Health Assessment Questionnaire disability progression in early rheumatoid arthritis: systematic review and analysis of two inception cohorts

The Longitudinal Course of Fatigue in Rheumatoid Arthritis: Results from the Norfolk Arthritis Register

Objective.

Fatigue is common and burdensome in rheumatoid arthritis (RA). Despite RA fatigue progression varying significantly between individuals in practice, existing longitudinal analyses only examine symptom advancement on a population level. This study aimed to determine fatigue trajectories at an individual level and to characterize those patients with the poorest prognosis, with a view to enabling earlier interventions.

Methods.

Patients with RA reporting clinically relevant baseline fatigue (≥ 20 mm on a 0–100 mm visual analog scale) were identified from a longterm inflammatory polyarthritis cohort (the Norfolk Arthritis Register). Fatigue changes from baseline to 1- and 4-year followups were calculated, and sex-stratified group-based trajectory modeling (GBTM) determined trajectories of the symptom between which baseline characteristics were compared.

Results.

Among 338 patients, only minimal average changes were observed between recruitment to 1 year (6.0 mm, SD 26.9) and 4 years (5.5 mm, SD 29.3). This was despite 45.6% and 40.7% of participants reporting clinically significant improvements (≥ 10 mm) at these respective followups. GBTM revealed varied trajectories of fatigue, which for both sexes consisted of Improved (men, n = 48 and women, n = 81) or persistent Moderate-high paths (n = 54, n = 105), and further included a persistent High trajectory in women (n = 50). Participants who followed persistent trajectories were best distinguished from improvers by patient-reported rather than demographic or clinical variables.

Conclusion.

Among patients with RA presenting with clinically relevant fatigue, distinct longitudinal symptom trajectories were identified on an individual level despite nominal average changes in fatigue on a group level. It is possible to identify and characterize subgroups of participants who report persistent fatigue and should therefore be targeted to receive future fatigue-alleviating interventions.

Heterogeneous Disease Trajectories Explain Variable Radiographic, Function and Quality of Life Outcomes in the Canadian Early Arthritis Cohort (CATCH)

Our objective was to identify distinct trajectories of disease activity state (DAS) and assess variation in radiographic progression, function and quality of life over the first two years of early rheumatoid arthritis (ERA). The CATCH (Canadian early ArThritis CoHort) is a prospective study recruiting ERA patients from academic and community rheumatology clinics in Canada. Sequential DAS28 scores were used to identify five mutually exclusive groups in the cohort (n = 1,586) using growth-based trajectory modeling. Distinguishing baseline sociodemographic and disease variables, treatment required, and differences in radiographic progression and quality of life measures over two years were assessed. The trajectory groups are characterized as: Group 1 (20%) initial high DAS improving rapidly to remission (REM); Group 2 (21%) initial moderate DAS improving rapidly to REM; Group 3 (30%) initial moderate DAS improving gradually to low DAS; Group 4 (19%) initial high DAS improving continuously to low DAS; and Group 5 (10%) initial high DAS improving gradually only to moderate DAS. Groups differed significantly in age, sex, race, education, employment, income and presence of comorbidities. Group 5 had persistent steroid requirements and the highest biologic therapy use. Group 2 had lower odds (OR 0.22, 95%CI 0.09 to 0.58) and Group 4 higher odds (OR 1.94, 95%CI 0.90 to 4.20) of radiographic progression compared to Group 1. Group 1 had the best improvement in physical function (Health Assessment Questionnaire 1.08 (SD 0.68) units), Physical Component Score (16.4 (SD 10.2) units), Mental Component Score (9.7 (SD 12.5) units) and fatigue (4.1 (SD 3.3) units). In conclusion, distinct disease activity state trajectories explain variable outcomes in ERA. Early prediction of disease course to tailor therapy and addressing social determinants of health could optimize outcomes.

Window of opportunity to achieve major outcomes in early rheumatoid arthritis patients: how persistence with therapy matters

Introduction

Benefits of disease-modifying anti-rheumatic drugs (DMARD) in early rheumatoid arthritis patients (ERAP) will be achieved if patients follow prescribed treatment. Objective was to investigate whether timing of first non-persistence period and/or duration of persistence during the first 4 years of follow-up predicted disease outcomes at the 5^th year in a cohort of ERAP, initiated in 2004.

Patients and Methods

Up to February 2015, charts of 107 ERAP with at least 5 years of follow-up and prospective 6-month assessments of disease activity, disability and persistence were reviewed. Non-persistence was defined as omission of DMARD and/or corticosteroids for at least 7 consecutive days; regarding methotrexate, one weekly missing dose was considered non-persistence. Persistence was recorded through an interview (up to 2008) and thereafter through a questionnaire; persistence duration was recorded in months of continuous medicationtaking. At the 5^th year, disease activity was defined according to Disease Activity Score (DAS)28, and disability according to Health Assessment Questionnaire (HAQ). Descriptive statistics and linear and Cox regression analyses were used.

Results

At study entry, patients were more frequently middle-aged (39.1 ± 13.3 years) and female (88.8 %), as well as more likely to have high disease activity and disability. Over the first 4 years of follow-up, 54.2 % of the patients had indications for oral corticosteroids and all traditional DMARDs. Almost 70 % had at least one period of non-persistence, and their follow-up (median, 25th–75th interquartile range) to first non-persistence period was 13 months (1–31). Persistence duration during the first 4 years predicted subsequent DAS28 (in addition to gender and baseline DAS28) and HAQ (in addition to age). During the 5^th year, 68 patients (56 women) achieved sustained remission (DAS28 < 2.6). In female population (n = 95), baseline DAS28 (odds ratio [OR], 0.65; 95 % confidence interval [CI], 0.50–0.83; p = 0.001) and persistence duration (OR, 1.04; 95 % CI, 1–1.08; p = 0.05) were predictors. Also, 84 patients achieved sustained function (HAQ <0.21), and baseline DAS28 and age were the only predictors. Timing of first non-persistence period did not impact outcomes.

Conclusions

Persistence duration with DMARDs within the first 4 years of RA predicted subsequent favorable outcomes in ERAP; additional predictors were younger age, male gender and lower disease activity at diagnosis.