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Drouet J, López-Medina C, Granger B, Fautrel B, Landewe RBM, Molto A, Gaujoux-Viala C, Kiltz U, Dougados M, Gossec L. Disease activity and widespread pain are main contributors to patient-reported global health in axial spondyloarthritis: an analysis of 6064 patients. Rheumatol Int 2024; 44:1455-1468. [PMID: 38597981 DOI: 10.1007/s00296-024-05576-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/02/2024] [Indexed: 04/11/2024]
Abstract
Global health (GH) and health-related quality of life are patient priorities in axial spondyloarthritis (axSpA). Our objective was to assess the relative importance of disease-related factors including disease activity, and patient-related factors including comorbidities, to explain GH in axSpA. Post hoc cross-sectional analyses of 4 sets (COMOSPA, PERSPA, COMEDSPA, and DESIR) of patients fulfilling ASAS criteria for axSpA. GH was assessed through the ASAS Health Index (ASAS-HI) or the EuroQoL-5D-3L (EQ-5D). Disease-related factors included disease activity (ASDAS, psoriasis, arthritis, enthesitis, and CRP), disease duration, diagnostic delay, bamboo spine, and treatment. Non-disease-related factors included sociodemographic characteristics, comorbidities and chronic widespread pain. Multivariable logistic and linear regressions and partial variances (R2) were applied to identify independent determinants of GH. In 6064 patients (range 284-2756 across datasets), mean age ranged 38.9-45.8 years, 51-68% were male. GH was generally moderate: median ASAS-HI ranged 5.0-7.0. GH was explained by ASDAS (range of odds ratios, OR, 2.60-4.48) and chronic widespread pain (range of OR 2.19-8.39); other determinants included comorbidities and sociodemographic characteristics. Only 47-57% of the total variance in GH could be explained by the models; disease activity (partial variance, 16-26%) and chronic widespread pain (partial variance 12-15%) were the key contributing variables. A wide range of disease and non-disease-related variables usually collected in studies could only explain 47-57% of the variability in GH. Among these, disease activity and chronic widespread pain were most relevant and of similar magnitude of importance. These findings will be helpful for shared decision-making.
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Affiliation(s)
- Juliette Drouet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France.
| | | | - Benjamin Granger
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
- Public Health Department, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Bruno Fautrel
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
- Rheumatology Department, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Robert B M Landewe
- Division of Clinical Immunology and Rheumatology, Amsterdam University Medical Center and Zuyderland Medical Center Heerlen, Heerlen, The Netherlands
| | - Anna Molto
- Rheumatology Department, Hôpital Cochin, Paris, France
- INSERM U-1183, CRESS, Université Paris Cité, Paris, France
| | - Cécile Gaujoux-Viala
- IDESP Univ Montpellier, INSERM, Rheumatology Department, CHU Nîmes, Montpellier, France
| | - Uta Kiltz
- Ruhr Universität Bochum, and Rheumazentrum Ruhrgebiet, Herne, Germany
| | - Maxime Dougados
- Rheumatology Department, Hôpital Cochin, Paris, France
- INSERM U-1183, CRESS, Université Paris Cité, Paris, France
| | - Laure Gossec
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
- Rheumatology Department, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
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Tumba MC, Silva RL, Arevalo AB, Sattui SE. Current perspective on infections and mitigation strategies in primary systemic vasculitis. Curr Rheumatol Rep 2024; 26:279-289. [PMID: 38668813 DOI: 10.1007/s11926-024-01149-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize and evaluate most recent evidence on the epidemiology of infections and associated risk factors in patients with primary systemic vasculitides (PSV), as well as discuss mitigation strategies including the risk of antibiotic prophylaxis. RECENT FINDINGS Infections remain one of the leading causes of mortality in patients with PSV, with rates of severe infection ranging from 16 to 40% in different cohorts. Older age, frailty, renal and pulmonary involvement, and higher burden of comorbidities have been recognized as important patient-associated risk factors. Treatments including higher cumulative doses of glucocorticoids are associated with an increased risk of infections, and recent studies show the potential benefit of interventions such as reduced-dose glucocorticoid regimens. Existing mitigation strategies include screening, vaccination, and infection prophylaxis. The latter remains particularly important for Pneumocystis jirovecii pneumonia; however, the benefit-risk ratio seems to be less clear outside of induction phase (i.e., high dose of glucocorticoids) and optimal treatment duration remains less clear. Patients with PSV are at increased risk of infections, due to disease itself, comorbidities, and treatment side effects. Awareness of the timing and types of infection, as well as mitigation strategies are imperative to ensure treatment success and survival for patients.
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Affiliation(s)
- Manuel Carpio Tumba
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Raisa Lomanto Silva
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ana B Arevalo
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Massachusetts, Boston, MA, USA
| | - Sebastian E Sattui
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA.
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Adas M, Dey M, Norton S, Lempp H, Buch MH, Cope A, Galloway J, Nikiphorou E. What role do socioeconomic and clinical factors play in disease activity states in rheumatoid arthritis? Data from a large UK early inflammatory arthritis audit. RMD Open 2024; 10:e004180. [PMID: 39004430 PMCID: PMC11253737 DOI: 10.1136/rmdopen-2024-004180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Persistently active rheumatoid arthritis (pactiveRA) may be due to the interplay between biological and non-biological factors. The role of socioeconomic factors remains unclear. OBJECTIVES To explore which biological and non-biological factors associate with pactiveRA. METHODS Adults with early RA in the National Early Inflammatory Arthritis Audit, recruited from May 2018 to October 2022, were included if having pactiveRA or persistently low RA (plowRA). The pactiveRA was defined as three consecutive Disease Activity Score-28 joints (DAS28) of >3.2 at baseline, 3 and 12 months. The plowRA was defined as DAS28 ≤3.2 at 3 and 12 months. Stepwise forward logistic regression was used to explore associations with pactiveRA (outcome). Age and gender were included a priori, with socioeconomic factors and comorbidities as exposure variables. RESULTS 682 patients with pactiveRA and 1026 plowRA were included. Compared with plowRA, patients with pactiveRA were younger (58, IQR: 49-67) versus (62, IQR: 52-72), and included more women (69% vs 59%). The pactiveRA was associated with worse scores in patient-reported outcomes at baseline, and anxiety and depression screens. Overall, there was clear social patterning in pactiveRA, with age-by-gender interaction. Logistic regression indicated age, gender, social deprivation and previous or current smoking, were independently associated with pactiveRA, after controlling for disease severity markers (seropositivity). Depression, lung disease, gastric ulcers and baseline corticosteroid use, were also associated with pactiveRA (p<0.05 for all). CONCLUSION Socioeconomic factors and deprivation were associated with pactiveRA, independent of clinical and disease characteristics. Identifying 'adverse' socioeconomic drivers of pactiveRA can help tailor interventions according to individual need.
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Affiliation(s)
- Maryam Adas
- Centre for Rheumatic Diseases, King's College London Faculty of Life Sciences & Medicine, London, UK
| | - Mrinalini Dey
- Centre for Rheumatic Diseases, King's College London Faculty of Life Sciences & Medicine, London, UK
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London Faculty of Life Sciences & Medicine, London, UK
- Health Psychology, King's College London Department of Psychology, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, King's College London Faculty of Life Sciences & Medicine, London, UK
| | - Maya H Buch
- The University of Manchester Centre for Musculoskeletal Research, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Andrew Cope
- Centre for Rheumatic Diseases, King's College London Faculty of Life Sciences & Medicine, London, UK
| | - James Galloway
- Centre for Rheumatic Diseases, King's College London Faculty of Life Sciences & Medicine, London, UK
- Department of Rheumatology, King's College Hospital NHS Trust, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London Faculty of Life Sciences & Medicine, London, UK
- Department of Rheumatology, King's College Hospital NHS Trust, London, UK
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Bechman K, Cook ES, Alveyn E, Houssien A, Stevens M, Russell MD, Adas M, Amlani-Hatcher P, Norton S, Lempp H, Ledingham JM, Galloway JB, Walker-Bone K. Occupational impacts of early inflammatory arthritis: results from the National Early Inflammatory Arthritis Audit. Rheumatology (Oxford) 2024; 63:1856-1867. [PMID: 37725361 PMCID: PMC11215985 DOI: 10.1093/rheumatology/kead484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/16/2023] [Accepted: 08/23/2023] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVES Inflammatory arthritis causes significant work disability. Studies regarding this frequently fail to report important contextual information such as employment type. Our objective was to explore work participation, by gender and occupation type, in early inflammatory arthritis. METHODS Data are from the National Early Inflammatory Arthritis Audit for 2018-2020. At diagnosis, clinicians collected information on demographics, inflammatory arthritis disease activity, and working status. Participants completed patient-reported outcomes at baseline, 3 months and 12 months, including occupation and Work Productivity and Activity Impairment (WPAI). Descriptive analyses of work participation and WPAI scores by occupational class at all time points were performed. Regression models were used to examine associations between WPAI score and occupation. RESULTS In all, 12 473 people received a diagnosis of inflammatory arthritis and reported employment status, among whom 5999 (47%) were in paid work for at least 20 hours/week. At diagnosis, the working cohort had statistically significant lower measures of disease activity (P < 0.001). Occupational data were available for 3694 individuals. At diagnosis, 2793 completed a WPAI; 200 (7.2%) had stopped work and 344 (12.3%) changed jobs because of inflammatory arthritis symptoms. There was a high burden of absenteeism (30%) and presenteeism (40%). Compared with managerial or professional workers, the burden of work disability was greater among those in routine (manual) occupations. During follow-up, 9.4% of WPAI completers stopped work and 14.6% changed roles. Work drop-out occurred almost entirely among people doing routine jobs. CONCLUSION It is easier to retain work in certain employment sectors. Participation in routine jobs is more affected, which may widen health inequalities.
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Affiliation(s)
- Katie Bechman
- Department of Inflammation Biology, Centre of Rheumatic Disease, King’s College London, London, UK
| | - Emma S Cook
- Department of Inflammation Biology, Centre of Rheumatic Disease, King’s College London, London, UK
| | - Edward Alveyn
- Department of Inflammation Biology, Centre of Rheumatic Disease, King’s College London, London, UK
| | - Abdullah Houssien
- Department of Inflammation Biology, Centre of Rheumatic Disease, King’s College London, London, UK
| | - Martin Stevens
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- MRC Versus Arthritis Centre for Musculoskeletal Health and Work, University of Southampton, Southampton, UK
| | - Mark D Russell
- Department of Inflammation Biology, Centre of Rheumatic Disease, King’s College London, London, UK
| | - Maryam Adas
- Department of Inflammation Biology, Centre of Rheumatic Disease, King’s College London, London, UK
- Department of Physiology, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | | | - Sam Norton
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Heidi Lempp
- Department of Inflammation Biology, Centre of Rheumatic Disease, King’s College London, London, UK
| | - Joanna M Ledingham
- Rheumatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - James B Galloway
- Department of Inflammation Biology, Centre of Rheumatic Disease, King’s College London, London, UK
| | - Karen Walker-Bone
- MRC Versus Arthritis Centre for Musculoskeletal Health and Work, University of Southampton, Southampton, UK
- Monash Centre for Occupational and Environmental Health, Monash University, Melbourne, Australia
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Lauper K, Kearsley-Fleet L, Galloway JB, Watson KD, Hyrich KL, Lunt M. Evaluation of serious infections, including Mycobacterium tuberculosis, during treatment with biologic disease-modifying anti-rheumatic drugs: does line of therapy matter? Rheumatology (Oxford) 2024; 63:1957-1964. [PMID: 37758229 PMCID: PMC11215981 DOI: 10.1093/rheumatology/kead515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/15/2023] [Accepted: 09/06/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVES This study aimed to evaluate if and how the incidence of serious infection (SI) and active tuberculosis (TB) differ among seven biologic DMARDs (bDMARDs) in patients with RA considering the line of therapy. METHODS Patients with RA from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis (BSRBR-RA) cohort who initiated etanercept, certolizumab, infliximab, adalimumab, abatacept, rituximab or tocilizumab from the first to fifth line of therapy were included. Follow-up extended up to 3 years. The primary outcome was SI and the secondary outcome was TB. Event rates were calculated and compared using Cox proportional hazards models, controlling for confounding with inverse probability of treatment weights. Comparisons were made overall and stratified by line of therapy. Sensitivity analysis was restricted to all treatment courses from 2009 (tocilizumab availability) until the end of the study (2018). RESULTS Among 33 897 treatment courses (62 513 patient-years) the incidence of SI was 4.4/100 patient-years (95% CI 4.2, 4.5). After adjustment, hazards ratios (HRs) of SI were slightly higher with adalimumab and infliximab compared with etanercept. However, no clear pattern was observed when stratifying by line of therapy in terms of incidence rate or HR. Sensitivity analyses showed similar HRs among these treatments. Regarding TB, all 49 cases occurred during the first three lines of treatment and rarely since 2009. CONCLUSION The risk of serious infections does not appear to be influenced by the line of therapy in patients with RA. However, the risk of TB seems to be more frequent during the initial lines of treatment or prior to 2009.
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Affiliation(s)
- Kim Lauper
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Division of Rheumatology, Geneva University Hospitals and Geneva Centre for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Lianne Kearsley-Fleet
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Kath D Watson
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - BSRBR-RA Contributors Group
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- National Institute of Health Research Manchester Biomedical Research Centre, Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Mark Lunt
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Takanashi S, Takeuchi T, Kaneko Y. Five-year follow-up of patients with difficult-to-treat rheumatoid arthritis. Rheumatology (Oxford) 2024:keae325. [PMID: 38851883 DOI: 10.1093/rheumatology/keae325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/09/2024] [Accepted: 05/27/2024] [Indexed: 06/10/2024] Open
Abstract
OBJECTIVES To elucidate the long-term outcomes of patients with difficult-to-treat rheumatoid arthritis (D2T RA). METHODS We collected data on the clinical course of patients who had been identified as D2T RA in 2018 until 2023. We stratified the patients according to outcomes at the last visit: resolved D2T RA, persistent D2T RA, and mortality. We compared their clinical characteristics and investigated the predictive factors for the resolution of D2T RA or mortality. Furthermore, we investigated the impact of the causes of D2T RA identified in 2018, multidrug resistance, comorbidities, and socioeconomic factors on outcomes in 2023. RESULTS Of 173 patients identified as D2T RA in 2018, 150 were included in the analysis. Among them, D2T RA was resolved in 67 (45%), 75 (50%) remained as D2T RA, and 8 (5%) died. Patients with resolved D2T RA were significantly younger at the latest visit (p= 0.02), had a higher proportion of treatment changes during five years (p= 0.002), and had a higher proportion of interleukin-6 receptor inhibitors use in 2023 (p= 0.04) than those in patients with persistent D2T RA or those who died. D2T RA resolved in 38% of patients with multidrug resistance, mainly with treatment changes. Rheumatic disease comorbidity index and glucocorticoid dose escalation were independent risk factors for mortality (odds ratio [OR], 3.50; p= 0.02 and OR, 31.9; p= 0.002, respectively). CONCLUSION Further modifications in RA treatment are useful for resolving D2T RA. Multiple comorbidities and glucocorticoid use are associated with mortality.
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Affiliation(s)
- Satoshi Takanashi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Saitama Medical University
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Pascual-Ramos V, Contreras-Yáñez I, Cuevas-Montoya M, Guaracha-Basañez GA, García-Alanis M, Rodríguez-Mayoral O, Chochinov HM. Factors Associated With Distress Related to Perceived Dignity in Patients With Rheumatic Diseases. J Clin Rheumatol 2024; 30:e115-e121. [PMID: 38595276 DOI: 10.1097/rhu.0000000000002083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND The loss of perceived dignity is an existential source of human suffering, described in patients with cancer and chronic diseases and hospitalized patients but rarely explored among patients with rheumatic diseases (RMDs). We recently observed that distress related to perceived dignity (DPD) was present in 26.9% of Mexican patients with different RMDs. The study aimed to investigate the factors associated with DPD. METHODS This cross-sectional study was performed between February and September 2022. Consecutive patients with RMDs completed patient-reported outcomes (to assess mental health, disease activity/severity, disability, fatigue, quality of life [QoL], satisfaction with medical care, and family function) and had a rheumatic evaluation to assess disease activity status and comorbidity. Sociodemographic variables and disease-related and treatment-related variables were retrieved with standardized formats. DPD was defined based on the Patient Dignity Inventory score. Multivariate regression analysis was used. RESULTS Four hundred patients were included and were representative of outpatients with RMDs, while 7.5% each were inpatients and patients from the emergency care unit. There were 107 patients (26.8%) with DPD. Past mental health-related comorbidity (Odds Ratio [OR]: 4.680 [95% Confidence Interval [CI]: 1.906-11.491]), the number of immunosuppressive drugs/patient (OR: 1.683 [95% CI: 1.015-2.791]), the physical health dimension score of the World Health Organization Quality of Life-Brief questionnaire (WHOQOL-BREF) (OR: 0.937 [95% CI: 0.907-0.967]), and the emotional health dimension score of the WHOQOL-BREF (OR: 0.895 [95% CI: 0.863-0.928]) were associated with DPD. CONCLUSIONS DPD was present in a substantial proportion of patients with RMDs and was associated with mental health-related comorbidity, disease activity/severity-related variables, and the patient QoL.
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Affiliation(s)
- Virginia Pascual-Ramos
- From the Department of Immunology and Rheumatology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Mexico City, Mexico
| | - Irazú Contreras-Yáñez
- From the Department of Immunology and Rheumatology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Mexico City, Mexico
| | - Maximiliano Cuevas-Montoya
- From the Department of Immunology and Rheumatology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Mexico City, Mexico
| | - Guillermo Arturo Guaracha-Basañez
- From the Department of Immunology and Rheumatology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Mexico City, Mexico
| | - Mario García-Alanis
- Department of Psychiatry. Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ, Mexico City, Mexico
| | | | - Harvey Max Chochinov
- Department of Neurology and Psychiatry, University of Manitoba, Cancer Care Manitoba, Winnipeg, Canada
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Bird A, Oakden-Rayner L, Smith LA, Zeng M, Ray S, Proudman S, Palmer LJ. Prognostic modeling in early rheumatoid arthritis: reconsidering the predictive role of disease activity scores. Clin Rheumatol 2024; 43:1503-1512. [PMID: 38536518 PMCID: PMC11018671 DOI: 10.1007/s10067-024-06946-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/23/2024] [Accepted: 03/20/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE In this prospective cohort study, we provide several prognostic models to predict functional status as measured by the modified Health Assessment Questionnaire (mHAQ). The early adoption of the treat-to-target strategy in this cohort offered a unique opportunity to identify predictive factors using longitudinal data across 20 years. METHODS A cohort of 397 patients with early RA was used to develop statistical models to predict mHAQ score measured at baseline, 12 months, and 18 months post diagnosis, as well as serially measured mHAQ. Demographic data, clinical measures, autoantibodies, medication use, comorbid conditions, and baseline mHAQ were considered as predictors. RESULTS The discriminative performance of models was comparable to previous work, with an area under the receiver operator curve ranging from 0.64 to 0.88. The most consistent predictive variable was baseline mHAQ. Patient-reported outcomes including early morning stiffness, tender joint count (TJC), fatigue, pain, and patient global assessment were positively predictive of a higher mHAQ at baseline and longitudinally, as was the physician global assessment and C-reactive protein. When considering future function, a higher TJC predicted persistent disability while a higher swollen joint count predicted functional improvements with treatment. CONCLUSION In our study of mHAQ prediction in RA patients receiving treat-to-target therapy, patient-reported outcomes were most consistently predictive of function. Patients with high disease activity due predominantly to tenderness scores rather than swelling may benefit from less aggressive treatment escalation and an emphasis on non-pharmacological therapies, allowing for a more personalized approach to treatment. Key Points • Long-term use of the treat-to-target strategy in this patient cohort offers a unique opportunity to develop prognostic models for functional outcomes using extensive longitudinal data. • Patient reported outcomes were more consistent predictors of function than traditional prognostic markers. • Tender joint count and swollen joint count had discordant relationships with future function, adding weight to the possibility that disease activity may better guide treatment when the components are considered separately.
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Affiliation(s)
- Alix Bird
- Australian Institute of Machine Learning, University of Adelaide, Corner Frome Road and North Terrace, Adelaide, SA, 5000, Australia.
- School of Public Health, The University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia.
| | - Lauren Oakden-Rayner
- Australian Institute of Machine Learning, University of Adelaide, Corner Frome Road and North Terrace, Adelaide, SA, 5000, Australia
- School of Public Health, The University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia
| | - Luke A Smith
- Australian Institute of Machine Learning, University of Adelaide, Corner Frome Road and North Terrace, Adelaide, SA, 5000, Australia
- School of Public Health, The University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia
| | - Minyan Zeng
- Australian Institute of Machine Learning, University of Adelaide, Corner Frome Road and North Terrace, Adelaide, SA, 5000, Australia
- School of Public Health, The University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia
| | - Shonket Ray
- Australian Institute of Machine Learning, University of Adelaide, Corner Frome Road and North Terrace, Adelaide, SA, 5000, Australia
- Artificial Intelligence and Machine Learning, GSK Plc, South San Francisco, CA, USA
| | - Susanna Proudman
- Department of Rheumatology, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | - Lyle J Palmer
- Australian Institute of Machine Learning, University of Adelaide, Corner Frome Road and North Terrace, Adelaide, SA, 5000, Australia
- School of Public Health, The University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia
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Biln NK, Guh D, Bansback N, Shojania K, Harrison M. The Association of Rheumatologist Supply and Multidisciplinary Care With Timely Patient Access to Rheumatologists: Evidence From British Columbia, Canada. Arthritis Care Res (Hoboken) 2024; 76:444-453. [PMID: 38018333 DOI: 10.1002/acr.25274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/25/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVE The objective was to understand how the expansion of rheumatology supply and the introduction of multidisciplinary care was associated with access to rheumatology services. METHODS We accessed Population Data BC, a longitudinal database with de-identified individual-level health data on all residents of British Columbia, Canada, to analyze physician visits and prescribing from 2010-2011 to 2019-2020. We calculated access as the time from referral to first rheumatologist visit and, for people with rheumatoid arthritis (RA), time to first disease-modifying antirheumatic drug (DMARD). Associations between lag time, patient characteristics, and system variables were explored using quantile regression. RESULTS Over the study period, there were 149,902 new rheumatologist visits, with 31% more visits in 2019-2020 than in 2010-2011. The proportion of first visits for patients with inflammatory arthritis increased from 28% to 51%. The median time from referral to first visit decreased by 22 days (35%) from 63 days (interquartile range 21-120 days) in 2010-2011. For people with RA, time from referral to DMARD decreased by 4 days (6%) to 62 days. Male sex, living in metropolitan areas, and having a rheumatologist who used a multidisciplinary care assessment code were associated with shorter times from referral to first DMARD. CONCLUSION Access to rheumatology care improved, and the increased proportion of patients with IA in the first visits case-mix indicates that rheumatologist supply and incentives for multidisciplinary care may have improved referral patterns. However, time to DMARDs for people with RA remained long, and we found signals of unequal access for female patients and people living outside of metropolitan areas.
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Affiliation(s)
- Norma K Biln
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Daphne Guh
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Nick Bansback
- University of British Columbia, St. Paul's Hospital, and Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Kam Shojania
- University of British Columbia and Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Mark Harrison
- University of British Columbia, St. Paul's Hospital, and Arthritis Research Canada, Vancouver, British Columbia, Canada
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Barber CEH, Lethebe BC, Szostakiwskyj JH, Barnabe C, Barber MRW, Katz S, England BR, Hazlewood GS. A population-based analysis of rheumatology care patterns for inflammatory arthritis during COVID-19 in Alberta, Canada. Semin Arthritis Rheum 2024; 65:152364. [PMID: 38237230 DOI: 10.1016/j.semarthrit.2024.152364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/19/2023] [Accepted: 01/03/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE The aim of the study was to understand the impact of the COVID-19 pandemic on inflammatory arthritis (IA) rheumatology care in Alberta, Canada. METHODS We used linked provincial health administrative datasets to establish an incident cohort of individuals with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and Ankylosing Spondylitis (AS) seen at least once by a rheumatologist. We examined incidence rates (IR) per 100,000 population, and patterns of follow-up care between 2011 and 2022. In a subset of individuals diagnosed five years prior to the pandemic, we report on those lost to follow-up during the pandemic, and those with virtual care visits followed by in-person visit within 30 days. Multivariable logistic regression was used to examine patient characteristics associated with these patterns of care. RESULTS The IR for RA in 2020 declined compared to previous years (44.6), but not for AS (9.2) or PsA (9.1). In 2021 IRs rose (RA 49.5; AS 11.8; PsA 11.8). Among those diagnosed within 5 years of the pandemic, 632 (6.0 %) were lost to follow-up, with characteristics of those lost to follow-up differing between IA types. 1444 individuals had at least one virtual visit followed within 30 days by an in-person follow-up. This was less common in males (OR 0.69-0.79) and more common for those with a higher frequency of physician visits prior to the pandemic (OR 1.27-1.32). CONCLUSION Impacts of patterns of care during the pandemic should be further explored for healthcare planning to uphold optimal care access and promote effective use of virtual care.
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Affiliation(s)
- Claire E H Barber
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Arthritis Research Canada, Vancouver, British Columbia, Canada.
| | - Brendan Cord Lethebe
- Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Cheryl Barnabe
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Megan R W Barber
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Steven Katz
- Department of Medicine, Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | - Bryant R England
- VA Nebraska-Western Iowa Health Care System & University of Nebraska Medical Center, Omaha, NE, USA
| | - Glen S Hazlewood
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Arthritis Research Canada, Vancouver, British Columbia, Canada
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11
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Vanderbleek JJ, Owensby JK, McAnnally A, England BR, Chen L, Curtis JR, Yun H. Classifying Multimorbidity Using Drug Concepts via the Rx-Risk Comorbidity Index: Methods and Comparative Cross-Sectional Study. Arthritis Care Res (Hoboken) 2024; 76:559-569. [PMID: 37986017 DOI: 10.1002/acr.25273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 06/26/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE The study objective was to update a method to identify comorbid conditions using only medication information in circumstances in which diagnosis codes may be undercaptured, such as in single-specialty electronic health records (EHRs), and to compare the distribution of comorbidities across Rx-Risk versus other traditional comorbidity indices. METHODS Using First Databank, RxNorm, and its web-based clients, RxNav and RxClass, we mapped Drug Concept Unique Identifiers (RxCUIs), National Drug Codes (NDCs), and Anatomical Therapeutic Chemical (ATC) codes to Rx-Risk, a medication-focused comorbidity index. In established rheumatoid arthritis (RA) and osteoarthritis (OA) cohorts within the Rheumatology Informatics System for Effectiveness registry, we then compared Rx-Risk with other comorbidity indices, including the Charlson Comorbidity Index, Rheumatic Disease Comorbidity Index (RDCI), and Elixhauser. RESULTS We identified 965 unique ingredient RxCUIs representing the 46 Rx-Risk comorbidity categories. After excluding dosage form and ingredient related RxCUIs, 80,911 unique associated RxCUIs were mapped to the index. Additionally, 187,024 unique NDCs and 354 ATC codes were obtained and mapped to the index categories. When compared to traditional comorbidity indices in the RA cohort, the median score for Rx-Risk (median 6.00 [25th percentile 2, 75th percentile 9]) was much greater than for Charlson (median 0 [25th percentile 0, 75th percentile 0]), RDCI (median 0 [25th percentile 0, 75th percentile 0]), and Elixhauser (median 1 [25th percentile 1, 75th percentile 1]). Analyses of the OA cohort yielded similar results. For patients with a Charlson score of 0 (85% of total), both the RDCI and Elixhauser were close to 1, but the Rx-Risk score ranged from 0 to 16 or more. CONCLUSION The misclassification and under-ascertainment of comorbidities in single-specialty EHRs can largely be overcome by using a medication-focused comorbidity index.
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Affiliation(s)
- Jared J Vanderbleek
- University of Alabama at Birmingham and University of Alabama at Birmingham Hospital
| | | | | | - Bryant R England
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha
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12
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Calvo-Gutiérrez J, López-Medina C, Otero-Varela L, Escudero-Contreras A, Ortega-Castro R, Ladehesa-Pineda L, Campos C, Bernabeu-Gonzalvez P, Pérez-Gómez A, García-Dorta A, Ruiz-Montesino D, Pombo-Suarez M, Ros-Vilamajo I, Sánchez-Alonso F, Castrejón I. Impact of multimorbidity on the first ts/bDMARD effectiveness and retention rate after two years of follow-up in patients with rheumatoid arthritis from the BIOBADASER registry. Arthritis Res Ther 2024; 26:57. [PMID: 38395899 PMCID: PMC10885598 DOI: 10.1186/s13075-024-03287-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Patients with Rheumatoid Arthritis (RA) have a higher prevalence of comorbidities compared to the general population. However, the implications of multimorbidity on therapeutic response and treatment retention remain unexplored. OBJECTIVES (a) To evaluate the impact of multimorbidity on the effectiveness of the first targeted synthetic or biologic disease-modifying antirheumatic drug (ts/bDMARD), in patients with RA after 2-year follow-up; (b) to investigate the influence of multimorbidity on treatment retention rate. METHODS Patients with RA from the BIOBADASER registry exposed to a first ts/bDMARDs were included. Patients were categorized based on multimorbidity status at baseline, defined as a Charlson Comorbidity index (CCI) score ≥ 3. A linear regression model, adjusted for sex and age, was employed to compare the absolute DAS28 score over time after ts/bDMARD initiation between the two groups. The Log-Rank test and Kaplan-Meier curve were used to compare the retention rates of the first ts/bDMARD between the groups. RESULTS A total of 1128 patients initiating ts/bDMARD were included, with 107 (9.3%) exhibiting multimorbidity. The linear regression model showed significantly higher DAS28 (beta coefficient 0.33, 95%CI:0.07-0.58) over a two-year period in patients with multimorbidity, even after adjusting for age and sex. Finally, no differences in the ts/bDMARD retention rate were found between groups (median 6.94-6.96 years in CCI < 3 vs. 5.68-5.62 in CCI ≥ 3; p = 0.610). CONCLUSIONS Multimorbidity in patients with RA was associated with greater DAS28 scores within the first two years after ts/bDMARD initiation, in comparison with patients without multimorbidity. A slightly shorter retention rate was found in patients with multimorbidity, although the difference was non-significant.
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Affiliation(s)
- Jerusalem Calvo-Gutiérrez
- Rehabilitation Department, Infanta Margarita University Hospital, Cabra, Cordoba, Spain
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Cordoba, Spain
| | - Clementina López-Medina
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Cordoba, Spain.
- Rheumatology Department, Reina Sofia University Hospital, Menendez Pidal Avenue, s/n. 14004, Cordoba, Spain.
- Medical and Surgical Sciences Department, University of Cordoba, Cordoba, Spain.
| | | | - Alejandro Escudero-Contreras
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Cordoba, Spain
- Rheumatology Department, Reina Sofia University Hospital, Menendez Pidal Avenue, s/n. 14004, Cordoba, Spain
- Medical and Surgical Sciences Department, University of Cordoba, Cordoba, Spain
| | - Rafaela Ortega-Castro
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Cordoba, Spain
- Rheumatology Department, Reina Sofia University Hospital, Menendez Pidal Avenue, s/n. 14004, Cordoba, Spain
- Medical and Surgical Sciences Department, University of Cordoba, Cordoba, Spain
| | - Lourdes Ladehesa-Pineda
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Cordoba, Spain
- Rheumatology Department, Reina Sofia University Hospital, Menendez Pidal Avenue, s/n. 14004, Cordoba, Spain
- Medical and Surgical Sciences Department, University of Cordoba, Cordoba, Spain
| | - Cristina Campos
- Rheumatology Department, Hospital General Universitario de Valencia, Valencia, Spain
| | | | - Ana Pérez-Gómez
- Rheumatology Department, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | - Alicia García-Dorta
- Rheumatology Department, Hospital Universitario de Canarias, Canarias, Spain
| | | | - Manuel Pombo-Suarez
- Rheumatology Department, Hospital Clínico Universitario de Santiago, A Coruña, Spain
| | | | | | - Isabel Castrejón
- Rheumatology Department, Gregorio Marañón University Hospital, Madrid, Spain
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13
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Bertsias A, Flouri ID, Repa A, Avgoustidis N, Kalogiannaki E, Pitsigavdaki S, Bertsias G, Sidiropoulos P. Patterns of comorbidities differentially affect long-term functional evolution and disease activity in patients with 'difficult to treat' rheumatoid arthritis. RMD Open 2024; 10:e003808. [PMID: 38242549 PMCID: PMC10806522 DOI: 10.1136/rmdopen-2023-003808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/04/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Characterisation of the long-term outcome of patients with 'difficult to treat' (D2T) rheumatoid arthritis and factors contributing to its evolution are unknown. Herein, we explored the heterogeneity and contributing factors of D2T long-term outcome. METHODS Patients included from a prospective single centre cohort study. The EULAR definition of D2T was applied. Longitudinal clustering of functional status (modified Health Assessment Questionnaire (mHAQ)) and disease activity (Disease Activity Score-28 (DAS28)) were assessed using latent-class trajectory analysis. Multiple linear mixed models were used to examine the impact of comorbidities and their clusters on the long-term outcome. RESULTS 251 out of 1264 patients (19.9%) were identified as D2T. Younger age, fibromyalgia, osteoarthritis, DAS28-erythrocyte sedimentation rate (ESR) at first biological or targeted synthetic disease-modifying antirheumatic drug (b/ts-DMARD) initiation and failure to reduce DAS28-ESR scores within the first 6 months of b/ts-DMARD therapy were significant predictors of patients becoming D2T. Long-term follow-up (total of 5872 person-years) revealed four groups of functional status evolution: 18.2% had stable, mildly compromised mHAQ (mean 0.41), 39.9% had gradual improvement (1.21-0.87) and two groups had either slow deterioration or stable significant functional impairment (HAQ>1). Similarly, four distinct groups of disease activity evolution were identified. Among the different clusters of comorbidities assessed, presence of 'mental-health and pain-related illnesses' or 'metabolic diseases' had significant contribution to mHAQ worsening (p<0.0001 for both) and DAS28 evolution (p<0.0001 and p=0.018, respectively). CONCLUSION D2T patients represent a heterogeneous group in terms of long-term disease course. Mental-health/pain-related illnesses as well as metabolic diseases contribute to long-term adverse outcomes and should be targeted in order to optimise the prognosis of this subset of rheumatoid arthritis.
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Affiliation(s)
- Antonios Bertsias
- Rheumatology, Clinical Immunology and Allergy Department, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Irini D Flouri
- Rheumatology, Clinical Immunology and Allergy Department, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Argyro Repa
- Rheumatology, Clinical Immunology and Allergy Department, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Nestor Avgoustidis
- Rheumatology, Clinical Immunology and Allergy Department, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Eleni Kalogiannaki
- Rheumatology, Clinical Immunology and Allergy Department, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Sofia Pitsigavdaki
- Rheumatology, Clinical Immunology and Allergy Department, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy Department, School of Medicine, University of Crete, Heraklion, Crete, Greece
- Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Crete, Greece
| | - Prodromos Sidiropoulos
- Rheumatology, Clinical Immunology and Allergy Department, School of Medicine, University of Crete, Heraklion, Crete, Greece
- Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Crete, Greece
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Tidblad L, Westerlind H, Delcoigne B, Askling J, Saevarsdottir S. Comorbidities and chance of remission in patients with early rheumatoid arthritis receiving methotrexate as first-line therapy: a Swedish observational nationwide study. RMD Open 2023; 9:e003714. [PMID: 38123483 DOI: 10.1136/rmdopen-2023-003714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVES This study aims to examine whether comorbidities affect the likelihood of reaching primary remission on methotrexate monotherapy as the first disease-modifying antirheumatic drug (DMARD) in early rheumatoid arthritis (RA). METHODS We used nationwide Swedish clinical and quality registers to collect RA disease activity measures and comorbidity data for patients diagnosed with RA 2007-2020 (n=11 001). The primary outcome was failure to reach 28-joint Disease Activity Score (DAS28) remission at 3 months. Secondary outcomes included Boolean, Simplified Disease Activity Index/Clinical Disease Activity Index remission, European Alliance of Associations for Rheumatology response and no swollen joint count at 3 and 6 months. For each comorbidity, and for combinations thereof, we calculated adjusted relative risks (RRs) of failure to reach remission, using modified Poisson regression. RESULTS In total, 53% (n=4019/7643) failed to reach DAS28 remission after 3 months of methotrexate monotherapy, ranging from 66% (n=25/38) among patients with chronic kidney disease to 48% (n=154/319) in patients with previous cancer. The risk of not reaching DAS28 remission at 3 months (RR adjusted for sex and age) was increased among patients with endocrine (RR 1.08, 95% CI 1.01 to 1.15), gastrointestinal (RR 1.16, 95% CI 1.03 to 1.30), infectious (RR 1.21, 95% CI 1.06 to 1.38), psychiatric (RR 1.24, 95% CI 1.15 to 1.35) and respiratory comorbidities (RR 1.16, 95% CI 1.01 to 1.32). Having three or more comorbidity categories was associated with a 27% higher risk of DAS28 remission failure at 3 months. A similar pattern was observed for the secondary outcomes. CONCLUSIONS Comorbidities decrease the chance of reaching remission on methotrexate as DMARD monotherapy in patients with early RA and are important to consider when assessing treatment outcomes.
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Affiliation(s)
- Liselotte Tidblad
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Helga Westerlind
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Bénédicte Delcoigne
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Saedis Saevarsdottir
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
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15
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Ozen G, Pedro S, Michaud K. Major adverse cardiovascular events and mortality with opioids versus NSAIDs initiation in patients with rheumatoid arthritis. Ann Rheum Dis 2023; 82:1487-1494. [PMID: 37460169 DOI: 10.1136/ard-2023-224339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/03/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Assess major adverse cardiovascular event (MACE) risk with opioids compared with non-steroidal anti-inflammatory drugs (NSAIDs) in patients with rheumatoid arthritis (RA) METHODS: We conducted a new-user active comparator cohort study among patients with RA within FORWARD, The National Databank for Rheumatic Diseases, with ≥1 year participation between 1998 and 2021. Each opioid initiator was matched to two NSAID initiators by propensity scores (PSs). Patients were followed until the occurrence of the composite endpoint of MACE (myocardial infarction, stroke, heart failure, cardiovascular disease (CVD) death, venous thromboembolism (VTE)) and all-cause mortality. The risk of outcomes was estimated using Cox proportional hazards with adjustment for PS weights and imbalanced covariables. RESULTS Among 6866 opioid initiators and 13 689 NSAID initiators, 212 vs 253 MACE (20.6/1000 person-years (PY) vs 18.9/1000 PY) and 144 vs 150 deaths (13.5/1000 PY vs 10.8/1000 PY) occurred, respectively. The risk of MACE with opioids was similar to NSAIDs (HR=1.02, 95% CI 0.85 to 1.22), whereas all-cause mortality with opioids was 33% higher than NSAIDs (HR=1.33, 95% CI 1.06 to 1.67) in PS-weighted models. Among the individual outcomes of MACE, VTE risk tended to be higher in opioid initiators than NSAID initiators (HR=1.41, 95% CI 0.84 to 2.35). Strong opioids had a higher risk for all-cause mortality and VTE than weak opioids compared with NSAIDs suggesting a dose-dependent association. CONCLUSION Opioids had similar MACE risk compared with NSAIDs in patients with RA with increased all-cause mortality and likely VTE, which suggests that opioids are not safer than NSAIDs, as clinicians have perceived.
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Affiliation(s)
- Gulsen Ozen
- Rheumatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sofia Pedro
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas, USA
| | - Kaleb Michaud
- Rheumatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas, USA
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16
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Faz-Munoz D, Martín-Nares E, Hernández-Delgado A, Hernández-Molina G. Comorbidities and causes of hospitalizations in a cohort of IgG4-related disease patients from a single center. Int J Rheum Dis 2023; 26:2351-2354. [PMID: 37401823 DOI: 10.1111/1756-185x.14802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 07/05/2023]
Affiliation(s)
- David Faz-Munoz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Eduardo Martín-Nares
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Alejandra Hernández-Delgado
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gabriela Hernández-Molina
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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17
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Rogers B, Famenini S, Perin J, Danila MI, Wipfler K, Michaud K, McMahan ZH. Clinical Features Associated With Rate of Fractures in Patients With Systemic Sclerosis: A US Cohort Study. Arthritis Care Res (Hoboken) 2023; 75:2379-2388. [PMID: 37093022 PMCID: PMC10836612 DOI: 10.1002/acr.25137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 03/29/2023] [Accepted: 04/18/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE Systemic sclerosis (SSc) is associated with several specific risk factors for fracture due to the complications of the disease and related medications. The present study was undertaken to examine the relationship between SSc-associated clinical features and fracture rate in a large US cohort. METHODS Participants with SSc in FORWARD, The National Databank for Rheumatic Diseases, were included (1998-2019). Age- and sex-matched individuals with osteoarthritis (OA) from the same database were included as comparators. The primary end point was self-reported major osteoporotic fracture. Cox proportional hazards models were used to study the associations between risk factors and fractures. RESULTS The study included 922 individuals (SSc patients, n = 154; OA patients, n = 768). Eighty-seven percent were female, with a mean age of 57.8 years. Fifty-one patients developed at least 1 fracture during a median of 4.2 years (0.5-22.0 years) of follow-up. Patients with SSc had more frequent fractures compared to OA comparators (hazard ratio [HR] 2.38 [95% confidence interval (95% CI) 1.47-3.83]). Among patients with SSc, a higher Rheumatic Disease Comorbidity Index score (HR 1.45 [95% CI 1.20-1.75]) and a higher Health Assessment Questionnaire disability index score (HR 3.83 [95% CI 2.12-6.93]) were associated with more fractures. Diabetes mellitus (HR 5.89 [95% CI 2.51-13.82]) and renal disease (HR 2.43 [95% CI 1.10-5.37]) were independently associated with fracture among SSc patients relative to SSc patients without these comorbidities. CONCLUSION Our findings highlight factors associated with fracture among patients with SSc. Disability as measured by the HAQ DI is a particularly strong indicator of fracture rate in SSc. Improving SSc patients' functional status, where possible, may lead to better long-term outcomes.
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Affiliation(s)
| | | | - Jamie Perin
- Johns Hopkins University, Baltimore, Maryland
| | - Maria I Danila
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham
| | - Kristin Wipfler
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | - Kaleb Michaud
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas, and University of Nebraska Medical Center, Omaha
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18
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Radner H. Viewpoint: how to measure comorbidities in patients with rheumatoid arthritis - clinical and academic value. Rheumatology (Oxford) 2023; 62:SI282-SI285. [PMID: 37871917 PMCID: PMC10650270 DOI: 10.1093/rheumatology/kead436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/08/2023] [Indexed: 10/25/2023] Open
Abstract
Given the high prevalence and the enormous impact on key outcomes, comorbidities are important to consider, especially in patients with RA. Comorbidity indices are tools to quantify the impact of the overall burden of coexisting diseases on a specific outcome of interest. Until now, no gold standard exists on how to measure comorbidities. A large variety of indices have been developed using different settings and therefore leading to conceptual differences. Choosing the right tool clearly depends on the intention (clinical or research purpose) and the specific research question. The current article will address the purpose and challenge of measuring comorbidities in RA patients.
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Affiliation(s)
- Helga Radner
- Division of Rheumatology, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
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19
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Surandran S, Ahmed S, Walton T, Nikiphorou E, Dey M. Multimorbidity in rheumatoid arthritis: common mechanistic links and impact and challenges in routine clinical practice. Rheumatology (Oxford) 2023; 62:SI260-SI270. [PMID: 37871920 DOI: 10.1093/rheumatology/kead489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/13/2023] [Indexed: 10/25/2023] Open
Abstract
Early identification and management of multimorbidity in patients with rheumatic and musculoskeletal diseases (RMDs), such as RA, is an integral, but often neglected, aspect of care. The prevalence and incidence of conditions such as osteoporosis, cardiovascular disease, pulmonary disease and malignancies, often co-existing with RA, continues to have significant implications for the management of this patient group. Multimorbidity in RMDs can be associated with inflammatory disease activity and target organ damage. Lifestyle factors, such as smoking and inactivity, further contribute to the burden of disease. Inflammation is the underlying factor, not just in RA but also many comorbidities. The current framework of a treat-to-target approach focuses on achieving early remission and inflammatory activity suppression. We describe how the comorbidity burden in people with RMDs impacts on disease outcome and treatment response. The importance of addressing comorbidity at an early stage and adopting a patient centred approach is critical in modern practice.
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Affiliation(s)
| | - Saad Ahmed
- Department of Rheumatology, Colchester General Hospital, Colchester, UK
| | - Tom Walton
- Department of Rheumatology, Colchester General Hospital, Colchester, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College Hospital, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Rheumatology, Countless of Chester Hospital NHS Foundation Trust, Chester, UK
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20
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England BR. The Multimorbidity Web in rheumatoid arthritis. Rheumatology (Oxford) 2023; 62:SI242-SI251. [PMID: 37871922 DOI: 10.1093/rheumatology/kead246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/17/2023] [Indexed: 10/25/2023] Open
Abstract
Multimorbidity, the presence of multiple chronic conditions, is highly prevalent in people with RA. An essential characteristic of multimorbidity is the interrelatedness of the different conditions that may develop in a multimorbid person. Recent studies have begun to identify and describe the Multimorbidity Web by elucidating unique multimorbidity patterns in people with RA. The primary multimorbidity patterns in this web are cardiopulmonary, cardiometabolic, and mental health and chronic pain multimorbidity. Once caught in the Multimorbidity Web, the consequences can be devastating, with reduced quality of life, physical function, survival, and treatment responses observed in multimorbid RA persons. The development of effective management and preventive approaches for multimorbidity in people with RA is in its infancy. Determining how best to assess, intervene, and prevent multimorbidity in RA is crucial to optimize long-term outcomes in people with RA.
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Affiliation(s)
- Bryant R England
- Division of Rheumatology & Immunology, Department of Internal Medicine, VA Nebraska-Western Iowa Health Care System, University of Nebraska Medical Center, Omaha, NE, USA
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Dolomisiewicz A, Ali H, Roul P, Yang Y, Cannon GW, Sauer B, Baker JF, Mikuls TR, Michaud K, England BR. Updating and Validating the Rheumatic Disease Comorbidity Index to Incorporate ICD-10-CM Diagnostic Codes. Arthritis Care Res (Hoboken) 2023; 75:2199-2206. [PMID: 36951260 PMCID: PMC10517070 DOI: 10.1002/acr.25116] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/10/2023] [Accepted: 03/21/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVE To update and validate the Rheumatic Disease Comorbidity Index (RDCI) utilizing International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. METHODS We defined ICD-9-CM (n = 1,068) and ICD-10-CM (n = 1,425) era cohorts (n = 862 in both) spanning the ICD-9-CM to ICD-10-CM transition in a multicenter, prospective rheumatoid arthritis registry. Information regarding comorbidities was collected from linked administrative data over 2-year assessment periods. An ICD-10-CM code list was generated from crosswalks and clinical expertise. ICD-9- and ICD-10-derived RDCI scores were compared using intraclass correlation coefficients (ICC). The predictive ability of the RDCI for functional status and death during follow-up was assessed using multivariable regression models and goodness-of-fit statistics (Akaike's information criterion [AIC] and quasi information criterion [QIC]) in both cohorts. RESULTS Mean ± SD RDCI scores were 2.93 ± 1.72 in the ICD-9-CM cohort and 2.92 ± 1.74 in the ICD-10-CM cohort. RDCI scores had substantial agreement in individuals who were in both cohorts (ICC 0.71 [95% confidence interval 0.68-0.74]). Prevalence of comorbidities was similar between cohorts with absolute differences <6%. Higher RDCI scores were associated with a greater risk of death and poorer functional status during follow-up in both cohorts. Similarly, in both cohorts, models including the RDCI score had the lowest QIC (functional status) and AIC (death) values, indicating better model performance. CONCLUSION The newly proposed ICD-10-CM codes for the RDCI-generated comparable RDCI scores to those derived from ICD-9-CM codes and are highly predictive of functional status and death. The proposed ICD-10-CM codes for the RDCI can be used in rheumatic disease outcomes research spanning the ICD-10-CM era.
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Affiliation(s)
- Anthony Dolomisiewicz
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE
- Department of Internal Medicine, Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Hanifah Ali
- Department of Internal Medicine, Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Punyasha Roul
- Department of Internal Medicine, Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Yangyuna Yang
- Department of Internal Medicine, Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE
| | | | - Brian Sauer
- Salt Lake City VA & University of Utah, Salt Lake City, UT
| | - Joshua F. Baker
- Corporal Michael J. Crescenz VA & University of Pennsylvania, Philadelphia, PA
| | - Ted R. Mikuls
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE
- Department of Internal Medicine, Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Kaleb Michaud
- Department of Internal Medicine, Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE
- FORWARD, The National Data Bank for Rheumatic Diseases, Wichita, KS
| | - Bryant R. England
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE
- Department of Internal Medicine, Division of Rheumatology & Immunology, University of Nebraska Medical Center, Omaha, NE
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Adas MA, Russell MD, Cook E, Alveyn E, Hannah J, Balachandran S, Oyebanjo S, Amlani-Hatcher P, Ledingham J, Norton S, Galloway JB. COVID-19 admissions and mortality in patients with early inflammatory arthritis: results from a UK national cohort. Rheumatology (Oxford) 2023; 62:2979-2988. [PMID: 36645234 PMCID: PMC10473194 DOI: 10.1093/rheumatology/kead018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/24/2022] [Accepted: 01/03/2023] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To describe the risks and predictors of coronavirus disease 2019 (COVID-19) hospitalization and mortality among patients with early inflammatory arthritis (EIA), recruited to the National Early Inflammatory Arthritis Audit (NEIAA). METHODS NEIAA is an observational cohort. We included adults with EIA from Feb 2020 to May 2021. Outcomes of interest were hospitalization and death due to COVID-19, using NHS Digital linkage. Cox proportional hazards were used to calculate hazard ratios for outcomes according to initial treatment strategy, with adjustment for confounders. RESULTS From 14 127 patients with EIA, there were 143 hospitalizations and 47 deaths due to COVID-19, with incidence rates per 100 person-years of 0.93 (95% CI 0.79, 1.10) for hospitalization and 0.30 (95% CI 0.23, 0.40) for death. Increasing age, male gender, comorbidities and ex-smoking were associated with increased risk of worse COVID-19 outcomes. Higher baseline DAS28 was not associated with COVID-19 admissions [confounder adjusted hazard ratio (aHR) 1.10; 95% CI 0.97, 1.24] or mortality (aHR 1.11; 95% CI 0.90, 1.37). Seropositivity was not associated with either outcome. Higher symptom burden on patient-reported measures predicted worse COVID-19 outcomes. In unadjusted models, CS associated with COVID-19 death (HR 2.29; 95% CI 1.02, 5.13), and SSZ monotherapy associated with COVID-19 admission (HR 1.92; 95% CI 1.04, 3.56). In adjusted models, associations for CS and SSZ were not statistically significant. CONCLUSION Patient characteristics have stronger associations with COVID-19 than the initial treatment strategy in patients with EIA. An important limitation is that we have not looked at treatment changes over time.
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Affiliation(s)
- Maryam A Adas
- Centre for Rheumatic Disease, King’s College London, London, UK
| | - Mark D Russell
- Centre for Rheumatic Disease, King’s College London, London, UK
| | - Emma Cook
- Centre for Rheumatic Disease, King’s College London, London, UK
| | - Edward Alveyn
- Centre for Rheumatic Disease, King’s College London, London, UK
| | - Jennifer Hannah
- Centre for Rheumatic Disease, King’s College London, London, UK
| | | | | | | | - Joanna Ledingham
- Rheumatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Sam Norton
- Centre for Rheumatic Disease, King’s College London, London, UK
- Psychology Department, Institute for Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
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Brown T, Hammond A, Ching A, Parker J. Work limitations and associated factors in rheumatoid arthritis, axial spondyloarthritis, osteoarthritis and fibromyalgia. Musculoskeletal Care 2023; 21:827-844. [PMID: 36975543 DOI: 10.1002/msc.1760] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Rheumatic and musculoskeletal diseases (RMD) impact on work participation. The aims of this study were to: examine work limitations of working people with: rheumatoid arthritis, axial spondyloarthritis (axSpA), osteoarthritis, or fibromyalgia using the Workplace Activity Limitations Scale (WALS, a measure of presenteeism); and identify personal, functioning and disability, and work contextual factors associated with presenteeism. METHODS Secondary analysis was conducted of a cross-sectional survey including work outcome measures (WORK-PROM study). A literature review identified variables (coded to ICF) to include in multivariable regressions examining factors associated with presenteeism. RESULTS Moderate to high WALS scores were identified in: 93.60% with FM; 69.90% OA; 65.20% RA; and 46.80% axSpA (n = 822). Similarities in work limitations were noted across conditions, although some more problematic in specific RMD. Participants received help with about a quarter of activities (27%RA; 25%FM; 23%OA; 17%axSpA) and work adaptations for less than a fifth causing difficulty (18%FM; 14%RA; 14%OA; 9%axSpA). Literature review identified 33 variables in the WORK-PROM dataset to include in multivariable regressions. Factors associated with higher WALS scores were worse: functional limitations, job strain, pain, difficulties with mental-interpersonal job demands, perceived health status, work-life balance, greater need for work accommodations and lack of perceived work support. DISCUSSION This study extends understanding of work limitations of working people with these four RMD, the extent of help and adaptations received, need for more work accommodation support, and focus on work support, work rehabilitation, and healthy workplace practices to help keep people working.
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Affiliation(s)
- Tamara Brown
- Centre for Human Movement and Rehabilitation Research, School of Health and Society, University of Salford, Salford, Greater Manchester, UK
| | - Alison Hammond
- Centre for Human Movement and Rehabilitation Research, School of Health and Society, University of Salford, Salford, Greater Manchester, UK
| | - Angela Ching
- Centre for Human Movement and Rehabilitation Research, School of Health and Society, University of Salford, Salford, Greater Manchester, UK
- King's Clinical Trials Unit, Institute of Psychiatry, Kings College London, London, UK
| | - Jennifer Parker
- Centre for Human Movement and Rehabilitation Research, School of Health and Society, University of Salford, Salford, Greater Manchester, UK
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Yates M, Bechman K, Adas MA, Wright H, Russell M, Nagra D, Clarke B, Ledingham J, Norton S, Galloway J. Online Patient-Reported Outcome Measure Engagement Is Dependent on Demographics and Locality: Findings From an Observational Cohort. J Rheumatol 2023; 50:1178-1184. [PMID: 37188382 DOI: 10.3899/jrheum.2021-1410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Online patient-reported outcome measures (PROMs) enable remote collection of perceptions of health status, function, and well-being. We aimed to explore patterns of PROM completion in patients with early inflammatory arthritis (EIA) recruited to the National Early Inflammatory Arthritis Audit (NEIAA). METHODS NEIAA is an observational cohort study design; we included adults from this cohort with a new diagnosis of EIA from May 2018 to March 2020. The primary outcome was PROM completion at baseline, 3 months, and 12 months. Mixed effects logistic regression and spatial regression models were used to identify associations between demographics (age, gender, ethnicity, deprivation, smoking, and comorbidity), clinical commissioning groups, and PROM completion. RESULTS Eleven thousand nine hundred eighty-six patients with EIA were included, of whom 5331 (44.5%) completed at least 1 PROM. Patients from ethnic minority backgrounds were less likely to return a PROM (adjusted odds ratio [aOR] 0.57, 95% CI 0.48-0.66). Greater deprivation (aOR 0.73, 95% CI 0.64-0.83), male gender (aOR 0.86, 95% CI 0.78-0.94), higher comorbidity burden (aOR 0.95, 95% CI 0.91-0.99), and current smoker status (aOR 0.73, 95% CI 0.64-0.82) also reduced odds of PROM completion. Spatial analysis identified 2 regions with high (North of England) and low (Southeast of England) PROM completion. CONCLUSION We define key patient characteristics (including ethnicity) that influence PROM engagement using a national clinical audit. We observed an association between locality and PROM completion, with varying response rates across regions of England. Completion rates could benefit from targeted education for these groups.
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Affiliation(s)
- Mark Yates
- M. Yates, PhD, K. Bechman, PhD, M. Russell, MB BChir, D. Nagra, MBBS, B. Clarke, MBBS, S. Norton, PhD, J. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK
| | - Katie Bechman
- M. Yates, PhD, K. Bechman, PhD, M. Russell, MB BChir, D. Nagra, MBBS, B. Clarke, MBBS, S. Norton, PhD, J. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK
| | - Maryam A Adas
- M.A. Adas, MSc, Centre for Rheumatic Disease, King's College London, London, UK, and Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Hannah Wright
- H. Wright, MSc, Healthcare Quality Improvement Partnership, London, UK
| | - Mark Russell
- M. Yates, PhD, K. Bechman, PhD, M. Russell, MB BChir, D. Nagra, MBBS, B. Clarke, MBBS, S. Norton, PhD, J. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK
| | - Deepak Nagra
- M. Yates, PhD, K. Bechman, PhD, M. Russell, MB BChir, D. Nagra, MBBS, B. Clarke, MBBS, S. Norton, PhD, J. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK
| | - Ben Clarke
- M. Yates, PhD, K. Bechman, PhD, M. Russell, MB BChir, D. Nagra, MBBS, B. Clarke, MBBS, S. Norton, PhD, J. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK
| | - Joanna Ledingham
- J. Ledingham, PhD, Portsmouth Hospitals University NHS Trust - Rheumatology Portsmouth, Portsmouth, UK
| | - Sam Norton
- M. Yates, PhD, K. Bechman, PhD, M. Russell, MB BChir, D. Nagra, MBBS, B. Clarke, MBBS, S. Norton, PhD, J. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK
| | - James Galloway
- M. Yates, PhD, K. Bechman, PhD, M. Russell, MB BChir, D. Nagra, MBBS, B. Clarke, MBBS, S. Norton, PhD, J. Galloway, PhD, Centre for Rheumatic Diseases, King's College London, London, UK;
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Pascual-Ramos V, Contreras-Yáñez I, Cuevas-Montoya M, Guaracha-Basáñez GA, García-Alanís CM, Rodríguez-Mayoral O, Chochinov HM. Perceived dignity is an unrecognized source of emotional distress in patients with rheumatic diseases: Results from the validation of the Mexican version of the Patient Dignity Inventory. PLoS One 2023; 18:e0289315. [PMID: 37540659 PMCID: PMC10403073 DOI: 10.1371/journal.pone.0289315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/17/2023] [Indexed: 08/06/2023] Open
Abstract
INTRODUCTION Dignity has rarely been explored in patients with rheumatic diseases (RMDs), which contrasts with patients´ observations that dignity is a relevant area for research focus. The study's primary objective was to adapt and validate the Mexican version of the Patient Dignity Inventory (PDI-Mx) in patients with RMDs, and to estimate the proportion of patients with distress related to perceived dignity (DPD) assessed with the PDI-Mx. METHODS This cross-sectional study was developed in 2 phases. Phase 1 consisted of pilot testing and questionnaire feasibility (n = 50 patients), PDI-Mx content validity (experts' agreement), construct validity (exploratory factor analysis), discriminant validity (Heterotrait-Monotrait correlations' rate [HTMT]), criterion validity (Spearman correlations) and PDI-Mx reliability with internal consistency (Cronbach's alpha) and test-retest (intra-class correlation coefficients [ICC]) in 220 additional outpatients (among whom 30 underwent test-retest). Phase 2 consisted of quantifying DPD (PDI-Mx cut-off ≥54.4) in 290 outpatients with RMDs. RESULTS Overall, patients were representative of typical outpatients with RMDs from a National tertiary care level center. The 25-item PDI-Mx was found feasible, valid (experts' agreement ≥82%; a 4-factor structure accounted for 68.7% of the total variance; HTMT = 0.608; the strength of the correlations was moderate to high between the PDI-Mx, the Depression, Anxiety, and Stress scale dimensions scores, and the Health Assessment Questionnaire Disability Index score) and reliable (Cronbach's ɑ = 0.962, ICC = 0.939 [95%CI = 0.913-0.961]). DPD was present in 78 patients (26.9%). CONCLUSIONS The PDI-Mx questionnaire showed good psychometric properties for assessing DPD in our population. Perceived dignity in patients with RMDs might be an unrecognized source of emotional distress.
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Affiliation(s)
- Virginia Pascual-Ramos
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Mexico City, Mexico
| | - Irazú Contreras-Yáñez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Mexico City, Mexico
| | - Maximiliano Cuevas-Montoya
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Mexico City, Mexico
| | - Guillermo A Guaracha-Basáñez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ), Mexico City, Mexico
| | - Cesar Mario García-Alanís
- Department of Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán (INCMyN-SZ, Mexico City, Mexico
| | | | - Harvey Max Chochinov
- Department of Psychiatry, University of Manitoba, Cancer Care Manitoba, Winnipeg, Canada
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Curtis JR, Yun H, Chen L, Ford SS, van Hoogstraten H, Fiore S, Ford K, Praestgaard A, Rehberg M, Choy E. Real-World Sarilumab Use and Rule Testing to Predict Treatment Response in Patients with Rheumatoid Arthritis: Findings from the RISE Registry. Rheumatol Ther 2023; 10:1055-1072. [PMID: 37349636 PMCID: PMC10326227 DOI: 10.1007/s40744-023-00568-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/30/2023] [Indexed: 06/24/2023] Open
Abstract
INTRODUCTION Clinical trial findings may not be generalizable to routine practice. This study evaluated sarilumab effectiveness in patients with rheumatoid arthritis (RA) and tested the real-world applicability of a response prediction rule, derived from trial data using machine learning (based on C-reactive protein [CRP] > 12.3 mg/l and seropositivity [anticyclic citrullinated peptide antibodies, ACPA +]). METHODS Sarilumab initiators from the ACR-RISE Registry, with ≥ 1 prescription on/after its FDA approval (2017-2020), were divided into three cohorts based on progressively restrictive criteria: Cohort A (had active disease), Cohort B (met eligibility criteria of a phase 3 trial in RA patients with inadequate response/intolerance to tumor necrosis factor inhibitors [TNFi]), and Cohort C (characteristics matched to the phase 3 trial baseline). Mean changes in Clinical Disease Activity Index (CDAI) and Routine Assessment of Patient Index Data 3 (RAPID3) were evaluated at 6 and 12 months. In a separate cohort, predictive rule was tested based on CRP levels and seropositive status (ACPA and/or rheumatoid factor); patients were categorized into rule-positive (seropositive with CRP > 12.3 mg/l) and rule-negative groups to compare the odds of achieving CDAI low disease activity (LDA)/remission and minimal clinically important difference (MCID) over 24 weeks. RESULTS Among sarilumab initiators (N = 2949), treatment effectiveness was noted across cohorts, with greater improvement noted for Cohort C at 6 and 12 months. Among the predictive rule cohort (N = 205), rule-positive (vs. rule-negative) patients were more likely to reach LDA (odds ratio: 1.5 [0.7, 3.2]) and MCID (1.1 [0.5, 2.4]). Sensitivity analyses (CRP > 5 mg/l) showed better response to sarilumab in rule-positive patients. CONCLUSIONS In real-world setting, sarilumab demonstrated treatment effectiveness, with greater improvements in the most selective population, mirroring phase 3 TNFi-refractory and rule-positive RA patients. Seropositivity appeared a stronger driver for treatment response than CRP, although optimization of the rule in routine practice requires further data.
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Affiliation(s)
- Jeffrey R Curtis
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA.
| | - Huifeng Yun
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - Lang Chen
- University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | | | | | | | | | | | | | - Ernest Choy
- CREATE Centre, Cardiff University, Cardiff, UK
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Johnson TM, Yang Y, Roul P, Sauer BC, Cannon GW, Kunkel G, Michaud K, Baker JF, Mikuls TR, England BR. A Narrowing Mortality Gap: Temporal Trends of Cause-Specific Mortality in a National Matched Cohort Study in US Veterans With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2023; 75:1648-1658. [PMID: 36331101 PMCID: PMC10275614 DOI: 10.1002/acr.25053] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/17/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine temporal trends in all-cause and cause-specific mortality in patients with rheumatoid arthritis (RA) in the Veterans Health Administration (VHA). METHODS We conducted a matched cohort study in the VHA from January 1, 2000 to December 31, 2017. Incident RA patients were matched up to 1:10 on age, sex, and VHA enrollment year to non-RA patients, then followed until death or end of study period. Cause of death was obtained from the National Death Index. Multivariable Cox regression models stratified by RA diagnosis years were used to examine trends in RA-related risk of all-cause and cause-specific mortality. RESULTS Among 29,779 incident RA patients (matched to 245,226 non-RA patients), 9,565 deaths occurred. RA patients were at increased risk of all-cause (adjusted hazard ratio [HRadj ] 1.23 [95% confidence interval (95% CI) 1.20-1.26]), cardiovascular (HRadj 1.19 [95% CI 1.14-1.23]), cancer (HRadj 1.19 [95% CI 1.14-1.24]), respiratory (HRadj 1.46 [95% CI 1.38-1.55]), and infection-related mortality (HRadj 1.59 [95% CI 1.41-1.80]). Interstitial lung disease was the cause of death most strongly associated with RA (HRadj 3.39 [95% CI 2.88-3.99]). Nearly 70% of excess deaths in RA were attributable to cardiopulmonary disease. All-cause mortality risk related to RA was lower among those diagnosed during 2012-2017 (HRadj 1.10 [95% CI 1.05-1.15]) compared to 2000-2005 (HRadj 1.31 [95% CI 1.26-1.36]), but still higher than for non-RA controls (P < 0.001). Cause-specific mortality trends were similar. CONCLUSION Excess RA-related mortality was driven by cardiovascular, cancer, respiratory, and infectious causes, particularly cardiopulmonary diseases. Although our findings support that RA-related mortality risk is decreasing over time, a mortality gap remains for all-cause and cause-specific mortality in RA.
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Affiliation(s)
- Tate M Johnson
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | | | | | - Brian C Sauer
- Salt Lake City VA Medical Center and University of Utah, Salt Lake City
| | - Grant W Cannon
- Salt Lake City VA Medical Center and University of Utah, Salt Lake City
| | - Gary Kunkel
- Salt Lake City VA Medical Center and University of Utah, Salt Lake City
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and FORWARD, the National Data Bank for Rheumatic Diseases, Wichita, Kansas
| | - Joshua F Baker
- Corporal Michael J. Crescenz VA Medical Center and University of Pennsylvania, Philadelphia
| | - Ted R Mikuls
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | - Bryant R England
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
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Dowell S, Swearingen CJ, Pedra‐Nobre M, Wollaston D, Najmey S, Elliott CL, Ford TL, North H, Dore R, Dolatabadi S, Ramanujam T, Kennedy S, Ott S, Jileaeva I, Richardson A, Wright G, Kerr GS. Associations of Cost Sharing With Rheumatoid Arthritis Disease Burden. ACR Open Rheumatol 2023; 5:381-387. [PMID: 37334885 PMCID: PMC10425581 DOI: 10.1002/acr2.11575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 05/09/2023] [Accepted: 05/16/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVE To evaluate the regional variation of cost sharing and associations with rheumatoid arthritis (RA) disease burden in the US. METHODS Patients with RA from rheumatology practices in Northeast, South, and West US regions were evaluated. Sociodemographics, RA disease status, and comorbidities were collected, and Rheumatic Disease Comorbidity Index (RDCI) score was calculated. Primary insurance types and copay for office visits (OVs) and medications were documented. Univariable pairwise differences between regions were conducted, and multivariable regression models were estimated to evaluate associations of RDCI with insurance, geographical region, and race. RESULTS In a cohort of 402 predominantly female, White patients with RA, most received government versus private sponsored primary insurance (40% vs. 27.9%). Disease activity and RDCI were highest for patients in the South region, where copays for OVs were more frequently more than $25. Copays for OVs and medications were less than $10 in 45% and 31.8% of observations, respectively, and more prevalent in the Northeast and West patient subsets than in the South subset. Overall, RDCI score was significantly higher for OV copays less than $10 as well as for medication copays less than $25, both independent of region or race. Additionally, RDCI was significantly lower for privately insured than Medicare individuals (RDCI -0.78, 95% CI [-0.41 to -1.15], P < 0.001) and Medicaid (RDCI -0.83, 95% CI [-0.13 to -1.54], P = 0.020), independent of region and race. CONCLUSION Cost sharing may not facilitate optimum care for patients with RA, especially in the Southern regions. More support may be required of government insurance plans to accommodate patients with RA with a high disease burden.
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Affiliation(s)
| | | | | | | | | | | | | | - Heather North
- Pardee University of North Carolina Health CareHendersonville
| | - Robin Dore
- David Geffen School of MedicineLos AngelesCalifornia
| | | | | | | | - Stephanie Ott
- Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio and Fairfield Medical CenterLancasterOhio
| | | | | | - Grace Wright
- Association of Women in RheumatologyFayettevilleNorth Carolina
| | - Gail S. Kerr
- Washington DC Veterans Affairs Medical Center, Georgetown University Hospital, and Howard University HospitalWashingtonDC
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Johnson TM, Mahabir CA, Yang Y, Roul P, Goldsweig AM, Binstadt BA, Baker JF, Sauer BC, Cannon GW, Mikuls TR, England BR. Aortic Stenosis Risk in Rheumatoid Arthritis. JAMA Intern Med 2023; 183:2807944. [PMID: 37523173 PMCID: PMC10391353 DOI: 10.1001/jamainternmed.2023.3087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/20/2023] [Indexed: 08/01/2023]
Abstract
Importance Although an increased risk of ischemic cardiovascular disease has been associated with rheumatoid arthritis (RA), the risk of aortic stenosis (AS) is unknown. Objective To examine the risk of incident AS, aortic valve intervention, AS-related death, and risk factors for AS development in patients with RA. Design, Setting, and Participants This cohort study linked data from the Veterans Health Administration (VHA) and Centers for Medicare & Medicaid Services from 2000 to 2019. Patients with RA were matched by age, sex, and VHA enrollment year with up to 10 patients without RA. The cohort was followed until incident AS, aortic valve intervention, or death. Data were analyzed from August 23, 2022, to March 3, 2023. Exposures the primary exposure was the presence of RA, defined using validated RA algorithms. Main Outcomes and Measures Aortic stenosis was defined as a composite of inpatient or outpatient diagnoses, surgical or transcatheter aortic valve replacement, or AS-related death using diagnostic and procedural codes. Risk of AS development was assessed with multivariable Cox proportional hazards models adjusted for race, ethnicity, smoking status, body mass index, rurality, comorbidities, and health care use. Results The cohort included 73 070 patients with RA (64 008 [87.6%] males; mean [SD] age, 63.0 [11.9] years) matched with 639 268 patients without RA (554 182 [86.7%] males; mean [SD] age, 61.9 [11.7] years) and 16 109 composite AS outcomes that occurred over 6 223 150 person-years. The AS incidence rate was 3.97 (95% CI, 3.81-4.13) per 1000 person-years in patients with RA and 2.45 (95% CI, 2.41-2.49) per 1000 person-years in the control patients (absolute difference, 1.52 per 1000 person-years). Rheumatoid arthritis was associated with an increased risk of composite AS (adjusted hazard ratio [AHR], 1.48; 95% CI, 1.41-1.55), aortic valve intervention (AHR, 1.34; 95% CI, 1.22-1.48), and AS-related death (AHR, 1.26; 95% CI, 1.04-1.54). Conclusions and Relevance In this cohort study, RA was associated with a higher risk of developing AS and the subsequent risks of undergoing aortic valve intervention and suffering from AS-related death. Future studies are needed to confirm whether valvular heart disease, specifically AS, may be an overlooked cardiovascular disease complication in RA.
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Affiliation(s)
- Tate M. Johnson
- Medicine & Research Service, VA Nebraska-Western Iowa Health Care System, Omaha
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Chetaj A. Mahabir
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Yangyuna Yang
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Punyasha Roul
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Andrew M. Goldsweig
- Department of Cardiology, Baystate Medical Center, Springfield, Massachusetts
| | - Bryce A. Binstadt
- Division of Pediatric Rheumatology, Allergy, and Immunology, University of Minnesota, Minneapolis
| | - Joshua F. Baker
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian C. Sauer
- Division of Rheumatology, Salt Lake City VA Medical Center, Salt Lake City, Utah
- Division of Rheumatology, University of Utah School of Medicine, Salt Lake City
| | - Grant W. Cannon
- Division of Rheumatology, Salt Lake City VA Medical Center, Salt Lake City, Utah
- Division of Rheumatology, University of Utah School of Medicine, Salt Lake City
| | - Ted R. Mikuls
- Medicine & Research Service, VA Nebraska-Western Iowa Health Care System, Omaha
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Bryant R. England
- Medicine & Research Service, VA Nebraska-Western Iowa Health Care System, Omaha
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
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Pisaniello HL, Lester S, Russell O, Black R, Tieu J, Richards B, Barrett C, Lassere M, March L, Buchbinder R, Whittle SL, Hill CL. Trajectories of self-reported pain-related health outcomes and longitudinal effects on medication use in rheumatoid arthritis: a prospective cohort analysis using the Australian Rheumatology Association Database (ARAD). RMD Open 2023; 9:e002962. [PMID: 37507204 PMCID: PMC10391633 DOI: 10.1136/rmdopen-2022-002962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE To determine distinct trajectories of self-reported pain-related health status in rheumatoid arthritis (RA), their relationship with sociodemographic factors and medication use. METHODS 988 Australian Rheumatology Association Database participants with RA (71% female, mean age 54 years, mean disease duration 2.3 years) were included. Distinct multi-trajectories over 15-year follow-up for five different self-reported pain-related health outcome measures (Health Assessment Questionnaire Disability Index, visual analogue scores for pain, arthritis, global health and the Assessment of Quality of Life utility index) were identified using latent variable discrete mixture modelling. Random effects models were used to determine associations with medication use and biologic therapy modification during follow-up. RESULTS Four, approximately equally sized, pain/health status groups were identified, ranging from 'better' to 'poorer', within which changes over time were relatively small. Important determinants of those with poorer pain/health status included female gender, obesity, smoking, socioeconomic indicators and comorbidities. While biologic therapy use was similar between groups during follow-up, biologic therapy modifications (plinear<0.001) and greater tendency of non-tumour necrosis factor inhibitor use (plinear<0.001) were observed in those with poorer pain/health status. Similarly, greater use of opioids, prednisolone and non-steroidal anti-inflammatory drugs was seen in those with poorer pain/health status. CONCLUSION In the absence of disease activity information, distinct trajectories of varying pain/health status were seen from the outset and throughout the disease course in this RA cohort. More biologic therapy modifications and greater use in anti-inflammatories, opioids and prednisolone were seen in those with poorer pain/health status, reflecting undesirable lived experience of persistent pain in RA.
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Affiliation(s)
- Huai Leng Pisaniello
- Discipline of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Rheumatology Research Group, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Susan Lester
- Rheumatology Research Group, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
- Deaprtment of Rheumatology, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Oscar Russell
- Discipline of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Rheumatology Research Group, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
- Deaprtment of Rheumatology, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Rachel Black
- Rheumatology Research Group, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
- Deaprtment of Rheumatology, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Joanna Tieu
- Rheumatology Research Group, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
- Deaprtment of Rheumatology, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Bethan Richards
- Department of Rheumatology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Claire Barrett
- Department of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Rheumatology, Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Marissa Lassere
- Department of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Rheumatology, St George Hospital, Kogarah, New South Wales, Australia
| | - Lyn March
- Florance and Cope Professorial Department of Rheumatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Department of Rheumatology, Institute of Bone and Joint Research at Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Samuel L Whittle
- Rheumatology Research Group, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
- Deaprtment of Rheumatology, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Catherine L Hill
- Rheumatology Research Group, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
- Deaprtment of Rheumatology, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
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Mielnik P, Sexton J, Fagerli KM, Bakland G, Hu Y, Kristianslund EK, Hoff M, Wierød A, Kvien TK. Discontinuation rate of sulfasalazine, leflunomide and methotrexate due to adverse events in a real-life setting (NOR-DMARD). Rheumatol Adv Pract 2023; 7:rkad053. [PMID: 37431434 PMCID: PMC10329773 DOI: 10.1093/rap/rkad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/05/2023] [Indexed: 07/12/2023] Open
Abstract
Objectives MTX, LEF and SSZ are conventional synthetic DMARDs (csDMARDs) with a well-established role in the treatment of RA. We aimed to estimate and compare the relative risks for adverse events (AEs) and the discontinuation of these drugs owing to AEs. Methods We included all 3339 patients from the NOR-DMARD study treated with MTX, LEF or SSZ in monotherapy. All reported AEs were compared between treatment groups using quasi-Poisson regression. In addition, drug retention rates were analysed using Kaplan-Meier estimates with Cox regression to control for possible confounders. We analysed drug retention rates and cumulative risk of discontinuation attributable to AEs using the Kaplan-Meier estimator. We assessed age, sex, baseline DAS in 28 joints with ESR (DAS28-ESR), seropositivity, prednisolone use, previous DMARD use, year of inclusion and co-morbidity as possible cofounders. Results We found that the discontinuation rate attributable to AEs was significantly higher for LEF and SSZ than for MTX. After the first year, it was 13.7% (95% CI 12.2, 15.2), 39.6% (95% CI 34.8, 44) and 43.4% (95% CI 38.2, 48.1) for MTX, SSZ and LEF, respectively. Similar results were found when adjusting for confounders. The overall AEs were comparable across the treatment groups. The AE profile was as expected for each drug. Conclusion Our work has shown a similar AE profile of csDMARDs to previous data. However, higher discontinuation rates for SSZ and LEF cannot be explained easily from AE profiles.
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Affiliation(s)
- Pawel Mielnik
- Correspondence to: Pawel Mielnik, Section for Rheumatology, Helse Førde, Svanehaugevegen 1, 6812 Førde, Norway. E-mail:
| | - Joseph Sexton
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Karen M Fagerli
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Gunnstein Bakland
- Department of Rheumatology, University Hospital of Northern Norway, Tromsø, Norway
| | - Yi Hu
- Lillehammer Hospital for Rheumatic Diseases, Lillehammer, Norway
| | - Eirik K Kristianslund
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Mari Hoff
- Department of Rheumatology, St. Olavs Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, NTNU—Norwegian University of Science and Technology, Trondheim, Norway
| | - Ada Wierød
- Department of Rheumatology, Vestre Viken/Drammen Hospital, Drammen, Norway
| | - Tore K Kvien
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Thoma LM, Wellsandt E, Wipfler K, Michaud K. Examining Rehabilitation Dose in Adults With Rheumatoid Arthritis: Association With Baseline Factors and Change in Clinical Outcomes. Arthritis Care Res (Hoboken) 2023; 75:1261-1268. [PMID: 36094858 PMCID: PMC10008510 DOI: 10.1002/acr.25019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/18/2022] [Accepted: 09/08/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the association of baseline factors with rehabilitation dose and the association of rehabilitation dose with meaningful change in physical function, pain, and fatigue over 6 months among adults with rheumatoid arthritis (RA). METHODS Using data from the National Databank for Rheumatic Diseases registry, we extracted baseline characteristics and self-reported physical function (Health Assessment Questionnaire), pain (visual analog scale [VAS]), fatigue (VAS), rehabilitation dose (low: 1-2 visits, medium: 3-8 visits, high: >8 visits), and follow-up outcomes 6 months later. Changes in clinical outcomes were categorized as improved, no change, or worsened. We calculated odds ratios (ORs) and 95% confidence intervals (95% CIs) using proportional odds logistic regression models to examine the association of the baseline factors with rehabilitation dose and the association of rehabilitation dose with changes in clinical outcomes, adjusting for potential confounders. RESULTS The sample included 1,381 adults with a new episode of rehabilitation (dose: low 27%, medium 42%, high 31%). Worse baseline physical function (adjusted OR 1.29 [95% CI 1.04-1.60]), but not pain (adjusted OR 1.04 [95% CI 0.99-1.10]) or fatigue (adjusted OR 0.98 [95% CI 0.93-1.03]), were associated with a higher rehabilitation dose. A high rehabilitation dose was associated with a favorable change in physical function (OR 1.51 [95% CI 1.14-1.98]), pain (OR 1.44 [95% CI 1.06-1.96]), and fatigue (OR 1.45 [95% CI 1.06-1.99]) compared to a low dose; only the association with physical function change persisted in adjusted models (adjusted OR 1.41 [95% CI 1.03-1.92]). CONCLUSION Using real-world data, this study supports a higher rehabilitation dose to improve physical function in adults with RA.
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Affiliation(s)
| | | | | | - Kaleb Michaud
- University of Nebraska Medical Center
- FORWARD, The National Databank for Rheumatic Diseases
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Lopez-Olivo MA, Michaud K, Schumacher R, Minnix J, Cinciripini P, Suarez-Almazor ME. Smoking cessation patterns, usefulness of quitting methods, and tobacco cessation motivators and barriers to quit in patients with rheumatoid arthritis. Clin Rheumatol 2023:10.1007/s10067-023-06593-w. [PMID: 37093403 DOI: 10.1007/s10067-023-06593-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/24/2023] [Accepted: 04/03/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE Tobacco use is highly discouraged in patients with rheumatoid arthritis (RA) due to related short and long-term health implications. We aimed to evaluate smoking cessation patterns in patients with RA. In addition, we ascertained perceptions on the usefulness of quitting methods, and perceived motivators and barriers to quit. METHODS We surveyed adults with RA enrolled in the FORWARD Databank who self-identified as former or current tobacco users. RESULTS Three hundred forty-eight participants completed the survey and responded to the question "do you currently smoke" (former use = 319; current use = 29). Nicotine replacement therapy (NRT) was perceived as extremely/somewhat useful by 31%, followed by individual 27% and group counseling 21%. Experiencing a major health event was the most common motivator to quit. Current users on average smoked 17 cigarettes per day. Six of the 29 current users had used electronic cigarettes in the past 30 days. The most frequent methods used to quit were "cold turkey quitting," NRT, and prescription medicines. Only 8 of the 23 current users had plans to quit or expressed being ready to make changes to quit. Reasons most frequently listed to not quit were using smoking to manage negative emotions, as a pleasurable habit, to manage other addictions, and to provide a sense of control (e.g., to cope with RA). CONCLUSIONS Current users expressed several negative emotions including coping with the disease and "being a pleasurable habit" when trying to quit. Future cessation programs should address these barriers to support patients with RA. Key Points • First study characterizing the smoking behavior of patients with RA in the USA. Current users were younger, had a shorter disease duration, and worse disease outcomes compared to former smokers. • Former and current users reported similar motivators to quit, with experiencing a major health event being most common. Only about a third of participants who quit or who were still smoking received advice from a health professional. • The most common reasons for not quitting were that smoking help to manage negative emotions and was a pleasurable habit. Future studies should focus on cessation programs that support participants with RA by addressing the unique perceptions about smoking in this population.
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Affiliation(s)
- Maria A Lopez-Olivo
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1444, Houston, TX, 77030, USA
| | - Kaleb Michaud
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, KS, USA
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Jennifer Minnix
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Cinciripini
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria E Suarez-Almazor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1444, Houston, TX, 77030, USA.
- Section of Rheumatology and Clinical Immunology, Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Federico LE, Johnson TM, England BR, Wysham KD, George MD, Sauer B, Hamilton BC, Hunter CD, Duryee MJ, Thiele GM, Mikuls TR, Baker JF. Circulating Adipokines and Associations With Incident Cardiovascular Disease in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2023; 75:768-777. [PMID: 35313088 PMCID: PMC10588673 DOI: 10.1002/acr.24885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/09/2022] [Accepted: 03/17/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess whether circulating levels of adiponectin, leptin, and fibroblast growth factor 21 (FGF-21) are associated with incident cardiovascular disease (CVD) in rheumatoid arthritis (RA). METHODS Adipokines were measured using banked enrollment serum from patients with RA and dichotomized above/below the median value. Incident CVD events (coronary artery disease [CAD], stroke, heart failure [HF] hospitalization, venous thromboembolism, CVD-related deaths) were identified using administrative data and the National Death Index. Covariates were derived from medical record, biorepository, and registry databases. Multivariable Cox models were generated to quantify associations between adipokine concentrations and CVD incidence. Five-year incidence rates were predicted. RESULTS Among 2,598 participants, 639 (25%) had at least 1 CVD event over 19,585 patient-years of follow-up. High adiponectin levels were independently associated with HF hospitalization (hazard ratio [HR] 1.39 [95% confidence interval (95% CI) 1.07-1.79], P = 0.01) and CVD-related death (HR 1.49 [95% CI 1.16-1.92], P = 0.002) but not with other CVD events. High leptin was independently associated with CVD-related death (HR 1.44 [95% CI 1.05-1.97], P = 0.02). High FGF-21 levels were independently associated with lower rates of CAD (HR 0.75 [95% CI 0.58-0.97], P = 0.03). In subgroup analyses, associations between high adiponectin and leptin levels with CVD-related death were driven by strong associations in nonobese patients. CONCLUSION Adipokines are associated with HF hospitalization and CVD-related death in patients with RA, with stronger associations in nonobese participants. These findings suggest that adipokines effectively predict clinically important outcomes in RA perhaps through an association with body composition and metabolic health. Further study is needed to determine whether adipokine measures might augment existing tools to identify RA patients at increased risk of CVD.
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Affiliation(s)
| | - Tate M. Johnson
- Tate M. Johnson, MD, Bryant R. England, MD, PhD, Geoffrey M. Thiele, PhD, Ted R. Mikuls, MD, MSPH: Veterans Affairs Nebraska–Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | - Bryant R. England
- Tate M. Johnson, MD, Bryant R. England, MD, PhD, Geoffrey M. Thiele, PhD, Ted R. Mikuls, MD, MSPH: Veterans Affairs Nebraska–Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | - Katherine D. Wysham
- Katherine D. Wysham, MD: Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Michael D. George
- Michael D. George, MD, MSCE: University of Pennsylvania, Philadelphia
| | - Brian Sauer
- Brian Sauer, PhD: University of Utah Medical Center and Veterans Affairs Salt Lake City Health Care System, Salt Lake City
| | - Bartlett C. Hamilton
- Bartlett C. Hamilton, MPH, Carlos D. Hunter, BS, Michael J. Duryee, MS: University of Nebraska Medical Center, Omaha
| | - Carlos D. Hunter
- Bartlett C. Hamilton, MPH, Carlos D. Hunter, BS, Michael J. Duryee, MS: University of Nebraska Medical Center, Omaha
| | - Michael J. Duryee
- Bartlett C. Hamilton, MPH, Carlos D. Hunter, BS, Michael J. Duryee, MS: University of Nebraska Medical Center, Omaha
| | - Geoffrey M. Thiele
- Tate M. Johnson, MD, Bryant R. England, MD, PhD, Geoffrey M. Thiele, PhD, Ted R. Mikuls, MD, MSPH: Veterans Affairs Nebraska–Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | - Ted R. Mikuls
- Tate M. Johnson, MD, Bryant R. England, MD, PhD, Geoffrey M. Thiele, PhD, Ted R. Mikuls, MD, MSPH: Veterans Affairs Nebraska–Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | - Joshua F. Baker
- Joshua F. Baker, MD, MSCE: University of Pennsylvania and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia
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Salaffi F, Di Matteo A, Farah S, Di Carlo M. Inflammaging and Frailty in Immune-Mediated Rheumatic Diseases: How to Address and Score the Issue. Clin Rev Allergy Immunol 2023; 64:206-221. [PMID: 35596881 PMCID: PMC10017626 DOI: 10.1007/s12016-022-08943-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 12/19/2022]
Abstract
Frailty is a new concept in rheumatology that can help identify people more likely to have less favorable outcomes. Sarcopenia and inflammaging can be regarded as the biological foundations of physical frailty. Frailty is becoming more widely accepted as an indicator of ageing and is linked to an increased risk of negative outcomes such as falls, injuries, and mortality. Frailty identifies a group of older adults that seem poorer and more fragile than their age-matched counterparts, despite sharing similar comorbidities, demography, sex, and age. Several studies suggest that inflammation affects immune-mediated pathways, multimorbidity, and frailty by inhibiting growth factors, increasing catabolism, and by disrupting homeostatic signaling. Frailty is more common in the community-dwelling population as people get older, ranging from 7 to 10% in those over 65 years up to 40% in those who are octogenarians. Different parameters have been validated to identify frailty. These primarily relate to two conceptual models: Fried's physical frailty phenotype and Rockwood's cumulative deficit method. Immune-mediated rheumatic diseases (IMRDs), such as rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus, systemic sclerosis, and vasculitis, are leading causes of frailty in developing countries. The aim of this review was to quantitatively synthesize published literature on the prevalence of frailty in IMRDs and to summarize current evidence on the relevance and applicability of the most widely used frailty screening tools.
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Affiliation(s)
- Fausto Salaffi
- Rheumatology Clinic, Università Politecnica Delle Marche, Carlo Urbani" Hospital, Via Aldo Moro, 25, 60035, Jesi, Ancona, Italy.
| | - Andrea Di Matteo
- Rheumatology Clinic, Università Politecnica Delle Marche, Carlo Urbani" Hospital, Via Aldo Moro, 25, 60035, Jesi, Ancona, Italy
| | - Sonia Farah
- Rheumatology Clinic, Università Politecnica Delle Marche, Carlo Urbani" Hospital, Via Aldo Moro, 25, 60035, Jesi, Ancona, Italy
| | - Marco Di Carlo
- Rheumatology Clinic, Università Politecnica Delle Marche, Carlo Urbani" Hospital, Via Aldo Moro, 25, 60035, Jesi, Ancona, Italy
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Lopatina E, Barber CEH, LeClercq SA, Noseworthy TW, Suter E, Mosher DP, Marshall DA. Healthcare resource utilization and costs in stable patients with rheumatoid arthritis: Comparing nurse-led and rheumatologist-led models of care delivery. Semin Arthritis Rheum 2023; 59:152160. [PMID: 36603500 DOI: 10.1016/j.semarthrit.2022.152160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Having previously shown similar clinical outcomes, this study compared the healthcare resource utilization and direct costs in stable patients with RA followed in the nurse-led care (NLC) and rheumatologist-led care (RLC) models. METHODS Previously collected clinical data were linked to data on practitioner claims, ambulatory care, and hospital discharges. Assessed resources included physician visits; emergency department (ED) visits; hospital admissions, and disease-modifying anti-rheumatic drugs (DMARDs). The mean per-patient resource utilization and cost (2020 Canadian dollars) over 1 year were compared between the groups using Wilcoxon rank-sum test. The mean per-patient cost of health services and total cost were also estimated using Generalized Linear Models (GLMs) accounting for the baseline differences between the groups. RESULTS Overall, 244 patients were included. No differences in the number of visits to the ED or to general practice and internal medicine physicians and orthopedic surgeons were found. The NLC group had fewer hospitalizations than the RLC group (p-value=0.03). The mean cost of health services was not statistically different in NLC and RLC groups ($2275 vs. $3772, p-value=0.30). The RLC group included more patients on biologic DMARDs, contributing to a higher mean total cost than the NLC group ($9191 vs. $3056, p-value<0.01). The mean cost estimates with GLMs were consistent with the observed costs. CONCLUSIONS A nurse-led model of care delivery for stable patients with RA was not associated with increases in healthcare resource utilization or cost as compared to RLC. NLC is one approach to meeting patient needs and better managing scarce healthcare resources.
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Affiliation(s)
- Elena Lopatina
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Claire E H Barber
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sharon A LeClercq
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tom W Noseworthy
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Esther Suter
- Department of Social Work, University of Calgary, Calgary, AB, Canada
| | - Dianne P Mosher
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Deborah A Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Wheeler AM, Roul P, Yang Y, Brittan KM, Sayles H, Singh N, Sauer BC, Cannon GW, Baker JF, Mikuls TR, England BR. Risk of Prostate Cancer in US Veterans With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2023; 75:785-792. [PMID: 35612872 PMCID: PMC9532468 DOI: 10.1002/acr.24890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/21/2022] [Accepted: 03/31/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Patients with rheumatoid arthritis (RA) have an increased risk of select cancers, including lymphoma and lung cancer. Whether RA influences prostate cancer risk is uncertain. We aimed to determine the risk of prostate cancer in patients with RA compared to patients without RA in the Veterans Health Administration (VA). METHODS We performed a matched (up to 1:5) cohort study of male patients with and without RA in the VA from 2000 to 2018. RA status, as well as covariates, were obtained from national VA databases. Prostate cancer was identified through linked VA cancer databases and the National Death Index. Multivariable Cox models compared prostate cancer risk between patients with RA and patients without RA, including models that accounted for retention in the VA system. RESULTS We included 56,514 veterans with RA and 227,284 veterans without RA. During 2,337,104 patient-years of follow-up, 6,550 prostate cancers occurred. Prostate cancer incidence (per 1,000 patient-years) was 3.50 (95% confidence interval [95% CI] 3.32-3.69) in patients with RA and 2.66 (95% CI 2.58-2.73) in patients without RA. After accounting for confounders and censoring for attrition of VA health care, RA was modestly associated with a higher prostate cancer risk (adjusted HR [HRadj ] 1.12 [95% CI 1.04-1.20]). There was no association between RA and prostate cancer mortality (HRadj 0.92 [95% CI 0.73-1.16]). CONCLUSION RA was associated with a modestly increased risk of prostate cancer, but not prostate cancer mortality, after accounting for relevant confounders and several potential sources of bias. However, even minimal unmeasured confounding could explain these findings.
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Affiliation(s)
- Austin M. Wheeler
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Punyasha Roul
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Yangyuna Yang
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Kaitlyn M. Brittan
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Harlan Sayles
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE
| | | | - Brian C. Sauer
- Salt Lake City VA Healthcare System & University of Utah, Salt Lake City, UT
| | - Grant W. Cannon
- Salt Lake City VA Healthcare System & University of Utah, Salt Lake City, UT
| | - Joshua F. Baker
- Corporal Michael J. Crescenz VA Medical Center & University of Pennsylvania, Philadelphia, PA
| | - Ted R. Mikuls
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Bryant R. England
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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Helget LN, England BR, Roul P, Sayles H, Petro AD, Neogi T, O’Dell JR, Mikuls TR. Cause-Specific Mortality in Patients With Gout in the US Veterans Health Administration: A Matched Cohort Study. Arthritis Care Res (Hoboken) 2023; 75:808-816. [PMID: 35294114 PMCID: PMC9477976 DOI: 10.1002/acr.24881] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 02/08/2022] [Accepted: 03/10/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare all-cause and cause-specific mortality risk between patients with gout and patients without gout in the Veteran's Health Administration (VHA). METHODS We performed a matched cohort study, identifying patients with gout in the VHA from January 1999 to September 2015 based on the presence of ≥2 International Classification of Diseases, Ninth Revision codes for gout (274.X). Gout patients were matched up to 1:10 on birth year, sex, and year of VHA enrollment with patients without gout and followed until death or end of study (December 2017). Cause of death was obtained from the National Death Index. Associations of gout with all-cause and cause-specific mortality were examined using multivariable Cox regression. RESULTS Gout (n = 559,243) and matched non-gout controls (n = 5,428,760) had a mean age of 67 years and were 99% male. There were 246,291 deaths over 4,250,371 patient-years in gout patients and 2,000,000 deaths over 40,441,353 patient-years of follow-up in controls. After matching, gout patients had an increased risk of death (hazard ratio [HR] 1.09 [95% confidence interval (95% CI) 1.08-1.09]), which was no longer present after adjusting for comorbidities (HR 0.98 [95% CI 0.97-0.98]). The strongest association of gout with cause-specific mortality was observed with genitourinary conditions (HR 1.50 [95% CI 1.47-1.54]). Gout patients were at lower risk of death related to neurologic (e.g., Alzheimer's disease and Parkinson's disease) (HR 0.63 [95% CI 0.62-0.65]) and mental health (HR 0.66 [95% CI 0.65-0.68]) conditions. CONCLUSION A higher risk of death among gout patients in the VHA was related to comorbidity burden. While deaths attributable to neurologic and mental health conditions were less frequent among gout patients, genitourinary conditions were the most overrepresented causes of death.
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Affiliation(s)
- Lindsay N. Helget
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Bryant R. England
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Punyasha Roul
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Harlan Sayles
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE
| | - Alison D. Petro
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Tuhina Neogi
- Boston University School of Medicine, Boston, MA
| | - James R. O’Dell
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Ted R. Mikuls
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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Elfishawi M, Rakholiya J, Gunderson TM, Achenbach SJ, Crowson CS, Matteson EL, Turesson C, Wadström K, Weyand C, Koster MJ, Warrington KJ. Lower Frequency of Comorbidities Prior to Onset of Giant Cell Arteritis: A Population-Based Study. J Rheumatol 2023; 50:526-531. [PMID: 36521923 PMCID: PMC10066824 DOI: 10.3899/jrheum.220610] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To assess the frequency of comorbidities and metabolic risk factors at and prior to giant cell arteritis (GCA) diagnosis. METHODS This is a retrospective case control study of patients with incident GCA between January 1, 2000, and December 31, 2019, in Olmsted County, Minnesota. Two age- and sex-matched controls were identified, and each assigned an index date corresponding to an incidence date of GCA. Medical records were manually abstracted for comorbidities and laboratory data at incidence date, 5 years, and 10 years prior to incidence date. Twenty-five chronic conditions using International Classification of Diseases, 9th revision, diagnosis codes were also studied at incidence date and 5 years prior to incidence date. RESULTS One hundred and twenty-nine patients with GCA (74% female) and 253 controls were identified. At incidence date, the prevalence of diabetes mellitus (DM) was lower among patients with GCA (5% vs 17%; P = 0.001). At 5 years prior to incidence date, patients were less likely to have DM (2% vs 13%; P < 0.001) and hypertension (27% vs 45%; P = 0.002) and had a lower mean number (SD) of comorbidities (0.7 [1.0] vs 1.3 [1.4]; P < 0.001) compared to controls. Moreover, patients had significantly lower median fasting blood glucose (FBG; 96 mg/dL vs 104 mg/dL; P < 0.001) and BMI (25.8 vs 27.7; P = 0.02) compared to controls. Multivariable logistic regression analysis revealed negative associations for FBG with GCA at 5 and 10 years prior to diagnosis/index date. CONCLUSION DM prevalence and median FBG and BMI were lower in patients with GCA up to 5 years prior to diagnosis, suggesting that metabolic factors influence the risk of GCA.
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Affiliation(s)
- Mohanad Elfishawi
- M. Elfishawi, MBBCh, MS, J. Rakholiya, MBBS, C. Weyand, MD, PhD, M.J. Koster, MD, K.J. Warrington, MD, Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA;
| | - Jigisha Rakholiya
- M. Elfishawi, MBBCh, MS, J. Rakholiya, MBBS, C. Weyand, MD, PhD, M.J. Koster, MD, K.J. Warrington, MD, Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tina M Gunderson
- T.M. Gunderson, MS, S.J. Achenbach, MS, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara J Achenbach
- T.M. Gunderson, MS, S.J. Achenbach, MS, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Cynthia S Crowson
- C.S Crowson, PhD, E.L. Matteson, MD, MPH, Division of Rheumatology, Department of Internal Medicine, and Department of Quantitative Health Sciences. Mayo Clinic, Rochester, Minnesota, USA
| | - Eric L Matteson
- C.S Crowson, PhD, E.L. Matteson, MD, MPH, Division of Rheumatology, Department of Internal Medicine, and Department of Quantitative Health Sciences. Mayo Clinic, Rochester, Minnesota, USA
| | - Carl Turesson
- C. Turesson, MD, PhD, Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden
| | - Karin Wadström
- K. Wadström, MD, PhD, Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, and Center for Rheumatology, Academic Specialist Center, Region Stockholm, Stockholm, Sweden
| | - Cornelia Weyand
- M. Elfishawi, MBBCh, MS, J. Rakholiya, MBBS, C. Weyand, MD, PhD, M.J. Koster, MD, K.J. Warrington, MD, Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew J Koster
- M. Elfishawi, MBBCh, MS, J. Rakholiya, MBBS, C. Weyand, MD, PhD, M.J. Koster, MD, K.J. Warrington, MD, Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth J Warrington
- M. Elfishawi, MBBCh, MS, J. Rakholiya, MBBS, C. Weyand, MD, PhD, M.J. Koster, MD, K.J. Warrington, MD, Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Ozen G, Dell'Aniello S, Pedro S, Michaud K, Suissa S. Reduction of Cardiovascular Disease and Mortality Versus Risk of New-Onset Diabetes Mellitus With Statin Use in Patients With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2023; 75:597-607. [PMID: 35119769 DOI: 10.1002/acr.24866] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/17/2022] [Accepted: 01/17/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To assess the effect of statin use on the risk of cardiovascular disease (CVD), all-cause mortality, and type 2 diabetes mellitus (DM) in patients with rheumatoid arthritis (RA). METHODS We identified a cohort of patients with RA between 1989 and 2018, within the UK Clinical Practice Research Datalink. We employed a prevalent new-user cohort design by which patients initiating statins were each matched to 2 concurrent nonusers by the time-conditional propensity score (TCPS). Patients were followed until the occurrence of the composite end point of myocardial infarction, stroke, hospitalized heart failure or CVD mortality, all-cause mortality, and incident type 2 DM. The Cox proportional hazards model was used to estimate the hazard ratio (HR) of each outcome associated with as-treated statin use, with adjustment for TCPS deciles and imbalanced covariables. RESULTS Among 1,768 statin initiators and 3,528 nonusers, 63 versus 340 CVD (3.0 per 100 person-years versus 2.7 per 100 person-years) and 62 versus 525 deaths (2.8 per 100 person-years versus 4.1 per 100 person-years) occurred. Incident type 2 DM was noted in 128 of 3,608 statin initiators (3.0 per 100 person-years) and 518 of 7,208 nonusers (2.0 per 100 person-years). Statin initiation was associated with 32% (HR 0.68 [95% confidence interval (95% CI) 0.51-0.90]) reduction in CVD, 54% (HR 0.46 [95% CI 0.35-0.60]) reduction in all-cause mortality, and 33% increase in type 2 DM (HR 1.33 [95% CI 1.09-1.63]). The number needed to treat/number needed to harm to prevent a CVD or all-cause mortality or to cause type 2 DM in 1 year was 102, 42, and 127, respectively. CONCLUSION Statins are associated with important reductions in CVD and mortality that outweigh the modest increase in type 2 DM risk in RA patients.
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Affiliation(s)
- Gulsen Ozen
- University of Nebraska Medical Center, Omaha
| | | | - Sofia Pedro
- FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | - Samy Suissa
- Jewish General Hospital and McGill University, Montreal, Quebec, Canada
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Albrecht K, Regierer AC, Strangfeld A, Marschall U, Callhoff J. High burden of polypharmacy and comorbidity in persons with psoriatic arthritis: an analysis of claims data, stratified by age and sex. RMD Open 2023; 9:rmdopen-2022-002960. [PMID: 36894195 PMCID: PMC10008426 DOI: 10.1136/rmdopen-2022-002960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/24/2023] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVE To assess polypharmacy in women and men with psoriatic arthritis (PsA). METHODS From the German BARMER health insurance database, 11 984 persons with PsA and disease-modifying antirheumatic drug therapy in 2021 were included and compared with sex-matched and age-matched controls without inflammatory arthritis. Medications were analysed by Anatomical Therapeutic Chemical (ATC) groups. Polypharmacy (≥5 concomitant drugs) was compared by sex, age and comorbidity using the Rheumatic Disease Comorbidity Index (RDCI) and the Elixhauser Score. The mean difference in the number of medications between persons with PsA and controls was estimated using a linear regression model. RESULTS Compared with controls, all ATC drug classes were significantly more frequent in persons with PsA, most commonly musculoskeletal (81% vs 30%), immunomodulatory (56% vs 2.6%), cardiovascular (62% vs 48%), alimentary tract/metabolic (57% vs 31%) and nervous system (50% vs 31%) drugs. Polypharmacy was significantly higher in PsA (49%) compared with controls (17%), more frequent in women (52%) compared with men (45%) and strongly increased with age and comorbidity. For each unit increase of the RDCI, the age-adjusted number of medications increased by 0.98 (95% CI 0.95 to 1.01) units in men and 0.93 (95% CI 0.90 to 0.96) units in women. Compared with controls, the number of medications in PsA (mean 4.9 (SD 2.8)) was 2.4 (95%CI 2.34; 2.43) units higher in women and 2.3 (95% CI 2.21 to 2.35) units higher in men. CONCLUSIONS Polypharmacy is common in PsA and is composed of PsA-specific medication as well as frequent medications for comorbidities, equally affecting women and men.
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Affiliation(s)
- Katinka Albrecht
- Epidemiology and Health Services Research, German Rheumatism Research Center Berlin, Berlin, Germany
| | - Anne Constanze Regierer
- Epidemiology and Health Services Research, German Rheumatism Research Center Berlin, Berlin, Germany
| | - Anja Strangfeld
- Epidemiology and Health Services Research, German Rheumatism Research Center Berlin, Berlin, Germany.,Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ursula Marschall
- Department Medicine and Health Services Research, BARMER Institute for Health System Research, Wuppertal, Germany
| | - Johanna Callhoff
- Epidemiology and Health Services Research, German Rheumatism Research Center Berlin, Berlin, Germany.,Institute for Social Medicine, Epidemiology and Health Economics, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Koster F, Bakx PLH, Kok MR, Barreto DL, Weel-Koenders AEAM. Multimorbidity status and annual healthcare expenditures of rheumatoid arthritis patients: a Dutch hospital-centered versus population-based comparison. Rheumatol Int 2023; 43:1067-1076. [PMID: 36763167 PMCID: PMC10125938 DOI: 10.1007/s00296-023-05282-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/20/2023] [Indexed: 02/11/2023]
Abstract
The prevalence of multimorbidity among rheumatoid arthritis (RA) patients is increasing and associated with worse outcomes. Therefore, management of multimorbid patients requires a multidisciplinary approach. However, healthcare systems consist of mono-disciplinary subsystems, which limits collaboration across subsystems. To study the importance of a multidisciplinary, integrated approach, associations between expenditures and multimorbidity are assessed in real-life data. Retrospective data on RA patients from a Dutch single-hospital are analyzed and compared to the Dutch RA population data. The Elixhauser index is used to measure the multimorbidity prevalence. Regression analyses were conducted to derive the relationship between multimorbidity, healthcare costs and self-reported quality of life (e.g. EQ-5D). When analyzing the impact of multimorbidity within RA patients in context of a single-hospital context, multimorbidity is only partially captured: 13% prevalence versus 24% of the Dutch population. Multimorbidity is associated with higher care expenditures. Depending on the type of multimorbidity, expenditures are €43-€5821 higher in a single-hospital and from €2259-€9648 in population data. Finally, medication use associated with chronic diseases and self-reported aspects of well-being are associated with similar increases in healthcare expenditures as multimorbidity based on hospital care. Within RA, a single-hospital approach underestimates the association between multimorbidity and healthcare expenditures as 43% of healthcare utilization and expenditures are missed. To overcome a single-provider perspective in healthcare and efficiently coordinate multimorbid patients, besides providing holistic care, professionals also need to use data providing comprehensive pictures of patients.
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Affiliation(s)
- Fiona Koster
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital Rotterdam, Rotterdam, The Netherlands. .,Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Pieter L H Bakx
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Marc R Kok
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital Rotterdam, Rotterdam, The Netherlands
| | - Deirisa Lopes Barreto
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital Rotterdam, Rotterdam, The Netherlands
| | - Angelique E A M Weel-Koenders
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital Rotterdam, Rotterdam, The Netherlands.,Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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England BR, Yang Y, Roul P, Haas C, Najjar L, Sayles H, Yu F, Sauer BC, Baker JF, Xie F, Michaud K, Curtis JR, Mikuls TR. Identification of Multimorbidity Patterns in Rheumatoid Arthritis Through Machine Learning. Arthritis Care Res (Hoboken) 2023; 75:220-230. [PMID: 35588095 PMCID: PMC10009900 DOI: 10.1002/acr.24956] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/18/2022] [Accepted: 05/10/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Recognizing that the interrelationships between chronic conditions that complicate rheumatoid arthritis (RA) are poorly understood, we aimed to identify patterns of multimorbidity and to define their prevalence in RA through machine learning. METHODS We constructed RA and age- and sex-matched (1:1) non-RA cohorts within a large commercial insurance database (MarketScan) and the Veterans Health Administration (VHA). Chronic conditions (n = 44) were identified from diagnosis codes from outpatient and inpatient encounters. Exploratory factor analysis was performed separately in both databases, stratified by RA diagnosis and sex, to identify multimorbidity patterns. The association of RA with different multimorbidity patterns was determined using conditional logistic regression. RESULTS We studied 226,850 patients in MarketScan (76% female) and 120,780 patients in the VHA (89% male). The primary multimorbidity patterns identified were characterized by the presence of cardiopulmonary, cardiometabolic, and mental health and chronic pain disorders. Multimorbidity patterns were similar between RA and non-RA patients, female and male patients, and patients in MarketScan and the VHA. RA patients had higher odds of each multimorbidity pattern (odds ratios [ORs] 1.17-2.96), with mental health and chronic pain disorders being the multimorbidity pattern most strongly associated with RA (ORs 2.07-2.96). CONCLUSION Cardiopulmonary, cardiometabolic, and mental health and chronic pain disorders represent predominant multimorbidity patterns, each of which is overrepresented in RA. The identification of multimorbidity patterns occurring more frequently in RA is an important first step in progressing toward a holistic approach to RA management and warrants assessment of their clinical and predictive utility.
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Affiliation(s)
- Bryant R England
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
| | | | | | - Christian Haas
- University of Nebraska, Omaha, and Vienna University of Economics and Business, Vienna, Austria
| | | | | | - Fang Yu
- University of Nebraska Medical Center, Omaha
| | - Brian C Sauer
- University of Utah and Veterans Affairs Salt Lake City, Salt Lake City
| | - Joshua F Baker
- Philadelphia Veterans Affairs and University of Pennsylvania, Philadelphia
| | | | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | | | - Ted R Mikuls
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha
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Tidblad L, Westerlind H, Delcoigne B, Askling J, Saevarsdottir S. Comorbidities and treatment patterns in early rheumatoid arthritis: a nationwide Swedish study. RMD Open 2022; 8:rmdopen-2022-002700. [PMID: 36564100 PMCID: PMC9791425 DOI: 10.1136/rmdopen-2022-002700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To examine how comorbidities in patients with early rheumatoid arthritis (RA) associate with use of different disease-modifying antirheumatic drugs (DMARDs). METHODS We used Swedish nationwide clinical and quality registers to collect comorbidity data for patients diagnosed with RA during 2006-2019 (n=13 505). We compared the use of DMARDs at diagnosis and after 1 year, in relation to comorbidity categories 5 years prior to RA diagnosis and overall comorbidity burden. For each comorbidity category, we also calculated adjusted ORs of being on treatment with other (or no) DMARDs compared with methotrexate (MTX) monotherapy 1 year after RA diagnosis. RESULTS At RA diagnosis, 68% (n=9178) of all patients were treated with MTX monotherapy, with the lowest proportion in patients with chronic kidney (CKD, 48%, n=50) and respiratory diseases (57%, n=413). At 1 year, most patients still received MTX monotherapy (<11% decrease, across all comorbidity categories). At 1 year, 13% received biological/targeted synthetic DMARDs, with the lowest proportion among patients with malignant diseases (OR=0.69, 95% CI=0.51 to 0.95). Being without DMARD at 1 year was more common among patients with CKD (OR=3.25, 95% CI=2.20 to 4.81), respiratory diseases (OR=1.83, 95% CI=1.32 to 2.53) or a history of hospitalisation due to infection (OR=1.47, 95% CI=1.23 to 1.75), and among patients with higher comorbidity burden and older age. CONCLUSION In a nationwide setting with universal healthcare, most comorbid conditions do not limit the initiation or continuation of MTX or other DMARDs in early RA, although patients with certain comorbid conditions, higher comorbidity burden and higher age were somewhat less intensively treated.
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Affiliation(s)
- Liselotte Tidblad
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Helga Westerlind
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Benedicte Delcoigne
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Saedis Saevarsdottir
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden,Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
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Ben Tekaya A, Hannech E, Saidane O, Rouached L, Bouden S, Tekaya R, Mahmoud I, Abdelmoula L. Association between Rheumatic Disease Comorbidity Index and factors of poor prognosis in a cohort of 280 patients with rheumatoid arthritis. BMC Rheumatol 2022; 6:78. [PMID: 36539858 PMCID: PMC9769002 DOI: 10.1186/s41927-022-00308-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is commonly associated with higher rates of comorbidities. Recent recommendations highlight screening comorbidities during the disease course because of their impact on patients' ability to function, on disease outcome, but also on treatment choices. Hence the interest of our study that aimed to quantify the impact of comorbidities among RA patients using a validated tool the Rheumatic Disease Comorbidity Index (RDCI) and to explore the association between comorbidities and disease characteristics. METHODS We conducted a cross-sectional study over 12 months period, including patients followed for an established RA according to the ACR/EULAR 2010 criteria and hospitalized in our rheumatology department. Patients' characteristics and disease features were collected for each patient. Comorbidities were quantified using the RDCI. We looked for the association between RDCI and patients characteristics and RA parameters. Univariable and multivariable analysis were made. RESULTS They were 280 patients: 233 female (83.2%) and 47 male (16.8%) with a mean age of 58.07 (SD 11.12) years. The mean follow-up period was 14.74 (SD 1.63) years. Comorbidities were noted in 133 patients (47.5%). The mean comorbidity score measured by the RDCI was 1.05 (SD 1.23). RDCI was positively correlated with age (p < 0.001, r = 0.359). RA patients whose age of disease onset exceeds 40 years have significantly higher RDCI (1.8 (SD 1.3) [CI 95%: 1.36-1.88] vs. 1.5 (SD 1.2), p = 0.007). Moreover, RDCI was significantly associated with the presence pulmonary involvement (p < 0.001) and ocular involvement (p = 0.002). RDCI was also associated with erosive RA (p = 0.006), the presence of atlanto-axial dislocation (p = 0.014), and coxitis (p = 0.029). Regarding therapy regimen, RDCI was statistically increased in patients receiving bDMARDs compared to patients under csDMARDs (2.8 (SD 1.6) vs. 1.0 (SD 1.0), p = 0.021). CONCLUSION In this study, comorbidity index was associated with signs of poor prognosis such as erosions, coxitis, and atlanto-axial dislocation. This confirmed the hypothesis that comorbidity can be a threat to the improvement in the long-term prognosis in RA patients.
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Affiliation(s)
- Aicha Ben Tekaya
- grid.413827.b0000 0004 0594 6356Rheumatology Department, Charles Nicolle Hospital, 1007 Tunis, Tunisia ,grid.12574.350000000122959819Faculty of medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Emna Hannech
- grid.413827.b0000 0004 0594 6356Rheumatology Department, Charles Nicolle Hospital, 1007 Tunis, Tunisia ,grid.12574.350000000122959819Faculty of medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Olfa Saidane
- grid.413827.b0000 0004 0594 6356Rheumatology Department, Charles Nicolle Hospital, 1007 Tunis, Tunisia ,grid.12574.350000000122959819Faculty of medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Leila Rouached
- grid.413827.b0000 0004 0594 6356Rheumatology Department, Charles Nicolle Hospital, 1007 Tunis, Tunisia ,grid.12574.350000000122959819Faculty of medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Selma Bouden
- grid.413827.b0000 0004 0594 6356Rheumatology Department, Charles Nicolle Hospital, 1007 Tunis, Tunisia ,grid.12574.350000000122959819Faculty of medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Rawdha Tekaya
- grid.413827.b0000 0004 0594 6356Rheumatology Department, Charles Nicolle Hospital, 1007 Tunis, Tunisia ,grid.12574.350000000122959819Faculty of medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Ines Mahmoud
- grid.413827.b0000 0004 0594 6356Rheumatology Department, Charles Nicolle Hospital, 1007 Tunis, Tunisia ,grid.12574.350000000122959819Faculty of medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Leila Abdelmoula
- grid.413827.b0000 0004 0594 6356Rheumatology Department, Charles Nicolle Hospital, 1007 Tunis, Tunisia ,grid.12574.350000000122959819Faculty of medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
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Witkam R, Verstappen SMM, Gwinnutt JM, Cook MJ, O'Neill TW, Cooper R, Humphreys J. The association between lower socioeconomic position and functional limitations is partially mediated by obesity in older adults with symptomatic knee osteoarthritis: Findings from the English Longitudinal Study of Ageing. Front Public Health 2022; 10:1053304. [PMID: 36600944 PMCID: PMC9806847 DOI: 10.3389/fpubh.2022.1053304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022] Open
Abstract
Objective To assess the longitudinal associations of socioeconomic position (SEP) with functional limitations and knee joint replacement surgery (JRS) in people with symptomatic knee osteoarthritis (OA), and whether body mass index (BMI) mediated these relationships. Methods Data came from the English Longitudinal Study of Ageing, a national longitudinal panel study of adults aged ≥50 years. A total of 1,499 participants (62.3% female; mean age 66.5 (standard deviation (SD) 9.4) years; 47.4% obese) self-reporting an OA diagnosis and knee pain, with at least one BMI measurement were included. Mixed effect models estimated longitudinal associations of each SEP variable (education, occupation, income, wealth and deprivation index) and obesity (BMI ≥30.0 kg/m2) with repeated measures of functional limitations. Cox regression analyses estimated associations between SEP indicators and obesity at baseline and risk of knee JRS at follow-up. Structural equation modeling estimated any mediating effects of BMI on these relationships. Results Lower SEP and obesity at baseline were associated with increased odds of functional limitations in people with knee OA [e.g., difficulty walking 100 yards: no qualification vs. degree adjOR 4.33 (95% CI 2.20, 8.55) and obesity vs. no obesity adjOR 3.06 (95% CI 2.14, 4.37); similar associations were found for the other SEP indicators]. A small proportion of the association between lower SEP and functional limitations could be explained by BMI (6.2-12.5%). Those with lower income, lower wealth and higher deprivation were less likely to have knee JRS [e.g., adjHR most vs. least deprived 0.37 (95% CI 0.19, 0.73)]; however, no clear association was found for education and occupation. Obesity was associated with increased hazards of having knee JRS [adjHR 1.87 (95% CI 1.32, 2.66)]. As the direction of the associations for SEP and obesity with knee JRS were in opposite directions, no mediation analyses were performed. Conclusions Lower SEP was associated with increased odds of functional limitations but lower hazards of knee JRS among people with knee OA, potentially indicating underutilization of JRS in those with lower SEP. Obesity partially mediated the relationship between lower SEP and increased odds of functional limitations, suggesting adiposity as a potential interventional target.
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Affiliation(s)
- Rozemarijn Witkam
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Suzanne M. M. Verstappen
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom,*Correspondence: Suzanne M. M. Verstappen
| | - James M. Gwinnutt
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Michael J. Cook
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Terence W. O'Neill
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Rachel Cooper
- Department of Sport and Exercise Sciences, Musculoskeletal Science and Sports Medicine Research Centre, Manchester Metropolitan University Institute of Sport, Manchester, United Kingdom,AGE Research Group, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom,NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Jennifer Humphreys
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Seyferth AV, Cichocki MN, Wang CW, Huang YJ, Huang YW, Chen JS, Kuo CF, Chung KC. Factors Associated With Quality Care Among Adults With Rheumatoid Arthritis. JAMA Netw Open 2022; 5:e2246299. [PMID: 36508216 PMCID: PMC9856345 DOI: 10.1001/jamanetworkopen.2022.46299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Although quality care markers exist for patients with rheumatoid arthritis (RA), the predictors of meeting these markers are unclear. OBJECTIVE To explore factors associated with quality care among patients with RA. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study using insurance claims from 2009 to 2017 was conducted, and 6 sequential logistic regression models were built to evaluate quality care markers. Quality care markers were measured at 1 year post-RA diagnosis for each patient. The MarketScan Research Database, which contains commercial and Medicare Advantage administrative claims data from more than 100 million individuals in the US, was used to identify patients aged 18 to 64 years with a diagnosis claim for RA. Patients with conditions presenting similar to RA and missing demographic characteristics were excluded. Data analysis occurred between February 18 and May 5, 2022. EXPOSURES Success or failure to meet selected RA quality care markers within 1 year after RA diagnosis. MAIN OUTCOMES AND MEASURES Prevalence of meeting successive quality care markers for RA. RESULTS Among 581 770 patients, 430 843 (74.1%) were women and the mean (SD) age was 48.9 (11.3) years. Most patients (236 285 [40.6%]) resided in the South and had an income less than or equal to $45 200 (490 366 [84.3%]). Of the total study population, 399 862 individuals (68.7%) met at least 1 quality care marker and 181 908 (31.3%) met 0 markers. Most commonly, patients met annual laboratory testing (299 323 [51.5%]) and referral to a rheumatologist (256 765 [44.1%]) markers. The least met marker was receiving hepatitis B screening prior to initiation of disease-modifying antirheumatic drug (DMARD) therapy (18 548 [3.2%]). Women were most likely to meet all quality care markers except receiving DMARDs with hepatitis B screening (odds ratio, 1.14; 95% CI, 1.12-1.16). Individuals with lower median household income had lower odds of receiving a rheumatologist referral, an annual physical examination, or annual laboratory testing, but greater odds of receiving the other quality care markers. Patients with Medicare and those with comorbidities were generally less likely to meet quality care markers. CONCLUSIONS AND RELEVANCE In this cohort study of patients with RA, findings indicated downstream associations with rheumatologist referral and receiving DMARDs and varied associations between meeting quality care markers and patient characteristics. These findings suggest that prioritizing early care, especially for vulnerable patients, will ensure that quality care continues.
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Affiliation(s)
- Anne V. Seyferth
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Meghan N. Cichocki
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Chien-Wei Wang
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Yun-Ju Huang
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Wei Huang
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Jung-Sheng Chen
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Chang-Fu Kuo
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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Guaracha-Basañez GA, Contreras-Yáñez I, Álvarez-Hernández E, Reyes-Cordero G, Flores-Alvarado DE, González-Chávez SA, Galarza-Delgado DÁ, Martínez-Leyva PR, Moctezuma-Ríos JF, García-García C, Medrano-Ramírez G, Gastelum-Strozzi A, Pacheco-Tena C, Peláez-Ballestas I, Pascual-Ramos V. Factors associated to COVID-19 vaccine acceptance in Mexican patients with rheumatic diseases: A cross-sectional and multicenter study. Hum Vaccin Immunother 2022; 18:2049131. [PMID: 35389817 PMCID: PMC9196644 DOI: 10.1080/21645515.2022.2049131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
COVID-19 vaccination is recommended in patients with rheumatic diseases (RDs) to prevent hospitalized COVID-19 and worse outcomes. However, patients’ willingness to receive a SARS-CoV-2 vaccine and the associated factors vary across populations, vaccines, and time. The objective was to identify factors associated with COVID-19 vaccine acceptance (VA) in Mexican outpatients with RDs. This multicenter study was performed between March 1 and September 30, 2021, and four national centers contributed with patients. Participants filled out a questionnaire, which included 32 items related to patients’ perception of the patient-doctor relationship, the COVID-19 vaccine component, the pandemic severity, the RD-related disability, comorbid conditions control, immunosuppressive treatment impact on the immune system, and moral/civil position of COVID-19 vaccine. Sociodemographic, disease-related, and treatment-related variables and previous influenza record vaccination were also obtained. Multiple logistic regression analyses identified factors associated with VA, which was defined based on a questionnaire validated in our population. There were 1439 patients whose data were analyzed, and the most frequent diagnoses were Rheumatoid Arthritis in 577 patients (40.1%) and Systemic Lupus Erythematosus in 427 (29.7%). Patients were primarily middle-aged women (1235 [85.8%]), with (mean±SD) 12.1 (±4.4) years of formal education. Years of education, corticosteroid use, patient perceptions about the vaccine and the pandemic severity, patient civil/moral position regarding COVID-19 vaccine, and previous influenza vaccination were associated with VA. In Mexican patients with RDs, COVID-19 VA is associated with individual social-demographic and disease-related factors, patient´s perceptions, and previous record vaccination. This information is crucial for tailoring effective vaccine messaging in Mexican patients with RDs.
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Affiliation(s)
- Guillermo Arturo Guaracha-Basañez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Irazú Contreras-Yáñez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | | | | | - Diana Elsa Flores-Alvarado
- Rheumatology Department, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - Dionicio Ángel Galarza-Delgado
- Rheumatology Department, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Perla Rocío Martínez-Leyva
- Rheumatology Department, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - Conrado García-García
- Department of Rheumatology, Hospital General de México "Dr. Eduardo Liceaga", México City, México
| | - Gabriel Medrano-Ramírez
- Department of Rheumatology, Hospital General de México "Dr. Eduardo Liceaga", México City, México
| | | | - César Pacheco-Tena
- Facultad de Medicina y Universidad Autónoma de Chihuahua, Chihuahua, Mexico
| | - Ingris Peláez-Ballestas
- Department of Rheumatology, Hospital General de México "Dr. Eduardo Liceaga", México City, México
| | - Virginia Pascual-Ramos
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
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Schreiber K, Frishman M, Russell MD, Dey M, Flint J, Allen A, Crossley A, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: comorbidity medications used in rheumatology practice. Rheumatology (Oxford) 2022; 62:e89-e104. [PMID: 36318967 PMCID: PMC10070063 DOI: 10.1093/rheumatology/keac552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Karen Schreiber
- Thrombosis & Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust , London, UK
- Department of Rheumatology, Danish Hospital for Rheumatic Diseases , Sonderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark , Odense, Denmark
| | - Margreta Frishman
- Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust , London, UK
| | - Mark D Russell
- Centre for Rheumatic Diseases, King’s College London , London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool , Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust , Shropshire, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology , London, UK
| | | | - Mary Gayed
- Rheumatology, University Hospital Birmingham NHS Foundation Trust , Birmingham, UK
| | - Kenneth Hodson
- The UK Teratology Information Service , Newcastle upon Tyne, UK
| | - Munther Khamashta
- Division of Women’s Health, Lupus Research Unit, King's College London , London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady’s Hospice and Care Service , Dublin, Ireland
| | - Sonia Panchal
- Rheumatology, South Warwickshire NHS Foundation Trust , Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital , Bath, UK
| | | | - Katherine Saxby
- Pharmacology, University College London Hospitals NHS Foundation Trust , London, UK
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust , London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham NHS Trust , Birmingham, UK
| | | | - Louise Warburton
- Shropshire Community NHS Trust , Shropshire, UK
- Primary Care and Health Sciences, Keele University , Keele, UK
| | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust , London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw, Teaching Hospitals NHS Foundation Trust , Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham , Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London , London, UK
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Novella-Navarro M, Balsa A. Difficult-to-Treat Rheumatoid Arthritis in Older Adults: Implications of Ageing for Managing Patients. Drugs Aging 2022; 39:841-849. [PMID: 36104655 PMCID: PMC9626415 DOI: 10.1007/s40266-022-00976-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2022] [Indexed: 11/30/2022]
Abstract
Difficult-to-treat rheumatoid arthritis is a heterogeneous term in which patients may present with difficulties in their management for different reasons. This can ultimately lead to patients being exposed to multiple treatments because of inefficacy (resulting from mechanisms intrinsic to rheumatoid arthritis or from non-inflammatory causes such as chronic pain syndrome or structural damage, among others), toxicity or adverse effects that may be linked to comorbidities. One particular group in which such characteristics may be more patent is older patients. Increasing life expectancy, an ageing population and the late onset of rheumatoid arthritis have led to an increased interest in the particularities of treating older patients. This may pose a challenge for physicians, as ageing has implications for optimal patient treatment owing to the potential presence of comorbidities, the risk of adverse events and perceptions of disease status by both physicians and patients. All of these factors may have implications for classifying and managing patients aged > 65 years as difficult-to-treat rheumatoid arthritis, as these patients could be misclassified. This can occur when a significant proportion may still exhibit signs of active disease but not necessarily be difficult to treat because the treatment criterion has not been fulfilled. Alternatively, patients may be exposed to multiple biologic/targeted disease-modifying antirheumatic drugs because of contraindications and/or comorbid conditions. Treatment-to-target strategies and an adequate assessment of inflammatory rheumatoid arthritis activity in older patients should be undertaken, taking special care with associated comorbidities, polypharmacy and risk profiles. Such an approach can help to ensure appropriate treatment for older adults and avoid the misclassification of difficult-to-treat patients.
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Affiliation(s)
| | - Alejandro Balsa
- Rheumatology Department, Hospital Universitario La Paz, Madrid, Spain
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