Progression of radiographic joint damage in different eras: trends towards milder disease in rheumatoid arthritis are attributable to improved treatment

Limited Diagnostic and Prognostic Value of Routine Radiographs in Newly Presenting Arthritis Suspected of Rheumatoid Arthritis: A Retrospective Study

OBJECTIVE

Current recommendations suggest that patients with newly presenting arthritis suspected of rheumatoid arthritis (RA) should undergo routine radiographs of hands and feet (X-HF) as the presence of RA-associated erosions might be of diagnostic and prognostic value. Our objective was to investigate the prevalence, diagnostic, and prognostic value of RA-associated erosions seen on routine X-HF in a large, recent cohort of patients with newly presenting arthritis.

METHODS

A retrospective cohort study was performed between 2016 and 2019 in patients with newly presenting arthritis suspected of RA. Patients were included if arthritis was present at diagnosis, rheumatoid factor and anticitrullinated protein antibodies were measured, RA was noted in the differential diagnosis, and routine X-HF were conducted. Outcomes were the prevalence of one or more RA-associated erosion(s), and whether diagnostic or prognostic classification were changed by erosivity. Seronegative patients, patients without acute phase reactants, and patients with longer symptom duration were analyzed as subgroups.

RESULTS

RA-associated erosions were found in 32 of 724 patients (4.4%, 95% confidence interval [95% CI] 3.1-6.2). Erosions led to a change of diagnostic classification in two patients (0.3%, 95% CI 0.01-1.1) and changed prognostic classification in three patients (0.4%, 95% CI 0.1-1.3). Seronegative patients and patients without elevated acute phase reactants had significantly lower prevalence of erosions (χ2 9.4, P = 0.002, χ2 6.5, P = 0.01). Longer symptom duration was not associated with a different prevalence of erosions (χ2 0.4, P = 0.81).

CONCLUSION

The recommendation of conducting routine X-HF in patients with newly presenting arthritis suspected of RA might be reconsidered due to low prevalence of early erosive disease and lack of diagnostic and prognostic value.

Joint Replacement Surgery in Patients with Rheumatoid Arthritis in South Korea: Analysis of a Large National Database

BACKGROUND

We aimed to investigate the current trend of joint replacement surgery incidence in patients with rheumatoid arthritis (RA) in South Korea and to compare the incidence of joint replacement surgery in each affected joint.

METHODS

We performed this big data analysis to investigate the current trend of joint replacement surgery incidence in patients with RA in South Korea and to compare the incidence of joint replacement surgery in each affected joint. This retrospective study was based on data from the Korea National Health Insurance claims database.

RESULTS

The prevalence of RA increased every year (0.13% in 2008, 0.25% in 2016). The number of newly diagnosed patients increased from 29,184 in 2010 to 38,347 in 2016. The incidence rate of joint replacement surgery in patients with RA increased from 0.72% in 2010 to 4.03% in 2016. The knee (68.3%) was the most commonly replaced joint. The relative risk (RR) of additional joint replacement surgery was highest for the shoulder joint (RR,1.454; 95% confidence interval, 0.763-2.771). The median time from diagnosis to surgery was the shortest in the elbow joint (379 days) and the longest in the shoulder joint (955 days). The median time for each joint was short in order of the elbows, ankles, hips, knees, and shoulders (p < 0.01).

CONCLUSIONS

The most frequently and initially replaced joints were different, but the prevalence and incidence of RA, as well as those of joint replacement surgery, have recently increased in South Korea. Joint replacement surgery in RA was the highest for the knee joint. The median time from diagnosis to surgery was shortest for the elbow, followed by the ankle, hip, knee, and shoulder. Regardless of whether patients are symptomatic, evaluation of large joints such as the knee, elbow, ankle, and hip should be considered from an early stage.

Frequency of joint inflammation is associated with local joint damage progression in rheumatoid arthritis despite long-term targeted treatment

OBJECTIVES

To investigate whether in rheumatoid arthritis (RA) frequency of local joint inflammation is associated with radiographic joint damage progression in that joint.

METHODS

Data from 473 patients with RA and available radiographs from the BeSt study were used. Patients were treated to target (Disease Activity Score of ≤2.4) for a median of 10 years. At each study visit every 3 months, joints were assessed for swelling and tenderness. Radiographs of hands and feet were made yearly. A generalised linear mixed model was used to assess the association between the percentage of study visits at which clinical inflammation was observed in a joint (cumulative inflammation) and radiographic joint damage in that same joint. Clinical inflammation was primarily defined as joint swelling (with or without joint tenderness). For secondary analyses, we also investigated joint tenderness without joint swelling. Damage was measured as the percentage of the maximum possible Sharp-Van der Heijde score in a particular joint.

RESULTS

Cumulative local joint swelling was associated with local progression of radiographic damage in the same joint (β=0.14, 95% CI 0.13 to 0.15). This association was also found in a subset of joints that were swollen at least once. Cumulative local joint tenderness without concurrent local joint swelling was less strongly associated with local radiographic joint damage progression (β=0.04, 95% CI 0.03 to 0.05).

CONCLUSIONS

In RA, long-term cumulative local joint inflammation is associated with joint damage progression in the same joint.

Have the Radiographic Characteristics of Total Knee Arthroplasty Recipients in Rheumatoid Arthritis Changed After the Induction of Biologic Disease Modifying Anti-Rheumatic Drugs?

OBJECTIVES

Whether the characteristics of patients with rheumatoid arthritis (RA) undergoing total knee arthroplasty (TKA) have changed in the era of biologic disease-modifying antirheumatic drugs (bDMARDs) is unclear. We compared the radiographic findings of the knees in TKA recipients with RA before and after the introduction of bDMARDs.

METHODS

Consecutive patients who underwent primary TKA between 1999 and 2002 (115 knees; 79 patients, group A) and between 2013 and 2017 (117 knees; 95 patients, group B) were retrospectively evaluated. Clinical data, including disease duration, medication, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and rheumatoid factor (RF), were collected. The Larsen classification, joint space narrowing (JSN), bone erosion, geode and osteophyte formation were evaluated on preoperative radiographs.

RESULTS

Osteophyte formation was significantly increased, and bone erosion and geode formation were significantly decreased in group B. In addition, medial-dominant JSN was significantly increased, and bicompartmental JSN was significantly decreased in group B. Medial-dominant JSN was positively, and bone erosion was negatively associated with osteophyte formation.

CONCLUSIONS

Following the introduction of bDMARDs, typical radiographic findings of rheumatoid knees have decreased, and secondary osteoarthritis (OA)-like changes, characterized by osteophyte formation and medial-dominant JSN, have increased in the knees of TKA recipients.

Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme

Background

Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.

Objectives

To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.

Design

Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.

Setting

Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).

Participants

Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.

Interventions

Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.

Main outcome measures

Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.

Results

Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.

Limitations

The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.

Conclusion

The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.

Future work

Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.

Trial registration

Current Controlled Trials ISRCTN70160382.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Using genetics to prioritize diagnoses for rheumatology outpatients with inflammatory arthritis

It is challenging to quickly diagnose slowly progressing diseases. To prioritize multiple related diagnoses, we developed G-PROB (Genetic Probability tool) to calculate the probability of different diseases for a patient using genetic risk scores. We tested G-PROB for inflammatory arthritis-causing diseases (rheumatoid arthritis, systemic lupus erythematosus, spondyloarthropathy, psoriatic arthritis, and gout). After validating on simulated data, we tested G-PROB in three cohorts: 1211 patients identified by International Classification of Diseases (ICD) codes within the eMERGE database, 245 patients identified through ICD codes and medical record review within the Partners Biobank, and 243 patients first presenting with unexplained inflammatory arthritis and with final diagnoses by record review within the Partners Biobank. Calibration of G-probabilities with disease status was high, with regression coefficients from 0.90 to 1.08 (1.00 is ideal). G-probabilities discriminated true diagnoses across the three cohorts with pooled areas under the curve (95% CI) of 0.69 (0.67 to 0.71), 0.81 (0.76 to 0.84), and 0.84 (0.81 to 0.86), respectively. For all patients, at least one disease could be ruled out, and in 45% of patients, a likely diagnosis was identified with a 64% positive predictive value. In 35% of cases, the clinician's initial diagnosis was incorrect. Initial clinical diagnosis explained 39% of the variance in final disease, which improved to 51% (P < 0.0001) after adding G-probabilities. Converting genotype information before a clinical visit into an interpretable probability value for five different inflammatory arthritides could potentially be used to improve the diagnostic efficiency of rheumatic diseases in clinical practice.

Subdeltoid Rice Bodies in a Patient with Rheumatoid Arthritis on Disease Modifying Antirheumatic Drug Therapy: A Case Report

CASE

A 58-year-old man with rheumatoid arthritis (RA) on disease modifying antirheumatic drug therapy presented with chronic right shoulder pain. Magnetic resonance imaging was concerning for rice body disease which was confirmed through histology after intraoperative deltoid bursa resection.

CONCLUSIONS

Rice bodies can develop regardless of RA symptom severity or the degree of RA medical therapy administered. Therefore, physicians should not disregard rice bodies as a possible cause of symptoms in individuals on appropriate RA medical therapy or who are demonstrating adequate RA symptom and flair control.

Secular changes in the progression of clinical markers and patient-reported outcomes in early rheumatoid arthritis

Objectives

To examine secular trends in the progression of clinical and patient-reported outcomes in early RA.

Methods

A total of 2701 patients recruited to the Early Rheumatoid Arthritis Study or Early Rheumatoid Arthritis Network with year of diagnosis from 1986 to 2011. The 5-year progression rates for patients diagnosed at different points in time were modelled using mixed-effects regression; 1990, 2002 and 2010, were compared. Clinical markers of disease included the 28-joint count DAS and the ESR. Patient-reported markers included the HAQ, visual analogue scale of pain and global health, and the Short-Form 36.

Results

Statistically significant improvements in both 28-joint count DAS and ESR were seen over the 5 years in patients diagnosed with RA compared with those diagnosed earlier. By 5 years, 59% of patients with diagnosis in 2010 were estimated to reach low disease activity compared with 48% with diagnosis in 2002 and 32% with diagnosis in 1990. Whilst HAQ demonstrated statistically significant improvements, these improvements were small, with similar proportions of patients achieving HAQ scores of ≤1.0 by 5 years with a diagnosis in 1990 compared with 2010. Levels of the visual analogue scale and the Mental Component Scores of the Short-Form 36 indicated similar, statistically non-significant levels over the 5 years, irrespective of year diagnosed.

Conclusion

This study demonstrates improvements in inflammatory markers over time in early RA, in line with improved treatment strategies. These have not translated into similar improvements in patient-reported outcomes relating to either physical or mental health.

Surgical Management of the Lumbar Spine in Rheumatoid Arthritis

STUDY DESIGN

Narrative review.

OBJECTIVE

To provide an overview on the diagnosis and surgical management of rheumatoid involvement of the lumbar spine. Rheumatoid arthritis (RA) is a chronic inflammatory disease of synovial joints, most commonly appendicular followed by axial. Although cervical spine involvement of RA is well documented, data on lumbar spine involvement and surgical management remains limited.

METHODS

Using PubMed, studies published prior to November 2018 with the keywords "RA, etiology"; "RA, spine management"; "RA, surgical management"; "RA, treatment"; "RA, DMARDs"; "RA, lumbar spine"; "RA, spine surgical outcomes"; "RA, imaging" were evaluated.

RESULTS

The narrative review addresses the epidemiology, manifestations, imaging, surgical complications, and operative and nonoperative management of RA involvement of the lumbar spine.

CONCLUSIONS

Rheumatoid involvement of the lumbar spine can present with lower back pain, neurogenic claudication, radiculopathy, spinal deformity, and instability. Patients with RA have significantly higher rates of vertebral fractures and complications following surgical intervention. However, in the setting of instability and spinal deformity, thoughtful surgical planning in conjunction with optimal medical management is recommended.

Anti-cyclic citrullinated peptide antibodies are associated with radiographic damage but not disease activity in early rheumatoid arthritis diagnosed in 2006-2011

Objective: The discovery of anti-citrullinated protein antibodies (ACPAs) and the introduction of new therapeutic options have had profound impacts on early rheumatoid arthritis (RA) care. Since ACPA status, most widely assessed as reactivity to cyclic citrullinated peptides (CCPs), influences treatment decisions in early RA, we aimed to determine whether anti-CCP remains a predictor of disease activity and radiographic joint damage in more recent 'real-world' early RA. Method: Two observational early RA cohorts from Sweden enrolled patients in 1996-1999 (TIRA-1, n = 239) and 2006-2009 (TIRA-2, n = 444). Clinical and radiographic data and ongoing treatment were prospectively collected up to 3 years. Two other cohorts served as confirmation cohorts (TRAM-1, with enrolment 1996-2000, n = 249; and TRAM-2, 2006-2011, n = 528). Baseline anti-CCP status was related to disease activity, pharmacotherapy, and radiographic joint damage according to Larsen score. Results: In the TIRA-1 cohort, anti-CCP-positive patients had significantly higher 28-joint Disease Activity Score, swollen joint count, C-reactive protein level, and erythrocyte sedimentation rate during follow-up compared with anti-CCP-negative patients. In TIRA-2, no such differences were found, but baseline anti-CCP positivity was associated with higher 3 year Larsen score (5.4 vs 3.5, p = 0.039). In TRAM-2, anti-CCP also predicted radiographic damage (8.9 vs 6.7, p = 0.027), with no significant differences in disease activity. Conclusion: In the early RA cohorts recruiting patients in 2006-2011, baseline anti-CCP positivity was not associated with disease activity over time, but was associated with increased radiographic damage at follow-up. Hence, close radiographic monitoring is warranted in early anti-CCP-positive RA regardless of disease activity.

[S2e guideline: treatment of rheumatoid arthritis with disease-modifying drugs]

BACKGROUND

Medication-based strategies to treat rheumatoid arthritis are crucial in terms of outcome. They aim at preventing joint destruction, loss of function and disability by early and consistent inhibition of inflammatory processes.

OBJECTIVE

Achieving consensus about evidence-based recommendations for the treatment of rheumatoid arthritis with disease-modifying anti-rheumatic drugs in Germany.

METHODS

Following a systematic literature research, a structured process among expert rheumatologists was used to reach consensus.

RESULTS

The results of the consensus process can be summed up in 6 overarching principles and 10 recommendations. There are several new issues compared to the version of 2012, such as differentiated adjustments to the therapeutic regime according to time point and extent of treatment response, the therapeutic goal of achieving remission as assessed by means of the simplified disease activity index (SDAI) as well as the potential use of targeted synthetic DMARDs (JAK inhibitors) and suggestions for a deescalating in case of achieving a sustained remission. Methotrexate still plays the central role at the beginning of the treatment and as a combination partner in the further treatment course. When treatment response to methotrexate is inadequate, either switching to or combining with another conventional synthetic DMARD is an option in the absence of unfavourable prognostic factors. Otherwise biologic or targeted synthetic DMARDs are recommended according to the algorithm. Rules for deescalating treatment with glucocorticoids and-where applicable-DMARDs give support for the management of patients who have reached a sustained remission.

DISCUSSION

The new guidelines set up recommendations for RA treatment in accordance with the treat-to-target principle. Modern disease-modifying drugs, now including also JAK inhibitors, are available in an algorithm.

Secular changes in functional disability, pain, fatigue and mental well-being in early rheumatoid arthritis. A longitudinal meta-analysis

OBJECTIVES

To conduct a systematic review and longitudinal meta-analysis of early rheumatoid arthritis (RA) cohorts with long-term data on pain, fatigue or mental well-being.

METHODS

Searches using PUBMED, EMBASE and PyscInfo were performed to identify all early RA cohorts with longitudinal measures of pain, fatigue or mental well-being, along with clinical measures. Using longitudinal meta-analyses, the progression of each outcome over the first 60-months was estimated. Cohorts were stratified based on the median recruitment year to investigate secular trends in disease progression.

RESULTS

Of 7,319 papers identified, 75 met the inclusion criteria and 46 cohorts from 41 publications provided sufficient data on 18,046 patients for meta-analysis. The Disease Activity Scores (DAS28) and the Short-Form 36 (SF-36) Physical Component Score (PCS) indicated that post-2002 cohorts had statistically significant improvements over the first 60-months compared to pre-2002 cohorts, with standardised mean differences (SMD) of 0.86 (95% Confidence Intervals 0.34 to 1.37) and 0.76 (95% CI 0.25 to 1.27) respectively at month-60. However, post-2002 cohorts indicated statistically non-significant improvements in pain, fatigue, functional disability and SF-36 Mental Component Score (MCS) compared to pre-2002 cohorts, with SMD of 0.24 (95% CI -0.25 to 0.74), 0.38 (95% CI -0.11 to 0.88), 0.34 (95% CI -0.15-0.84) and -0.08 (95% CI -0.41 to 0.58) at month-60 respectively.

CONCLUSIONS

Recent cohorts indicate improved levels of disease activity and physical quality of life, however this has not translated into similar improvements in levels of pain, fatigue and functional disability by 60-months.

Secular trends of sustained remission in rheumatoid arthritis, a nationwide study in Sweden

Objectives

The aim of this study of patients with RA in Sweden was to investigate secular trends in achieving sustained remission (SR), i.e. DAS28 <2.6 on at least two consecutive occasions and lasting for at least 6 months.

Methods

All adult RA patients registered in the Swedish Rheumatology Quality register through 2012, with at least three registered visits were eligible, a total of 29 084 patients. Year of symptom onset ranged from 1955, but for parts of the analysis only patients with symptom onset between 1994 and 2009 were studied. In total, 95% of patients fulfilled the ACR 1987 classification criteria for RA. Odds of reaching SR for each decade compared with the one before were calculated with logistic regression and individual years of symptom onset were compared with life table analysis.

Results

Of patients with symptom onset in the 1980s, 1990s and 2000s, 35.0, 43.0 and 45.6% reached SR, respectively (P < 0.001 for each increment), and the odds of SR were higher in every decade compared with the one before. The hazard ratio for reaching SR was 1.15 (95% CI 1.14, 1.15) for each year from 1994 to 2009 compared with the year before. Five years after symptom onset in 2009, 45.3% of patients had reached SR compared with 15.9% in 1999.

Conclusion

There is a clear secular trend towards increased incidence of SR in patients with RA in Sweden. This trend most likely reflects earlier diagnosis and treatment start, and adherence to national and international guidelines recommending the treat to target approach.

Real world long-term impact of intensive treatment on disease activity, disability and health-related quality of life in rheumatoid arthritis

Background

The emphasis on treating rheumatoid arthritis (RA) intensively reduces disease activity but its impact in routine care is uncertain. We evaluated temporal changes in disease activities and outcomes in a 10-year prospective observational cohort study of patients in routine care at one unit.

Methods

The Guy’s and St Thomas’ RA cohort was established in 2005. It involved most RA patients managed in this hospital. Clinical diagnoses of RA were made by rheumatologists. Patients were seen regularly in routine care. Each visit included measurement of disease activity scores for 28 joints (DAS28), health assessment questionnaire scores (HAQ) and EuroQol scores. Patients received intensive treatments targeting DAS28 remission.

Results

In 1693 RA patients mean DAS28 scores fell from 2005 to 15 by 11% from 4.08 (95% CI: 3.91, 4.25) in 2005 to 3.64 (3.34, 3.78); these falls were highly significant (p < 0.001). DAS28 components: swollen joint counts fell by 32% and ESR by 24%; in contrast tender joint counts and patient global assessments showed minimal or no reductions. The reduction in DAS28 scores was predominantly between 2005 and 2010, with no falls from 2011 onwards. Associated with falls in mean DAS28s, patients achieving remission increased (18% in 2005; 27% in 2015) and the number with active disease (DAS28 > 5.1) decreased (25% in 2005; 16% in 2015). In 752 patients seen at least annually for 3 years, persisting remission (68 patients) and intermittent remission (376 patients) were associated with less disability and better health related quality of life. Over time biologic use increased, but they were used infrequently in patients in persistent remission.

Conclusions

Over 10 years an intensive management strategy in a routine practice setting increased combination DMARD and biologic use: disease activity levels declined; this association is in keeping with a causal relationship. Patients who achieved remission, even transiently, had better functional outcomes than patients never achieving remission.

Electronic supplementary material

The online version of this article (10.1186/s41927-019-0054-y) contains supplementary material, which is available to authorized users.

Incidence and Predictive Factors for Orthopedic Surgery in Patients with Psoriatic Arthritis

Objective.

To investigate the incidence of orthopedic procedures in patients with psoriatic arthritis (PsA), and how patient characteristics, time of diagnosis, and treatment affect the need for surgery.

Methods.

We reviewed the medical history of 1432 patients with possible PsA at Haukeland University Hospital in Bergen, Norway. There were 590 patients (mean age 49 yrs, 52% women) who had sufficient journal information and a confirmed diagnosis of PsA, and who were included in the present study. Relevant orthopedic procedures were obtained from the hospital’s administrative patient records. Survival analyses were completed to evaluate the effect of different factors such as year of diagnosis, age, sex, radiographic changes, disease activity, and treatment, on the risk of surgery.

Results.

There were 171 procedures (25% synovectomies, 15% arthrodesis, and 53% prostheses) performed on 117 patients. These factors all increased the risk of surgery: female sex [relative risk (RR) 1.9, p = 0.001], age ≥ 70 years at diagnosis (RR 2.4, p = 0.001), arthritis in initial radiographs (RR 2.2, p = 0.006), and maximum erythrocyte sedimentation rate 30–59 mm/h (RR 1.6, p = 0.026). Time period of diagnosis had no effect on the outcome. In a subanalysis of surgery exclusive of hip and knee arthroplasty, diagnosis in earlier years (1954–1985 vs 1999–2011) was a risk factor (RR 2.1, p = 0.042). Antirheumatic treatment changed significantly over time.

Conclusion.

There were 20% of patients with PsA who needed surgery. We found that the prognosis of patients with PsA did not change regarding the risk of orthopedic surgery, despite the change in treatment. A possible explanation is the increase in large joint replacements in the general population.

Long-Term Increase of Radiographic Damage and Disability in Patients with RA in Relation to Disease Duration in the Era of Biologics. Results from the SCQM Cohort

Objectives: There is little information on the relation between disease duration, disability and radiographic outcome since the introduction of biologics into the therapy of rheumatoid arthritis (RA). No long -term cohort studies have been conducted on this subject so far. To analyse radiographic damage, disability, and disease activity in RA-patients dependent on disease duration in the Swiss national RA cohort (SCQM). Methods: The primary outcome was the association between the radiographic destruction, assessed by Ratingen scores, and disease duration. All patients with at least one clinical visit were analysed with polynomial and multiple negative binomial models. Results: The disease duration in the 8678 patients with available radiographs analysed ranged between less than 1 and more than 65 years (median 8.3). Disease duration and radiographic destruction were significantly associated with an average increase of Ratingen scores by 8.3% per year. Apart from disease duration, positive rheumatoid factor was the strongest predictor for radiographic destruction. While DAS28-scores remained stable in patients with a disease duration of more than 5 years (median DAS28 2.8), HAQ-DI scores increased continuously by 0.018 for each additional year. Conclusion: In this RA cohort, patients show a continuous increase of articular destruction and physical disability in parallel with disease duration. Even when nowadays a satisfactory control of disease activity can be achieved in most patients, RA remains a destructive disease leading to joint destruction and physical disability in many patients.

Predictors for orthopaedic surgery in patients with rheumatoid arthritis: results from a retrospective cohort study of 1010 patients diagnosed from 1972 to 2009 and followed up until 2015

OBJECTIVES

To investigate how patient characteristics, time of diagnosis, and treatment affect the need for orthopaedic surgery in patients with rheumatoid arthritis (RA).

METHOD

We reviewed the medical history of 1544 patients diagnosed with RA at Haukeland University Hospital in Bergen, Norway, from 1972 to 2009, of whom 1010 (mean age 57 years, 69% women) were included in the present study. Relevant orthopaedic procedures were obtained from the Norwegian Arthoplasty Register and the hospital's administrative patient records. In total, 693 procedures (joint synovectomies 22%, arthrodeses 21%, prostheses 41%, and forefoot procedures 12%) were performed in 315 patients. Survival analyses were completed to evaluate the impact of different factors such as age, gender, radiographic changes, and year of diagnosis, on the risk of undergoing surgery.

RESULTS

Patients diagnosed in 1972-1985 and 1986-1998 had a relative risk of undergoing surgery of 2.4 and 2.2 (p < 0.001), respectively, compared to patients diagnosed in 1999-2009. Radiographic changes at diagnosis and female gender were also significant risk factors. Anti-rheumatic medication was significantly different in the three time periods.

CONCLUSION

Patients with a diagnosis in the early years had a greatly increased risk of having orthopaedic surgery performed. This is probably due to the year of diagnosis being a proxy for the type and intensity of medical treatment.

Trends in Joint Replacement Surgery in Patients with Rheumatoid Arthritis

Objective.

This study analyzed trends in large total joint arthroplasties (TJA) and in the proportion of these procedures performed on patients with rheumatoid arthritis (RA).

Methods.

The US Nationwide Inpatient Sample (2002–2012) was used to identify the incidences of total shoulder (TSA), elbow (TEA), knee (TKA), hip (THA), and ankle (TAA) arthroplasty and the proportion of these performed with coexisting RA.

Results.

The prevalence of RA among patients with TJA increased 3.0%. The prevalence of RA among cases of TEA and TSA decreased by 50% (p < 0.0001) and 18% (p = 0.0016), respectively; a 38.0% decrease occurred in the prevalence of RA among TAA (p = 0.06); and nonsignificant increases were seen among THA and TKA. The average age difference between RA and non-RA patients undergoing TJA narrowed by 2 years (p < 0.0001). There was a greater reduction in the proportion of TSA, TEA, and TAA groups among women with RA than men with RA. In the TSA and TEA groups, there was a reduction in the proportion of whites with RA, but not blacks. The proportion of privately insured TSA and TAA patients with RA decreased, while patients with RA undergoing TSA, TEA, or TAA who were receiving Medicaid (government medical insurance) remained relatively stable over time.

Conclusion.

The prevalence of RA has decreased among TSA and TEA patients. A nonsignificant decline occurred among TAA patients. The average age of TJA patients with RA is beginning to mirror those without RA. Sex ratios for TSA, TEA, and TAA patients are following a similar pattern. These results may be evidence of the success of modern RA treatment strategies.

Role of ultrasound imaging in individuals at risk of RA

Early diagnosis and treatment improves outcomes for patients with rheumatoid arthritis (RA). Studies have shown that musculoskeletal ultrasound is more sensitive than clinical examination in identifying synovitis. This review aims to address the role of ultrasound in identifying (1) patients with early inflammatory arthritis (IA) at risk of progression to RA and (2) those without clinical synovitis at risk of progression to early IA and therefore early RA.

Infections With Biologics in Rheumatoid Arthritis and Related Conditions: a Scoping Review of Serious or Hospitalized Infections in Observational Studies

Biologic use is a major advance in the treatment of several autoimmune conditions, including rheumatoid arthritis. In this review, we summarize key studies of serious/hospitalized infections in rheumatoid arthritis (RA). RA is a risk factor for infections. High RA disease activity is associated with higher risk of serious infection. The risk of serious infections with tumor necrosis factor inhibitor (TNFi) biologics is increased in the first 6 months of initiating therapy, and this risk was higher compared to the use of traditional disease-modifying anti-rheumatic drugs (DMARDs). Emerging data also suggest that biologics may differ from each other regarding the risk of serious or hospitalized infections. Past history of serious infections, glucocorticoid dose, and older age were other important predictors of risk of serious infections in patients treated with biologics.

Trends in Treatment, Outcomes, and Incidence of Orthopedic Surgery in Patients with Rheumatoid Arthritis: An Observational Cohort Study Using the Japanese National Database of Rheumatic Diseases

OBJECTIVE

In this study, we investigated the changes in clinical outcome, treatment, and incidence of orthopedic surgery in patients with rheumatoid arthritis (RA) from 2004 to 2014.

METHODS

Data were studied from the Japanese nationwide cohort database, NinJa (National Database of Rheumatic Diseases by iR-net in Japan), from 2004 to 2014. The time trends in the incidence of orthopedic procedures were analyzed using linear regression analysis. The cross-sectional annual data were compared between 2004 and 2014 to analyze the changes in clinical outcome and treatment.

RESULTS

The incidence of orthopedic surgeries in patients with RA consistently decreased from 72.2 procedures per 1000 patients in 2004 to 51.5 procedures per 1000 patients in 2014 (regression coefficient = -0.0028, 95% CI -0.0038 to -0.0019, p < 0.001). The greatest reduction was found in total knee arthroplasty and total hip arthroplasty. Disease activity and functional disability improved significantly over this decade. The proportions of patients receiving methotrexate and biologic disease-modifying antirheumatic drugs significantly increased from 39.6% and 1.7% in 2004 to 63.8% and 27.4% in 2014, respectively.

CONCLUSION

The overall incidence of orthopedic surgeries in patients with RA significantly decreased, accompanied by improved clinical outcomes because of the expanded use of effective drugs; however, the declining trend differed between procedures or locations. The results from the present study suggest that there might be a change in supply and demand for orthopedic surgeries.

Intake of ω-3 polyunsaturated fatty acids in patients with rheumatoid arthritis: A systematic review and meta-analysis

OBJECTIVES

Rheumatoid arthritis (RA) is a chronic, autoimmune inflammatory disease of multiple joints that puts the patient at high risk for developing cardiovascular diseases (CVDs). The aim of the present study was to conduct an up-to-date systematic review and meta-analysis of published randomized controlled trials (RCTs) to assess potential changes in RA disease activity, inflammation, and CVD risk after oral intake of ω-3 polyunsaturated fatty acids.

METHODS

Publications up to July 31, 2016 were examined using the PubMed, SCOPUS, and EMBASE databases.

INCLUSION CRITERIA

English language; human subjects; both sexes; RCTs; oral intake of ω-3 fatty acids; minimum duration of 3 mo; and no medication change throughout intervention. The Cochrane Risk of Bias tool was used to assess quality of trials. We included 20 RCTs, involving 717 patients with RA in the intervention group and 535 RA patients in the control group.

RESULTS

Despite the evidence of overall low quality of trials, consumption of ω-3 fatty acids was found to significantly improve eight disease-activity-related markers. Regarding inflammation, only leukotriene B4 was reduced (five trials, standardized mean difference [SMD], -0.440; 95% confidence interval [CI], -0.676 to -0.205; I² = 46.5%; P < 0.001). A significant amelioration was found for blood triacylglycerol levels (three trials, SMD, -0.316; 95% CI, -0.561 to -0.070; I² = 0.0%; P = 0.012).

CONCLUSION

The beneficial properties of ω-3 polyunsaturated fatty acids on RA disease activity confirm the results of previous meta-analyses. Among five proinflammatory markers evaluated, only leukotriene B4 was found to be reduced. However, a positive effect on blood lipid profile of patients with RA was evident, perhaps for the first time.

Rheumatoid arthritis management of early disease

PURPOSE OF REVIEW

Early effective treatment has led to major improvements in patients with rheumatoid arthritis. This review aims to address the treatment of early rheumatoid arthritis, in particular the different therapeutic strategies evaluated in clinical trials to achieve optimal disease control.

RECENT FINDINGS

The use of biological disease-modifying antirheumatic drugs (bDMARDs) has significantly improved patient outcomes. Overall, studies using bDMARD induction have shown early clinical improvements, with high proportions achieving remission with minimal radiographic progression. As these drugs are still relatively costly, conventional synthetic DMARDs, as monotherapy or in combination, remain the mainstay of treatment initiation. Good, albeit somewhat slower, responses can be achieved with these drugs. Strategies incorporating glucocorticoids and a treat-to-target approach (i.e. regular monitoring of disease activity and early treatment escalation with a conventional synthetic or b-DMARD, if needed) have shown additional benefit. In patients achieving low disease activity or remission, bDMARD dose reduction and withdrawal, and even drug-free remission have been possible in some.

SUMMARY

In patients with early rheumatoid arthritis, conventional synthetic DMARDs and glucocorticoids used within a treat-to-target setting, and the addition of a bDMARD if required, outcomes have improved significantly. A proportion of patients are able to deescalate treatment after bDMARD therapy, with a significant minority achieving drug-free remission.

Rheumatoid Arthritis Exacerbates the Severity of Osteonecrosis of the Jaws (ONJ) in Mice. A Randomized, Prospective, Controlled Animal Study

Rheumatoid arthritis (RA), an autoimmune inflammatory disorder, results in persistent synovitis with severe bone and cartilage destruction. Bisphosphonates (BPs) are often utilized in RA patients to reduce bone destruction and manage osteoporosis. However, BPs, especially at high doses, are associated with osteonecrosis of the jaw (ONJ). Here, utilizing previously published ONJ animal models, we are exploring interactions between RA and ONJ incidence and severity. DBA1/J mice were divided into four groups: control, zoledronic acid (ZA), collagen-induced arthritis (CIA), and CIA-ZA. Animals were pretreated with vehicle or ZA. Bovine collagen II emulsified in Freund's adjuvant was injected to induce arthritis (CIA) and the mandibular molar crowns were drilled to induce periapical disease. Vehicle or ZA treatment continued for 8 weeks. ONJ indices were measured by micro-CT (µCT) and histological examination of maxillae and mandibles. Arthritis development was assessed by visual scoring of paw swelling, and by µCT and histology of interphalangeal and knee joints. Maxillae and mandibles of control and CIA mice showed bone loss, periodontal ligament (PDL) space widening, lamina dura loss, and cortex thinning. ZA prevented these changes in both ZA and CIA-ZA groups. Epithelial to alveolar crest distance was increased in the control and CIA mice. This distance was preserved in ZA and CIA-ZA animals. Empty osteocytic lacunae and areas of osteonecrosis were present in ZA and CIA-ZA but more extensively in CIA-ZA animals, indicating more severe ONJ. CIA and CIA-ZA groups developed severe arthritis in the paws and knees. Interphalangeal and knee joints of CIA mice showed advanced bone destruction with cortical erosions and trabecular bone loss, and ZA treatment reduced these effects. Importantly, no osteonecrosis was noted adjacent to areas of articular inflammation in CIA-ZA mice. Our data suggest that ONJ burden was more pronounced in ZA treated CIA mice and that RA could be a risk factor for ONJ development. © 2016 American Society for Bone and Mineral Research.

Have radiographic progression rates in early rheumatoid arthritis changed? A systematic review and meta-analysis of long-term cohorts

OBJECTIVE

To evaluate, firstly, all published data on baseline and annual progression rates of radiographic damage from all longitudinal observational cohorts, and secondly, the association of standard clinical and laboratory parameters with long-term radiographic joint damage.

METHODS

A comprehensive search of the literature from 1975 to 2014, using PubMed, SCOPUS and Cochrane databases, identified a total of 28 studies that investigated long-term radiographic progression, and 41 studies investigating predictors of long-term radiographic progression. This was submitted and approved by PROSPERO in February 2014 (Registration Number: CRD42014007589).

RESULTS

Meta-analysis indicated an overall baseline rate of 2.02%, and a yearly increase of 1.08% of maximum damage. Stratified analysis found that baseline radiographic scores did not differ significantly between cohorts recruiting patients pre- and post-1990 (2.01% vs 2.03%; P > 0.01); however, the annual rate of progression was significantly reduced in the post-1990 cohorts (0.68% vs 1.50%; P < 0.05). High levels of acute phase markers, baseline radiographic damage, anti-CCP and RF positivity remain consistently predictive of long-term radiographic joint damage.

CONCLUSION

Critical changes in treatment practices over the last three decades are likely to explain the reduction in the long-term progression of structural joint damage. Acute phase markers and presence of RF/anti-CCP are strongly associated with increased radiographic progression.

Changing clinical patterns in rheumatoid arthritis management over two decades: sequential observational studies

Background

Rheumatoid arthritis (RA) treatment paradigms have shifted over the last two decades. There has been increasing emphasis on combination disease modifying anti-rheumatic drug (DMARD) therapy, newer biologic therapies have become available and there is a greater focus on achieving remission. We have evaluated the impact of treatment changes on disease activity scores for 28 joints (DAS28) and disability measured by the health assessment questionnaire scores (HAQ).

Methods

Four cross-sectional surveys between 1996 and 2014 in two adjacent secondary care rheumatology departments in London evaluated changes in drug therapy, DAS28 and its component parts and HAQ scores (in three surveys). Descriptive statistics used means and standard deviations (SD) or medians and interquartile ranges (IQR) to summarise changes. Spearman’s correlations assessed relationships between assessments.

Results

1324 patients were studied. Gender ratios, age and mean disease duration were similar across all cohorts. There were temporal increases in the use of any DMARDs (rising from 61 % to 87 % of patients from 1996-2014), combination DMARDs (1 % to 41 %) and biologic (0 to 32 %). Mean DAS28 fell (5.2 to 3.7), active disease (DAS28 > 5.1) declined (50 % to 18 %) and DAS28 remission (DAS28 < 2.6) increased (8 % to 28 %). In contrast HAQ scores were unchanged (1.30 to 1.32) and correlations between DAS28 and HAQ weakened (Spearman’s rho fell from 0.56 to 0.44).

Conclusions

Treatment intensity has increased over time, disease activity has fallen and there are more remissions. However, these improvements in controlling synovitis have not resulted in comparable reductions in disability measured by HAQ. As a consequence the relationship between DAS28 and HAQ has become weaker over time. Although the reasons for this divergence between disease activity and disability are uncertain, focussing treatment entirely in suppressing synovitis may be insufficient.

Rheumatoid Arthritis: Trends in Antirheumatic Drug Use, C-reactive Protein Levels, and Surgical Burden

Objective.

Over the past decade, the therapeutic approach used to treat patients with rheumatoid arthritis (RA) has considerably changed. It remains unclear whether these changes have been accompanied by decreased disease severity and surgical treatment burden at the population level. Therefore, we investigated time trends in antirheumatic drug consumption, C-reactive protein (CRP) levels, and use of orthopedic surgery among Danish patients with RA.

Methods.

Using medical databases, we identified all patients with RA living in Northern Denmark during 1996–2012. For each calendar year, we computed the annual rate of antirheumatic drug use (1996–2010), the median CRP value in mg/l (1996–2011), and the proportions of patients who underwent hip replacement and other orthopedic procedures (1996–2012).

Results.

Antirheumatic drug consumption per patient increased 5-fold, from 145.0 defined daily doses (DDD) in 1996 to 695.4 DDD in 2010. Median CRP declined from 20.5 mg/l [interquartile range (IQR), 10.0 to 43.5 mg/l] in 1996 to 10.0 mg/l (IQR, 4.2–17.8 mg/l) in 2011. From 1996 to 2012, declining proportions of patients with RA underwent hip replacement (14.9% to 10.1%) and other joint operations (29.1% to 23.4%), while the annual proportion of patients who underwent soft tissue procedures increased from 20.7% to 23.4%.

Conclusion.

Antirheumatic drug consumption has substantially increased among patients with RA since 1996, in association with reduced disease activity (i.e., lower CRP levels), fewer joint procedures (including hip replacements), and more soft tissue procedures.

Towards prevention of autoantibody-positive rheumatoid arthritis: from lifestyle modification to preventive treatment

Recent advances in research into the earliest phases of RA have provided additional insights into the processes leading from the healthy to the diseased state. These insights have opened the way for the development of preventive strategies for RA, which represents a significant paradigm shift from treatment to prevention and will have major implications for patients as well as society. It would be a huge step forward if clinical signs and symptoms, disability, impaired quality of life and the need for chronic immunosuppressive treatment could be prevented. RA can be seen as a prototypic autoimmune disease, and discoveries about the preclinical diseased state for RA could potentially facilitate research into prevention of other immune-mediated inflammatory diseases such as type 1 diabetes, SLE and multiple sclerosis. This review focuses on the current knowledge of factors contributing to the development of RA and discusses the opportunities for intervention.

Perioperative Treatment of Patients with Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease mediated by a widespread chronic systematic inflammatory process that causes joint deterioration, which leads to pain, disability, and poor quality of life. The increased use of disease-modifying antirheumatic drugs has been shown to markedly slow disease progression, which has translated into a decrease in the need for orthopaedic intervention in this population. However, a substantial percentage of patients with the disease fail optimal pharmacologic treatment and still require surgical intervention. A thorough understanding of medical considerations in these patients and improved knowledge of the medical complications caused by the disease process and the pharmacologic therapy used to treat it may lead to improved preoperative planning and medical clearance, which may ultimately improve the overall postoperative outcome.

Pain in systemic inflammatory rheumatic diseases

The sometimes intense, persistent and disabling pain associated with rheumatoid arthritis (RA) and spondyloarthritis frequently has a multifactorial, simultaneously central and peripheral origin, and it may be due to currently active inflammation or joint damage and tissue destruction caused by a previous inflammatory condition. The symptoms of inflammatory pain symptoms can be partially relieved by non-steroidal anti-inflammatory drugs, but many patients continue to experience moderate pain due to alterations in central pain regulation mechanisms, as in the case of the chronic widespread pain (CWP) characterising fibromyalgia. The importance of distinguishing CWP from inflammatory pain is underlined by the fact that drugs such as tumour necrosis factor inhibitors are expensive, and direct costs are higher in patients with concomitant CWP than in those without. The management of pain requires a combination approach that includes pharmacological analgesia, and biological and non-biological treatments because, although joint replacement surgery can significantly improve RA-related pain, it may only be available to patients with the most severe advanced disease.

The impact of steroids, methotrexate, and biologics on clinical and radiographic outcomes in patients with rheumatoid arthritis undergoing fusions at the craniovertebral junction

OBJECTIVE

Rheumatoid arthritis (RA) is an inflammatory disease that affects the craniovertebral junction (CVJ). Patients may suffer from atlantoaxial instability (AAI) and basilar invagination (BI) with variable presentations ranging from pain to quadriparesis. Managing these patients is often challenging due to their chronic use of steroids, methotrexate, and biologics; which impedes bone and wound healing. We report our experience with the surgical management of these patients undergoing fusions at the CVJ.

MATERIALS AND METHODS

We conducted a retrospective study identifying all patients with the diagnosis of RA who underwent spinal fusions at our institution over the past 11 years. A total of 205 patients were identified amongst which 18 patients (8.8%) who underwent 20 fusions involving the CVJ. Demographic, clinical, and radiographic data were analyzed.

RESULTS

Five patients had AAI and 13 patients had BI. Two patients with C1-2 fusions underwent reoperation: One for pseudoarthrosis and one for BI. The average preoperative Nurick was 1.4 and improved to 0.5 postoperatively (P < 0.001). After conducting analyses stratified by dichotomous preoperative variables, the presence of steroids, methotrexate, biologics, and prednisone dosage less than 7.5 mg did not affect outcomes. Prednisone dosages ≥7.5 mg had significantly smaller improvements in Nurick score compared to patients not on steroids or on prednisone dosages <7.5 mg (0.40 vs 1.36, P = 0.042). Similarly, patients on biologics had significantly smaller improvements in Nurick score compared to patients not on biologics (0.27 vs 1.16, P = 0.038).

CONCLUSION

Fusions at the CVJ in patients with RA on daily prednisone dosages of less than 7.5 mg and/or methotrexate can be performed safely with good outcomes, fusion rates, and acceptable complication profiles. Daily prednisone dosages of more than 7.5 mg or biologics may impact clinical outcomes.

The impact of steroids, methotrexate, and biologics on clinical and radiographic outcomes in patients with rheumatoid arthritis undergoing fusions at the craniovertebral junction

Objective:

Rheumatoid arthritis (RA) is an inflammatory disease that affects the craniovertebral junction (CVJ). Patients may suffer from atlantoaxial instability (AAI) and basilar invagination (BI) with variable presentations ranging from pain to quadriparesis. Managing these patients is often challenging due to their chronic use of steroids, methotrexate, and biologics; which impedes bone and wound healing. We report our experience with the surgical management of these patients undergoing fusions at the CVJ.

Materials and Methods:

We conducted a retrospective study identifying all patients with the diagnosis of RA who underwent spinal fusions at our institution over the past 11 years. A total of 205 patients were identified amongst which 18 patients (8.8%) who underwent 20 fusions involving the CVJ. Demographic, clinical, and radiographic data were analyzed.

Results:

Five patients had AAI and 13 patients had BI. Two patients with C1-2 fusions underwent reoperation: One for pseudoarthrosis and one for BI. The average preoperative Nurick was 1.4 and improved to 0.5 postoperatively (P < 0.001). After conducting analyses stratified by dichotomous preoperative variables, the presence of steroids, methotrexate, biologics, and prednisone dosage less than 7.5 mg did not affect outcomes. Prednisone dosages ≥7.5 mg had significantly smaller improvements in Nurick score compared to patients not on steroids or on prednisone dosages <7.5 mg (0.40 vs 1.36, P = 0.042). Similarly, patients on biologics had significantly smaller improvements in Nurick score compared to patients not on biologics (0.27 vs 1.16, P = 0.038).

Conclusion:

Fusions at the CVJ in patients with RA on daily prednisone dosages of less than 7.5 mg and/or methotrexate can be performed safely with good outcomes, fusion rates, and acceptable complication profiles. Daily prednisone dosages of more than 7.5 mg or biologics may impact clinical outcomes.

A systematic review of the influence of anti-TNF on infection rates in patients with rheumatoid arthritis

OBJECTIVE

The present article aims to provide a systematic review of the influence of antitumor necrosis factor (TNF) on infection rates in patients with rheumatoid arthritis (RA).

METHOD

Medline was searched to obtain quality control information on infection rates in RA patients treated with anti-TNF.

RESULTS

A high proportion of RA patients are now established users of anti-TNF agents. Data from national registries in European countries of patients with RA treated with anti-TNF suggest that biological therapies are closely linked to sepsis. Although previous studies reported a higher risk of infections, there are now emerging data with longer duration of follow-up that suggested an adjusted hazard risk of 1.2. Elderly patients and those with longstanding disease may have a higher rate of serious infections compared to their counterparts who were younger with early disease. There are now emerging data to suggest that anti-TNF therapy is associated with the development of neutropenia shortly after the commencement of treatment. The biologic registries found that RA patients treated with monoclonal antibodies are at increased risk of tuberculosis (TB) compared to those on TNF receptor blockers. This risk of infection needs to be weighed against the established benefits of TNF blockers.

CONCLUSION

Current evidence suggests that anti-TNF treatment in RA is closely linked to infection. Patients need to be aware of the risk of infection together with the established benefits of TNF blockers in order to give informed consent for treatment.

Hospitalization rates and utilization among patients with rheumatoid arthritis: a population-based study from 1987 to 2012 in Olmsted County, Minnesota

OBJECTIVE

To examine whether all-cause hospitalization rates for patients with rheumatoid arthritis (RA) differ from those for patients without RA.

PATIENTS AND METHODS

This was a retrospective population-based cohort study focused on Olmsted County, Minnesota. The RA cohort consisted of patients 18 years and older who first fulfilled 1987 American College of Rheumatology criteria for RA in the 1980 to 2007 period, and was compared with a cohort of similar age, sex, and calendar year without RA. Data on all hospitalizations were retrieved electronically for the 1987 to 2012 period. Analyses used person-year methods and rate ratios (RRs) comparing patients with and without RA.

RESULTS

The 799 patients with RA experienced 2968 hospitalizations, and the 797 patients without RA experienced 2069 hospitalizations. Patients with RA were hospitalized at a greater rate than were patients without RA (RR, 1.51; 95% CI, 1.42-1.59). This increased rate of hospitalization was found in both sexes, all age groups, all calendar years studied, and throughout disease duration. Men with RA were hospitalized for depression at a greater rate than were men without RA (RR, 7.16; 95% CI, 2.78-30.67). Patients with RA were hospitalized at a greater rate for diabetes mellitus than were subjects without RA (RR, 2.45; 95% CI, 1.34-4.89). In patients with RA, the indicators of disease severity (eg, seropositivity, erosions, and nodules) in the first year after RA incidence were associated with higher rates of hospitalization.

CONCLUSION

Patients with RA were hospitalized for all causes at a greater rate than were patients without RA. Increased rates of hospitalization were true for several disease categories and patient subgroups.

A genetic study on C5-TRAF1 and progression of joint damage in rheumatoid arthritis

Introduction

The severity of joint damage progression in rheumatoid arthritis (RA) is heritable. Several genetic variants have been identified, but together explain only part of the total genetic effect. Variants in Interleukin-6 (IL-6), Interleukin-10 (IL-10), C5-TRAF1, and Fc-receptor-like-3 (FCRL3) have been described to associate with radiographic progression, but results of different studies were incongruent. We aimed to clarify associations of these variants with radiographic progression by evaluating six independent cohorts.

Methods

In total 5,895 sets of radiographs of 2,493 RA-patients included in six different independent datasets from the Netherlands, Sweden, Spain and North-America were studied in relation to rs1800795 (IL-6), rs1800896 (IL-10), rs2900180 (C5-TRAF1) and rs7528684 (FCRL3). Associations were tested in the total RA-populations and in anti-citrullinated peptide antibodies (ACPA)-positive and ACPA-negative subgroups per cohort, followed by meta-analyses. Furthermore, the associated region C5-TRAF1 was fine-mapped in the ACPA-negative Dutch RA-patients.

Results

No associations were found for rs1800795 (IL-6), rs1800896 (IL-10) and rs7528684 (FCRL3) in the total RA-population and after stratification for ACPA. Rs2900180 in C5-TRAF1 was associated with radiographic progression in the ACPA-negative population (P-value meta-analysis = 5.85 × 10⁻⁷); the minor allele was associated with more radiographic progression. Fine-mapping revealed a region of 66Kb that was associated; the lowest P-value was for rs7021880 in TRAF1. The P-value for rs7021880 in meta-analysis was 6.35 × 10⁻⁸. Previous studies indicate that the region of rs7021880 was associated with RNA expression of TRAF1 and C5.

Conclusion

Variants in IL-6, IL-10 and FCRL3 were not associated with radiographic progression. Rs2900180 in C5-TRAF1 and linked variants in a 66Kb region were associated with radiographic progression in ACPA-negative RA.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-014-0514-0) contains supplementary material, which is available to authorized users.

Has the severity of rheumatoid arthritis at presentation diminished over time?

OBJECTIVE

To examine the pattern of disease severity in patients with rheumatoid arthritis (RA) at presentation to the Norfolk Arthritis Register (NOAR) over 20 years.

METHODS

NOAR is a primary-care-based cohort of patients with recent-onset inflammatory polyarthritis. At baseline, subjects are assessed and examined by a research nurse. The Health Assessment Questionnaire (HAQ) is administered and the DAS28 (28-joint Disease Activity Score) is calculated. Information is collected on disease-modifying antirheumatic drug exposure. In this study, patients (symptom duration of < 2 years at baseline) were grouped into 4 cohorts (Cohort 1: 1990-1994; Cohort 2: 1995-1999; Cohort 3: 2000-2004; Cohort 4: 2005-2008). The American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) 2010 criteria for RA were applied retrospectively at baseline. Regression analyses were used to examine whether calendar year of presentation to NOAR was associated with baseline HAQ and DAS28 scores. Potential confounders included age at symptom onset, sex, rheumatoid factor, and anticyclic citrullinated peptide antibody positivity.

RESULTS

A total of 1724 patients met the ACR/EULAR 2010 RA criteria at baseline. Unadjusted mean DAS28 scores decreased over time. Calendar year of presentation to NOAR was significantly associated with lower DAS28 scores over time [Y = 4.51 + (-0.56 × year) + (0.44 × year(2))]. Although unadjusted median HAQ scores increased over time, calendar year of presentation to NOAR was not significantly associated with HAQ scores [Y = (1.1) + (0.023 × year) + (0.05 × year(2))]. Similar results were observed in each subpopulation of patients.

CONCLUSION

While baseline disease activity has lessened slightly over time, there has been no improvement in baseline levels of functional disability.

Changing trends in cervical spine fusions in patients with rheumatoid arthritis

STUDY DESIGN

Retrospective data analysis.

OBJECTIVE

To compare the trends in primary cervical spine fusion procedures in patients with rheumatoid arthritis (RA) against those in the general population.

SUMMARY OF BACKGROUND DATA

RA severely impacts multiple joints in the body and can result in substantial deformity and functional impairment. Cervical spine involvement is common. In the past decade, treatment for RA has changed substantially with the introduction of biologically based, disease-modifying antirheumatic medications. Recent literature has shown decreasing rates of total joint arthroplasty in patients with RA.

METHODS

Cases of cervical spine fusion in the general population and in patients with RA were identified from the Nationwide Inpatient Sample from 1992 through 2008. US population counts were obtained from the Census Bureau. Data were analyzed with computer software (significance, P < 0.05 for all analyses). Linear regression models were used to describe national rates of cervical spine fusion in patients with and without RA.

RESULTS

There was a marked increase in the number of cervical fusion procedures in the studied population. Over time, the incidence of atlantoaxial fusion increased in the general population (P < 0.01) and decreased in patients with RA (P < 0.01). Compared with the general population, patients with RA had a significantly lower rate of increase in the incidence of posterior cervical fusion (P < 0.01) and a significantly higher rate of increase in the incidence of anterior cervical fusion (P < 0.01).

CONCLUSION

In the US, the absolute number of primary cervical fusion procedures from 1992 through 2008 increased in the general population and in patients with RA. However, the patients with RA had a significantly lower incidence of undergoing atlantoaxial and posterior cervical surgical procedures than did the general population.

LEVEL OF EVIDENCE

2.

Change of psychological distress and physical disability in patients with rheumatoid arthritis over the last two decades

OBJECTIVE

During the past decades, a more cautious approach with respect to prescribing medication and physical exercise progressed toward evidence-based guidelines regarding the management of rheumatoid arthritis (RA). Currently, physical activity and other means to improve well-being and functioning are encouraged, and the disease is targeted earlier with more intensive and aggressive pharmacologic treatment. The current study examined whether psychological distress and physical disability in patients with RA reduced over the last 2 decades and whether this is explained by a reduction of disease activity.

METHODS

From 1990-2011, consecutive patients with RA (n = 1,151, age range 17-86 years, 68% female, 62% rheumatoid factor positive) were monitored at diagnosis and after 3-5 years of treatment (followup). Depressed mood, anxiety, and physical disability were predicted in multiple linear regression analyses by year of assessment, disease activity, and patient demographics.

RESULTS

Over the decades, depressed mood (P = 0.01), anxiety (P = 0.001), and physical disability (P = 0.02) reduced at diagnosis and within-treatment improvement of anxiety (P = 0.04) and physical disability (P < 0.001) increased. Percentages of patients with depressed mood, anxiety, and physical disability at followup changed from 25%, 23%, and 53%, respectively, 2 decades ago to 14%, 12%, and 31%, respectively, currently. After taking account of reduction in disease activity, the decrease in physical disability remained significant (P < 0.001).

CONCLUSION

Over the last 2 decades, psychological distress and physical disability decreased. This favorable trend might partly be due to reduced disease activity. The results indicate that patients with RA have a better opportunity to live a valued life currently than 20 years ago.

A genetic variant in the region of MMP-9 is associated with serum levels and progression of joint damage in rheumatoid arthritis

OBJECTIVES

The severity of joint destruction is highly variable between rheumatoid arthritis (RA) patients. The majority of its heritability is still unexplained. Several autoimmune diseases share genetic risk variants that may also influence disease progression. We aimed to identify genetic risk factors for the severity of joint damage in RA by studying genetic susceptibility loci of several autoimmune diseases.

METHODS

In phase 1, 3143 sets of x-rays of 646 Dutch RA patients taken over 7 years (Sharp van der Heijde (SHS) scored) were studied. Genotyping was done by Immunochip. Associations of single-nucleotide polymorphisms (SNPs) with minor allele frequency (MAF) >0.01 and joint destruction were analysed. In phase 2, 686 North American RA patients with 926 SHS-scored x-rays over 15 years of follow-up were evaluated. In both phases multiple testing corrections were done for the number of uncorrelated SNPs; the thresholds for significance were p<1.1×10(-6) and p<0.0036. Matrix metalloproteinase 9 (MMP-9) levels were measured with ELISA in baseline serum samples.

RESULTS

In phase 1, 109 SNPs associated significantly with joint destruction (p<1.1×10(-6)). Of these, 76 were located in the HLA region; the 33 non-HLA variants were studied in phase 2. Here two variants were associated with the severity of joint destruction: rs451066 on chromosome 14 (p=0.002, MAF=0.20) and rs11908352 on chromosome 20 (p=0.002, MAF=0.21). Rs11908352 is located near the gene encoding MMP-9. Serum levels of MMP-9 were significantly associated with the rs11908352 genotypes (p=0.007).

CONCLUSIONS

These data indicate that two loci that confer risk to other autoimmune diseases also affect the severity of joint destruction in RA. Rs11908352 may influence joint destruction via MMP-9 production.

Is there a place for initial treatment with biological DMARDs in the early phase of RA?

The use of biological disease-modifying antirheumatic drugs (bDMARDs) has changed the face of rheumatoid arthritis (RA). Achieving remission, normal function and prevention of joint damage are now possible for many patients with RA. In clinical practice, however, particularly with cost considerations, bDMARDs are usually prescribed after failure of one or more conventional synthetic DMARDs. With evidence that early treatment has a greater impact than later on, the question regarding initial bDMARD therapy and their potential role within a window of opportunity to influence disease outcomes remain. The increasing emphasis on early diagnosis and research into the preclinical phase of the disease also heralds the question, 'Can bDMARDs prevent the development of RA?' The aim of this review is to review randomised controlled trials with bDMARDs as initial therapy in early RA and to discuss their role in early disease.

Five-year Favorable Outcome of Patients with Early Rheumatoid Arthritis in the 2000s: Data from the ESPOIR Cohort

Objective.

To report the 5-year outcome of a large prospective cohort of patients with very early rheumatoid arthritis (RA), and to identify factors predictive of outcome.

Methods.

Patients were recruited if they had early arthritis of < 6 months’ duration, had a high probability of developing RA, and had never been prescribed disease-modifying antirheumatic drugs (DMARD) or steroids. Logistic regression analysis was used to determine factors that predict outcome.

Results.

We included 813 patients from December 2002 to April 2005. Age was 48.1 ± 12.6 years, delay before referral 103.1 ± 52.4 days, 28-joint Disease Activity Score (DAS28) 5.1 ± 1.3, Health Assessment Questionnaire (HAQ) 1.0 ± 0.7; 45.8% and 38.7% had rheumatoid factor or antibodies to cyclic citrullinated peptide (anti-CCP), respectively; 22% had hand or foot erosions; 78.5% fulfilled the American College of Rheumatology/European League Against Rheumatism criteria for RA at baseline and 93.8% during followup. At 5 years, 573 patients were evaluated. The outcome was mild for most patients: disease activity (median DAS28 = 2.5) and HAQ disability (median 0.3) were well controlled over time; 50.6% achieved DAS28 remission and 64.7% low disease activity. Radiographic progression was low (2.9 Sharp unit/year) and only a few patients required joint surgery. Nevertheless, some patients developed new comorbidities. During the 5 years, 82.7% of patients had received at least 1 DMARD (methotrexate, 65.9%), 18.3% a biological DMARD, and about 60% prednisone at least once. Anti-CCP was the best predictor of remaining in the cohort for 5 years, of prescription of synthetic or biologic DMARD, and of radiographic progression.

Conclusion.

The 5-year outcome of an early RA cohort in the 2000s was described. Anti-CCP was a robust predictor of outcome. The generally good 5-year outcome could be related to early referral and early effective treatment, key processes in the management of early RA in daily practice.