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.

Increased risk of osteoporotic fractures in Swedish patients with rheumatoid arthritis despite early treatment with potent disease-modifying anti-rheumatic drugs: a prospective general population-matched cohort study

Objective: To study the difference in incidence and risk of fragility fractures between rheumatoid arthritis (RA) patients followed up early in the disease and the general population in Sweden; and the fracture risk changes in RA patients diagnosed in the 1990s and 2000s because of earlier, more potent pharmacological treatment in the later period.Method: Patients with early RA were recruited from the BARFOT cohort, a Swedish multicentre observational study of early RA patients (n = 2557). All patients fulfilled 1987 American College of Rheumatology criteria and were included between 1992 and 2006. Each patient was matched by gender, age, and residential area with four controls from the general population (n = 10 228). Fractures of forearm, upper arm, and hip were identified by ICD-9 and ICD-10 codes through Swedish national medical registries.Results: During follow-up of 12.9 ± 4.7 years (mean ± sd), 14% (n = 470) of RA patients and 11% (n = 1418) of controls experienced a fracture (p < 0.001). When dividing the patients and controls into two groups according to inclusion period, an 8 year follow-up time was used. RA patients included in the 1990s had a higher incidence rate (IR) of hip and other fractures. RA patients included in the 2000s had a higher IR of all fracture sites. The hazard ratio of fractures was 1.4 in the total RA cohort, and the risk was increased in both the 1990s and 2000s.Conclusion: We observed an increased risk of fragility fractures in RA patients diagnosed in both the 1990s and 2000s, despite patients in the 2000s obtaining potent pharmacological treatment early in the disease.