuma.2010.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 07/28/2010] [Accepted: 08/18/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of a specific physical therapy treatment on stiffness, pain and quality of life (HRQL) in rheumatic patients. METHODS Experimental, prospective, longitudinal and intervention study. It involved 29 individuals with a mean age (SD) of 54.16 (11,9) years, belonging to the Salmantina Association of Rheumatoid Arthritis Patients, randomized into 2 groups: treatment (GT) and control (GC). The study analyzed the time in minutes of morning stiffness, pain -using the Downie Scale- and CVRS through the Nottingham Health Profile (NHP) and the Health Questionnaire SF-36 (SF-36). It carries out an individual treatment that includes mainly physiotherapy manual techniques in one or two sessions per week for six months. RESULTS The time of early morning stiffness showed a mean (SD) 21.38 (29.99) minutes (GC=20,38, GT=22.19), increasing in GC (26.82) and decreasing in GT (12,5). Pain presented at the beginning a mean (SD) 3.6 (2.03) points (GC=2,85, GT=4.22) decreasing in GT (3.68) and increasing in GC (3.45). There was an improvement of CVRS in the GT with decreased scores on four dimensions of NHP (pain, sleep, physical mobility and emotional reactions) and increases in SF-36 (physical problems, social function, pain, function physics). In any case the results were statistically significant. CONCLUSION The study cannot conclude the effectiveness of physiotherapy in the treatment of rheumatoid arthritis although the results show a decrease of morning stiffness and pain and increased CVRS, which is clinically interesting.
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Le Loet X, Strotz V, Lequerre T, Boumier P, Pouplin S, Mejjad O, Daragon A, Jouen F, Vittecoq O, Fardellone P, Menard JF. Combining anti-cyclic citrullinated peptide with the American College of Rheumatology 1987 criteria failed to improve early rheumatoid arthritis diagnosis in the community-based very early arthritis cohort. Rheumatology (Oxford) 2011; 50:1901-7. [DOI: 10.1093/rheumatology/ker217] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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FOOCHAROEN C, NANAGARA R, SUWANNAROJ S, MAHAKKANUKRAUH A. Clinical features and disease outcomes of undifferentiated arthritis in Thailand. Int J Rheum Dis 2011; 14:e14-21. [DOI: 10.1111/j.1756-185x.2011.01606.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pollard LC, Graves H, Scott DL, Kingsley GH, Lempp H. Perceived barriers to integrated care in rheumatoid arthritis: views of recipients and providers of care in an inner-city setting. BMC Musculoskelet Disord 2011; 12:19. [PMID: 21241497 PMCID: PMC3031274 DOI: 10.1186/1471-2474-12-19] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Accepted: 01/17/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A number of recent reports published in the UK have put the quality of care of adults with Rheumatoid Arthritis (RA) centre stage. These documents set high standards for health care professionals and commissioning bodies that need to be implemented into routine clinical practice. We therefore have obtained the views of recipients and providers of care in inner city settings as to what they perceive are the barriers to providing integrated care. METHODS We conducted focus groups and face to face interviews between 2005-8 with 79 participants (patients, carers, specialist medical and nursing outpatient staff and general practitioners (GPs)) working in or attending three hospitals and three primary care trusts (PCT). RESULTS Three barriers were identified that stood in the way of seamless integrated care in RA from the perspective of patients, carers, specialists and GPs: (i) early referral (e.g. 'gate keeper's role of GPs); (ii) limitations of ongoing care for established RA (e.g. lack of consultation time in secondary care) and (iii) management of acute flares (e.g. pressure on overbooked clinics). CONCLUSION This timely study of the multi-perspective views of recipients and providers of care was conducted during the time of publications of many important reports in the United Kingdom (UK) that highlighted key components in the provision of high quality care for adults with RA. To achieve seamless care across primary and secondary care requires organisational changes, greater personal and professional collaboration and GP education about RA.
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Affiliation(s)
- Louise C Pollard
- Department of Rheumatology King's College London School of Medicine, London, UK.
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Filer A, de Pablo P, Allen G, Nightingale P, Jordan A, Jobanputra P, Bowman S, Buckley CD, Raza K. Utility of ultrasound joint counts in the prediction of rheumatoid arthritis in patients with very early synovitis. Ann Rheum Dis 2010; 70:500-7. [PMID: 21115552 PMCID: PMC3033529 DOI: 10.1136/ard.2010.131573] [Citation(s) in RCA: 148] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Early therapy improves outcomes in rheumatoid arthritis (RA). It is therefore important to improve predictive algorithms for RA in early disease. This study evaluated musculoskeletal ultrasound, a sensitive tool for the detection of synovitis and erosions, as a predictor of outcome in very early synovitis. METHODS 58 patients with clinically apparent synovitis of at least one joint and symptom duration of ≤3 months underwent clinical, laboratory, radiographic and 38 joint ultrasound assessments and were followed prospectively for 18 months, determining outcome by 1987 American College of Rheumatology (ACR) and 2010 ACR/European League Against Rheumatism criteria. Sensitivity and specificity for 1987 RA criteria were determined for ultrasound variables and logistic regression models were then fitted to evaluate predictive ability over and above the Leiden rule. RESULTS 16 patients resolved, 13 developed non-RA persistent disease and 29 developed RA by 1987 criteria. Ultrasound demonstrated subclinical wrist, elbow, knee, ankle and metatarsophalangeal joint involvement in patients developing RA. Large joint and proximal interphalangeal joint ultrasound variables had poor predictive ability, whereas ultrasound erosions lacked specificity. Regression analysis demonstrated that greyscale wrist and metacarpophalangeal joint involvement, and power Doppler involvement of metatarsophalangeal joints provided independently predictive data. Global ultrasound counts were inferior to minimal power Doppler counts, which significantly improved area under the curve values from 0.905 to 0.962 combined with the Leiden rule. CONCLUSION In a longitudinal study, extended ultrasound joint evaluation significantly increased detection of joint involvement in all regions and outcome groups. Greyscale and power Doppler scanning of metacarpophalangeal joints, wrists and metatarsophalangeal joints provides the optimum minimal ultrasound data to improve on clinical predictive models for RA.
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Affiliation(s)
- Andrew Filer
- Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, Institute for Biomedical Research, The University of Birmingham, Birmingham B15 2TT, UK.
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VELPULA UMAD, AGRAWAL SUMEET, THOMAS JOE, PRABU VNAGA, RAJASEKHAR LIZA, NARSIMULU GUMDAL. Low Body Mass Index Is Adversely Associated with Radiographic Joint Damage in Indian Patients with Early Rheumatoid Arthritis. J Rheumatol 2010; 38:434-8. [PMID: 21078713 DOI: 10.3899/jrheum.100535] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective.Various factors affect joint damage in rheumatoid arthritis (RA). The influence of body mass index (BMI) is not adequately known. As BMI is potentially modifiable, we studied its influence on radiological joint damage in patients with RA.Methods.Treatment-naive patients with early RA (< 24 mo) were included. Demographic data were collected along with swollen joint count (SJC), tender joint count (TJC), erythrocyte sedimentation rate (ESR), and IgM-rheumatoid factor (IgM-RF). Radiographs of hands and feet were obtained. BMI and Disease Activity Score for 28-joint count (DAS28-ESR) were calculated. Joint damage was assessed using the Simplified Erosions Narrowing Score (SENS).Results.A total of 101 patients were studied (81 women; mean age 41.91 ± 11.99 yrs). Mean disease duration was 10.77 ± 6.73 months; 55 patients (54.5%) were IgM-RF-positive. Mean BMI was 22.82 ± 4.66 kg/m2 with 24 (23.8%) patients having low, 42 (41.6%) normal, and 35 (34.7%) high BMI. Mean SENS score was 16.81 ± 11.10; mean DAS28 was 6.23 ± 0.96. Significant correlation was noted between SENS and DAS28 (r = 0.28; p < 0.005). There was significant negative correlation between BMI and SENS (r = −0.509; p < 0.0005). In patients with low BMI, mean SENS (26.62 ± 13.45) was significantly higher than in patients with normal (15.88 ± 8.38; p < 0.001) and high BMI (11.20 ± 7.32; p < 0.001). Patients with normal BMI also had significantly higher SENS scores than those with high BMI (p < 0.05). One-way ANOVA did not reveal significant differences in DAS28 between groups. SENS was significantly higher in the IgM-RF-positive group (19.55 ± 11.36) than in the IgM-RF-negative group (13.54 ± 9.94; p < 0.01); DAS28 was not different between the 2 groups (6.22 ± 0.98 vs 6.26 ± 0.96, respectively). Within the 2 IgM-RF groups, a significant negative correlation was seen between BMI and SENS. Multiple regression analysis revealed RF, DAS28, and BMI were independently associated with SENS. BMI accounted for 23.04% of the variance in SENS independent of DAS28 and IgM-RF.Conclusion.Low BMI is adversely associated with joint damage in patients with early RA.
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Mjaavatten MD, van der Heijde D, Uhlig T, Haugen AJ, Nygaard H, Sidenvall G, Helgetveit K, Kvien TK. The likelihood of persistent arthritis increases with the level of anti-citrullinated peptide antibody and immunoglobulin M rheumatoid factor: a longitudinal study of 376 patients with very early undifferentiated arthritis. Arthritis Res Ther 2010; 12:R76. [PMID: 20444271 PMCID: PMC2911852 DOI: 10.1186/ar2995] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 04/12/2010] [Accepted: 05/05/2010] [Indexed: 11/17/2022] Open
Abstract
Introduction We wanted to assess the importance of the levels of anti-citrullinated peptide antibody (anti-CCP) and immunoglobulin M (IgM) rheumatoid factor (RF) in predicting development of persistent arthritis from undifferentiated arthritis (UA), and to investigate whether there is an added predictive value for persistent arthritis in testing for both anti-CCP and IgM RF. Methods Patients with UA (exclusion of definite non-rheumatoid arthritis (RA) diagnoses) included in the Norwegian very early arthritis clinic were assessed for development of persistent arthritic disease. The effect of antibody level on the likelihood of persistent arthritis was investigated, and the sensitivity and specificity for persistent arthritis for anti-CCP and IgM RF, separately and combined, was determined. Results A total of 376 UA patients were included (median arthritis duration 32 days). 59 (15.7%) patients were IgM RF positive, and 62 (16.5%) anti-CCP positive. One hundred, seventy-four (46.3%) had persistent disease after one year. Overlap of anti-CCP and IgM RF positivity was 58%. Sensitivity/specificity for persistent arthritis was 28/95% for IgM RF alone, 30/95% for anti-CCP alone, and 37/92% for positivity of both anti-CCP and IgM RF. The likelihood for persistent disease increased with increasing levels of both anti-CCP and IgM RF. Conclusions The likelihood of developing persistent arthritis in UA patients increases with the level of anti-CCP and IgM RF. Testing both anti-CCP and IgM RF has added predictive value in UA patients. This study suggests that antibody level should be taken into account when making risk assessments in patients with UA.
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Affiliation(s)
- Maria D Mjaavatten
- Department of Rheumatology, Diakonhjemmet Hospital, P,O, Box 23 Vinderen, 0319 Oslo, Norway.
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Mjaavatten MD, Uhlig T, Haugen AJ, Nygaard H, Sidenvall G, Helgetveit K, Kvien TK. Positive anti-citrullinated protein antibody status and small joint arthritis are consistent predictors of chronic disease in patients with very early arthritis: results from the NOR-VEAC cohort. Arthritis Res Ther 2009; 11:R146. [PMID: 19796386 PMCID: PMC2787285 DOI: 10.1186/ar2820] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Revised: 09/21/2009] [Accepted: 10/01/2009] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The current 1987 American College of Rheumatology (ACR) classification criteria for rheumatoid arthritis (RA) have proven less useful in early arthritis. The objective of this study was to identify and compare predictors of three relevant outcomes of chronic arthritis in a cohort of very early arthritis patients. METHODS The Norwegian Very Early Arthritis Cohort (NOR-VEAC) includes adult patients with at least one swollen joint of < or = 16 weeks' duration. Patients are followed for 2 years with comprehensive clinical and laboratory examinations. Logistic regression analyses were performed to determine independent predictors of three outcomes: persistent synovitis, prescription of disease-modifying anti-rheumatic drugs (DMARDs), and established clinical RA diagnosis within one year. RESULTS Of 384 patients eligible for one year follow-up (56.3% females, mean (SD) age 45.8 (14.7) years, median (IQR) duration of arthritis 31 (10-62) days), 14.4% were anti-CCP2 positive, and 11.2% were IgM RF positive. 98 patients (25.5%) had persistent synovitis, 106 (27.6%) had received DMARD treatment during follow-up, while 68 (17.7%) were diagnosed with RA. Consistent independent predictors across all three outcomes were positive anti-citrullinated protein antibody (ACPA) status (odds ratio (OR) 3.2, 5.6 and 19.3), respectively, and small joint arthritis (proximal interphalangeal joint (PIP), metacarpo-phalangeal joint (MCP), and/or metatarso-phalangeal joint (MTP) joint swelling) (OR 1.9, 3.5, and 3.5, respectively). CONCLUSIONS Positive ACPA status and small joint arthritis were consistent predictors of three relevant outcomes of chronic arthritis in very early arthritis patients. This consistency supports DMARD prescription as a valid surrogate endpoint for chronic arthritis. Importantly, this surrogate is used in ongoing efforts to develop new diagnostic criteria for early RA.
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Affiliation(s)
- Maria D Mjaavatten
- Department of Rheumatology, Diakonhjemmet Hospital, P.O. box 23 Vinderen, 0319 Oslo, Norway.
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Reneses S, Pestana L, Fernandez‐Suarez A, Criado R, Wichmann I, Garcia A, Nuñez‐Roldan A. A recent onset inflammatory polyarthritis register in Spain: factors that predict remission. Scand J Rheumatol 2009; 36:378-85. [PMID: 17963168 DOI: 10.1080/03009740701286748] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Tamai M, Kawakami A, Uetani M, Takao S, Arima K, Iwamoto N, Fujikawa K, Aramaki T, Kawashiri SYA, Ichinose K, Kamachi M, Nakamura H, Origuchi T, Ida H, Aoyagi K, Eguchi K. A prediction rule for disease outcome in patients with undifferentiated arthritis using magnetic resonance imaging of the wrists and finger joints and serologic autoantibodies. ACTA ACUST UNITED AC 2009; 61:772-8. [DOI: 10.1002/art.24711] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Raza K, Filer A. Predicting the development of RA in patients with early undifferentiated arthritis. Best Pract Res Clin Rheumatol 2009; 23:25-36. [PMID: 19233043 DOI: 10.1016/j.berh.2008.08.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The rapidity with which bone and cartilage damage occurs in patients with rheumatoid arthritis (RA), and the increasing body of evidence for the effectiveness of early intervention in RA, mean that there is a great need for approaches to accurately predict the development of RA in patients with early undifferentiated arthritis. We will review developments in the prediction of outcome on the basis of clinical and laboratory features, including measures of anti-citrullinated protein/peptide antibody status. Although accurate predictions are possible in the majority of patients using recently developed predictive algorithms which utilize clinical and serological variables, there remains a group of patients for whom it is very difficult to predict the development of RA. The utility of new strategies for prediction will be discussed, including recently discovered genetic associations of RA, an assessment of material from the primary site of pathology (the joint), and assessment using the highly sensitive imaging modalities of ultrasound and magnetic resonance imaging.
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Affiliation(s)
- Karim Raza
- Rheumatology Research Group, Division of Immunity and Infection, Institute of Biomedical Research, MRC Centre for Immune Regulation, University of Birmingham, Birmingham, UK.
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Javier Narváez García F. [Treating undifferentiated arthritis. What, when, how and how long?]. REUMATOLOGIA CLINICA 2009; 5 Suppl 1:31-39. [PMID: 21794640 DOI: 10.1016/j.reuma.2008.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2008] [Accepted: 12/16/2008] [Indexed: 05/31/2023]
Abstract
With the establishment of early arthritis clinics, patients can now be increasingly attended early in the course of their disease. This means that a significant proportion of these patients cannot be classified into a specific diagnosis using the traditional American College of Rheumatology (ACR) classification criteria. In these patients with undifferentiated arthritis (UA), even more important than assigning a diagnosis is the need to distinguish between patients who will develop a persistent and/or erosive disease and will be candidates for prompt treatment with disease-modifying antirheumatic drugs (DMARD), and patients in whom the disease is self limiting. Serologic markers in combination with clinical features at presentation, integrated into predictive models, are the tools currently available to the clinician for identifying these patients. Several studies have demonstrated the advantages of early treatment in UA.
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Grijalva CG, Chung CP, Stein CM, Mitchel EF, Griffin MR. Changing patterns of medication use in patients with rheumatoid arthritis in a Medicaid population. Rheumatology (Oxford) 2008; 47:1061-4. [PMID: 18499716 DOI: 10.1093/rheumatology/ken193] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To examine changes in patterns of medication utilization in patients with RA. METHODS Data from Tennessee Medicaid (TennCare) databases (1995-2004) were used to identify adults with both a diagnosis of RA and at least one DMARD prescription each year. Annual age-specific utilization of DMARDs, glucocorticoids, NSAIDs and narcotics was measured on the last day of each year to determine the point prevalence of use of these agents. RESULTS Records from 23 342 patients with treated RA were analysed. Most patients were females (78%) and white (74%). The median age was 57 yrs (interquartile range: 48-65). The proportion of patients who had a current DMARD prescription on the index date increased from 62% in 1995 to 71% in 2004 (P < 0.001). MTX was the most commonly used DMARD. By the end of 2004, 22% of patients had a current prescription for a biologic, and etanercept represented 51% of all biologic therapies. During the study period, the overall utilization of glucocorticoids decreased from 46% to 38% (P < 0.001), whereas NSAID utilization increased from 33% to 38% (P < 0.001), and use of narcotics increased from 38% to 55% (P < 0.001). A secondary analysis that identified RA patients based on diagnosis codes alone, showed similar patterns, but lower DMARD utilization which increased from 33% to 52% overall and from 0% to 16% for biologics. CONCLUSIONS The utilization of DMARDs increased in TennCare patients with RA, and by 2004, use of biologics was substantial. Although glucocorticoid utilization decreased, use of both NSAIDs and narcotics increased.
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Affiliation(s)
- C G Grijalva
- Department of Preventive Medicine, Vanderbilt University School of Medicine, 1500 21st Avenue, 2600 VAV, Nashville, TN 37212, USA.
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Advances in the genetics of rheumatoid arthritis point to subclassification into distinct disease subsets. Arthritis Res Ther 2008; 10:205. [PMID: 18394179 PMCID: PMC2453775 DOI: 10.1186/ar2384] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In the past few years considerable advances have been made in the genetics of susceptibility to rheumatoid arthritis (RA). For decades the HLA-DRB1 alleles were the only extensively replicated genetic factor, but more genetic risk factors have now been identified that predispose to RA. Interestingly, several of the observed genetic variants conferred risk to anticitrulline-peptide antibody (ACPA)-positive RA and two variants may be restricted to ACPA-negative RA, pointing to the need for subclassification of RA. The current manuscript reviews recently identified genetic factors predisposing to ACPA-positive RA and ACPA-negative RA. Additionally, although being scarcely explored, genetic variants affecting the severity of disease course are discussed.
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Abstract
Rheumatoid arthritis (RA) varies over time in individual patients and there are marked differences between patients in its impact and progression. The course of RA is therefore unique to each individual patient and is affected by the overall pattern of disease; many patients have classical polyarticular disease but there is also a range of subtypes, such as fibromyalgic and polymyalgic disease. Some patients with RA enter a period of sustained remission; this varies between 10% and 36% of cases; its frequency is mainly influenced by the different approaches to studying RA patients over time, and does not represent a true difference in disease outcome. Most patients have persisting synovial inflammation and disease activity scores average between 3 and 4; there is some evidence that inflammation is less marked in late RA. Persisting synovitis results in increasing disability - this worsens by an average of 0.6% each year - and in joint damage, which increases by an average of 2% each year. Comorbidities and extra-articular features are commonplace: about one-third of patients, respectively, have associated cardiovascular disease, lung disease or extra-articular features, although severe extra-articular problems like vasculitis affect only about 10% of patients. Some aspects of the course of RA are influenced by genetic risks; currently these are only weak predictors but it is anticipated their value will increase with time.
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Affiliation(s)
- David L Scott
- Department of Rheumatology, Kings College London School of Medicine, Weston Education Centre, 10 Cutcombe Road, London SE5 9RS, UK.
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Savolainen E, Kautiainen H, Koivula MK, Luosujärvi R, Risteli J, Kaipiainen-Seppänen O. Change of diagnoses and outcome of patients with early inflammatory joint diseases during a mean 13-month follow-up. Scand J Rheumatol 2007; 36:194-7. [PMID: 17657673 DOI: 10.1080/03009740601089309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the state of the disease and verify the diagnoses during a 7-24-month follow-up of adult patients with newly diagnosed inflammatory joint diseases in a defined population. METHODS Patients with previously undiagnosed synovitis in at least one peripheral joint or signs of inflammation in sacroiliac, glenohumeral or hip joints were enrolled on their first hospital visit in 2000 and followed-up for up to 24 months in Kuopio. RESULTS A total of 138/173 adult patients completed a mean 13-month follow-up. During the follow-up the diagnosis was specified for 15/81 (19%) patients previously classified as undifferentiated arthritis (UA). Eight patients developed rheumatoid arthritis (RA). Of 28 patients with RA, 92% were on disease-modifying anti-rheumatic drugs (DMARDs) and 75% had a combination treatment with two or more DMARDs. According to the diagnosis at baseline, 75% of cases with RA, 38% with spondyloarthropathies (SpAs) and 42% with UA had active synovitis or arthralgia at follow-up. In multivariate analysis, older patients at disease onset were less likely to be in remission (p = 0.011). CONCLUSION The diagnosis could be specified for 19% of patients with UA. Fifteen of 20 patients with RA had an active disease despite treatment with DMARDs. Patients with SpAs and UA had a better short-term outcome. Patients with active disease need aggressive therapy in all age groups.
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Paget S. The European League Against Rheumatism guidelines for early arthritis. NATURE CLINICAL PRACTICE. RHEUMATOLOGY 2007; 3:374-5. [PMID: 17534291 DOI: 10.1038/ncprheum0527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Accepted: 04/23/2007] [Indexed: 05/15/2023]
Affiliation(s)
- Stephen Paget
- Weill Medical College of Cornell University and the Hospital for Special Surgery, New York, NY 10021, USA.
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van der Helm-van Mil AHM, le Cessie S, van Dongen H, Breedveld FC, Toes REM, Huizinga TWJ. A prediction rule for disease outcome in patients with recent-onset undifferentiated arthritis: how to guide individual treatment decisions. ACTA ACUST UNITED AC 2007; 56:433-40. [PMID: 17265478 DOI: 10.1002/art.22380] [Citation(s) in RCA: 261] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE In patients with undifferentiated arthritis (UA), methotrexate is effective for inhibiting symptoms, structural damage, and progression to rheumatoid arthritis (RA). However, 40-50% of patients with UA experience spontaneous remission. Thus, adequate decision-making regarding treatment of patients with early UA requires identification of those patients in whom RA will develop. METHODS A prediction rule was developed using data from the Leiden Early Arthritis Clinic, an inception cohort of patients with recent-onset arthritis (n = 1,700). The patients who presented with UA were selected (n = 570), and progression to RA or another diagnosis in this group was monitored for 1 year of followup. The clinical characteristics with independent predictive value for the development of RA were selected using logistic regression analysis. The diagnostic performance of the prediction rule was evaluated using the area under the curve (AUC). Cross-validation controlled for overfitting of the data (internal validation). An independent cohort of patients with UA was used for external validation. RESULTS The prediction rule consisted of 9 clinical variables: sex, age, localization of symptoms, morning stiffness, the tender joint count, the swollen joint count, the C-reactive protein level, rheumatoid factor positivity, and the presence of anti-cyclic citrullinated peptide antibodies. Each prediction score varied from 0 to 14 and corresponded to the percent chance of RA developing. For several cutoff values, the positive and negative predictive values were determined. The AUC values for the prediction rule, the prediction model after cross-validation, and the external validation cohort were 0.89, 0.87, and 0.97, respectively. CONCLUSION In patients who present with UA, the risk of developing RA can be predicted, thereby allowing individualized decisions regarding the initiation of treatment with disease-modifying antirheumatic drugs in such patients.
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Abstract
We created the McGill Range of Motion Index (McROMI) to allow us to ascribe a score to global limited range of motion (ROM) in patients with polyarthritis. Our goal was to have an easy-to-use index that required only visual estimation of ROM and could be performed by allied health professionals with limited training. The index was created with a range of motion ranking technique involving rheumatologists at McGill University and its validity was tested in patients with early inflammatory arthritis in the McGill Early Arthritis Registry. We hypothesized a valid index would correlate with various process and outcome measures. We found correlations between the McROMI and function (Health Assessment Questionnaire), Health Related Quality of Life (SF-36), pain, a global assessment of inflammatory disease activity (DAS28), and the number of tender and swollen joints. The McROMI demonstrates good validity as a measure of ROM in early inflammatory arthritis. It will prove useful in future research as a means of controlling for ROM as a confounder of various outcomes and in studies of therapeutic maneuvers to improve ROM.
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Affiliation(s)
- Murray Baron
- Division of Rheumatology, Jewish General Hospital, Montreal, Quebec, Canada.
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28
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Symmons DPM, Silman AJ. Aspects of early arthritis. What determines the evolution of early undifferentiated arthritis and rheumatoid arthritis? An update from the Norfolk Arthritis Register. Arthritis Res Ther 2007; 8:214. [PMID: 16817941 PMCID: PMC1779379 DOI: 10.1186/ar1979] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Over 3500 patients with recent onset inflammatory polyarthritis (IP) have been recruited by the Norfolk Arthritis Register (NOAR) since 1990. Longitudinal data from this cohort have been used to examine the prevalence and predictors of remission, functional disability, radiological outcome, cardiovascular mortality and co-morbidity and the development of non-Hodgkin's lymphoma. Rheumatoid factor titre, high baseline C-reactive protein and high baseline HAQ score are all predictors of a poor outcome. There is a strong association between possession of the shared epitope and the development of erosions. Patients who satisfy the American College of Rheumatology criteria for rheumatoid arthritis (RA) have a worse prognosis than those who do not. However, it appears that these patients are a poorly defined subset of all those with IP rather than having an entirely separate disease entity. New statistical techniques offer exciting possibilities for using longitudinal datasets such as NOAR to explore the long-term effects of treatment in IP and RA.
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Combe B, Landewe R, Lukas C, Bolosiu HD, Breedveld F, Dougados M, Emery P, Ferraccioli G, Hazes JMW, Klareskog L, Machold K, Martin-Mola E, Nielsen H, Silman A, Smolen J, Yazici H. EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2007; 66:34-45. [PMID: 16396980 PMCID: PMC1798412 DOI: 10.1136/ard.2005.044354] [Citation(s) in RCA: 555] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2006] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To formulate EULAR recommendations for the management of early arthritis. METHODS In accordance with EULAR's "standardised operating procedures", the task force pursued an evidence based approach and an approach based on expert opinion. A steering group comprised of 14 rheumatologists representing 10 European countries. The group defined the focus of the process, the target population, and formulated an operational definition of "management". Each participant was invited to propose issues of interest regarding the management of early arthritis or early rheumatoid arthritis. Fifteen issues for further research were selected by use of a modified Delphi technique. A systematic literature search was carried out. Evidence was categorised according to usual guidelines. A set of draft recommendations was proposed on the basis of the research questions and the results of the literature search.. The strength of the recommendations was based on the category of evidence and expert opinion. RESULTS 15 research questions, covering the entire spectrum of "management of early arthritis", were formulated for further research; and 284 studies were identified and evaluated. Twelve recommendations for the management of early arthritis were selected and presented with short sentences. The selected statements included recognition of arthritis, referral, diagnosis, prognosis, classification, and treatment of early arthritis (information, education, non-pharmacological interventions, pharmacological treatments, and monitoring of the disease process). On the basis of expert opinion, 11 items were identified as being important for future research. CONCLUSIONS 12 key recommendations for the management of early arthritis or early rheumatoid arthritis were developed, based on evidence in the literature and expert consensus.
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Affiliation(s)
- B Combe
- Immuno-Rhumatologie, Lapeyronie Hosp, Montpellier, France.
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Forslind K, Hafström I, Ahlmén M, Svensson B. Sex: a major predictor of remission in early rheumatoid arthritis? Ann Rheum Dis 2006; 66:46-52. [PMID: 17158139 PMCID: PMC1798403 DOI: 10.1136/ard.2006.056937] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The treatment goal of early rheumatoid arthritis is remission. This study reports remission rates in clinical practice using a cohort of patients with early rheumatoid arthritis. METHODS 698 patients with early rheumatoid arthritis were included. Mean age at inclusion was 58 years and mean disease duration was 6.4 months; 64% of the patients were women, 56% were positive for antibodies to cyclic citrullinated peptide and 60% were positive for rheumatoid factor. Remission was defined as a disease activity score <2.6, with or without ongoing treatment with drugs for rheumatoid arthritis. RESULTS After 2 years, 261 of 689 patients were in remission (37.9%), and after 5 years, the remission rate was 38.5%. However, only 26.1% were in remission at both these time points. Multiple logistic regression analyses found sex to be a main predictor for remission. Thus, significantly fewer women were in remission after 2 years (32.1% v 48%, p = 0.001) after 5 years (30.8% v 52.4%, p = 0.001) and at both these time points (19.1% v 39.3%, p = 0.001). Although disease activity was not with certainty more pronounced in women at onset of disease, the disease course became markedly worse in women. The disparity in remission frequency between women and men could not be explained by differences in disease duration, age or treatment with disease modifying antirheumatic drugs or glucocorticoids. CONCLUSIONS Early remission of rheumatoid arthritis by 28-joint Disease Activity Score<2.6 was as frequent or more frequent in this study than in most previous reports. Importantly, women had more severe disease with a considerably lower remission rate than men, although the disease activity before treatment seemed similar.
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Affiliation(s)
- K Forslind
- Section of Rheumatology, Helsingborgs Lasarett, Helsingborg, Sweden
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Cohen G, Gossec L, Dougados M, Cantagrel A, Goupille P, Daures JP, Rincheval N, Combe B. Radiological damage in patients with rheumatoid arthritis on sustained remission. Ann Rheum Dis 2006; 66:358-63. [PMID: 16935911 PMCID: PMC1856000 DOI: 10.1136/ard.2006.057497] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the radiological damage progression in patients with recent rheumatoid arthritis in sustained remission. METHODS A cohort of 191 patients with active early (<1 year) rheumatoid arthritis was prospectively assessed at baseline, 3 and 5 years by the Disease Activity Score (DAS) and the Sharp-van der Heijde Score (SHS) for radiographic damage. Patients in remission (DAS<1.6) at the 3-year and 5-year time points were compared with patients with a persistently active rheumatoid arthritis by Wilcoxon's signed rank test. RESULTS 57 patients died, were lost to follow-up or had incomplete data; 30 (15.7% of those who completed) patients were in remission at 3 and 5 years. The SHS in these two groups was not significantly different at baseline (p = 0.15), but was lower in the remission group at 5 years (p = 0.0047). The median (IQR) radiographic score increased from 0.5 (0-7) at baseline to 2.5 (0-14) after 5 years for the remission group (p = 0.18) and from 2 (0-7) to 13 (3-29) in the group with active rheumatoid arthritis (p<0.001). 5 (16.7%) patients in remission had relevant progression of radiographic damage (ie, progression >4.1 points) and 6 (20%) presented new erosions in a previously unaffected joint between the third and the fifth years. CONCLUSION Patients with early rheumatoid arthritis in sustained remission did not present statistically significant radiographic degradation at the group level; nevertheless, 16.7% of these patients did present degradation. Absence of progression should be part of the remission definition in rheumatoid arthritis.
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Affiliation(s)
- G Cohen
- Immuno-Rhumatologie, Montpellier I University, Centre Hospitalier Universitaire Lapeyronie, Montpellier, France
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Haugeberg G, Emery P. Value of dual-energy x-ray absorptiometry as a diagnostic and assessment tool in early rheumatoid arthritis. Rheum Dis Clin North Am 2006; 31:715-28. [PMID: 16287593 DOI: 10.1016/j.rdc.2005.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
New research has revealed common pathophysiologic and cellular mechanisms behind the development of osteoporosis and joint damage in rheumatoid arthritis (RA). Because osteoporosis is a direct consequence of the inflammatory disease process, bone mass measurements in principle could be an outcome marker of inflammation, of damage, and of response to therapeutic intervention. Several devices have been developed for quantitative bone mass assessment including dual energy x-ray absorptiometry (DXA), which is considered the reference standard. This article based on current data and understanding discusses the use of DXA as a diagnostic and assessment tool especially in early RA.
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Affiliation(s)
- Glenn Haugeberg
- Department of Rheumatology, Sørlandet Hospital, Kristiansand, Norway
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Abstract
The treatment of rheumatoid arthritis (RA) has changed dramatically in the past decade as advancements in the understanding of the pathobiology of the disease have led to novel therapeutic agents. The recognition that early diagnosis and treatment leads to improvements in morbidity and mortality has altered the therapeutic strategy such that early therapy is now considered the standard of care. This review focuses on the challenges in making the diagnosis of early RA, including a broad differential diagnosis for inflammatory polyarthritis, poor performance of the standard classification criteria, difficulty in clinical assessment of synovitis, absence of absolute laboratory tests, inability of conventional radiography to detect bony changes early, and barriers to rheumatology care. Additionally, the pathogenesis of RA is highlighted, with particular emphasis on cytokine biology as it relates to therapeutic regimens. Relevant clinical trials in early RA are reviewed and discussed, including trials of combination disease-modifying antirheumatic drugs and biological therapy. The role of induction therapy as a novel therapeutic approach is highlighted. The search for predictors of response is reviewed and the external validity of the trials is analysed. Finally, the trials in early RA therapy suggest that swift intervention with combinations of medications is required for patients with severe RA. However, further research is needed to determine which regimen is appropriate for the individual patient with RA.
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Affiliation(s)
- Amy C Cannella
- University of Nebraska Medical Center, Omaha, Nebraska 68198-3025, USA.
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Baddoura R, Haddad S, Awada H, Al-Masri AF, Merheb G, Attoui S, Okais J, Messayke J, Ghandour F. Severity of rheumatoid arthritis: the SEVERA study. Clin Rheumatol 2005; 25:700-4. [PMID: 16362443 DOI: 10.1007/s10067-005-0136-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2005] [Revised: 10/19/2005] [Accepted: 10/23/2005] [Indexed: 11/26/2022]
Abstract
This study aims to assess the severity of rheumatoid arthritis (RA) in rheumatology practice in our population. All outpatients and inpatients with RA seen by registered rheumatologists over a 1-year period were included. Severity was measured using the Larsen score for hands and wrists and the Modified Health Assessment Questionnaire (M-HAQ). Two hundred ninety-eight RA cases were included. Mean age was 51.5 years. Among them, 261 (87.6%) were females. Disease duration was less than a year in 26 subjects (8.7%) and 10 years and above in 108 (36.2%) with a mean of 8.9. There were 220 (73.8%) subjects who had M-HAQ score <1. In 61 (20.5%) subjects, M-HAQ score was > or =1 and <2, and 17 (5.7%) had M- HAQ score > or =2. In relation with disease duration, M-HAQ starts with an average (SD) value of 0.7 (0.6) during the first year, decreases to 0.4 (0.4) at 5-year disease duration and increases after 10 years of disease progression to an average of 0.9 (0.8). Mean (SD) Larsen score was 51.9 (29.5) and median was 45. A total of 25% had a Larsen score > or =50% of maximum. Larsen score increased significantly (p<0.0001) with disease duration, starting at an average (SD) of 36.1 (14.9) during the first year, rising to 42.5 (15.8) around 5 years and reaching 73.9 (36.9) after 10 years. RA severity in our practice is comparable to that reported in Western populations in terms of radiological damage; however, functional status differs, possibly reflecting cultural differences.
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Affiliation(s)
- Rafic Baddoura
- Rheumatology Department, Hotel-Dieu Hospital, St Joseph University, Beirut, Lebanon.
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Abstract
Patients who cannot be classified as having a well-defined arthropathy typically are labeled as having undifferentiated arthritis. Some patients develop sufficient features to permit classification, whereas others remain undifferentiated, but with persistent joint inflammation, functional disability, and development of radiographic damage. Identifying the subset of patients destined to develop rheumatoid arthritis, spondyloarthropathy, or a more severe and persistent form of undifferentiated arthritis and choosing appropriate treatment strategies remain challenges for clinicians. Numerous investigative strategies are available with which to characterize undifferentiated arthritis and assess prognosis. This article discusses the characteristics of undifferentiated arthritis at presentation and the investigative strategies that can be used to predict prognosis and outcome early in the disease course. Therapeutic strategies also are explored.
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Affiliation(s)
- Carol A Hitchon
- Department of Medicine, University of Manitoba and Arthritis Center, RR149 8700 Sherbrook Street, Winnipeg, Manitoba R3A 1M4, Canada
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Stockman A, Tait BD, Wolfe R, Brand CA, Rowley MJ, Varney MD, Buchbinder R, Muirden KD. Clinical, laboratory and genetic markers associated with erosions and remission in patients with early inflammatory arthritis: a prospective cohort study. Rheumatol Int 2005; 26:500-9. [PMID: 16151812 DOI: 10.1007/s00296-005-0027-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2004] [Accepted: 07/03/2005] [Indexed: 11/24/2022]
Abstract
We investigated the relationship between clinical, laboratory and genetic markers and outcome measures in 159 patients with recent onset of inflammatory arthritis (IA). The majority of patients were managed in community-based rheumatology practice. Median duration of arthritis at baseline was 3 months with median follow-up of 4.0 years (range 0-10). Markers of disease activity and 1987 ACR criteria for rheumatoid arthritis (RA) were estimated every 6 months for the first 2 years and annually thereafter. Presence of shared epitopes (SE) was established by PCR-based method. Main outcome variables were attainment of remission and presence of erosions on X-rays of hands and feet at 3 years. Remission was seen in 34.3% of patients and was independently related to age 60 and older (odds ratio (OR) 3.2; 95% confidence interval (CI), 1.2-8.7) and inversely to the presence of rheumatoid factor (RF) (OR 8.3; 95% CI, 3.2-21.3 for persistent arthritis). Patients with two SE were likely to have persistent arthritis (P=0.006), but this was not significant when corrected for RF. Independent predictors for erosions at 3 years were RF (OR 7.5; 95% CI, 1.9-29.5) and area under the curve for number of swollen joints (OR 1.08; 95% CI, 1.02-1.16). SE status was not predictive of erosions at 3 years (OR 1.6; 95% CI, 0.7-3.7). In univariate analysis, patients possessing DERAA motif on DRB1 were less likely to have erosive disease than without this motif at 4 years (OR 0.21; 95% CI, 0.0-0.9, P=0.037) but this finding was partly explained by adjusting for RF (adjusted OR 0.24; 95% CI 0.04-1.37). In this study of recent onset IA, active disease and RF were associated with poor outcome. Whilst SE did not predict erosive disease, patients with DERAA motif may be protected against erosions whilst the presence of two SE alleles suggests persistence of arthritis.
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Affiliation(s)
- A Stockman
- Rheumatology Unit, Royal Melbourne Hospital, Grattan Street, Parkville, 3050, Victoria, Australia.
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Rantapää-Dahlqvist S. Diagnostic and prognostic significance of autoantibodies in early rheumatoid arthritis. Scand J Rheumatol 2005; 34:83-96. [PMID: 16095003 DOI: 10.1080/03009740510017689] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A positive rheumatoid factor (RF) test has been included as one of the criteria for the diagnosis of rheumatoid arthritis (RA) according to the 1987 classification criteria of the American College of Rheumatology (ACR). During the past 20-30 years many different autoantibodies have been described in patients with RA. The presence of some of the autoantibodies in RA directed against various autoantigens, such as anti-neutrophil cytoplasmic antibodies, anti-nuclear antibodies, antibodies against interleukin-1 (IL-1), anti-cardiolipin antibodies, and antibodies against oxidized low density lipoprotein, is not specific for RA and these are not discussed here. This review summarizes the most relevant autoantibodies, and discusses their sensitivity, specificity, and possible diagnostic and prognostic significance in early RA. The antibodies are presented with the two clinically most relevant antibody tests first, followed by others in alphabetic order.
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Wise EM, Isaacs JD. Management of rheumatoid arthritis in primary care--an educational need? Rheumatology (Oxford) 2005; 44:1337-8. [PMID: 16105914 DOI: 10.1093/rheumatology/kei086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Mäkinen H, Kautiainen H, Hannonen P, Sokka T. Is DAS28 an appropriate tool to assess remission in rheumatoid arthritis? Ann Rheum Dis 2005; 64:1410-3. [PMID: 15941836 PMCID: PMC1755218 DOI: 10.1136/ard.2005.037333] [Citation(s) in RCA: 144] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To study which cut off point of DAS28 corresponds to fulfilment of the American Rheumatism Association (ARA) preliminary remission criteria, and clinical remission criteria in patients with rheumatoid arthritis (RA). METHODS All adult patients diagnosed with RA at Jyväskylä Central Hospital 1997-98 were assessed for remission at 5 years. Remission was defined as (a) ARA remission; (b) clinical remission (defined as no tender or swollen joints and normal erythrocyte sedimentation rate). DAS28 was used to measure disease activity. A receiver operating characteristics curve analysis was performed to calculate a cut off point of DAS28 that best corresponds to the ARA remission criteria and the clinical remission criteria. RESULTS 161 patients (mean age 57 years, 107 (66%) female, 98 (61%) with positive rheumatoid factor, and 51 (32%) with erosions) were studied. At 5 years, 19 (12%) patients met the ARA remission criteria, and 55 (34%) met the clinical remission criteria. The cut off value of DAS28 was 2.32 for the ARA remission criteria, and 2.68 for the clinical remission criteria. In patients with DAS28 <2.32, 11/57 (19%) had tender joints, 6/57 (11%) had swollen joints, and 4/57 (7%) had both tender and swollen joints (66 joint count). CONCLUSION In this study the DAS28 cut off point for the ARA remission was lower than in previous studies. The cut off point for DAS28 remission remains controversial. A substantial proportion of patients below the DAS28 cut off point for remission have tender or swollen joints, or both. DAS28 may not be an appropriate tool for assessment of remission in RA.
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Affiliation(s)
- H Mäkinen
- Jyväskylä Central Hospital, Keskussairaalantie 19, 40620 Jyväskylä, Finland.
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Aletaha D, Breedveld FC, Smolen JS. The need for new classification criteria for rheumatoid arthritis. ACTA ACUST UNITED AC 2005; 52:3333-6. [PMID: 16255014 DOI: 10.1002/art.21410] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Daniel Aletaha
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna General Hospital, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Aletaha D, Eberl G, Nell VPK, Machold KP, Smolen JS. Attitudes to early rheumatoid arthritis: changing patterns. Results of a survey. Ann Rheum Dis 2004; 63:1269-75. [PMID: 15361385 PMCID: PMC1754776 DOI: 10.1136/ard.2003.015131] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine if rheumatologists have changed their views on diagnosis and treatment of early rheumatoid arthritis (RA). METHODS Three consecutive questionnaires were sent out to international rheumatologists in 1997, 2000, and 2003. The following aspects of early RA were covered: definition; patient referral time; diagnostic means; follow up intervals; and treatment strategies. All initial participants who responded to at least one of the follow up surveys were included in the analysis. RESULTS RA is now defined by a smaller number of affected joints (monarthritis: 9.8% respondents in 1997 v 17.4% in 2003), and shorter symptom duration (<3 months: 65.5% in 1997 v 85.8% in 2003). Early referrals (<6 weeks) increased (8.9% in 1997 v 17.4% in 2003). Serological test for diagnosis was mostly rheumatoid factor (100% in 2003), but anti-CCP was already used by 17.4% in 2003. Follow up of patients with early RA intensified (every 2 weeks: 16.1% in 1997 v 30.4% in 2003; every month: 47.8% in 2003 v 64.3% in 1997). Treatment with disease modifying antirheumatic drugs (DMARDs) mainly comprised methotrexate, sulfasalazine, and antimalarial drugs. Leflunomide was among the two favourite DMARDs of 10.9% in 2003, whereas no biological agent was so. In 2003, 46.7% respondents started treatment with DMARDs if RA was suspected (30.9% in 1997); no one waited for erosions to occur (7.3% in 1997). CONCLUSION The data obtained in this study suggest that the concept of diagnosing and treating RA early is accepted by a large proportion of the rheumatological community.
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Affiliation(s)
- D Aletaha
- Division of Rheumatology, Department of Internal Medicine III, University of Vienna, Vienna General Hospital, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Lindqvist E, Eberhardt K, Bendtzen K, Heinegård D, Saxne T. Prognostic laboratory markers of joint damage in rheumatoid arthritis. Ann Rheum Dis 2004; 64:196-201. [PMID: 15458956 PMCID: PMC1755350 DOI: 10.1136/ard.2003.019992] [Citation(s) in RCA: 225] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate whether determination of a set of laboratory markers at baseline provides prognostic information on joint damage in hands and feet in rheumatoid arthritis. METHODS 183 patients with early rheumatoid arthritis included in a prospective study were examined. Radiographic changes in hands and feet at 5 and 10 years after inclusion were evaluated (Larsen). The markers analysed were: erythrocyte sedimentation rate (ESR); HLA-DRB alleles typed by restriction fragment length polymorphism; and C reactive protein, cartilage oligomeric matrix protein (COMP), rheumatoid factor (RF) (IgG, IgA, and IgM subtypes), antibodies against cyclic citrullinated peptide (anti-CCP), and antibodies against interleukin 1alpha (anti-IL1alpha), analysed by immunoassays. Multiple linear regression with backward elimination was used to determine the prognostic value of the variables. RESULTS 117/176 patients were positive for IgG RF, 138/176 for IgA RF, 139/176 for IgM RF, 140/176 for anti-CCP, and 40/182 for anti-IL1alpha. After five years, ESR, the presence of IgA RF, serum COMP, and the presence of anti-CCP were significantly associated with more severe joint damage, and the presence of anti-IL1alpha with less severe joint damage. Baseline C reactive protein and anti-CCP predicted radiographic outcome after 10 years. A stronger prediction was obtained by combining the prognostic factors. CONCLUSIONS Early determination of anti-CCP, IgA RF, anti-IL-1alpha, ESR, C reactive protein, and COMP predicted the development of joint damage in hands and feet in this cohort. A combination of these measures reflecting different aspects of the disease process should be useful for evaluating prognosis in individual patients with early rheumatoid arthritis.
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Affiliation(s)
- E Lindqvist
- Department of Rheumatology, Lund University Hospital, S-221 85 Lund, Sweden.
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Forslind K, Ahlmén M, Eberhardt K, Hafström I, Svensson B. Prediction of radiological outcome in early rheumatoid arthritis in clinical practice: role of antibodies to citrullinated peptides (anti-CCP). Ann Rheum Dis 2004; 63:1090-5. [PMID: 15308518 PMCID: PMC1755129 DOI: 10.1136/ard.2003.014233] [Citation(s) in RCA: 286] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the role of anti-cyclic citrullinated peptide antibody (anti-CCP) for the prediction of radiological outcome in patients with early rheumatoid arthritis. METHODS Anti-CCP was assessed at baseline in 379 patients with early rheumatoid arthritis (disease duration <1 year). Radiological joint damage and progression were assessed by Larsen score after two years of follow up (end point) and used as outcome variables. The prognostic value of anti-CCP and other demographic and disease related baseline variables were assessed by univariate and multivariate analyses, including calculation of odds ratios (OR), predictive values, and multiple logistic regression models. RESULTS The presence of anti-CCP was associated with significantly higher Larsen score both at baseline and at end point. Univariate predictor analysis showed that anti-CCP had the highest significant OR for radiological joint damage and progression after baseline Larsen score, followed by rheumatoid factor, erythrocyte sedimentation rate (ESR), C reactive protein, age, smoking status, and sex. In stepwise multiple regression analyses, baseline Larsen score, anti-CCP, and ESR were selected as significant independent predictors of the radiological outcomes. CONCLUSIONS There is good evidence for an association of anti-CCP with radiological joint changes in rheumatoid arthritis. Anti-CCP is an independent predictor of radiological damage and progression. Though prediction in early rheumatoid arthritis is still far from perfect, the use of anti-CCP in clinical practice should make it easier for rheumatologists to reach judicious treatment decisions.
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Affiliation(s)
- K Forslind
- Section of Rheumatology, Helsingborgs Iasarett, Helsingborg, Sweden
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Hammond A, Young A, Kidao R. A randomised controlled trial of occupational therapy for people with early rheumatoid arthritis. Ann Rheum Dis 2004; 63:23-30. [PMID: 14672887 PMCID: PMC1754722 DOI: 10.1136/ard.2002.001511] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Occupational therapy (OT) aims at improving performance of daily living tasks, facilitating successful adjustments in lifestyle, and preventing losses of function. OBJECTIVE To evaluate the effects of a pragmatic, comprehensive OT programme on self management and health status of people with early rheumatoid arthritis (RA) (<2.5 years). METHODS A randomised, controlled "assessor blinded" trial was conducted with assessments made at entry, 6, 12, and 24 months. Main outcomes were AIMS2: physical function (PF), pain visual analogue scale (VAS), and Arthritis Self-Efficacy Scale (ASES). RESULTS Groups had similar disease duration (9 months OT (n = 162) v 10 months control (n = 164)). The OT group received 7.57 (SD 3.04) hours of therapy. Self management significantly increased in the OT group. Otherwise, there were no significant differences in any outcome measures, or between groups, by ACR functional class: AIMS2: PF (F = 0.04; p = 0.96); pain VAS (F = 0.29; p = 0.74); total ASES score (F = 0.93; p = 0.39). CONCLUSIONS OT improved self management but not health status in early RA. Functional ability remains reasonably good for many in the first five years, so preventive benefits of self management may not yet be apparent and longer follow up is needed. Although many considered the education and therapy useful, insufficient numbers in the OT group used self management sufficiently to make a difference. Behavioural approaches can improve adherence and, potentially, the long term benefits. Future research should evaluate OT as a complex intervention and develop programmes from a theoretical and evidence base.
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Affiliation(s)
- A Hammond
- Rheumatology, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY, UK.
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Smolen JS, Aletaha D. The challenge of following process, damage, and function in patients with rheumatoid arthritis in clinical care. Curr Rheumatol Rep 2003; 5:336-40. [PMID: 12967513 DOI: 10.1007/s11926-003-0014-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Josef S Smolen
- Department of Rheumatology, Internal Medicine III, Vienna General Hospital, University of Vienna, Wolkersbergenstrasse 1, Vienna A-1130, Austria.
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Abstract
The outcome of rheumatoid arthritis (RA) is influenced by both genetic and non-genetic (environmental) factors. Treatment is the most important environmental factor which influences RA outcome. This chapter considers non-treatment environmental influences on the outcome of RA. There is evidence that socio-economic factors (such as level of formal education and area of residence), smoking, diet and psychological factors may affect the levels of pain and physical disability experienced by RA patients. More work is needed in order to understand the mechanisms underlying these associations. Smoking may also adversely affect radiological outcome in the longer term. It is possible that pregnancy may improve the outcome of RA. Contrary to popular lay opinion, there is no evidence that the weather has any influence on RA.
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Affiliation(s)
- Deborah P M Symmons
- ARC Epidemiology Unit, University of Manchester Medical School, Oxford Road, M13 9PT, Manchester, UK.
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Abstract
Therapeutic possibilities for the treatment of early rheumatoid arthritis (RA) have expanded largely. New treatment modalities appear very effective with respect to relevant outcomes, such as radiographic progression. At the same time, the costs of disease-modifying antirheumatic drugs (DMARDs) have exponentially increased so that--given the rather high prevalence of RA--cost may become a limiting factor in the treatment of patients with RA. Therefore, there is a need to define the profile of those patients that should be treated with the most effective, and, unfortunately, the most costly, DMARDs. The authors describe herewith the heterogeneity of RA with respect to its most important outcomes, as well as the inability to predict those outcomes appropriately at the individual patient level. This heterogeneity of RA is not acknowledged in the modern landmark clinical trials that the authors base therapeutic decisions on, and the external validity of those trials is at stake. In this article, the authors discuss the consequences of the heterogeneity of RA in light of the perceived lack of external validity of evidence-generating landmark trials. The authors propose the following solutions to overcome this discrepancy: 1) earlier recognition of RA, and 2) appropriate prediction of treatment efficacy, because the most challenging scientific efforts may be taken in the near future in order to arrive at a tailor-made therapy for every individual presenting with RA.
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Affiliation(s)
- Robert B M Landewé
- Department of Internal Medicine and Rheumatology, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
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Brahee DD, Pierre-Jerome C, Kettner NW. Clinical and radiological manifestations of the rheumatoid wrist. A comprehensive review. J Manipulative Physiol Ther 2003; 26:323-9. [PMID: 12819627 DOI: 10.1016/s0161-4754(03)00046-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The intent of this review article is to present the common clinical and radiological features of the rheumatoid wrist as seen in everyday practice. Imaging of the rheumatoid wrist is discussed with emphasis on magnetic resonance imaging (MRI) and its current and future role in the diagnosis and treatment follow-up of the disease. DATA SOURCE A search of the current medical literature from 1990 to present through PubMed was performed without constraints. Search terms used included: MRI, rheumatoid arthritis, wrist, treatment, diagnosis, radiology, clinical manifestations, and incidence. STUDY SELECTION The articles included in this review were selected by historical significance, date of publication, pertinent review information, and, most specifically, those articles studying the current uses for imaging the rheumatoid wrist. DATA SYNTHESIS This review demonstrated an overall agreement between numerous studies that the usefulness of MRI evaluation of the rheumatoid wrist is in its early stages of development. Many of the features of this examination of the wrist are discussed and contrasted with plain film radiographic examination. RESULTS The role of the clinician in the diagnosis and treatment, including complementary care, as well as the follow-up of rheumatoid arthritis in the wrist is unquestionable. The role of plain film examination as a diagnostic tool is excellent. The current and future role of MRI of rheumatoid arthritis is becoming obvious and will likely become the diagnostic imaging tool of choice in the near future. CONCLUSION MRI provides more specific information on rheumatoid lesions in the wrist than plain film imaging. This is especially true when intravenous contrast is utilized. The clinician's use of physical examination, laboratory examination, radiography, and MRI will provide for early diagnosis, treatment, and follow-up of RA in the wrist.
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Affiliation(s)
- Deborah D Brahee
- Private practice of chiropractic radiology, N. Miami, FL 33161, USA.
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Symmons DPM. Epidemiology of rheumatoid arthritis: determinants of onset, persistence and outcome. Best Pract Res Clin Rheumatol 2002; 16:707-22. [PMID: 12473269 DOI: 10.1053/berh.2002.0257] [Citation(s) in RCA: 165] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Rheumatoid arthritis (RA) is the most common chronic inflammatory joint disease. There is some evidence that it may have been brought from North America to Europe during the 18th century. Its arrival in rural parts of the developing world is still more recent. The incidence and prevalence of RA appear to have fallen in Europe, North America and Japan in the last 50 years. During this time the peak age of onset has risen. Risk factors for the development of RA include genetic factors, an adverse pregnancy outcome, smoking, obesity and recent infections. The oral contraceptive pill and some dietary constituents may be protective. Older age and female gender are risk factors both for the development of RA and for a worse outcome. This risk factor profile offers some opportunities for primary and secondary prevention. However, treatment is the greatest determinant of RA outcome.
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Affiliation(s)
- Deborah P M Symmons
- University of Manchester Medical School, Oxford Road, Manchester, M13 9PT, UK
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