Validity of the Health Assessment Questionnaire Predicting All-Cause Mortality in Early Rheumatoid Arthritis: Reply to three letters to the editor

We appreciate the interest in our manuscript concerning the Health Assessment Questionnaire disability index (HAQ) in an early rheumatoid arthritis incident cohort (the CATCH cohort) which predicted all-cause mortality (1). We will clarify queries raised in letters to the editor (2-4).

Health Assessment Questionnaire at One Year Predicts All-Cause Mortality in Patients With Early Rheumatoid Arthritis

OBJECTIVE

Higher self-reported disability (high Health Assessment Questionnaire [HAQ] score) has been associated with hospitalizations and mortality in established rheumatoid arthritis (RA), but associations in early RA are unknown.

METHODS

Patients with early RA (symptom duration <1 year) enrolled in the Canadian Early Arthritis Cohort who initiated disease-modifying antirheumatic drugs and had completed HAQ data at baseline and 1 year were included in the study. Discrete-time proportional hazards models were used to estimate crude and multi-adjusted associations of baseline HAQ and HAQ at 1 year with all-cause mortality in each year of follow-up.

RESULTS

A total of 1,724 patients with early RA were included. The mean age was 55 years, and 72% were women. Over 10 years, 62 deaths (3.6%) were recorded. Deceased patients had higher HAQ scores at baseline (mean ± SD 1.2 ± 0.7) and at 1 year (0.9 ± 0.7) than living patients (1.0 ± 0.7 and 0.5 ± 0.6, respectively; P < 0.001). Disease Activity Score in 28 joints (DAS28) was higher in deceased versus living patients at baseline (mean ± SD 5.4 ± 1.3 versus 4.9 ± 1.4) and at 1 year (mean ± SD 3.6 ± 1.4 versus 2.8 ± 1.4) (P < 0.001). Older age, male sex, lower education level, smoking, more comorbidities, higher baseline DAS28, and glucocorticoid use were associated with mortality. Contrary to HAQ score at baseline, the association between all-cause mortality and HAQ score at 1 year remained significant even after adjustment for confounders. For baseline HAQ score, the unadjusted hazard ratio (HR) was 1.46 (95% confidence interval [95% CI] 1.02-2.09), and the adjusted HR was 1.25 (95% CI 0.81-1.94). For HAQ score at 1 year, the unadjusted HR was 2.58 (95% CI 1.78-3.72), and the adjusted HR was 1.75 (95% CI 1.10-2.77).

CONCLUSION

Our findings indicate that higher HAQ score and DAS28 at 1 year are significantly associated with all-cause mortality in a large early RA cohort.

Palindromic Rheumatism Frequently Precedes Early Rheumatoid Arthritis: Results From an Incident Cohort

Background

This multicenter incident cohort aimed to characterize how often early rheumatoid arthritis (ERA) patients self‐report episodic joint inflammation (palindromic rheumatism) preceding ERA diagnosis and which characteristics differentiate these patients from those without prior episodic symptoms.

Methods

Data were from patients with early confirmed or suspected RA (more than 6 weeks and less than 12 months) enrolled in the Canadian Early ArThritis CoHort (CATCH) between April 2017 to March 2018 who completed study case report forms assessing joint pain and swelling prior to ERA diagnosis. Chi‐square and t tests were used to compare characteristics of patients with and without self‐reported episodic joint inflammation prior to ERA diagnosis. Multivariable logistic regression was used to identify sociodemographic and clinical measures associated with past episodic joint inflammation around the time of ERA diagnosis.

Results

A total of 154 ERA patients were included; 66% were female, and mean (SD) age and RA symptom duration were 54 (15) years and 141 (118) days. Sixty‐five (42%) ERA patients reported a history of episodic joint pain and swelling, half of whom reported that these symptoms preceded ERA diagnosis by over 6 months. ERA patients with past episodic joint inflammation were more often female, had higher income, were seropositive, had more comorbidities, fewer swollen joints, and lower Clinical Disease Activity Index (CDAI) around the time of ERA diagnosis (P < 0.05). These associations remained significant in multivariable regression adjusting for other sociodemographic and RA clinical measures.

Conclusion

Almost half of ERA patients experienced episodic joint inflammation prior to ERA diagnosis. These patients were more often female, had higher income, and presented with milder disease activity at ERA diagnosis.

Prevalence and Characteristics of Metabolic Syndrome Differ in Men and Women with Early Rheumatoid Arthritis

Objective

Metabolic syndrome (MetS) prevalence in early rheumatoid arthritis (ERA) is conflicting. The impact of sex, including menopause, has not been described. We estimated the prevalence and factors associated with MetS in men and women with ERA.

Methods

A cross‐sectional study of the Canadian Early Arthritis Cohort (CATCH) was performed. Participants with baseline data to estimate key MetS components were included. Sex‐stratified logistic regression identified baseline variables associated with MetS.

Results

The sample included 1543 participants; 71% were female and the mean age was 54 (SD 15) years. MetS prevalence was higher in men 188 (42%) than women 288 (26%, P < 0.0001) and increased with age. Frequent MetS components in men were hypertension (62%), impaired glucose tolerance (IGT, 40%), obesity (36%), and low high‐density lipoprotein cholesterol (36%). Postmenopausal women had greater frequency of hypertension (65%), IGT (32%), and high triglycerides (21%) compared with premenopausal women (P < 0.001). In multivariate analysis, MetS was negatively associated with seropositivity and pulmonary disease in men. Increasing age was associated with MetS in women. In postmenopausal women, corticosteroid use was associated with MetS. Psychiatric comorbidity was associated with MetS in premenopausal women. MetS status was not explained by disease activity or core RA measures.

Conclusion

The characteristics and associations of MetS differed in men and women with ERA. Sex differences, including postmenopausal status, should be considered in comorbidity screening. With this knowledge, the interplay of MetS, sex, and RA therapeutic response on cardiovascular outcomes should be investigated.

The Pharmacology of Spinal Opioids and Ziconotide for the Treatment of Non-Cancer Pain

Background

Intrathecal drug delivery has undergone a revitalization following a better understanding of this delivery route and its pharmacokinetics. Driven by patient safety and outcomes, clinicians are motivated to rethink the traditional spinal infusion pump patient selection criteria and indications. We review the current understanding of the pharmacology of commonly employed intrathecal agents and the clinical relevance.

Methods

Search strategies for data acquisition included Medline database, PubMed, Google scholar, along with international and national professional meeting content, with key words including pharmacology of opioids, intrathecal therapy, ziconotide, pharmacokinetics, and intrathecal drug delivery. The search results were limited to the English language.

Results

Over 300 papers were identified. The literature was condensed and digested to evaluate the most commonly used medications in practice, sto serve as a foundation for review. We review on-label medications: ziconotide and morphine, and off label medications including fentanyl, sufentail, and hydromorphine.

Conclusion

Intrathecal therapy has level-one evidence for use for malignant pain and nonmalignant pain, with continued cost savings and improved safety. To most effectively serve our patients, a clear appreciation for the pharmacology of these commonly employed medication is paramount..

Determining the Minimally Important Difference in the Clinical Disease Activity Index for Improvement and Worsening in Early Rheumatoid Arthritis Patients

OBJECTIVE

Simplified measures to quantify rheumatoid arthritis (RA) disease activity are increasingly used. The minimum clinically important differences (MCID) for some measures, such as the Clinical Disease Activity Index (CDAI), have not been well-defined in real-world clinic settings, especially for early RA patients with low/moderate disease activity.

METHODS

Data from Canadian Early Arthritis Cohort patients were used to examine absolute change in CDAI in the first year after enrollment, stratified by disease activity. MCID cut points were derived to optimize the sum of sensitivity and specificity versus the gold standard of patient self-reported improvement or worsening. Sensitivity, specificity, positive predictive values, and negative predictive values were calculated against patient self-reported improvement (gold standard) and for change in pain, Health Assessment Questionnaire (HAQ), and Disease Activity Score in 28 joints (DAS28) improvement. Discrimination was examined using the area under receiver operator curves. Similar methods were used to evaluate MCIDs for worsening for patients who achieved low disease activity.

RESULTS

A total of 578 patients (mean ± SD age 54.1 ± 15.3 years, 75% women, median [interquartile range] disease duration 5.3 [3.3, 8.0] months) contributed 1,169 visit pairs to the improvement analysis. The MCID cut points for improvement were 12 (patients starting in high disease activity: CDAI >22), 6 (moderate: CDAI 10-22), and 1 (low disease activity: CDAI <10). Performance characteristics were acceptable using these cut points for pain, HAQ, and DAS28. The MCID for CDAI worsening among patients who achieved low disease activity was 2 units.

CONCLUSION

These minimum important absolute differences in CDAI can be used to evaluate improvement and worsening and increase the utility of CDAI in clinical practice.

The frequency of and associations with hospitalization secondary to lupus flares from the 1000 Faces of Lupus Canadian cohort

Objectives

Hospitalization is a major factor in health care costs and a surrogate for worse outcomes in chronic disease. The aim of this study was to determine the frequency of hospitalization secondary to lupus flare, the causes of hospitalization, and to determine risk factors for hospitalization in patients with systemic lupus erythematosus (SLE).

Methods

Data were collected as part of the 1000 Canadian Faces of Lupus, a prospective cohort study, where annual major lupus flares including hospitalizations were recorded over a 3-year period.

Results

Of 665 patients with available hospitalization histories, 68 reported hospitalization related to a SLE flare over 3 years of follow-up. The average annual hospitalization rate was 7.6% (range 6.6–8.9%). The most common reasons for hospitalization were: hematologic (22.1%), serositis (20.6%), musculoskeletal (MSK) (16.2%), and renal (14.7%). Univariate risk factors for lupus hospitalization included (OR [95% CI]; p < 0.05): juvenile-onset lupus (2.2 [1.1–4.7]), number of ACR SLE criteria (1.4 [1.1–1.7], baseline body mass index (BMI) (1.1 [1.0–1.1]), psychosis (3.4 [1.2–9.9]), aboriginal race (3.2 [1.5–6.7]), anti-Smith (2.6 [1.2–5.4]), erythrocyte sedimentation rate >25 mm/hr (1.9 [1.1–3.4]), proteinuria >0.5 g/d (4.2 [1.9–9.3], and SLAM-2 score (1.1 [1.0–1.2]). After multivariate regression only BMI, number of ACR criteria, and psychosis were associated with hospitalization for lupus flare.

Conclusions

The mean annual rate of hospitalization attributed to lupus was lower than expected. Hematologic, serositis, MSK and renal were the most common reasons. In a regression model elevated BMI, more ACR criteria and psychosis were associated with hospitalization.

The Relationship Between Function and Disease Activity as Measured by the HAQ and DAS28 Varies Over Time and by Rheumatoid Factor Status in Early Inflammatory Arthritis (EIA). Results from the CATCH Cohort

Objective:

To investigate the relationship between function and disease activity in early inflammatory arthritis (EIA).

Methods:

Canadian Early Arthritis Cohort (CATCH) (n=1143) is a multi-site EIA cohort. Correlations between the Health Assessment Questionnaire Disability Index (HAQ) and DAS28 were done at every 3 months for the first year and then at 18 and 24 months. We also investigated the relationship between HAQ and DAS28 by age (<65 versus ≥65) and RF (positive vs negative).

Results:

Mean HAQ and DAS28 scores were highest at the initial visit with HAQ decreasing over 24 months from a baseline of 0.94 to 0.40 and DAS28 scores decreasing from 4.54 to 2.29. All correlations between HAQ and DAS28 were significant at all time points (p<0.01). The correlations between HAQ and DAS28 were variable over time. The strongest correlation between HAQ and DAS28 occurred at initial visit (most DMARD naive) (n=1,143) and 18 months (r=0.57, n=321) and 24 months (r=0.59, n=214). The baseline correlation between HAQ and DAS28 was significantly different than correlations obtained at 3, 6, and 12 months (p=0.02, 0.01, and 0.01, respectively). Age did not change the association between HAQ and DAS28 {<65 years old (r=0.50, n=868) versus ≥65 (r=0.48, n=254), p=0.49}. The correlation between HAQ and DAS28 was stronger with RF+ patients (r=0.63, n=636) vs RF negative (r=0.47, n=477), p=0.0043

Conclusion:

Over 2 years in EIA, HAQ and DAS both improved; correlations at time points were different over 2 years and RF status affected the correlations.

Patterns and predictors of change in outcome measures in clinical trials in scleroderma: an individual patient meta-analysis of 629 subjects with diffuse cutaneous systemic sclerosis

OBJECTIVE

To examine the range and responsiveness to change of clinical outcome measures and study predictors of clinical response in patients with diffuse cutaneous systemic sclerosis (dcSSc) in the context of clinical trials.

METHODS

Data were combined from 629 patients with dcSSc who participated in 7 multicenter clinical therapeutic trials. Trials used common outcome measures: modified Rodnan skin thickness score (MRSS), Health Assessment Questionnaire disability index (HAQ DI), patient's global assessment of disease activity, pulmonary function tests (forced vital capacity, diffusing capacity for carbon monoxide), hand span, and oral aperture.

RESULTS

The combined database included 629 patients (82% women, mean ± SD age 46.5 ± 11.8 years, mean ± SD disease duration 19.4 ± 15.9 months). Outcomes tended to improve during trials for patients with more severe disease at study entry and to worsen for patients with less severe disease at entry. Disease duration was mildly negatively predictive of change in MRSS at 6 months (r = -0.27, P < 0.001), and substantial bidirectional variation in change in MRSS and HAQ DI score was seen across the spectrum of disease duration. Sixty-three percent of patients with "early" disease (disease duration <18 months) had a decline in MRSS, and 37% had an increase in MRSS. Eighty-one percent of patients with "late" disease (disease duration ≥ 18 months) had a decline in MRSS, and 19% had an increase in MRSS. Multivariate mixed models did not demonstrate that any baseline variables were strongly predictive of subsequent outcome.

CONCLUSION

Among patients with dcSSc enrolled in clinical trials, standard outcome measures tend to improve in those with more severe disease at study entry and to worsen in those with less severe disease at entry. Overall, the MRSS improves during trials, while HAQ DI scores and lung function are mostly static. None of these variables, including disease duration, reliably identifies groups of subjects whose MRSS will predictably increase or decrease in the course of a clinical trial. These findings have important implications for clinical trial design in scleroderma.

The minimally important difference (MID) for patient-reported outcomes including pain, fatigue, sleep and the health assessment questionnaire disability index (HAQ-DI) in primary Sjögren's syndrome

OBJECTIVES

We wanted to determine the MID for the HAQ, pain, fatigue, sleep and global VAS (0-100mm) in Sjögren's syndrome (SS) using a patient-reported overall health status anchor.

METHODS

Patients with a diagnosis of primary Sjögren's syndrome (pSS) who had answered a standardised questionnaire at two consecutive visits including an overall health status question: 'How would you describe your overall status since your last visit: much better, better, the same, worse, much worse?' were included. The MID was calculated as the mean change between visits for those who rated their disease as better or worse. Scales on VAS were from 0 (best) to 100 (worst).

RESULTS

Forty patients met the inclusion criteria (97% female, mean age 58 years, mean disease duration 10 years). The mean baseline HAQ was 0.68. Ten rated their status as better and 14 as worse than the previous visit. MID estimates for improvemenT/worsening (SD) respectively were: -7.4 (27.8) / 20.7 (20.0) for pain VAS, -6.2 (28.3) / 15.2 (21.8) for fatigue VAS, -24.0 (24.0) / 15.2 (28.0) for sleep VAS, -0.18 (0.23) / 0.14 (0.30) for HAQ and -23.1 (21.6) / 16.4 (20.9) for global VAS. Spearman's rho correlation coefficients for the patient-reported outcomes were 0.38 (pain VAS), 0.54 (fatigue VAS), 0.55 (sleep VAS), 0.39 (HAQ), and 0.57 (global VAS), p<0.05.

CONCLUSIONS

The MID for pain and fatigue are greater for worsening than improvement. A small change in the HAQ is detected as a change in status by the patient. This knowledge may aid those who treat SS and in designing intervention studies.

Digital ulcers: overt vascular disease in systemic sclerosis

RP is an almost universal manifestation of SSc, with 95% of all patients being affected, and resulting in digital ulcers (DUs) in approximately 30% of the patients each year. DUs are a major clinical problem, being associated with substantial morbidity (reduced quality of life, pain, disability and disfigurement) that can escalate to gangrene and amputation. Ideally, the treatment of DUs would improve tissue integrity and viability, promote ulcer healing and reduce the formation of new ulcers. Treatments that have shown potential include calcium channel blockers, prostacyclin analogues and endothelin receptor antagonists. However, until recently, management was based on empirical experience. The recent approval (in Europe) of the dual endothelin receptor antagonist, bosentan, to reduce the number of new DUs in patients with SSc and ongoing DU disease, means that there is now an approved therapy--and new hope--for the treatment of DUs in these severely afflicted patients.

Lack of correlation of the health assessment questionnaire disability index with lung parameters in systemic sclerosis associated pulmonary arterial hypertension

OBJECTIVE

Pulmonary arterial hypertension (PAH) affects the quality of life (QoL) and the ability to perform the activities of daily living (ADLs) in patients with systemic sclerosis (SSc). We determined whether the Health Assessment Questionnaire-Disability Index (HAQ-DI), a self-assessment measure of function, correlates with a patient's PAH status in a population of SSc patients with PAH.

METHODS

Forty-one patients from one centre with systemic scleroderma, dyspnea and PAH were included. All patients filled in a HAQ-DI, and underwent evaluation with pulmonary function tests (PFTs), 6-minute walk distance (6MWD), degree of dyspnea (Borg dyspnea index), NYHA functional class, and expert PAH physician global assessment every 6 months. Change in HAQ DI was studied to determine relationship to changes in PAH.

RESULTS

The HAQ-DI scores had no significant correlation with PAH, including NYHA functional class (r=0.38, p=0.39), Borg dyspnea index (r=0.60, p=0.37), 6MWD (r=-0.04, p=0.86), % predicted DLCO (r=0.31, p=0.25), % predicted FVC (r=0.02, p=0.93), and expert PAH physician global assessment (r=0.06, p=0.97).

CONCLUSION

HAQ-DI is not an adequate measure of PAH status in SSc patients with PAH. Although PAH causes severe morbidity and death, changes in PAH severity were not reflected in an overall functional status change as assessed by the HAQ-DI. Thus, HAQ-DI changes do not reflect PAH status in SSc.

Learning from past mistakes: assessing trial quality, power and eligibility in non-renal systemic lupus erythematosus randomized controlled trials

OBJECTIVES

To evaluate the post hoc study power of randomized controlled trials (RCTs) in the treatment of non-renal SLE and to determine the generalizability of these RCTs using an SLE database.

METHODS

RCTs in non-renal SLE were identified using PubMed (1975-2007). Inclusion/exclusion criteria, trial quality (5-point scale) and results of each study were recorded. The inclusion/exclusion criteria were compared with an SLE database to determine the proportion of patients from the database who would theoretically be eligible for these trials. For each negative study, we calculated the post hoc study power. We also looked for temporal improvements of trials in the literature and examined if pharmaceutical involvement influenced trial quality.

RESULTS

Sixty-four articles were included; the mean power of 30 negative studies was 24.6 +/- s.e.m. 3.9% (range 2.5-81.1%). Only one study had a power > 80%. Overall, potential eligibility of SLE patients in the database was 45.1 +/- s.e.m. 3.6%. Only 14 studies (21.9%) were of good quality. Fortunately, RCT quality is improving over time (trials <1995, compared with 1996-2002 and >2003; P < 0.001). Trials with pharmaceutical involvement had a significantly higher number of enrollees and better study quality.

CONCLUSIONS

Negative RCTs in SLE were mostly underpowered but the generalizability of these trials was high. Determination of study power and the impact of eligibility criteria on generalizability of study results are crucial in the design of clinical trials to ensure applicability to clinical practice.

Arthritis risk after acute bacterial gastroenteritis

OBJECTIVES

Reactive arthritis (ReA) may occur from bacterial gastroenteritis. We studied the risk of arthritis after an outbreak of Escherichia coli O157:H7 and Campylobacter species within a regional drinking water supply to examine the relationship between the severity of acute diarrhoea and subsequent symptoms of arthritis.

METHODS

Participants with no known history of arthritis before the outbreak participated in a long-term follow-up study. Of the 2299 participants, 788 were asymptomatic during the outbreak, 1034 had moderate symptoms of acute gastroenteritis and 477 had severe symptoms that necessitated medical attention. The outcomes of interest were new arthritis by self-report and a new prescription of medication for arthritis during the follow-up period.

RESULTS

After a mean follow-up of 4.5 yrs after the outbreak, arthritis was reported in 15.7% of participants who had been asymptomatic during the outbreak, and in 17.6 and 21.6% of those who had moderate and severe symptoms of acute gastroenteritis, respectively (P-value for trend = 0.009). Compared with the asymptomatic participants, those with moderate and severe symptoms of gastroenteritis had an adjusted relative risk of arthritis of 1.19 [95% confidence interval (CI) 0.99-1.43] and 1.33 (95% CI 1.07-1.66), respectively. No association was observed between gastroenteritis and the subsequent risk of prescription medication for arthritis (P = 0.49).

CONCLUSIONS

Acute bacterial gastroenteritis necessitating medical attention was associated with a higher risk of arthritic symptoms, but not arthritic medications, up to 4 yrs afterwards. The nature and chronicity of these arthritic symptoms requires further study.

Long-term effects of bosentan on quality of life, survival, safety and tolerability in pulmonary arterial hypertension related to connective tissue diseases

OBJECTIVES

This study investigated the long-term effects of bosentan, an oral endothelin ET(A)/ET(B) receptor antagonist, in patients with pulmonary arterial hypertension (PAH) exclusively related to connective tissue diseases (CTD).

METHODS

A total of 53 patients with PAH related to connective tissue diseases (PAH-CTD) in World Health Organization (WHO) functional class III received bosentan 62.5 mg twice a day for 4 weeks and then 125 mg twice a day for 44 weeks in this open non-comparative study. Assessments at weeks 16 and 48 included WHO class, clinical worsening, quality of life (Short-Form Health Survey (SF-36) and health assessment questionnaire (HAQ) modified for scleroderma), and survival (week 48 only). Safety and tolerability were monitored throughout the study.

RESULTS

At week 48, WHO class improved in 27% of patients (95% CI 16-42%) and worsened in 16% (95% CI 7-29%). Kaplan-Meier estimates were 68% (95% CI 55-82%) for absence of clinical worsening and 92% (95% CI 85-100%) for survival. Overall changes in quality of life were minimal. There were no unexpected side effects observed during the study.

CONCLUSIONS

In most patients, bosentan was associated with improvement or stability of clinical status. The 92% estimate for survival at 48 weeks is a significant achievement in this patient population.

Calcium channel blockers for primary Raynaud's phenomenon: a meta-analysis

BACKGROUND

To determine the efficacy of calcium channel blockers (CCBs) for primary Raynaud's phenomenon (RP). Primary outcomes were frequency and severity of RP attacks.

METHODS

A meta-analysis was conducted using primary data sources: Medline, Current Contents and the Cochrane Controlled Trials Register. Inclusion criteria were randomized controlled trials (RCTs) of >2 days' duration with <35% dropouts. Eighteen of 31 trials were eligible for inclusion [13 nifedipine vs placebo; five other CCBs vs placebo (n = 361)]. The main reasons for trial exclusion were: subset data (primary RP) not provided (n = 10); data published more than once (n = 1); lack of control group (n = 1); and lack of randomization (n = 1). Data were abstracted independently and a weighted mean difference (WMD) was calculated for the outcomes.

RESULTS

The WMD (95% confidence interval) of all CCBs vs placebo for reduction in the frequency of attacks (n = 17) over 1 week was -5.00 (-9.02, -0.99) (P = 0.01) or -2.80 (-3.90, -1.70) when heterogeneity was considered, and -6.05 (-11.19,-0.19) (P = 0.04) for nifedipine alone (n = 10). The WMD of all CCBs vs placebo (n = 8) for reduction in severity of attacks (assessed with a 10-cm visual analogue scale) was -1.39 (-2.20, -0.58) (P = 0.0007) and -1.81 (-3.08, -0.54) (P = 0.005) for nifedipine alone (n = 5).

CONCLUSIONS

Several small RCTs of CCBs for primary RP have been conducted and have yielded clinical improvement in the frequency and severity of ischaemic attacks. Most trials were crossover trials in which order effect was not studied; this may have introduced bias. The effect size may have been small because of low dosing in studies. The efficacy of CCBs for reducing severity and frequency of ischaemic attacks in primary RP is small (average of 2.8 to 5.0 fewer attacks per week and a 33% reduction in severity).

Treatment of osteoarthritis of the hip and knee: a comparison of NSAID use in patients for whom surgery was and was not recommended

OBJECTIVE

To determine if NSAID use was different between OA (hip and/or knee) patients treated surgically to those treated medically.

METHODS

We conducted a case control study, in which cases (n = 433) had had a total joint replacement within a two-year period, while controls (n = 195) had seen a rheumatologist or orthopedic surgeon, and not been recommended for surgery. Current and previous NSAID use was surveyed.

RESULTS

Cases were older than controls (70 vs. 64 years, p < 0.0001), and were more likely to have OA in the hips (45% vs. 21%, p < 0.0001), to have severe OA (p < 0.0001), and to be male (42% vs. 28%, p < 0.0008). Potential confounding variables were statistically adjusted using logistic regression. Although disease duration was similar in cases and controls (9.8 years), cases had tried fewer NSAIDs (1.3 +/- 0.05 vs. 2.3 +/- 0.08 in controls, p < 0.0001). Cases were less likely to have taken any NSAID (86% vs. 94% of controls; OR 0.40, p < 0.007) or to have had intra-articular steroids (OR 0.19, p < 0.0001). Two or more NSAIDs were used (ever) in 38% of cases vs. 70% of controls (p < 0.0001); and 3 or more NSAIDs in 5% vs. 38% (p < 0.0001). Women were less apt to have obtained total joint replacements (OR 0.62, p < 0.0001), including TKRs even when adjusting for severity of OA.

CONCLUSIONS

NSAIDs are used less by orthopedic surgeons than rheumatologists in our centre. Some subjects were offered a joint replacement without even a failure of medical management. The reasons for differences in prescribing trends are unknown. Referral biases may exist.

The health assessment questionnaire (HAQ) is strongly predictive of good outcome in early diffuse scleroderma: results from an analysis of two randomized controlled trials in early diffuse scleroderma

OBJECTIVE

Scoring poorly on the health assessment questionnaire (HAQ) has recently been shown to be a strong predictor of morbidity and mortality in rheumatoid arthritis (RA), while a good HAQ score is predictive of a better outcome. In patients presenting with early diffuse scleroderma prognosis is variable. Our goal was to determine possible baseline predictors of future good outcomes.

METHODS

We used the raw data from two randomized controlled trials (RCTs) in early diffuse scleroderma: methotrexate (Pope et al.) and D-penicillamine (Clements et al.). Subjects in the methotrexate trial were divided into the following groups: (1) those with at least 20% improvement in the primary outcome measurements [patient global assessment, physician global assessment, UCLA skin tethering score, modified Rodnan skin score (MRSS), DLCO as % predicted and HAQ disability] at 1 yr vs (2) the others. Baseline factors (including age, gender, skin scores, physician and patient global assessments, HAQ disability and pain scores, DLCO and physical parameters) were analysed to find baseline variables strongly correlated with later improvement. These variables were explored in the D-penicillamine trial to determine if (in a separate trial) they were still predictive of improved outcome at 1 and 2 yr. Adjusted models were used to find baseline predictors of good outcome. The median HAQ-DI was 1.3 (methotrexate) and 1.0 (D-penicillamine).

RESULTS

A baseline HAQ disability score of less than the median was predictive of at least a 20% improvement at 1 and 2 yr with odds ratios of 1.77 to 5.05, in four of the five outcome measurements (in both groups); with strongly significant P values for 3 of 5 outcomes (UCLA skin score, MRSS, patient global skin score; P<0.02) from the methotrexate study group. These three outcomes were strongly correlated with improvement (r between 0.25 and 0.35). Although data from the D-penicillamine trial were less convincing, in both trials the less than median HAQ-DI and HAQ pain scores showed a stronger association with improved outcome, more so than age, gender, skin score and baseline global assessment.

CONCLUSION

A low baseline HAQ (defined as less than the median HAQ score) is predictive of improved outcome in diffuse scleroderma at 1 and 2 yr.

Calcium-channel blockers for Raynaud's phenomenon in systemic sclerosis

OBJECTIVE

Most patients with systemic sclerosis (SSc) have Raynaud's phenomenon (RP), which is often more severe than idiopathic RP. This study was a meta-analysis to determine the efficacy of calcium-channel blockers for the treatment of RP in SSc. The primary outcome measures were frequency and severity of ischemic attacks, digital skin temperature, patient and physician global assessments, and digital ulcers.

METHODS

The Cochrane search strategy was used to ascertain all trials in all languages. Primary data sources included Medline, Current Contents, and the Cochrane Controlled Trials Register. Studies that met the inclusion criteria were randomized controlled trials of >2 days' duration with a dropout rate of <35%. Twenty-nine studies were found, of which 8 randomized controlled trials were eligible for inclusion. The total number of patients included was small (n = 109). Most trials included primary and secondary RP, and the main reasons for trial exclusion were inability to extract subset data on SSc patients (18 trials), data published previously (2 trials), and lack of a control group (1 trial). Data were abstracted independently by 2 reviewers, and either a weighted mean difference (WMD) or a standardized mean difference (SMD) was calculated for all continuous outcomes; however, information was not available for all outcomes within trials.

RESULTS

The WMD of all calcium-channel blockers versus placebo (6 trials) and of nifedipine alone versus placebo (5 trials) for the reduction in the frequency of ischemic attacks over a 2-week period was -8.31 (95% confidence interval [95% CI] -15.71, -0.91) and -10.21 (95% CI -20.09, -0.34), respectively. The SMD of all calcium-channel blockers versus placebo (3 trials) and of nifedipine alone versus placebo (2 trials) for the reduction in the severity of ischemic attacks was -0.69 (95% CI -1.21, -0.17) and -0.99 (95% CI -1.74, -0.24), respectively.

CONCLUSION

Calcium-channel blockers for RP in SSc have been tested in several small clinical trials and appear to lead to significant clinical improvement in both the frequency and the severity of ischemic attacks. Most trials were crossover trials in which order effect was not studied. This could have introduced bias. The results of this study suggest that the efficacy of calcium-channel blockers in reducing the severity and frequency of ischemic attacks in RP secondary to SSc is moderate at best (mean reduction of 8.3 attacks in 2 weeks and 35% less severity), and a further large, randomized controlled trial needs to be conducted.

A randomized, controlled trial of methotrexate versus placebo in early diffuse scleroderma

OBJECTIVE

Early diffuse scleroderma (systemic sclerosis; SSc) has no proven treatment. This study was undertaken to examine the efficacy of methotrexate (MTX) in improving the skin and other disease parameters in early diffuse SSc.

METHODS

Seventy-one patients with diffuse SSc of <3 years' duration were enrolled in a multicenter, randomized, placebo-controlled, double-blind trial. Thirty-five patients were treated with MTX and 36 with placebo. Treatment was administered for 12 months. The primary outcome measures were skin score (as determined with 2 different indices) and physician global assessment.

RESULTS

At baseline, there were no statistically significant differences in skin scores, carbon monoxide diffusing capacity (DLco), physician global assessment, or other secondary outcome measurements between the 2 treatment groups. At study completion, results slightly favored the MTX group (mean +/- SEM modified Rodnan skin score 21.4+/-2.8 in the MTX group versus 26.3+/-2.1 in the placebo group [P < 0.17]; UCLA skin score 8.8+/-1.2 in the MTX group versus 11.0+/-0.9 in the placebo group [P < 0.15]; DLco in the MTX group 75.7+/-4.6 versus 61.8+/-3.4 in the placebo group [P < 0.2]). In addition, physician global assessment results favored MTX (P < 0.035), whereas patient global assessment did not differ significantly between groups. When between-group differences for changes in scores from baseline to 12 months were examined using intent-to-treat methodology, MTX appeared to have a favorable effect on skin scores (modified Rodnan score -4.3 in the MTX group versus 1.8 in the placebo group [P < 0.009]; UCLA score -1.2 in the MTX group versus 1.2 in the placebo group [P < 0.02]), but differences in the degree of change in the DLco and physician global assessment were not significant. For the UCLA skin score, these differences in results were not statistically significant after adjustment for baseline differences in sex distribution and steroid use. Dropout rates were similar in the 2 groups.

CONCLUSION

Although results of this trial demonstrated a trend in favor of MTX versus placebo in the treatment of early diffuse SSc, the between-group differences were small and the power to rule out false-negative results was only 50%. Our findings do not provide evidence that MTX is significantly effective in the treatment of early diffuse SSc.

A Canadian survey on the management of corticosteroid induced osteoporosis by rheumatologists

OBJECTIVE

To survey the practice pattern of Canadian rheumatologists (CR) on their management of corticosteroid induced osteoporosis in their premenopausal (PrM) and postmenopausal (PoM) female patients.

METHODS

The practice pattern was surveyed using a 17 item questionnaire probing the diagnosis, prevention, treatment, and monitoring of osteoporosis in PrM and PoM women receiving longterm oral systemic corticosteroid therapy.

RESULTS

Most CR investigated and treated osteoporosis themselves, 13% referred to other specialists for investigation, and 22% referred for treatment. Eighty-two percent of CR used dual energy x-ray absorptiometry (DEXA) to confirm a diagnosis of osteoporosis. Most CR initiated investigation for osteoporosis at the start or within the first year of starting longterm systemic corticosteroid therapy: PrM 87% and PoM 93%. The most frequently used initial strategy for the prevention of osteoporosis was as follows. PrM: calcium and vitamin D3 (53%); PoM: hormone replacement therapy (HRT) and calcium (29%). The most common initial choice for treatment of established osteoporosis was as follows: PrM: etidronate (53%); PoM: bisphosphonates +/- HRT (53%). Ninety-six percent of CR used only bone mineral density (BMD) measurement to monitor therapy for corticosteroid induced osteoporosis. Most CR monitored BMD every 12 to 24 months for PrM (81%) and PoM (84%). The BMD parameter(s) (T and Z scores as measured by DEXA) used to initiate therapy for corticosteroid induced osteoporosis was variable.

CONCLUSION

It appears that, while certain trends are evident, there is still considerable variability in the management of corticosteroid induced osteoporosis.

The frequency and significance of anticardiolipin antibodies in scleroderma

OBJECTIVE

To determine the frequency and significance of anticardiolipin antibodies (aCL) in scleroderma.

METHODS

We serially tested for aCL in a standardized fashion in patients with scleroderma who were outpatients and gave consent to enter this study.

RESULTS

Sixty-three patients participated in this study. Thirty-six had diffuse scleroderma and 27 had limited scleroderma. Three (4.8%) were positive for aCL, of whom 2 had limited scleroderma. In only one patient aCL may have been clinically significant. This woman had limited scleroderma for years and had medium vessel occlusive disease with gangrene eventually requiring midfoot amputations and chronic warfarin treatment. She did not have features of systemic lupus erythematosus or other overlap conditions. The other 2 patients had no manifestations of the antiphospholipid antibody syndrome.

CONCLUSION

aCL in scleroderma rarely manifest clinically. The range of frequency of positive aCL in the literature is from 0 to 63%. From our study and the literature, we cannot ascertain if the prevalence is different in limited and diffuse scleroderma.

The lack of associations between rheumatoid arthritis and both nulliparity and infertility

OBJECTIVES

Rheumatoid arthritis (RA) is an autoimmune disease that occurs more commonly in women and frequently onsets in women of childbearing age. Pregnancy often causes disease remission, with a subsequent flare postpartum. Nulliparity may be a risk factor for RA, but the literature does not consistently report this finding. There may be a production of antibodies in women with RA that could lead to infertility, and subsequent nulliparity, but this has not been proved. We wanted to determine whether there was a relationship between nulliparity, infertility, oral contraceptive use, and adverse pregnancy outcome in women with newly diagnosed RA.

METHODS

Through a case control study, using a mailed questionnaire, we compared the fertility and pregnancy outcome histories of 34 women between the ages of 19 and 44 years with recent-onset RA with 68 healthy controls matched for age and marital status. The response rate was 97%. A review of the literature also was performed to study the associations between RA and infertility and nulliparity, using Medline searching key references.

RESULTS

We found no association between infertility and the onset of RA. Seventy-one percent of women with RA and 68% of controls had been pregnant. There was a trend toward increased nulliparity in these patients, but the result was not statistically significant (odds ratio [OR], 1.4; P<.6). There were no differences in the number of children (2.6 v. 2.7; P<.6) and parity outcomes in the two groups. Age at first pregnancy was younger in the women with RA (22.6 v. 25.5 years; P<.008), but the education level was higher in the controls (P<.0001), which may explain these differences. Oral contraceptive use was lower in the RA women, but more RA women had long-term use (greater than or equal to 5 years), and neither result was statistically significant. Literature review shows that at best, there are weak negative associations between current estrogen use and RA, and no association with nulliparity and infertility.

CONCLUSIONS

It appears that infertility, the number of pregnancies, and pregnancy outcome are not strongly associated with the risk of developing RA in women of childbearing age. However, in this study there may have been selection biases in the women with RA and the controls that differentially could have affected their reproductive outcomes. Thus, a true association could have been missed. Most other published studies find no association between nulliparity and RA.

A study of the frequency of pericardial and pleural effusions in scleroderma

OBJECTIVE

To determine the frequency of pericardial and pleural effusions in scleroderma.

METHODS

Using a case-control format, patients with scleroderma and no known cardiac disease were recruited. Echocardiograms and chest radiographs were performed. Age- and gender-matched controls had echocardiograms performed which were read by a cardiologist, blinded to the diagnosis. The medical records of 60 other scleroderma patients were also reviewed.

RESULTS

Thirty-seven scleroderma subjects were recruited, of whom 18 had diffuse disease. Only eight subjects with diffuse disease and five with limited scleroderma had normal echocardiograms compared to 20 of 37 controls (P < 0.1). Two had pericardial effusions, both with diffuse scleroderma, and none of the controls had effusions present. Pulmonary hypertension occurred in three with diffuse disease and no controls. A chart review of a further 60 patients with scleroderma was performed. Pleural effusions were identified in 7% (4/58) of the cohort of scleroderma patients and were more frequent in diffuse disease (10%). A total of 17% (4/23) of diffuse and 4% (1/23) of limited scleroderma patients had evidence of pericardial effusions.

CONCLUSIONS

Pericardial effusions do occur in scleroderma without evidence of clinical cardiac dysfunction and are more common in diffuse scleroderma. Pleural effusions in scleroderma occur less frequently, in 70%.