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Jiang LQ, Zhang RD, Musonye HA, Zhao HY, He YS, Zhao CN, He T, Tian T, Gao ZX, Fang Y, Wang P, Ni J, Pan HF. Hormonal and reproductive factors in relation to the risk of rheumatoid arthritis in women: a prospective cohort study with 223 526 participants. RMD Open 2024; 10:e003338. [PMID: 38195516 PMCID: PMC10826586 DOI: 10.1136/rmdopen-2023-003338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/11/2023] [Indexed: 01/11/2024] Open
Abstract
OBJECTIVE This study aimed to examine rheumatoid arthritis (RA) risk associated with hormonal and reproductive factors in women from the large cohort of the UK Biobank. METHODS Data on hormonal and reproductive factors in women were collected from a prospective cohort of 223 526 UK Biobank participants. The potential relationship between reproductive factors and RA risk was assessed using restricted cubic spline. Hazard ratios (HR) were estimated using Cox proportional hazard regressions. RESULTS During a median follow-up of 12.39 years, 3313 women with RA were identified. Age at menarche >14 years was associated with a greater RA risk (HR 1.13, 95% CI 1.02 to 1.26) compared with menarche at 13. The multiple adjusted HR for RA in women with menopause at <45 years was 1.46. Reproductive years <33 increased the risk of RA (HR 1.39, 95% CI 1.21 to 1.59). Compared with those with 2 children, women with ≥4 children were associated with a higher risk of RA (HR 1.18, 95% CI 1.04 to 1.34). Women who had a hysterectomy (HR 1.40, 95% CI 1.25 to 1.56) or oophorectomy (HR 1.21, 95% CI 1.08 to 1.35) had a higher risk of RA than those without a hysterectomy or oophorectomy. Both hormone replacement therapy (HRT) use (HR 1.46, 95% CI 1.35 to 1.57) and HRT duration (HR 1.02, 95% CI 1.01 to 1.03) were associated with a higher risk of RA. CONCLUSIONS Some hormonal and reproductive factors were associated with a higher risk of RA. Hormonal and reproductive factors should be considered in risk assessment and formulating management plans in female patients with RA.
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Affiliation(s)
- Ling-Qiong Jiang
- Department of Epidemiology and Biostatistics, Anhui Medical University School of Public Health, Hefei, Anhui, China
- Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ruo-Di Zhang
- Department of Epidemiology and Biostatistics, Anhui Medical University School of Public Health, Hefei, Anhui, China
- Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Harry Asena Musonye
- Department of Epidemiology and Biostatistics, Anhui Medical University School of Public Health, Hefei, Anhui, China
- Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Hao-Yun Zhao
- Department of Clinical Medicine, Anhui Medical University, Hefei, China
| | - Yi-Sheng He
- Department of Epidemiology and Biostatistics, Anhui Medical University School of Public Health, Hefei, Anhui, China
- Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Chan-Na Zhao
- Department of Epidemiology and Biostatistics, Anhui Medical University School of Public Health, Hefei, Anhui, China
- Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Tian He
- Department of Epidemiology and Biostatistics, Anhui Medical University School of Public Health, Hefei, Anhui, China
- Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Tian Tian
- Department of Epidemiology and Biostatistics, Anhui Medical University School of Public Health, Hefei, Anhui, China
| | - Zhao-Xing Gao
- Department of Epidemiology and Biostatistics, Anhui Medical University School of Public Health, Hefei, Anhui, China
- Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yang Fang
- Department of Epidemiology and Biostatistics, Anhui Medical University School of Public Health, Hefei, Anhui, China
- Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Peng Wang
- Teaching Center for Preventive Medicine, School of Public Health, Anhui Medical University, Hefei, China
| | - Jing Ni
- Department of Epidemiology and Biostatistics, Anhui Medical University School of Public Health, Hefei, Anhui, China
- Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Hai-Feng Pan
- Department of Epidemiology and Biostatistics, Anhui Medical University School of Public Health, Hefei, Anhui, China
- Institute of Kidney Disease, Inflammation & Immunity Mediated Diseases, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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Boman A, Kokkonen H, Berglin E, Alenius GM, Rantapää-Dahlqvist S. Hormonal and Reproductive Factors in Relation to Cardiovascular Events in Women with Early Rheumatoid Arthritis. J Clin Med 2022; 12:jcm12010208. [PMID: 36615009 PMCID: PMC9820904 DOI: 10.3390/jcm12010208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
Hormonal and reproductive factors affect the risk for cardiovascular events (CVE) in the general population. Although the risk of CVE is increased in rheumatoid arthritis (RA), the knowledge about the impact of hormonal factors for CVE in RA is sparse. Female postmenopausal patients ≤80 years with early RA were consecutively included in this observational study (n = 803) between 1 January 1996 until 31 December 2017. Questionnaires regarding hormonal factors were distributed from the index date. Data regarding CVE were obtained from the Swedish National Health Register and Cause of Death Register. Associations between CVE and hormonal factors were analyzed using Cox proportional hazard regression. Of the postmenopausal women, 64 women had a CVE after RA onset. The time period from menopause to RA onset was significantly longer for CVE cases with higher proportion of postmenopausal women. In Cox proportional hazard regression models, years from last childbirth and multiparity were associated with higher CVE risk. Adjustments for traditional risk factors did not affect the results except for hypertension. RA onset after menopause and a longer duration from menopause until onset increased the CVE risk. Multiparity was associated with higher CVE risk whilst oral contraceptives decreased the risk. These results can contribute to identification of high-risk patients for CVE beyond traditional risk factors.
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Christensen AO, Li G, Young CH, Snow B, Khan SA, DeVore SB, Edwards S, Bouma GJ, Navratil AM, Cherrington BD, Rothfuss HM. Peptidylarginine deiminase enzymes and citrullinated proteins in female reproductive physiology and associated diseases†. Biol Reprod 2022; 107:1395-1410. [PMID: 36087287 PMCID: PMC10248218 DOI: 10.1093/biolre/ioac173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/30/2022] [Accepted: 09/07/2022] [Indexed: 09/15/2023] Open
Abstract
Citrullination, the post-translational modification of arginine residues, is catalyzed by the four catalytically active peptidylarginine deiminase (PAD or PADI) isozymes and alters charge to affect target protein structure and function. PADs were initially characterized in rodent uteri and, since then, have been described in other female tissues including ovaries, breast, and the lactotrope and gonadotrope cells of the anterior pituitary gland. In these tissues and cells, estrogen robustly stimulates PAD expression resulting in changes in levels over the course of the female reproductive cycle. The best-characterized targets for PADs are arginine residues in histone tails, which, when citrullinated, alter chromatin structure and gene expression. Methodological advances have allowed for the identification of tissue-specific citrullinomes, which reveal that PADs citrullinate a wide range of enzymes and structural proteins to alter cell function. In contrast to their important physiological roles, PADs and citrullinated proteins are also involved in several female-specific diseases including autoimmune disorders and reproductive cancers. Herein, we review current knowledge regarding PAD expression and function and highlight the role of protein citrullination in both normal female reproductive tissues and associated diseases.
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Affiliation(s)
- Amanda O Christensen
- Department of Zoology and Physiology, University of Wyoming, Laramie, WY 82071, USA
| | - Guangyuan Li
- Department of Zoology and Physiology, University of Wyoming, Laramie, WY 82071, USA
| | - Coleman H Young
- Department of Zoology and Physiology, University of Wyoming, Laramie, WY 82071, USA
| | - Bryce Snow
- Department of Zoology and Physiology, University of Wyoming, Laramie, WY 82071, USA
| | | | - Stanley B DeVore
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Sydney Edwards
- Animal Reproduction and Biotechnology Laboratory, Department of Biomedical Sciences, Colorado State University, Fort Collins, CO 80523, USA
| | - Gerrit J Bouma
- Animal Reproduction and Biotechnology Laboratory, Department of Biomedical Sciences, Colorado State University, Fort Collins, CO 80523, USA
| | - Amy M Navratil
- Department of Zoology and Physiology, University of Wyoming, Laramie, WY 82071, USA
| | - Brian D Cherrington
- Department of Zoology and Physiology, University of Wyoming, Laramie, WY 82071, USA
| | - Heather M Rothfuss
- Department of Zoology and Physiology, University of Wyoming, Laramie, WY 82071, USA
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Desai N, Federico L, Baker JF. Lifestyle, Hormonal, and Metabolic Environmental Risks for Rheumatoid Arthritis. Rheum Dis Clin North Am 2022; 48:799-811. [PMID: 36332996 DOI: 10.1016/j.rdc.2022.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although there is a substantial body of literature focused on understanding noninhalational risk-factors for rheumatoid arthritis, the data are mixed and often conflicting. Given the other health benefits for certain lifestyle modifications, it seems reasonable for clinicians to promote healthy lifestyle habits related to diet, exercise, maintenance of health weight, and maintenance of good dental hygiene. Overall, however, these lifestyle modifications may be expected to have modest benefit, and other strategies to prevent rheumatoid arthritis in high-risk patients are needed.
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Affiliation(s)
- Nancy Desai
- Division of Rheumatology, University of Pennsylvania, 3400 Spruce Street, 5 White Building, Philadelphia, PA 19104, USA
| | - Lydia Federico
- Division of Rheumatology, University of Pennsylvania, 3400 Spruce Street, 5 White Building, Philadelphia, PA 19104, USA
| | - Joshua F Baker
- Division of Rheumatology, University of Pennsylvania, 3400 Spruce Street, 5 White Building, Philadelphia, PA 19104, USA; Philadelphia VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA; Department of Epidemiology and Biostatistics, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104 USA.
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Raine C, Giles I. What is the impact of sex hormones on the pathogenesis of rheumatoid arthritis? Front Med (Lausanne) 2022; 9:909879. [PMID: 35935802 PMCID: PMC9354962 DOI: 10.3389/fmed.2022.909879] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/05/2022] [Indexed: 11/13/2022] Open
Abstract
Rheumatoid arthritis (RA) is the most common inflammatory rheumatic disease and has a female predominance of around 3:1. The relationship between sex hormones and RA has been of great interest to researchers ever since Philip Hench's observations in the 1930's regarding spontaneous disease amelioration in pregnancy. Extensive basic scientific work has demonstrated the immunomodulatory actions of sex hormones but this therapeutic potential has not to date resulted in successful clinical trials in RA. Epidemiological data regarding both endogenous and exogenous hormonal factors are inconsistent, but declining estrogen and/or progesterone levels in the menopause and post-partum appear to increase the risk and severity of RA. This review assimilates basic scientific, epidemiological and clinical trial data to provide an overview of the current understanding of the relationship between sex hormones and RA, focusing on estrogen, progesterone and androgens.
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The Genetic, Environmental, and Immunopathological Complexity of Autoantibody-Negative Rheumatoid Arthritis. Int J Mol Sci 2021; 22:ijms222212386. [PMID: 34830268 PMCID: PMC8618508 DOI: 10.3390/ijms222212386] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 12/19/2022] Open
Abstract
Differences in clinical presentation, response to treatment, and long-term outcomes between autoantibody-positive and -negative rheumatoid arthritis (RA) highlight the need for a better comprehension of the immunopathogenic events underlying the two disease subtypes. Whilst the drivers and perpetuators of autoimmunity in autoantibody-positive RA have started to be disclosed, autoantibody-negative RA remains puzzling, also due its wide phenotypic heterogeneity and its possible misdiagnosis. Genetic susceptibility appears to mostly rely on class I HLA genes and a number of yet unidentified non-HLA loci. On the background of such variable genetic predisposition, multiple exogeneous, endogenous, and stochastic factors, some of which are not shared with autoantibody-positive RA, contribute to the onset of the inflammatory cascade. In a proportion of the patients, the immunopathology of synovitis, at least in the initial stages, appears largely myeloid driven, with abundant production of proinflammatory cytokines and only minor involvement of cells of the adaptive immune system. Better understanding of the complexity of autoantibody-negative RA is still needed in order to open new avenues for targeted intervention and improve clinical outcomes.
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Bouzit L, Malspeis S, Sparks JA, Cui J, Karlson EW, Yoshida K, Costenbader KH. Assessing improved risk prediction of rheumatoid arthritis by environmental, genetic, and metabolomic factors. Semin Arthritis Rheum 2021; 51:1016-1022. [PMID: 34416623 PMCID: PMC8475497 DOI: 10.1016/j.semarthrit.2021.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/29/2021] [Accepted: 07/06/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE We sought to improve seropositive rheumatoid arthritis (RA) risk prediction using a novel weighted genetic risk score (wGRS) and preclinical plasma metabolites associated with RA risk. Predictive performance was compared to previously validated models including RA-associated environmental factors. METHODS This nested case-control study matched incident seropositive RA cases (meeting ACR 1987 or EULAR/ACR 2010 criteria) in the Nurses' Health Studies (NHS) to two controls on age, blood collection features, and post-menopausal hormone use at pre-RA blood draw. Environmental variables were measured at the questionnaire cycle preceding blood draw. Four models were generated and internally validated using a bootstrapped optimism estimate: (a) base with environmental factors (E), (b) environmental, genetic and gene-environment interaction factors (E + G + GEI), c) environmental and metabolic factors (E + M), and d) all factors (E + G + GEI + M). A fifth model including all factors and interaction terms was fit using ridge regression and cross-validation. Models were compared using area under the receiver operating characteristic curve (AUC). RESULTS 150 pre-RA cases and 455 matched controls were included. The E model yielded an optimism-corrected AUC of 0.622. The E + M model did not show improvement over the E model (corrected AUC 0.620). Including genetic factors increased prediction, producing corrected AUCs of 0.677 in the E + G + GEI model and 0.674 in the E + G + GEI + M model. Similarly, the performance of the cross-validated ridge regression model yielded an AUC of 0.657. CONCLUSION Addition of wGRS and gene-environment interaction improved seropositive RA risk prediction models. Preclinical metabolite levels did not significantly contribute to prediction.
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Affiliation(s)
- Lilia Bouzit
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA; Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Susan Malspeis
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jing Cui
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth W Karlson
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kazuki Yoshida
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Karen H Costenbader
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Novella-Navarro M, Plasencia-Rodríguez C, Nuño L, Balsa A. Risk Factors for Developing Rheumatoid Arthritis in Patients With Undifferentiated Arthritis and Inflammatory Arthralgia. Front Med (Lausanne) 2021; 8:668898. [PMID: 34211986 PMCID: PMC8239127 DOI: 10.3389/fmed.2021.668898] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/24/2021] [Indexed: 12/18/2022] Open
Abstract
Currently, there is an increasing interest in treating patients at risk of rheumatoid arthritis (RA) to prevent the development of this chronic disease. In this sense, research has focused attention on the early identification of predictive factors of this disease. Autoantibodies and markers of systemic inflammation can be present before clinical arthritis and RA development. So, the phase of inflammatory arthralgia preceding clinical arthritis is an important part of the window of opportunity and, starting treatment might prevent progression to chronic arthritis. Additionally, the early diagnosis and treatment initiation, in patients with inflammatory arthritis at risk of persistence and/or erosive progression, are fundamental because may allow optimal clinical responses, better chances of achieving sustained remission, preventing irreversible organ damage and optimizing long-term outcomes. This review aims to give an overview of clinical risk factors for developing RA, both in suspected arthralgia and in undifferentiated arthritis. Besides taking into consideration the role of serological markers (immunological and acute phase reactants) and clinical features assessed at consultation such as: articular affection and patient's clinical perception. Other features as sociodemographic and environmental factors (lifestyle habits, microbiota, periodontal disease among others), have been included in this revision to give an insight on strategies to prevent development of RA and/or to treat it in early stages.
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Affiliation(s)
| | | | - Laura Nuño
- Rheumatology Department Hospital Universitario La Paz, Madrid, Spain
| | - Alejandro Balsa
- Rheumatology Department Hospital Universitario La Paz, Madrid, Spain
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Cavalcante AFDS, Martin P, Skare TL. Gynecological/Obstetric Background and Rheumatoid Arthritis: A Cross-sectional Study in Brazilian Patients. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:357-361. [PMID: 34077986 PMCID: PMC10304980 DOI: 10.1055/s-0041-1729149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To study a sample of rheumatoid arthritis (RA) patients for their gynecological/obstetric history and compare them to controls to determine their influences on number of pregnancies, menarche, menopause and reproductive years following RA onset. METHODS This is a cross-sectional study of 122 RA patients and 126 controls. Patients and controls were questioned about age of menarche, age of menopause, number of pregnancies and abortions. Reproductive years were calculated as the difference between age at menopause and age at menarche. For comparison, we used the Mann-Whitney, unpaired t, chi-squared, and Spearman tests. The adopted significance was 5%. RESULTS In the RA patients with disease beginning in the postmenopausal years, the period of reproductive years (age at menopause - age of menarche) showed a positive correlation with age at disease onset (rho = 0.46; 95% confidence interval [CI] = 0.20-0.55 with p = 0.0008). The number of pregnancies was higher in patients with postmenopausal disease onset when compared with those with premenopausal disease onset (median of 3 with interquartile range [IQR] = 2-4 versus median of 2 with IQR = 1-3; p = 0.009), and RA patients had more pregnancies than controls (p = 0.0002). CONCLUSION The present study shows that, in our population, the duration of reproductive years and the number of pregnancies are linked to the onset of RA.
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Zhu J, Niu Z, Alfredsson L, Klareskog L, Padyukov L, Jiang X. Age at menarche, age at natural menopause, and risk of rheumatoid arthritis - a Mendelian randomization study. Arthritis Res Ther 2021; 23:108. [PMID: 33836822 PMCID: PMC8034136 DOI: 10.1186/s13075-021-02495-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/29/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Hormonal reproductive factors have been suggested to play an important role in the etiology of rheumatoid arthritis (RA), an autoimmune inflammatory disorder affecting primarily women. We conducted a two-sample Mendelian randomization (MR) study examining three relevant exposures, age at menarche (AAM), age at natural menopause (ANM), and age at first birth (AFB) with the risk of RA. METHODS We collected summary statistics from the hitherto largest GWAS conducted in AAM (N = 329,345), ANM (N = 69,360), AFB (N = 251,151), and RA (Ncase = 14,361, Ncontrol = 43,923), all of European ancestry. We constructed strong instruments using hundreds of exposure-associated genetic variants and estimated causal relationship through different MR approaches including an inverse-variance weighted method, an MR-Egger regression and a weighted median method. We conducted a multivariable MR to control for pleiotropic effect acting in particular through obesity and socioeconomic status. We also performed important sensitivity analyses to verify model assumptions. RESULTS We did not find any evidence in support for a causal association between genetically predicted reproductive factors and risk of RA (ORper-SD increment in AAM = 1.06 [0.98-1.15]; ORper-SD increment in ANM = 1.05 [0.98-1.11], OR per-SD increment in AFB = 0.85 [0.65-1.10]). Results remained consistent after removing palindromic SNPs (ORper-SD increment in AAM = 1.06 [0.97-1.15], ORper-SD increment in ANM = 1.05 [0.98-1.13], ORper-SD increment in AFB = 0.81 [0.61-1.07]) or excluding SNPs associated with potential confounding traits (ORper-SD increment in AAM = 1.03 [0.94-1.12], ORper-SD increment in ANM = 1.04 [0.95-1.14]). No outlying instrument was identified through the leave-one-out analysis. CONCLUSIONS Our MR study does not convincingly support a casual effect of reproductive factors, as reflected by age at menarche, age at menopause, and age at first birth, on the development of RA. Despite the largely augmented set of instruments we used, these instruments only explained a modest proportion of phenotypic variance of exposures. Our knowledge regarding this topic is still insufficient and future studies with larger sample size should be designed to replicate or dispute our findings.
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Affiliation(s)
- Jingjing Zhu
- The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Zheng Niu
- Department of Gynecology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lars Alfredsson
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institute, Tomtebodavägen 5, 17 177, Stockholm, Sweden
| | - Lars Klareskog
- Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
| | - Leonid Padyukov
- Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
| | - Xia Jiang
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institute, Tomtebodavägen 5, 17 177, Stockholm, Sweden. .,Program in Genetic Epidemiology and Statistical Genetics, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA. .,West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
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Salliot C, Nguyen Y, Gusto G, Gelot A, Gambaretti J, Mariette X, Boutron-Ruault MC, Seror R. Female hormonal exposures and risk of rheumatoid arthritis in the French E3N-EPIC cohort study. Rheumatology (Oxford) 2021; 60:4790-4800. [PMID: 33547777 DOI: 10.1093/rheumatology/keab101] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/08/2020] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To assess the relationships between female hormonal exposures and risk of RA in a prospective cohort of French women. METHODS E3N (Etude Epidémiologique auprès des femmes de la Mutuelle générale de l'Education Nationale) is an on-going French prospective cohort that included 98 995 women aged 40-65 years in 1990. Every 2-3 years, women completed mailed questionnaires on their lifestyles, reproductive factors and health conditions. Cox proportional hazards regression models were used to determine factors associated with risk of incident RA, with age as the time scale, adjusted for known risk factors of RA, and considering endogenous and exogenous hormonal factors. Hazard ratios (HRs) and 95% CIs were estimated. Effect modification by smoking history was investigated. RESULTS A total of 698 incident cases of RA were ascertained among 78 452 women. In multivariable-adjusted Cox regression models, risk of RA was increased with early age at first pregnancy (<22 vs ≥27 years; HR = 1.34; 95% CI 1.0, 1.7) and menopause (≤45 vs ≥53 years; HR = 1.40; 95% CI 1.0, 1.9). For early menopause, the association was of similar magnitude in ever and never smokers, although the association was statistically significant only in ever smokers (HR = 1.54; 95% CI 1.0, 2.3). We found a decreased risk in nulliparous women never exposed to smoking (HR = 0.44; 95% CI 0.2, 0.8). Risk of RA was inversely associated with exposure to progestogen only in perimenopause (>24 vs 0 months; multi-adjusted HR = 0.77; 95% CI 0.6, 0.9). CONCLUSIONS These results suggest an effect of both endogenous and exogenous hormonal exposures on RA risk and phenotype that deserves further investigation.
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Affiliation(s)
- Carine Salliot
- Center for Research in Epidemiology and Population Health (CESP), Institut Pour la Santé et la Recherche Médicale (INSERM) U1018, Université Paris-Saclay, Villejuif.,Rheumatology Department, Centre Hospitalier Régional d'Orléans, Orléans.,Center of Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut Pour la Santé et la Recherche Médicale (INSERM) U1184, Université Paris-Saclay, Paris
| | - Yann Nguyen
- Center for Research in Epidemiology and Population Health (CESP), Institut Pour la Santé et la Recherche Médicale (INSERM) U1018, Université Paris-Saclay, Villejuif.,Department of Internal Medicine, AP-HP.Nord, Hôpital Beaujon, Université de Paris, Clichy
| | - Gaëlle Gusto
- Center for Research in Epidemiology and Population Health (CESP), Institut Pour la Santé et la Recherche Médicale (INSERM) U1018, Université Paris-Saclay, Villejuif.,Institut Gustave Roussy, Université Paris-Saclay, Villejuif
| | - Amandine Gelot
- Center for Research in Epidemiology and Population Health (CESP), Institut Pour la Santé et la Recherche Médicale (INSERM) U1018, Université Paris-Saclay, Villejuif.,Institut Gustave Roussy, Université Paris-Saclay, Villejuif
| | - Juliette Gambaretti
- Center for Research in Epidemiology and Population Health (CESP), Institut Pour la Santé et la Recherche Médicale (INSERM) U1018, Université Paris-Saclay, Villejuif.,Institut Gustave Roussy, Université Paris-Saclay, Villejuif
| | - Xavier Mariette
- Center of Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut Pour la Santé et la Recherche Médicale (INSERM) U1184, Université Paris-Saclay, Paris.,Rheumatology Department, Assistance Publique-Hôpitaux de Paris (AP-HP), AP-HP, Université Paris-Saclay-Hôpital Bicêtre, Paris, France
| | - Marie-Christine Boutron-Ruault
- Center for Research in Epidemiology and Population Health (CESP), Institut Pour la Santé et la Recherche Médicale (INSERM) U1018, Université Paris-Saclay, Villejuif.,Institut Gustave Roussy, Université Paris-Saclay, Villejuif
| | - Raphaèle Seror
- Center of Immunology of Viral Infections and Auto-immune Diseases (IMVA), Institut Pour la Santé et la Recherche Médicale (INSERM) U1184, Université Paris-Saclay, Paris.,Rheumatology Department, Assistance Publique-Hôpitaux de Paris (AP-HP), AP-HP, Université Paris-Saclay-Hôpital Bicêtre, Paris, France
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12
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Menopausal factors and risk of seropositive rheumatoid arthritis in postmenopausal women: a nationwide cohort study of 1.36 million women. Sci Rep 2020; 10:20793. [PMID: 33247198 PMCID: PMC7695821 DOI: 10.1038/s41598-020-77841-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 11/13/2020] [Indexed: 01/21/2023] Open
Abstract
In previous literature regarding development of rheumatoid arthritis (RA), female reproductive factors have been described as protective factors, risk factors, or irrelevant, leading to inconsistent results. The aim of this study was to investigate the effect of female reproductive factors on the incidence of seropositive RA. A large population-based retrospective cohort of the National Health Insurance Service data in South Korea was used. Postmenopausal women who participated in both cardiovascular and breast cancer screening in 2009 were included and followed until date of seropositive RA diagnosis, death, or December 31, 2018. Multivariable-adjusted Cox proportional hazards model was used to assess the association between reproductive factors and incident seropositive RA. Of 1,357,736 postmenopausal women, 6056 women were diagnosed with seropositive RA, and the incidence rate was 54.16 cases/100,000 person-years. Reproductive factors other than hormone replacement therapy (HRT) were not significantly associated with seropositive RA incidence. Postmenopausal women who used HRT ≥ 5 years were associated with a higher aHR of incident seropositive RA than never-users (aHR 1.25; 95% CI 1.09–1.44). Alcohol consumption less than 30 g per day (aHR 0.80; 95% CI 0.74–0.87), regular physical activity (aHR 0.90; 95% CI 0.84–0.97), diabetes mellitus (aHR 0.85; 95% CI 0.78–0.93), and cancer (aHR 0.77; 95% CI 0.64–0.92) were associated with lower risk of seropositive RA. Most female reproductive factors did not significantly affect the development of seropositive RA in postmenopausal women. Only HRT is associated with a small but significant increase in risk of seropositive RA.
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13
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Salliot C, Nguyen Y, Boutron-Ruault MC, Seror R. Environment and Lifestyle: Their Influence on the Risk of RA. J Clin Med 2020; 9:jcm9103109. [PMID: 32993091 PMCID: PMC7601336 DOI: 10.3390/jcm9103109] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/22/2020] [Accepted: 09/22/2020] [Indexed: 12/23/2022] Open
Abstract
Background: Rheumatoid arthritis (RA) is a complex disease in which environmental agents are thought to interact with genetic factors that lead to triggering of autoimmunity. Methods: We reviewed environmental, hormonal, and dietary factors that have been suggested to be associated with the risk of RA. Results: Smoking is the most robust factor associated with the risk of RA, with a clear gene–environment interaction. Among other inhalants, silica may increase the risk of RA in men. There is less evidence for pesticides, pollution, and other occupational inhalants. Regarding female hormonal exposures, there is some epidemiological evidence, although not consistent in the literature, to suggest a link between hormonal factors and the risk of RA. Regarding dietary factors, available evidence is conflicting. A high consumption of coffee seems to be associated with an increased risk of RA, whereas a moderate consumption of alcohol is inversely associated with the risk of RA, and there is less evidence regarding other food groups. Dietary pattern analyses (Mediterranean diet, the inflammatory potential of the diet, or diet quality) suggested a potential benefit of dietary modifications for individuals at high risk of RA. Conclusion: To date, smoking and silica exposure have been reproducibly demonstrated to trigger the emergence of RA. However, many other environmental factors have been studied, mostly with a case-control design. Results were conflicting and studies rarely considered potential gene–environment interactions. There is a need for large scale prospective studies and studies in predisposed individuals to better understand and prevent the disease and its course.
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Affiliation(s)
- Carine Salliot
- Centre for Research in Epidemiology and Population Health, (CESP), INSERM U1018, Université Paris-Sud, F-94800 Villejuif, France; (C.S.); (Y.N.); (M.-C.B.-R.)
- Rheumatology Department, Centre Hospitalier Régional d’Orléans, 45100 Orléans, France
- Centre of Immunology of Viral Infections and Auto-immune Diseases (IMVA), INSERM U1184, Université Paris-Sud, F-94270 Le Kremlin Bicêtre, France
| | - Yann Nguyen
- Centre for Research in Epidemiology and Population Health, (CESP), INSERM U1018, Université Paris-Sud, F-94800 Villejuif, France; (C.S.); (Y.N.); (M.-C.B.-R.)
- Department of Internal Medicine, AP-HP. Nord, Hôpital Beaujon, Université de Paris, F-92100 Clichy, France
| | - Marie-Christine Boutron-Ruault
- Centre for Research in Epidemiology and Population Health, (CESP), INSERM U1018, Université Paris-Sud, F-94800 Villejuif, France; (C.S.); (Y.N.); (M.-C.B.-R.)
| | - Raphaèle Seror
- Centre of Immunology of Viral Infections and Auto-immune Diseases (IMVA), INSERM U1184, Université Paris-Sud, F-94270 Le Kremlin Bicêtre, France
- Rheumatology Department, AP-HP, Hôpitaux universitaires Paris-Saclay—Hôpital Bicêtre, F-94270 Le Kremlin Bicêtre, France
- Correspondence: ; Tel.: +33(0)145-213-759
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14
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Wang KX, Gao Y, Lu C, Li Y, Zhou BY, Qin XM, Du GH, Gao L, Guan DG, Lu AP. Uncovering the Complexity Mechanism of Different Formulas Treatment for Rheumatoid Arthritis Based on a Novel Network Pharmacology Model. Front Pharmacol 2020; 11:1035. [PMID: 32754034 PMCID: PMC7365894 DOI: 10.3389/fphar.2020.01035] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 06/25/2020] [Indexed: 12/13/2022] Open
Abstract
Traditional Chinese medicine (TCM) with the characteristics of “multi-component-multi-target-multi-pathway” has obvious advantages in the prevention and treatment of complex diseases, especially in the aspects of “treating the same disease with different treatments”. However, there are still some problems such as unclear substance basis and molecular mechanism of the effectiveness of formula. Network pharmacology is a new strategy based on system biology and poly-pharmacology, which could observe the intervention of drugs on disease networks at systematical and comprehensive level, and especially suitable for study of complex TCM systems. Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease, causing articular and extra articular dysfunctions among patients, it could lead to irreversible joint damage or disability if left untreated. TCM formulas, Danggui-Sini-decoction (DSD), Guizhi-Fuzi-decoction (GFD), and Huangqi-Guizhi-Wuwu-Decoction (HGWD), et al., have been found successful in controlling RA in clinical applications. Here, a network pharmacology-based approach was established. With this model, key gene network motif with significant (KNMS) of three formulas were predicted, and the molecular mechanism of different formula in the treatment of rheumatoid arthritis (RA) was inferred based on these KNMSs. The results show that the KNMSs predicted by the model kept a high consistency with the corresponding C-T network in coverage of RA pathogenic genes, coverage of functional pathways and cumulative contribution of key nodes, which confirmed the reliability and accuracy of our proposed KNMS prediction strategy. All validated KNMSs of each RA therapy-related formula were employed to decode the mechanisms of different formulas treat the same disease. Finally, the key components in KNMSs of each formula were evaluated by in vitro experiments. Our proposed KNMS prediction and validation strategy provides methodological reference for interpreting the optimization of core components group and inference of molecular mechanism of formula in the treatment of complex diseases in TCM.
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Affiliation(s)
- Ke-Xin Wang
- Modern Research Center for Traditional Chinese Medicine, Shanxi University, Taiyuan, China.,Institute of Integrated Bioinformedicine and Translational Science, Hong Kong Baptist University, Hong Kong, Hong Kong
| | - Yao Gao
- Modern Research Center for Traditional Chinese Medicine, Shanxi University, Taiyuan, China.,Institute of Integrated Bioinformedicine and Translational Science, Hong Kong Baptist University, Hong Kong, Hong Kong
| | - Cheng Lu
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yao Li
- Institute of Integrated Bioinformedicine and Translational Science, Hong Kong Baptist University, Hong Kong, Hong Kong
| | - Bo-Ya Zhou
- Department of Ultrasound, Eighth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xue-Mei Qin
- Modern Research Center for Traditional Chinese Medicine, Shanxi University, Taiyuan, China
| | - Guan-Hua Du
- Modern Research Center for Traditional Chinese Medicine, Shanxi University, Taiyuan, China.,Institute of Materia Medica, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Li Gao
- Modern Research Center for Traditional Chinese Medicine, Shanxi University, Taiyuan, China
| | - Dao-Gang Guan
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China.,Guangdong Key Laboratory of Single Cell Technology and Application, Southern Medical University, Guangzhou, China
| | - Ai-Ping Lu
- Institute of Integrated Bioinformedicine and Translational Science, Hong Kong Baptist University, Hong Kong, Hong Kong
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15
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Wadström H, Pettersson A, Smedby KE, Askling J. Risk of breast cancer before and after rheumatoid arthritis, and the impact of hormonal factors. Ann Rheum Dis 2020; 79:581-586. [PMID: 32161056 PMCID: PMC7213316 DOI: 10.1136/annrheumdis-2019-216756] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/16/2020] [Accepted: 02/25/2020] [Indexed: 12/13/2022]
Abstract
Objectives To examine the risk of incident breast cancer in women with rheumatoid arthritis (RA), and the risk of RA in women with a history of breast cancer, taking antihormonal treatment for breast cancer into account. Methods Using nationwide Swedish registers, women with new-onset RA diagnosed in 2006–2016 were identified and analysed using a cohort and a case–control design. Each patient with RA was matched on age, sex and place of residence to five randomly selected subjects from the general population. Through register linkages, we collected information on breast cancer, breast cancer risk factors (reproductive history and hormone replacement therapy) and socio-economy. The relative risk of breast cancer after RA was assessed using Cox regression, and the relative risk of RA in women with a history of breast cancer was assessed using conditional logistic regression. Results The risk of incident breast cancer in women with RA was reduced and the association was not attenuated by adjustment for breast cancer risk factors (HR=0.80, 95% CI 0.68 to 0.93). The risk of RA in women with a history of breast cancer was similarly reduced (OR=0.87, 95% CI 0.79 to 0.95). Women with breast cancer treated with tamoxifen (OR=0.86, 95% CI 0.62 to 1.20) or aromatase inhibitors (OR=0.97, 95% CI 0.69 to 1.37) did not have an increased risk of RA compared with women with breast cancer treated differently. Conclusions The decreased occurrence of breast cancer in patients with RA is present already before RA diagnosis; these reduced risks are not readily explained by hormonal risk factors. Adjuvant antihormonal therapy for breast cancer does not seem to increase RA risk.
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Affiliation(s)
- Hjalmar Wadström
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Pettersson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Karin E Smedby
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Patient Area Hematology, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Rheumatology, Theme Inflammation and Infection, Karolinska University Hospital, Solna, Sweden
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16
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Guan Y, Zhang H, Quang D, Wang Z, Parker SCJ, Pappas DA, Kremer JM, Zhu F. Machine Learning to Predict Anti-Tumor Necrosis Factor Drug Responses of Rheumatoid Arthritis Patients by Integrating Clinical and Genetic Markers. Arthritis Rheumatol 2019; 71:1987-1996. [PMID: 31342661 DOI: 10.1002/art.41056] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/18/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Accurate prediction of treatment responses in rheumatoid arthritis (RA) patients can provide valuable information on effective drug selection. Anti-tumor necrosis factor (anti-TNF) drugs are an important second-line treatment after methotrexate, the classic first-line treatment for RA. However, patient heterogeneity hinders identification of predictive biomarkers and accurate modeling of anti-TNF drug responses. This study was undertaken to investigate the usefulness of machine learning to assist in developing predictive models for treatment response. METHODS Using data on patient demographics, baseline disease assessment, treatment, and single-nucleotide polymorphism (SNP) array from the Dialogue on Reverse Engineering Assessment and Methods (DREAM): Rheumatoid Arthritis Responder Challenge, we created a Gaussian process regression model to predict changes in the Disease Activity Score in 28 joints (DAS28) for the patients and to classify them into either the responder or the nonresponder group. This model was developed and cross-validated using data from 1,892 RA patients. It was evaluated using an independent data set from 680 patients. We examined the effectiveness of the similarity modeling and the contribution of individual features. RESULTS In the cross-validation tests, our method predicted changes in DAS28 (ΔDAS28), with a correlation coefficient of 0.405. It correctly classified responses from 78% of patients. In the independent test, this method achieved a Pearson's correlation coefficient of 0.393 in predicting ΔDAS28. Gaussian process regression effectively remapped the feature space and identified subpopulations that do not respond well to anti-TNF treatments. Genetic SNP biomarkers showed small contributions in the prediction when added to the clinical models. This was the best-performing model in the DREAM Challenge. CONCLUSION The model described here shows promise in guiding treatment decisions in clinical practice, based primarily on clinical profiles with additional genetic information.
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Affiliation(s)
| | | | | | | | | | - Dimitrios A Pappas
- Columbia University College of Physicians and Surgeons, New York, New York, and Corrona LLC, Waltham, Massachusetts
| | - Joel M Kremer
- Corrona LLC, Waltham, Massachusetts, and Albany Medical College and The Center for Rheumatology, Albany, New York
| | - Fan Zhu
- Chinese Academy of Sciences, Chongqing, China
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17
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Littlejohn EA. Pregnancy and rheumatoid arthritis. Best Pract Res Clin Obstet Gynaecol 2019; 64:52-58. [PMID: 31672290 DOI: 10.1016/j.bpobgyn.2019.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/09/2019] [Indexed: 12/17/2022]
Abstract
Rheumatoid arthritis commonly affects women of childbearing age. Fertility, family planning, control of disease activity and birth outcomes are all important issues to be discussed at preconception counseling. New data has offered insight on trends of fertility, disease control during pregnancy, and birth outcomes. This chapter provides an updated overview on expected disease course and management issues at each juncture with a particular focus on maintenance of tight disease control.
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Affiliation(s)
- Emily Adele Littlejohn
- Cleveland Clinic, Department of Rheumatology and Immunology, 9500 Euclid Ave # A50, Cleveland, OH, 44195, USA.
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18
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Chen WMY, Subesinghe S, Muller S, Hider SL, Mallen CD, Scott IC. The association between gravidity, parity and the risk of developing rheumatoid arthritis: A systematic review and meta-analysis. Semin Arthritis Rheum 2019; 50:252-260. [PMID: 31530401 DOI: 10.1016/j.semarthrit.2019.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 08/18/2019] [Accepted: 09/09/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To establish if gravidity and parity associate with the development of rheumatoid arthritis (RA), and to establish if this effect is influenced by the time elapsed since pregnancy/childbirth, the number of pregnancies/childbirths, and serological status, through systematically reviewing the literature and undertaking a meta-analysis. METHODS We searched Medline/EMBASE (from 1946 to 2018) using the terms "rheumatoid arthritis.mp" or "arthritis, rheumatoid/" and "pregnancy.mp" or "pregnancy/" or "parity.mp" or "parity/" or "gravidity.mp" or "gravidity/" (observational study filter applied). Case-control/cohort studies that examined the relationship between parity/gravidity and the risk of RA in women were included. Studies reporting effect size data for RA in ever vs. never parous/gravid women as ORs/RRs with 95% confidence intervals were included in a meta-analysis. Other relationships (i.e. risk by pregnancy/childbirth numbers) were analysed descriptively. RESULTS Twenty studies (from 626 articles) met our inclusion criteria, comprising 14 case-control (4799 cases; 11,941 controls) and 6 cohort studies (8575 cases; 2,368,439 individuals). No significant association was observed in the meta-analysis of studies reporting the risk of RA in ever vs. never parous women (OR 0.91; 95% CI 0.80-1.04) and ever vs. never gravid women (OR 0.86; 95% CI 0.46-1.62). No consistent evidence of a relationship between the number of pregnancies/childbirths and RA risk was seen. No significant association was observed between being pregnant, or in the immediate post-partum period, and the risk of developing RA. CONCLUSION Our systematic review does not support the concept that gravidity and parity are associated with the risk of RA development.
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Affiliation(s)
- Winnie M Y Chen
- Department of Academic Rheumatology, King's College London, London, UK
| | - Sujith Subesinghe
- Department of Academic Rheumatology, King's College London, London, UK; Department of Rheumatology, Guy's and St Thomas' NHS Trust, London, UK
| | - Sara Muller
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University, Staffordshire ST5 5BG, Keele, UK
| | - Samantha L Hider
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University, Staffordshire ST5 5BG, Keele, UK; Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University, Staffordshire ST5 5BG, Keele, UK
| | - Ian C Scott
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Primary Care Sciences, Keele University, Staffordshire ST5 5BG, Keele, UK; Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK.
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19
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Pan TD, Mueller BA, Dugowson CE, Richardson ML, Nelson JL. Disease progression in relation to pre-onset parity among women with rheumatoid arthritis. Semin Arthritis Rheum 2019; 50:1-6. [PMID: 31324468 DOI: 10.1016/j.semarthrit.2019.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 06/10/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) often ameliorates during pregnancy and flares postpartum, but the relationship of pregnancy and childbirth to RA prognosis is unclear. We examined RA severity for association with parity prior to RA onset and asked whether time from birth (latency) and/or the mother's HLA genotype influenced results. METHODS A cohort study was conducted of 222 women previously identified in a prospective study of newly diagnosed RA, who returned for follow-up evaluation a median of 8 years later. Stratified analyses using Mantel-Haenszel methods were conducted to evaluate 5 RA severity measures based on hand and wrist radiographs, physical exams, and Health Assessment Questionnaires for association with parity. RESULTS Overall, we observed little evidence of altered risk of progression to severe RA in relation to pre-onset parity, adjusting for RA onset age and time to follow-up. Stratifying parous women who had only live births by latency (<15 years/15+ years) showed no difference in risk of severe RA compared to nulligravid women. Live birth deliveries were significantly protective for women with 0 but not for those with 1 or 2 copies of the RA risk-associated HLA-DRB1 shared epitope sequence for erosion score (RR 0.26 95% CI 0.09-0.89) and joint count (RR 0.28 95% CI 0.09-0.87). CONCLUSION We observed little evidence of difference in severe RA by pre-onset parity overall. However, among women not predisposed to RA by possessing the risk-associated HLA genotype, parous women who had only live births had lower risk of progression to severe RA as measured by erosion score and joint count.
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Affiliation(s)
- Tiffany D Pan
- Department of Epidemiology, University of Washington, Box 357236, Seattle, WA 98195 USA; Department of Anthropology, University of Washington, Box 353100, Seattle, WA 98195 USA.
| | - Beth A Mueller
- Department of Epidemiology, University of Washington, Box 357236, Seattle, WA 98195 USA; Public Health Sciences Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., PO Box 19024, Seattle, WA 98109 USA
| | - Carin E Dugowson
- Division of Rheumatology, University of Washington, Box 356428, Seattle, WA 98195 USA
| | - Michael L Richardson
- Department of Radiology, University of Washington, Box 357115, Seattle, WA 98195 USA
| | - J Lee Nelson
- Division of Rheumatology, University of Washington, Box 356428, Seattle, WA 98195 USA; Division of Clinical Research, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., PO Box 19024, Seattle, WA 98109 USA
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20
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Cruz GI, Shao X, Quach H, Quach D, Ho KA, Sterba K, Noble JA, Patsopoulos NA, Busch MP, Triulzi DJ, Ladas N, Blasczyk R, Wong WSW, Solomon BD, Niederhuber JE, Criswell LA, Barcellos LF. Mother-child histocompatibility and risk of rheumatoid arthritis and systemic lupus erythematosus among mothers. Genes Immun 2019; 21:27-36. [PMID: 30635658 PMCID: PMC7039805 DOI: 10.1038/s41435-018-0055-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 10/20/2018] [Accepted: 11/01/2018] [Indexed: 12/12/2022]
Abstract
The study objective was to test the hypothesis that having histocompatible children increases the risk of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), possibly by contributing to the persistence of fetal cells acquired during pregnancy. We conducted a case control study using data from the UC San Francisco Mother Child Immunogenetic Study and studies at the Inova Translational Medicine Institute. We imputed human leukocyte antigen (HLA) alleles and minor histocompatibility antigens (mHags). We created a variable of exposure to histocompatible children. We estimated an average sequence similarity matching (SSM) score for each mother based on discordant mother-child alleles as a measure of histocompatibility. We used logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals. A total of 138 RA, 117 SLE, and 913 control mothers were analyzed. Increased risk of RA was associated with having any child compatible at HLA-B (OR 1.9; 1.2-3.1), DPB1 (OR 1.8; 1.2-2.6) or DQB1 (OR 1.8; 1.2-2.7). Compatibility at mHag ZAPHIR was associated with reduced risk of SLE among mothers carrying the HLA-restriction allele B*07:02 (n = 262; OR 0.4; 0.2-0.8). Our findings support the hypothesis that mother-child histocompatibility is associated with risk of RA and SLE.
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Affiliation(s)
- Giovanna I Cruz
- Genetic Epidemiology and Genomics Lab, Division of Epidemiology, School of Public Health, University of California Berkeley, 324 Stanley Hall, Berkeley, CA, 94720-3220, USA
| | - Xiaorong Shao
- Genetic Epidemiology and Genomics Lab, Division of Epidemiology, School of Public Health, University of California Berkeley, 324 Stanley Hall, Berkeley, CA, 94720-3220, USA
| | - Hong Quach
- Genetic Epidemiology and Genomics Lab, Division of Epidemiology, School of Public Health, University of California Berkeley, 324 Stanley Hall, Berkeley, CA, 94720-3220, USA
| | - Diana Quach
- Genetic Epidemiology and Genomics Lab, Division of Epidemiology, School of Public Health, University of California Berkeley, 324 Stanley Hall, Berkeley, CA, 94720-3220, USA
| | - Kimberly A Ho
- Rosalind Russell/Ephraim P. Engleman Rheumatology Research Center, Department of Medicine, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Kirsten Sterba
- Rosalind Russell/Ephraim P. Engleman Rheumatology Research Center, Department of Medicine, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Janelle A Noble
- Children's Hospital Oakland Research Institute, 5700 M.L.K. Jr. Way, Oakland, CA, 94609, USA
| | - Nikolaos A Patsopoulos
- Division of Genetics, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, 77 Avenue Louis Pasteur, Boston, MA, 02115, USA.,Program in Translational Neuropsychiatric Genomics, Institute for the Neurosciences, Department of Neurology, Brigham & Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Program in Medical and Population Genetics, Broad Institute of Massachusetts Institute of Technology and Harvard, 415 Main Street, Cambridge, MA, 02142, USA
| | - Michael P Busch
- Blood Systems Research Institute, 270 Masonic Avenue, San Francisco, CA, 94118-4417, USA
| | - Darrell J Triulzi
- Institute for Transfusion Medicine, Department of Pathology, University of Pittsburgh, 3636 Blvd. of the Allies, Pittsburgh, PA, 15213, USA
| | - Nektarios Ladas
- Institute for Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | - Rainer Blasczyk
- Institute for Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | - Wendy S W Wong
- Division of Medical Genomics, Inova Translational Medicine Institute, 8110 Gatehouse Road, Falls Church, VA, 22042, USA
| | - Benjamin D Solomon
- Division of Medical Genomics, Inova Translational Medicine Institute, 8110 Gatehouse Road, Falls Church, VA, 22042, USA
| | - John E Niederhuber
- Division of Medical Genomics, Inova Translational Medicine Institute, 8110 Gatehouse Road, Falls Church, VA, 22042, USA.,School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Lindsey A Criswell
- Rosalind Russell/Ephraim P. Engleman Rheumatology Research Center, Department of Medicine, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Lisa F Barcellos
- Genetic Epidemiology and Genomics Lab, Division of Epidemiology, School of Public Health, University of California Berkeley, 324 Stanley Hall, Berkeley, CA, 94720-3220, USA. .,California Institute for Quantitative Biosciences (QB3), University of California Berkeley, 174 Stanley Hall, Berkeley, CA, 94720-3220, USA.
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21
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Alpízar-Rodríguez D, Pluchino N, Canny G, Gabay C, Finckh A. The role of female hormonal factors in the development of rheumatoid arthritis. Rheumatology (Oxford) 2017; 56:1254-1263. [PMID: 27686101 DOI: 10.1093/rheumatology/kew318] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Indexed: 01/18/2023] Open
Abstract
RA is the most common chronic systemic autoimmune disease, with a higher prevalence in women, suggesting female hormonal factors play a role in the development of the disease. However, many controversies still exist. The aim of this review was to appraise data from recent research concerning female hormonal factors and their association with RA disease development. The study of female hormonal factors is challenging because serum levels may differ throughout a woman's lifetime and interact with various environmental, immunological, genetic and endocrine factors influencing the development of autoimmunity. As some female hormonal factors may be potentially modifiable, understanding their impact on RA development is clinically relevant and may result in specific preventive interventions in high-risk populations.
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Affiliation(s)
| | - Nicola Pluchino
- Division of Gynecology, Department of Obstetrics and Gynecology, University Hospitals of Geneva, Geneva, Switzerland.,Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Geraldine Canny
- Department of Research affairs, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Cem Gabay
- 3Division of Rheumatology, Department of Internal Medicine Specialties
| | - Axel Finckh
- 3Division of Rheumatology, Department of Internal Medicine Specialties
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22
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Bengtsson C, Malspeis S, Orellana C, Sparks JA, Costenbader KH, Karlson EW. Association Between Menopausal Factors and the Risk of Seronegative and Seropositive Rheumatoid Arthritis: Results From the Nurses' Health Studies. Arthritis Care Res (Hoboken) 2017; 69:1676-1684. [PMID: 28085997 DOI: 10.1002/acr.23194] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 01/10/2017] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To investigate whether menopausal factors are associated with the development of serologic rheumatoid arthritis (RA) phenotypes. METHODS Data were analyzed from the Nurses' Health Studies (NHS; 1976-2010 and NHSII 1989-2011). A total of 120,700 female nurses ages 30-55 years in the NHS, and a total of 116,430 female nurses ages 25-42 years in the NHSII, were followed via biennial questionnaires on lifestyle and disease outcomes. In total, 1,096 incident RA cases were confirmed by questionnaire and chart review. Seropositive RA was defined as rheumatoid factor positive (RF) or antibodies to citrullinated protein antigen (ACPA) positive, and seronegative RA was defined as RF negative and ACPA negative. We used Cox proportional hazards models to obtain multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs) of seropositive/seronegative RA associated with menopausal status, age at menopause, type of menopause, ovulatory years, and postmenopausal hormone therapy (PMH) use. RESULTS Postmenopausal women had a 2-fold increased risk of seronegative RA, compared with premenopausal women (NHS: HR 1.8 [95% CI 1.1-3.0], NHSII: HR 2.4 [95% CI 1.4-3.9], and pooled HR 2.1 [95% CI 1.4-3.0]). Natural menopause at early age (≤44 years) was associated with an increased risk of seronegative RA (pooled HR 2.4 [95% CI 1.5-4.0]). None of the menopausal factors was significantly associated with seropositive RA. We observed no association between PMH use and the risk of seronegative or seropositive RA, except that PMH use of ≥8 years was associated with increased risk of seropositive RA (pooled HR 1.4 [95% CI 1.1-1.9]). CONCLUSION Postmenopause and natural menopause at an early age were strongly associated with seronegative RA, but only marginally with seropositive RA, suggesting potential differences in the etiology of RA subtypes.
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Affiliation(s)
- Camilla Bengtsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Susan Malspeis
- Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Cecilia Orellana
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jeffrey A Sparks
- Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Karen H Costenbader
- Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elizabeth W Karlson
- Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts
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23
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Orellana C, Saevarsdottir S, Klareskog L, Karlson EW, Alfredsson L, Bengtsson C. Oral contraceptives, breastfeeding and the risk of developing rheumatoid arthritis: results from the Swedish EIRA study. Ann Rheum Dis 2017; 76:1845-1852. [PMID: 28818831 PMCID: PMC5705848 DOI: 10.1136/annrheumdis-2017-211620] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/15/2017] [Accepted: 06/24/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To study whether oral contraceptive (OC) use or breastfeeding (BF) influence the risk of rheumatoid arthritis (RA), stratifying the cases by presence/absence of anticitrullinated protein antibodies (ACPA), and whether these factors interact with known risk factors in the development of ACPA-positive RA. METHODS Women aged ≥18 years, participants in the population-based case-control Swedish Epidemiological Investigation of RA study (2641 cases/4251 controls), completed an extensive questionnaire regarding OC, BF and potential confounders. We calculated ORs, with 95% CIs, adjusted for age, residential area, smoking and alcohol consumption. Attributable proportion due to interaction (AP) was estimated to evaluate presence of interaction. RESULTS Compared with never users, ever and past OC users had a decreased risk of ACPA-positive RA (OR=0.84 (95% CI 0.74 to 0.96); OR=0.83 (95% CI 0.73 to 0.95), respectively). No significant associations were found for ACPA-negative RA. Long duration of OC use (>7 years vs never use) decreased the risk of both ACPA-positive (p=0.0037) and ACPA-negative RA (p=0.0356).A history of long BF decreased the risk only of ACPA-positive RA in a dose-dependent manner (p=0.0086), but this trend did not remain after adjustments. A significant interaction was observed between the lack of OC use and smoking (AP=0.28 (95% CI 0.14-0.42)) on the risk of ACPA-positive RA. No interactions were found for BF. CONCLUSIONS OC decreased the risk of RA, especially ACPA-positive RA, where an interaction with smoking was observed. A long duration of OC use decreased the risk of both disease subsets. We could not confirm an association between BF and a decreased risk of either ACPA-positive or ACPA-negative RA.
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Affiliation(s)
- Cecilia Orellana
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Saedis Saevarsdottir
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Rheumatology Unit, Department of Medicine, Solna, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Lars Klareskog
- Rheumatology Unit, Department of Medicine, Solna, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth W Karlson
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lars Alfredsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden
| | - Camilla Bengtsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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24
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Alpizar-Rodriguez D, Mueller RB, Möller B, Dudler J, Ciurea A, Zufferey P, Kyburz D, Walker UA, von Mühlenen I, Roux-Lombard P, Mahler M, Lamacchia C, Courvoisier DS, Gabay C, Finckh A. Female hormonal factors and the development of anti-citrullinated protein antibodies in women at risk of rheumatoid arthritis. Rheumatology (Oxford) 2017; 56:1579-1585. [DOI: 10.1093/rheumatology/kex239] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Indexed: 12/13/2022] Open
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25
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Ren L, Guo P, Sun QM, Liu H, Chen Y, Huang Y, Cai XJ. Number of parity and the risk of rheumatoid arthritis in women: A dose-response meta-analysis of observational studies. J Obstet Gynaecol Res 2017; 43:1428-1440. [PMID: 28613016 DOI: 10.1111/jog.13370] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 03/10/2017] [Accepted: 04/02/2017] [Indexed: 01/16/2023]
Abstract
AIM The association between parity and rheumatoid arthritis (RA) risk has been investigated, but results are controversial. Thus, our aim was to systematically analyze the effect of number of parity on the risk of RA in women. METHODS Relevant published studies were identified using PubMed and embase databases through 1 April 2016. We pooled the relative risks (RR) and 95% confidence intervals (CI) using random-effects models. RESULTS In all, 12 studies with a total of 2 497 580 participants and 11 521 RA cases were included. A borderline significant inverse association was observed when we compared parity with nulliparity for RA, with summarized RR = 0.90 (95%CI: 0.79-1.02; I2 = 58.5%, Pheterogeneity = 0.010). In dose-response analysis, we observed a significant nonlinear (Pnonlinearity = 0.000) relation between parity number and the risk of RA. Compared with null parity, the pooled RR of RA were 0.89 (95%CI: 0.86-0.93), 0.84 (95%CI: 0.79-0.89), 0.85 (95%CI: 0.79-0.90), 0.88 (95%CI: 0.81-0.95), 0.90 (95%CI: 0.83-0.97), 0.92 (95%CI: 0.84-1.02), and 0.94 (95%CI: 0.83-1.07) for 1, 2, 3, 4, 5, 6, and 7 live births, respectively. Subgroup and sensitivity analyses showed similar associations. No publication bias was found. CONCLUSION The findings from the current meta-analysis indicate that parity was related to decreased risk of RA. The greatest risk reduction appeared when the parity number reached two. Further studies are warranted to confirm our findings.
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Affiliation(s)
- Lei Ren
- Department of Spinal Surgery, Third Affiliated Hospital of Zunyi Medical University, Zunyi Medical University, Zunyi, China
| | - Peng Guo
- Department of Hepatobiliary Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Qiao-Mei Sun
- Department of Dermatology, Chengdu Second People's Hospital, Chengdu, China.,School of Graduate Studies, Zunyi Medical University, Zunyi, China
| | - Hong Liu
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Southwest Medical University, Luzhou, China
| | - Yu Chen
- Department of Joint Surgery, Third Affiliated Hospital of Zunyi Medical University, Zunyi Medical University, Zunyi, China
| | - Ying Huang
- Department of Respiration, Third Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xiao-Jun Cai
- Department of Spinal Surgery, Third Affiliated Hospital of Zunyi Medical University, Zunyi Medical University, Zunyi, China
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26
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Deane KD, Demoruelle MK, Kelmenson LB, Kuhn KA, Norris JM, Holers VM. Genetic and environmental risk factors for rheumatoid arthritis. Best Pract Res Clin Rheumatol 2017; 31:3-18. [PMID: 29221595 PMCID: PMC5726551 DOI: 10.1016/j.berh.2017.08.003] [Citation(s) in RCA: 322] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/12/2017] [Accepted: 07/17/2017] [Indexed: 01/13/2023]
Abstract
Multiple genetic and environmental factors have been associated with an increased risk for rheumatoid arthritis (RA). Of these, the strongest associations have been seen with female sex, a family history of RA, the genetic factor the "shared epitope," and exposure to tobacco smoke. There is also renewed interest in mucosal inflammation and microbial factors as contributors to the development of RA. However, the identification of a "preclinical" period of RA that can be defined as local or systemic autoimmunity as measured by autoantibodies and other biomarkers prior to the development of clinically apparent synovitis suggests that the risk factors for RA are acting long prior to first clinical evidence of IA. As such, a major challenge to the field will be to investigate the full spectrum of the development of RA, from initiation and propagation of autoimmunity during preclinical RA and transition to clinically apparent synovitis and classifiable RA, to determine which genetic and environmental factors are important at each stage of disease development. Understanding the exact role and timing of action of risk factors for RA is especially important given the advent of prevention trials in RA, and the hope that a full understanding of genetic and environmental factors in RA could lead to effective preventive interventions.
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Affiliation(s)
- Kevin D Deane
- Division of Rheumatology, University of Colorado Denver School of Medicine, USA.
| | | | - Lindsay B Kelmenson
- Division of Rheumatology, University of Colorado Denver School of Medicine, USA
| | - Kristine A Kuhn
- Division of Rheumatology, University of Colorado Denver School of Medicine, USA
| | - Jill M Norris
- Department of Epidemiology, Colorado School of Public Health, USA
| | - V Michael Holers
- Division of Rheumatology, University of Colorado Denver School of Medicine, USA
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27
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Sapir-Koren R, Livshits G. Rheumatoid arthritis onset in postmenopausal women: Does the ACPA seropositive subset result from genetic effects, estrogen deficiency, skewed profile of CD4(+) T-cells, and their interactions? Mol Cell Endocrinol 2016; 431:145-63. [PMID: 27178986 DOI: 10.1016/j.mce.2016.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 05/04/2016] [Accepted: 05/09/2016] [Indexed: 12/28/2022]
Abstract
Rheumatoid arthritis (RA) incidence displays a differentiated age-dependent female-to-male ratio in which women outnumber men. Evidence that the peak incidence of RA in women coincides with menopause age, suggests a potential estrogenic role to disease etiology. Estrogens exert physiologically both stimulatory and inhibitory effects on the immune system. Epidemiologic and animal model studies with estrogen deprivation or supplementation suggested estrogens as to play, mainly, a protective role in RA immunopathology. In this review, we propose that some yet unidentified disturbances associated with estrogen circulating levels, differentiated by the menopausal status, play a major role in women's RA susceptibility. We focus on the interaction between estrogen deprivation and genetic risk alleles for anti-citrullinated protein antibodies (ACPA) seropositive RA, as a major driving force for increased immune reactivity and RA susceptibility, in postmenopausal women. This opens up new fields for research concerning the association among different irregular estrogenic conditions, the cytokine milieu, and age/menopausal status bias in RA.
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Affiliation(s)
- Rony Sapir-Koren
- Human Population Biology Research Group, Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gregory Livshits
- Human Population Biology Research Group, Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Lilian and Marcel Pollak Chair of Biological Anthropology, Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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28
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Sparks JA, Chang SC, Deane KD, Gan RW, Demoruelle MK, Feser ML, Moss L, Buckner JH, Keating RM, Costenbader KH, Gregersen PK, Weisman MH, Mikuls TR, O’Dell JR, Holers VM, Norris JM, Karlson EW. Associations of Smoking and Age With Inflammatory Joint Signs Among Unaffected First-Degree Relatives of Rheumatoid Arthritis Patients: Results From Studies of the Etiology of Rheumatoid Arthritis. Arthritis Rheumatol 2016; 68:1828-38. [PMID: 26866831 PMCID: PMC5103164 DOI: 10.1002/art.39630] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 02/04/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To examine whether genetic, environmental, and serologic rheumatoid arthritis (RA) risk factors are associated with inflammatory joint signs in a cohort of first-degree relatives (FDRs) of RA patients. METHODS We evaluated RA risk factors and inflammatory joint signs in a prospective cohort of FDRs without RA in the Studies of the Etiology of RA. Genetic factors included 5 HLA-DRB1 shared epitope alleles and 45 RA-associated single-nucleotide polymorphisms; loci were combined using genetic risk scores weighted by RA risk. Environmental factors (smoking, body mass index, education, and parity) and RA-related autoantibodies were assessed at baseline. Physical examination was performed at baseline and 2-year follow-up, by observers who were blinded with regard to autoantibody status, to assess inflammatory joint signs as tender or swollen joints at sites typical for RA. Logistic regression was performed to evaluate associations of genetic, environmental, and serologic factors with inflammatory joint signs. RESULTS We analyzed 966 non-Hispanic white FDRs at baseline and 262 at 2-year follow-up after excluding those with inflammatory joint signs at baseline. The mean ± SD age was 47.2 ± 15.5 years, 71% were female, and 55% were shared epitope positive. Smoking >10 pack-years was associated with inflammatory joint signs at baseline (odds ratio [OR] 1.89 [95% confidence interval (95% CI) 1.26-2.82]) and at 2 years (OR 2.66 [95% CI 1.01-7.03]), compared to never smokers. There was a significant interaction between smoking and age with regard to risk of inflammatory joint signs (P = 0.02). FDRs younger than 50 years with >10 pack-years had the highest risk of inflammatory joint signs (OR 4.39 [95% CI 2.22-8.66], compared to never smokers younger than 50 years). CONCLUSION In a high-risk cohort of FDRs, smoking and age were associated with both prevalent and incident inflammatory joint signs at sites typical for RA. Further prospective investigations of the factors affecting the transitions between preclinical RA phases are warranted.
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Affiliation(s)
- Jeffrey A. Sparks
- Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Shun-Chiao Chang
- Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kevin D. Deane
- Division of Rheumatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Ryan W. Gan
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
| | - M. Kristen Demoruelle
- Division of Rheumatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Marie L. Feser
- Division of Rheumatology, University of Colorado School of Medicine, Aurora, Colorado
| | - LauraKay Moss
- Division of Rheumatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jane H. Buckner
- Benaroya Research Institute at Virginia Mason, Seattle, Washington
| | | | - Karen H. Costenbader
- Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Ted R. Mikuls
- Veteran Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | - James R. O’Dell
- Veteran Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | - V. Michael Holers
- Division of Rheumatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jill M. Norris
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
| | - Elizabeth W. Karlson
- Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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29
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Too CL, Muhamad NA, Ilar A, Padyukov L, Alfredsson L, Klareskog L, Murad S, Bengtsson C. Occupational exposure to textile dust increases the risk of rheumatoid arthritis: results from a Malaysian population-based case-control study. Ann Rheum Dis 2015; 75:997-1002. [PMID: 26681695 PMCID: PMC4893106 DOI: 10.1136/annrheumdis-2015-208278] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/18/2015] [Indexed: 12/16/2022]
Abstract
Objectives Lung exposures including cigarette smoking and silica exposure are associated with the risk of rheumatoid arthritis (RA). We investigated the association between textile dust exposure and the risk of RA in the Malaysian population, with a focus on women who rarely smoke. Methods Data from the Malaysian Epidemiological Investigation of Rheumatoid Arthritis population-based case–control study involving 910 female early RA cases and 910 female age-matched controls were analysed. Self-reported information on ever/never occupationally exposed to textile dust was used to estimate the risk of developing anti-citrullinated protein antibody (ACPA)-positive and ACPA-negative RA. Interaction between textile dust and the human leucocyte antigen DR β-1 (HLA-DRB1) shared epitope (SE) was evaluated by calculating the attributable proportion due to interaction (AP), with 95% CI. Results Occupational exposure to textile dust was significantly associated with an increased risk of developing RA in the Malaysian female population (OR 2.8, 95% CI 1.6 to 5.2). The association between occupational exposure to textile dust and risk of RA was uniformly observed for the ACPA-positive RA (OR 2.5, 95% CI 1.3 to 4.8) and ACPA-negative RA (OR 3.5, 95% CI 1.7 to 7.0) subsets, respectively. We observed a significant interaction between exposure to occupational textile dust and HLA-DRB1 SE alleles regarding the risk of ACPA-positive RA (OR for double exposed: 39.1, 95% CI 5.1 to 297.5; AP: 0.8, 95% CI 0.5 to 1.2). Conclusions This is the first study demonstrating that textile dust exposure is associated with an increased risk for RA. In addition, a gene–environment interaction between HLA-DRB1 SE and textile dust exposure provides a high risk for ACPA-positive RA.
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Affiliation(s)
- Chun Lai Too
- Institute for Medical Research, Jalan Pahang, Kuala Lumpur, Malaysia
- Rheumatology Unit, Department of Medicine, Center for Molecular Medicine L8:O4, Karolinska University Hospital, Stockholm, Sweden
| | - Nor Asiah Muhamad
- Institute for Medical Research, Jalan Pahang, Kuala Lumpur, Malaysia
| | - Anna Ilar
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Leonid Padyukov
- Rheumatology Unit, Department of Medicine, Center for Molecular Medicine L8:O4, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Alfredsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lars Klareskog
- Rheumatology Unit, Department of Medicine, Center for Molecular Medicine L8:O4, Karolinska University Hospital, Stockholm, Sweden
| | - Shahnaz Murad
- Institute for Medical Research, Jalan Pahang, Kuala Lumpur, Malaysia
| | - Camilla Bengtsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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30
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Pikwer M, Orellana C, Källberg H, Pikwer A, Turesson C, Klareskog L, Alfredsson L, Saevarsdottir S, Bengtsson C. Parity influences the severity of ACPA-negative early rheumatoid arthritis: a cohort study based on the Swedish EIRA material. Arthritis Res Ther 2015; 17:358. [PMID: 26653988 PMCID: PMC4704530 DOI: 10.1186/s13075-015-0869-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 11/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In women with rheumatoid arthritis (RA) it has been observed that during pregnancy a majority of patients experience amelioration, but after delivery a relapse of the disease is common. However, there are few studies, with diverging results, addressing the effect of parity on the severity of RA over time. Our aim was to explore the impact of parity, with stratification for anti-citrullinated protein antibody (ACPA) status as well as for onset during reproductive age or not. METHODS Female RA cases aged 18-70 years were recruited for the Epidemiological Investigation of Rheumatoid Arthritis (EIRA). Information on disease severity (the health assessment questionnaire (HAQ) and the disease activity score 28 (DAS28)) was retrieved from the Swedish Rheumatology Quality Register at inclusion and 3, 6, 12 and 24 months after diagnosis. Mixed models were used to compare mean DAS28 and HAQ scores over time in parous and nulliparous women. Mean differences at individual follow-up visits were compared using analysis of covariance. The odds of having DAS28 or HAQ above the median in parous verus nulliparous women were estimated in logistic regression models. RESULTS A total of 1237 female cases (mean age 51 years, 65 % ACPA-positive) were included. ACPA-negative parous women, aged 18-44 years, had on average 1.17 units higher DAS28 (p < 0.001) and 0.43 units higher HAQ score (p < 0.001) compared to nulliparous women during the follow-up time, adjusted for age. In this subgroup, the average DAS28 and HAQ scores were significantly higher in parous women at all follow-up time points. Younger parous ACPA-negative women were significantly more likely to have DAS28 and HAQ values above the median compared to nulliparous women at all follow-up visits. No association between parity and severity of ACPA-positive disease was observed. CONCLUSIONS Parity was a predictor of a more severe RA among ACPA-negative younger women, which might indicate that immunomodulatory changes during and after pregnancy affect RA severity, in particular for the ACPA-negative RA phenotype.
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Affiliation(s)
- Mitra Pikwer
- Rheumatology Unit, Mälarsjukhuset Hospital, Eskilstuna, Sweden. .,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden. .,Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden. .,Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.
| | - Cecilia Orellana
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Henrik Källberg
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Andreas Pikwer
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden.
| | - Carl Turesson
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.
| | - Lars Klareskog
- Rheumatology Unit, Department of Medicine, Karolinska Institutet and Karolinska University Hospital Solna, Stockholm, Sweden.
| | - Lars Alfredsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden. .,Centre of Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden.
| | - Saedis Saevarsdottir
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden. .,Rheumatology Unit, Department of Medicine, Karolinska Institutet and Karolinska University Hospital Solna, Stockholm, Sweden.
| | - Camilla Bengtsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
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31
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Postmenopausal hormone therapy and the risk of rheumatoid arthritis: results from the Swedish EIRA population-based case-control study. Eur J Epidemiol 2015; 30:449-57. [PMID: 25762170 PMCID: PMC4457806 DOI: 10.1007/s10654-015-0004-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 02/19/2015] [Indexed: 12/11/2022]
Abstract
To study the association between postmenopausal hormone therapy (PMH) use and the risk of rheumatoid arthritis (RA) stratifying the cases by the presence/absence of antibodies against citrullinated peptides (ACPA). A subset of the Epidemiological Investigation of RA (EIRA), a population-based case-control study, comprising postmenopausal women aged 50–70 living in Sweden, between 2006 and 2011 was analysed (523 cases and 1057 controls). All participants answered an extensive questionnaire, including questions regarding PMH use and potential confounders (education, smoking, BMI, oral contraceptives, reproductive factors). We calculated odds ratios (OR) of developing ACPA-positive/-negative RA, with 95 % confidence intervals (CI) and adjusted for age, residential area and smoking. Current users of PMH had a decreased risk of ACPA-positive RA compared with never users (OR 0.6, 95 % CI 0.3–0.9). The decreased risk was observed mainly in the age-group 50–59 years (OR 0.3, 95 % CI 0.1–0.8) but not in the age-group 60–70 years (OR 0.8, 95 % CI 0.4–1.4). Among current users of a combined therapy (estrogen plus progestogens) an OR of 0.3 (95 % CI 0.1–0.7) of ACPA-positive RA was observed, while no significant association was found among women who used estrogen only (OR 0.8, 95 % CI 0.5–1.6). No association between PMH use and ACPA-negative RA was found. PMH use might reduce the risk of ACPA-positive RA in post-menopausal women over 50 years of age, but not of ACPA-negative RA. The negative influence of this treatment on the risk of other chronic conditions cannot be overlooked.
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Jiang X, Frisell T, Askling J, Karlson EW, Klareskog L, Alfredsson L, Källberg H. To What Extent Is the Familial Risk of Rheumatoid Arthritis Explained by Established Rheumatoid Arthritis Risk Factors? Arthritis Rheumatol 2015; 67:352-62. [DOI: 10.1002/art.38927] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 10/21/2014] [Indexed: 01/03/2023]
Affiliation(s)
- Xia Jiang
- Karolinska InstitutetStockholmSweden
| | | | - Johan Askling
- Karolinska Institutet and Karolinska University Hospital SolnaStockholmSweden
| | | | | | - Lars Alfredsson
- Karolinska Institutet and Centre for Occupational and Environmental Medicine, Stockholm County CouncilStockholmSweden
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van der Woude D, Toes REM, Scherer HU. How undifferentiated arthritis evolves into chronic arthritis. Best Pract Res Clin Rheumatol 2014; 28:551-64. [PMID: 25481549 DOI: 10.1016/j.berh.2014.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Undifferentiated arthritis (UA) is a frequently occurring clinical presentation with a variable outcome. While some forms of UA will spontaneously remit, other forms will progress to chronic arthritis; an outcome that would preferably be prevented. Which immunological factors are normally at the basis of resolution of inflammation, and what, on the other hand, causes inflammation to persist? This review provides an overview of the immunological mechanisms involved in these two scenarios, including specific examples of how these mechanisms apply, or can be influenced in rheumatic diseases. Furthermore, what do we know about risk factors for chronic arthritis, such as the development of autoantibodies? The recent years have provided many insights concerning risk factors for autoantibody-positive versus autoantibody-negative rheumatoid arthritis, which are discussed along with a possible pathophysiological model incorporating autoantibodies into the larger process of disease development. Finally, the evolution of the autoantibody response over time is described.
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Affiliation(s)
- D van der Woude
- Department of Rheumatology, Leiden University Medical Center, The Netherlands.
| | - R E M Toes
- Department of Rheumatology, Leiden University Medical Center, The Netherlands.
| | - H U Scherer
- Department of Rheumatology, Leiden University Medical Center, The Netherlands.
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Genetics, environment, and gene-environment interactions in the development of systemic rheumatic diseases. Rheum Dis Clin North Am 2014; 40:637-57. [PMID: 25437282 DOI: 10.1016/j.rdc.2014.07.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Rheumatic diseases offer distinct challenges to researchers because of heterogeneity in disease phenotypes, low disease incidence, and geographic variation in genetic and environmental factors. Emerging research areas, including epigenetics, metabolomics, and the microbiome, may provide additional links between genetic and environmental risk factors in the pathogenesis of rheumatic disease. This article reviews the methods used to establish genetic and environmental risk factors and studies gene-environment interactions in rheumatic diseases, and provides specific examples of successes and challenges in identifying gene-environment interactions in rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis. Emerging research strategies and future challenges are discussed.
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Sparks JA, Chen CY, Jiang X, Askling J, Hiraki LT, Malspeis S, Klareskog L, Alfredsson L, Costenbader KH, Karlson EW. Improved performance of epidemiologic and genetic risk models for rheumatoid arthritis serologic phenotypes using family history. Ann Rheum Dis 2014; 74:1522-9. [PMID: 24685909 DOI: 10.1136/annrheumdis-2013-205009] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/16/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To develop and validate rheumatoid arthritis (RA) risk models based on family history, epidemiologic factors and known genetic risk factors. METHODS We developed and validated models for RA based on known RA risk factors, among women in two cohorts: the Nurses' Health Study (NHS, 381 RA cases and 410 controls) and the Epidemiological Investigation of RA (EIRA, 1244 RA cases and 971 controls). Model discrimination was evaluated using the area under the receiver operating characteristic curve (AUC) in logistic regression models for the study population and for those with positive family history. The joint effect of family history with genetics, smoking and body mass index (BMI) was evaluated using logistic regression models to estimate ORs for RA. RESULTS The complete model including family history, epidemiologic risk factors and genetics demonstrated AUCs of 0.74 for seropositive RA in NHS and 0.77 for anti-citrullinated protein antibody (ACPA)-positive RA in EIRA. Among women with positive family history, discrimination was excellent for complete models for seropositive RA in NHS (AUC 0.82) and ACPA-positive RA in EIRA (AUC 0.83). Positive family history, high genetic susceptibility, smoking and increased BMI had an OR of 21.73 for ACPA-positive RA. CONCLUSIONS We developed models for seropositive and seronegative RA phenotypes based on family history, epidemiological and genetic factors. Among those with positive family history, models using epidemiologic and genetic factors were highly discriminatory for seropositive and seronegative RA. Assessing epidemiological and genetic factors among those with positive family history may identify individuals suitable for RA prevention strategies.
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Affiliation(s)
- Jeffrey A Sparks
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chia-Yen Chen
- Harvard School of Public Health and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Xia Jiang
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Rheumatology Unit, Department of Medicine, Karolinska Institutet/Karolinska Hospital, Stockholm, Sweden
| | - Linda T Hiraki
- Research Institute, Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Susan Malspeis
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lars Klareskog
- Rheumatology Unit, Department of Medicine, Karolinska Institutet/Karolinska Hospital, Stockholm, Sweden
| | - Lars Alfredsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden Centre for Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden
| | - Karen H Costenbader
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Elizabeth W Karlson
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Parity in young women associates with ACPA-negative RA. Nat Rev Rheumatol 2013. [DOI: 10.1038/nrrheum.2013.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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