Impact of early age at menopause on disease outcomes in postmenopausal women with rheumatoid arthritis: a large observational cohort study of Korean patients with rheumatoid arthritis

Trends in rheumatoid arthritis burden in China and globally, 1990-2021: A longitudinal study based on the GBD database

BACKGROUND

Rheumatoid arthritis (RA) is a chronic autoimmune disease that imposes significant health and economic burdens worldwide, particularly in developing countries such as China.

METHOD

In this study, the Global Burden of Disease, The GBD database system stratified the incidence,prevalence,death and disability-adjusted life years (DALYs) of RA in China and the world from 1990 to 2021 by age, sex and period. Joinpoint Regression Program 5.1.0 was then used to calculate average annual percent change (AAPC) and 95% confidence interval (95% confidence interval). CI) to identify trends in disease burden. In addition, data collation using WPS allows for the comparison of RA burdens across different age groups, genders and time points in China and globally, and the data is rigorously screened and processed to ensure accuracy and comparability.

RESULTS

From 1990 to 2021, ASIR of RA in China increased by 0.54%, while the global ASIR rose by 0.41%.The number of RA cases in China increased cumulatively by 133%, compared to a global increase of 125.21%.Simultaneously, ASPR in China and globally increased by 17% and 14.44%, respectively.Regarding mortality, although the number of RA-related deaths increased in both China and globally, ASMR decreased by 26.23% in China and 22.86% globally.The trend in ASDR was consistent with ASMR, with declines of 0.40% in China and 1.46% globally.Furthermore, the study revealed significant gender disparities in RA both in China and globally, with women experiencing higher incidence, prevalence, mortality, and DALYs than men.The burden of RA increased significantly with age, particularly among middle-aged and older adults aged 45 and above.

CONCLUSION

Over the past 30 years, the burden of RA in China and globally has undergone significant changes.The study found that while RA related mortality and DALYs have slightly decreased in China and globally, the incidence and prevalence rates have continued to rise, particularly among women and middle-aged to elderly populations.Population aging and changes in lifestyle are key drivers of the increasing RA burden, with women showing higher susceptibility and burden due to their unique physiological characteristics and societal roles.The study highlights the need to strengthen early screening and intervention, optimize personalized treatment plans, and pay special attention to the unique needs of elderly and female populations.Additionally, promoting healthy lifestyles, improving primary healthcare services, and implementing supportive policies can effectively alleviate the health and socioeconomic burden of RA, ensuring a better quality of life for patients.

Global, regional, and national epidemiology of rheumatoid arthritis among people aged 20-54 years from 1990 to 2021

Rheumatoid arthritis (RA) is a global epidemic. We conducted a cross-sectional study using the Global Burden of Disease (GBD) 2021 dataset to examine RA trends in patients aged 20-54 years worldwide. Key outcomes included incidence, mortality, and disability-adjusted life years (DALYs), as well as trends over time, stratifying by region, country, age, sex, and Sociodemographic Index (SDI). We also assessed the contribution of smoking to RA-related mortality and DALYs. Over the past 32 years, the global RA-related incidence rate increased from 11.66 (95% UI 9.60-13.94) to 13.48 (95% UI 11.08-16.06) per 100,000 population. RA-related DALYs rate increased from 26.37 (95% UI 18.43-36.99) to 30.71 (95% UI 20.82-44.08) per 100,000 population, with females bearing a higher burden. And the RA-related mortality rate decreased from 0.09 (95% UI 0.08-0.1) to 0.06 (95% UI 0.05-0.07) per 100,000 population. Regional disparities were evident, with lower SDI regions experiencing the larger change. Smoking remained a significant risk factor, accounting for 9.01% of RA-related mortality in 2021. Overall, we highlighted the rising global burden of RA, particularly among females and in lower SDI regions, emphasizing disparities in healthcare resources, prevention, and early diagnosis.

Early menopause is associated with higher disease activity independent of inflammation in postmenopausal-onset rheumatoid arthritis

OBJECTIVE

Early menopause (EM, age ≤ 45 years) is associated with an increased risk of developing rheumatoid arthritis (RA). We aimed to investigate its impact on disease characteristics in RA patients.

METHODS

This cross-sectional study included natural post-menopausal RA patients from an observational RA cohort recruited between January 2015 and October 2023. Demographic characteristics and clinical data were collected. Patients were divided into EM and usual menopause (UM, menopause age > 45 years) groups. Patients-reported outcomes (PROs, included patient global assessment of disease activity [PtGA], pain visual analogue scale [VAS] and Stanford health assessment questionnaire disability index [HAQ-DI]), and PROs-associated indicators (included 28-joint tender joint count [TJC28] and provider global assessment of disease activity [PrGA]) were assessed.

RESULTS

Among 1427 female RA patients, 557 natural post-menopausal RA patients were enrolled. The peak menopause age was between 46 and 50 years, with RA incidence peaking 5 years post-menopause. Compared with UM patients, RA patients with natural EM (n = 98,17.6%) exhibited more serious disease, including worse PROs and PROs-associated indicators, as well as higher C-reactive protein (CRP, all P < 0.05). Among 344 (61.8%) patients with RA onset after menopause, EM patients (n = 62, 18.0%) were characterized with worse PROs and PROs-associated indicators than those with UM patients (all P < 0.05), but no difference in inflammatory makers. Multivariate linear regression showed that menopause age was independently and negatively associated with PROs, including PtGA (β = -0.872, 95% CI -1.619, -0.125), HAQ-DI (β = -0.646, 95% CI -1.059, -0.233) in RA patients especially in those onset after menopause (PtGA [β = -1.028, 95% CI -2.022, -0.034]; HAQ-DI [β = -0.916, 95% CI -1.461, -0.370]).

CONCLUSION

Early menopause impacts on PROs independent of inflammation in patients with RA especially in those with postmenopausal-onset RA, which imply the importance of differentiation of non-inflammatory disease activity.

The Impact of Menopause on Autoimmune and Rheumatic Diseases

The prevalence of autoimmune and rheumatological diseases is significantly higher in women, likely due to the effect of sex hormones influencing the development and function of the immune system, a phenomenon observed particularly during pregnancy. Oestrogens, in particular, appear to be a major factor in modulating the immune response, as their receptors are present in nearly all immune cells, where they regulate the expression of genes involved in inflammation. However, there is limited data on how menopause impacts autoimmune diseases, despite evidence suggesting that the menopausal perturbation of hormone levels may lead to the development of autoimmune conditions or alter the course of an already established disease. This review focuses on rheumatic conditions, aiming to provide a comprehensive understanding of how menopause influences the onset, progression, and clinical features of autoimmune diseases. The best evidence is available for rheumatoid arthritis and systemic lupus erythematosus, two paradigmatic autoimmune diseases in which menopause elicits opposite outcomes. Despite these data, there is a notable lack of evidence and research on the impact of menopause in other inflammatory arthritis and connective tissue diseases. This gap highlights a crucial area for future research and unmet needs to be addressed. Understanding how menopausal changes impact autoimmunity and rheumatic diseases will be crucial for improving the management of autoimmune and rheumatological diseases in women.

How is age at menopause and reproductive lifespan associated with chronic pain outcomes in postmenopausal women?

ABSTRACT

Female sex is a prominent risk factor for chronic pain, although the underlying mechanisms are not fully understood. This cross-sectional study aimed to investigate the relationship between age at menopause, reproductive lifespan, and chronic pain in a sample of postmenopausal women aged 40 to 93 years. Data were collected from the Tromsø study conducted in Norway between 2015 and 2016 (Tromsø7). Chronic pain was assessed using a single question, which formed a sample size of 5741 participants. Chronic widespread pain was evaluated using the more comprehensive Graphical Index of Pain, resulting in a sample size of 5920 women. Premenopausal women and those who experienced menstrual cessation due to chemotherapy/radiation or hormonal intrauterine devices were excluded from the analysis. Adjusted relative risk ratios with 95% confidence intervals were calculated to determine associations. The results showed that early menopause was associated with a 1% increase in the prevalence of chronic pain for each year of earlier onset at menopause (0.992, CI 95% 0.985-0.998). This association was also observed in women who experienced natural menopause only. However, the association between menopause and chronic widespread pain did not reach statistical significance in the fully adjusted analysis (0.996, CI 95% 0.975-1.017). There were no significant associations found between reproductive lifespan and either outcome. In conclusion, the findings suggest that early menopause in postmenopausal women is linked to a higher prevalence of chronic pain. However, reproductive lifespan does not appear to have a significant impact on chronic pain or chronic widespread pain.

Hormonal and reproductive factors in relation to the risk of rheumatoid arthritis in women: a prospective cohort study with 223 526 participants

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.

Unveiling difficult-to-treat rheumatoid arthritis: long-term impact of biologic or targeted synthetic DMARDs from the KOBIO registry

BACKGROUND

While the availability of biological or targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs) has improved outcomes for rheumatoid arthritis (RA) patients, there remains a subset of individuals who fail to achieve low disease activity or remission despite multiple cycles of b/tsDMARDs. This state is referred to as 'difficult-to-treat (D2T)' RA.

METHODS

Data from the Korean College of Rheumatology Biologics registry were utilized to analyze patients with RA who were treated with b/tsDMARDs.

RESULTS

Among 2,321 RA patients with RA treated with b/tsDMARDs, 271 (11.7%) were diagnosed with D2T RA. Lower age (OR = 0.98, p < 0.001), longer disease duration (OR = 1.06, p < 0.001), lower patient global assessment (OR = 0.89, p = 0.045), higher SDAI (OR = 1.06, p = 0.014) and RAPID3 (OR = 1.06, p = 0.002), lower RF positivity (OR = 0.65, p = 0.04), and lower prior use of methotrexate (OR = 0.44, p = 0.008), sulfasalazine (OR = 0.59, p = 0.003), and leflunomide (OR = 0.67, p = 0.013) were associated with D2T RA. The drug survival rate of b/tsDMARDs did not differ between patients with D2T RA and non-D2T RA (p = 0.35). However, the drug survival of individual b/tsDMARD differed between patients with D2T RA and non-D2T RA after eight years. Patients with D2T RA withdrew from b/tsDMARDs due to inefficacy more frequently than those without D2T RA (p < 0.001).

CONCLUSIONS

D2T RA patients experienced higher disease activity despite maintaining b/tsDMARD therapy. Withdrawal rates due to inefficacy were higher in D2T RA. Effective therapeutic strategies are needed to improve disease control and treatment outcomes in this unique patient population.