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Torlinska B, Raza K, Filer A, Jutley G, Sahbudin I, Singh R, de Pablo P, Rankin E, Rhodes B, Amft N, Justice E, McGrath C, Baskar S, Trickey J, Calvert M, Falahee M. Predictors of quality of life, functional status, depression and fatigue in early arthritis: comparison between clinically suspect arthralgia, unclassified arthritis and rheumatoid arthritis. BMC Musculoskelet Disord 2024; 25:307. [PMID: 38643104 PMCID: PMC11031996 DOI: 10.1186/s12891-024-07446-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 04/15/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is often preceded by symptomatic phases during which classification criteria are not fulfilled. The health burden of these "at-risk" stages is not well described. This study assessed health-related quality of life (HRQoL), function, fatigue and depression in newly presenting patients with clinically suspect arthralgia (CSA), unclassified arthritis (UA) or RA. METHODS Cross-sectional analysis of baseline Patient-Reported Outcome Measures (PROMs) was conducted in patients from the Birmingham Early Arthritis Cohort. HRQoL, function, depression and fatigue at presentation were assessed using EQ-5D, HAQ-DI, PHQ-9 and FACIT-F. PROMs were compared across CSA, UA and RA and with population averages from the HSE with descriptive statistics. Multivariate linear regression assessed associations between PROMs and clinical and sociodemographic variables. RESULTS Of 838 patients included in the analysis, 484 had RA, 200 had CSA and 154 had UA. Patients with RA reported worse outcomes for all PROMs than those with CSA or UA. However, "mean EQ-5D utilities were 0.65 (95%CI: 0.61 to 0.69) in CSA, 0.61 (0.56 to 0.66) in UA and 0.47 (0.44 to 0.50) in RA, which was lower than in general and older (≥ 65 years) background populations." In patients with CSA or UA, HRQoL was comparable to chronic conditions such as heart failure, severe COPD or mild angina. Higher BMI and older age (≥ 60 years) predicted worse depression (PHQ-9: -2.47 (-3.85 to -1.09), P < 0.001) and fatigue (FACIT-F: 5.05 (2.37 to 7.73), P < 0.001). Women were more likely to report worse function (HAQ-DI: 0.13 (0.03 to 0.21), P = 0.01) and fatigue (FACIT-F: -3.64 (-5.59 to -1.70), P < 0.001), and residents of more deprived areas experienced decreased function (HAQ-DI: 0.23 (0.10 to 0.36), P = 0.001), greater depression (PHQ-9: 1.89 (0.59 to 3.18), P = 0.004) and fatigue (FACIT-F: -2.60 (-5.11 to 0.09), P = 0.04). After adjustments for confounding factors, diagnostic category was not associated with PROMs, but disease activity and polypharmacy were associated with poorer performance across all PROMs. CONCLUSIONS Patient-reported outcomes were associated with disease activity and sociodemographic characteristics. Patients presenting with RA reported a higher health burden than those with CSA or UA, however HRQoL in the pre-RA groups was significantly lower than population averages.
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Affiliation(s)
- Barbara Torlinska
- Centre for Patient-Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
| | - Karim Raza
- Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2WB, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research and the Research into Inflammatory Arthritis Centre Versus Arthritis, University of Birmingham, Birmingham, UK
| | - Andrew Filer
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2WB, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research and the Research into Inflammatory Arthritis Centre Versus Arthritis, University of Birmingham, Birmingham, UK
| | - Gurpreet Jutley
- Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2WB, UK
| | - Ilfita Sahbudin
- Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2WB, UK
- Department of Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ruchir Singh
- Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2WB, UK
| | - Paola de Pablo
- Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2WB, UK
| | - Elizabeth Rankin
- Department of Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Benjamin Rhodes
- Department of Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nicole Amft
- Department of Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Justice
- Department of Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Catherine McGrath
- Department of Rheumatology, Frimley Park Hospital NHS Foundation Trust, Camberley, UK
| | - Sangeetha Baskar
- Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Jeanette Trickey
- Department of Rheumatology, The County Hospital, Wye Valley NHS Trust, Hereford, UK
| | - Melanie Calvert
- Centre for Patient-Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
- National Institute for Health Research (NIHR) Applied Research Centre West Midlands, Birmingham, UK
- Health Data Research UK, London, UK
| | - Marie Falahee
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2WB, UK.
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2
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Boeren AMP, Khidir SJH, de Jong PHP, van der Helm-van Mil AHM, van Mulligen E. Patient-reported swelling in arthralgia patients at risk for rheumatoid arthritis: is it of value? Rheumatology (Oxford) 2023:kead606. [PMID: 37952171 DOI: 10.1093/rheumatology/kead606] [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: 06/28/2023] [Revised: 09/26/2023] [Accepted: 10/27/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE Patients with Clinically Suspect Arthralgia (CSA) are at risk for developing Rheumatoid Arthritis (RA). These patients often report joint swelling while this is not objectified by physical examination. To explore the value of patient-reported swelling in CSA, we aimed to determine its association with subclinical joint-inflammation on imaging and RA-development. METHODS In two independent, similarly designed CSA-cohorts from the Netherlands, symptomatic patients at risk for RA were studied. At baseline, patients indicated whether they had experienced swelling in hand joints. Subclinical joint-inflammation was assessed with MRI or ultrasound (US). Patients were followed for inflammatory arthritis development. RESULTS In total, 534 CSA-patients from two independent cohorts were studied, patient-reported swelling was present in 57% in cohort 1, and in 43% in cohort 2. In both cohorts patient-reported swelling was associated with subclinical joint-inflammation. Using MRI, it associated specifically with tenosynovitis (OR 3.7 (95%CI 2.0-6.9)) and when using US with synovitis (OR 2.3 (95%CI 1.04-5.3)). CSA-patients with self-reported swelling at baseline developed arthritis more often, with hazard ratios of 3.7 (95%CI 2.0-6.9) and 3.4 (95%CI 1.4-8.4) in cohort 1 and 2, respectively. This was independent of clinical predictors (e.g. morning stiffness), autoantibody-positivity and US-detected subclinical joint-inflammation. However, when corrected for MRI-detected subclinical joint-inflammation, self-reported swelling was no longer an independent predictor. CONCLUSION Patient-reported joint swelling in CSA relates to subclinical joint-inflammation and is an independent risk factor for RA-development, but it is less predictive than the presence of MRI-detected subclinical joint-inflammation.
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Affiliation(s)
- Anna M P Boeren
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sarah J H Khidir
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pascal H P de Jong
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elise van Mulligen
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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3
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van Boheemen L, Ter Wee MM, Falahee M, Filer A, van Beers-Tas M, Finckh A, Hensvold A, Raza K, van Schaardenburg D. The Symptoms in Persons At Risk of Rheumatoid Arthritis (SPARRA) questionnaire: predicting clinical arthritis development. Scand J Rheumatol 2023; 52:460-467. [PMID: 36174085 DOI: 10.1080/03009742.2022.2116806] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE There is a need to better define symptom characteristics associated with arthritis development in individuals at risk of rheumatoid arthritis (RA). We investigated whether reported symptoms in at-risk individuals could predict arthritis development and whether predictive symptoms differed between seropositive and seronegative at-risk individuals. METHOD At-risk individuals from four cohorts (Netherlands, UK, Sweden, and Switzerland) completed the Symptoms in Persons At Risk of Rheumatoid Arthritis (SPARRA) questionnaire. Participants had either (i) anti-citrullinated protein antibodies and/or rheumatoid factor, or (ii) relevant symptoms with or without RA antibodies. Follow up was ≥ 24 months or until clinical arthritis development. Stepwise forward selection created SPARRA prediction models for the combined group and for a seropositive subgroup. RESULTS Of 214 participants, the mean age was 50 years, 67% were female, and 27% (n = 58) developed clinical arthritis after a median time of 7 months. Four symptoms predicted arthritis development: self-reported joint swelling, joint pain moving from side to side (combined group only), feeling pins and needles in the joints, and often feeling fatigued (predicting non-arthritis). CONCLUSION Specific symptoms can provide useful information to estimate a person's RA risk. Differences in predictive symptoms between seropositive and seronegative at-risk individuals need to be further investigated. Future research is needed to determine whether changes in symptoms over time improve prediction and to determine the value of SPARRA in optimizing the selection of individuals who need to consult a rheumatologist.
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Affiliation(s)
- L van Boheemen
- Department of Rheumatology, Amsterdam UMC, Academic Medical Center, Amsterdam, The Netherlands
- Department of Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - M M Ter Wee
- Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M Falahee
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - A Filer
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M van Beers-Tas
- Department of Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - A Finckh
- Department of Medicine, Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
| | - A Hensvold
- Department of Rheumatology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Centrum for Rheumatology, Academic Specialist Center, Stockholm, Sweden
| | - K Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - D van Schaardenburg
- Department of Rheumatology, Amsterdam UMC, Academic Medical Center, Amsterdam, The Netherlands
- Department of Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
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4
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Studenic P, Hensvold A, Kleyer A, van der Helm-van Mil A, Pratt AG, Sieghart D, Krönke G, Williams R, de Souza S, Karlfeldt S, Johannesson M, Krogh NS, Klareskog L, Catrina AI. Prospective Studies on the Risk of Rheumatoid Arthritis: The European Risk RA Registry. Front Med (Lausanne) 2022; 9:824501. [PMID: 35273981 PMCID: PMC8901993 DOI: 10.3389/fmed.2022.824501] [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: 11/29/2021] [Accepted: 01/28/2022] [Indexed: 12/14/2022] Open
Abstract
Background The accumulation of risk for the development of rheumatoid arthritis (RA) is regarded as a continuum that may start with interacting environmental and genetic factors, proceed with the initiation of autoimmunity, and result in the formation of autoantibodies such as anti-citrullinated peptide antibodies (ACPA). In parallel, at-risk individuals may be asymptomatic or experience joint pain (arthralgia) that is itself non-specific or clinically suspicious for evolving RA, even in the absence of overt arthritis. Optimal strategies for the management of people at-risk of RA, both for symptom control and to delay or prevent progression to classifiable disease, remain poorly understood. Methods To help address this, groups of stakeholders from academia, clinical rheumatology, industry and patient research partners have collaborated to advance understanding, define and study different phases of the at-risk state. In this current report we describe different European initiatives in the field and the successful effort to build a European Registry of at-risk people to facilitate observational and interventional research. Results We outline similarities and differences between cohorts of at-risk individuals at institutions spanning several countries, and how to best combine them within the new database. Over the past 2 years, besides building the technical infrastructure, we have agreed on a core set of variables that all partners should strive to collect for harmonization purposes. Conclusion We emphasize to address this process from different angles and touch on the biologic, epidemiologic, analytic, and regulatory aspects of collaborative studies within a meta-database of people at-risk of RA.
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Affiliation(s)
- Paul Studenic
- Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden.,Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Aase Hensvold
- Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden.,Academic Specialist Centre-Stockholm Health Care Services, Centre for Rheumatology, Stockholm, Sweden
| | - Arnd Kleyer
- Universitätsklinikum Erlangen, Deutsches Zentrum Immuntherapie, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.,Department of Internal Medicine 3 - Rheumatology and Immunology, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Annette van der Helm-van Mil
- Department of Rheumatology, Leids Universitair Medisch Centrum, Leiden, Netherlands.,Department of Rheumatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Arthur G Pratt
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.,Musculoskeletal Services Directorate, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Daniela Sieghart
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Gerhard Krönke
- Universitätsklinikum Erlangen, Deutsches Zentrum Immuntherapie, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.,Department of Internal Medicine 3 - Rheumatology and Immunology, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Ruth Williams
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - Savia de Souza
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - Susanne Karlfeldt
- Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden.,Academic Specialist Centre-Stockholm Health Care Services, Centre for Rheumatology, Stockholm, Sweden
| | - Martina Johannesson
- Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden
| | | | - Lars Klareskog
- Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden.,Rheumatology Section, Theme Inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden
| | - Anca I Catrina
- Department of Medicine Solna, Division of Rheumatology, Karolinska Institutet, Stockholm, Sweden
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5
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Hensvold A, Klareskog L. Towards prevention of autoimmune diseases: The example of rheumatoid arthritis. Eur J Immunol 2021; 51:1921-1933. [PMID: 34110013 DOI: 10.1002/eji.202048952] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/18/2021] [Indexed: 12/16/2022]
Abstract
Prevention is the ultimate aim for clinicians and scientists concerned with severe diseases, like many immune-mediated conditions. Here, we describe recent progress in the understanding of etiology and molecular pathogenesis of rheumatoid arthritis (RA), which make this disease a potential prototype for prevention that may include both public health measures and targeted and personalized approaches that we call "personalized prevention." Critical components of this knowledge are (i) better understanding of the dynamics of the RA-associated autoimmunity that may begin many years before onset of joint inflammation; (ii) insights into how this immunity may be triggered at mucosal surfaces after distinct environmental challenges; (iii) better understanding of which features of the pre-existing immunity may cause symptoms that precede joint inflammation and predict a high risk for imminent arthritis development; and (iv) how molecular events occurring before onset of inflammation might be targeted by existing or future therapies, ultimately by specific targeting of Major histocompatibility complex (MHC) class II restricted and RA-specific immunity. Our main conclusion is that studies and interventions in the phase of autoimmunity preceding RA offer new opportunities to prevent the disease and thereby also understand the molecular pathogenesis of its different variants.
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Affiliation(s)
- Aase Hensvold
- Division of Rheumatology, Department of Medicine, Karolinska Institutet and Karolinska University Hospital (Solna), Stockholm, Sweden.,Center for Rheumatology, Academic Specialist Center, Stockholm, Sweden
| | - Lars Klareskog
- Division of Rheumatology, Department of Medicine, Karolinska Institutet and Karolinska University Hospital (Solna), Stockholm, Sweden.,Center for Rheumatology, Academic Specialist Center, Stockholm, Sweden.,Rheumatology Section, Theme inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden
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6
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The pre-clinical phase of rheumatoid arthritis: From risk factors to prevention of arthritis. Autoimmun Rev 2021; 20:102797. [PMID: 33746022 DOI: 10.1016/j.autrev.2021.102797] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/29/2021] [Indexed: 02/06/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease considered as a multistep process spanning from the interaction of genetic (e.g., shared epitope or non-HLA loci), environmental and behavioral risk factors (e.g., smoking) leading to breaking immune tolerance and autoimmune processes such as the production of autoantibodies (e.g., antibodies against citrullinated proteins ACPA or rheumatoid factors, RF), development of the first symptoms without clinical arthritis, and, finally, the manifestation of arthritis. Despite the typical joint involvement in established RA, the pathogenesis of the disease likely begins far from joint structures: in the lungs or periodontium in association with citrullination, intestinal microbiome, or adipose tissue, which supports normal findings in synovial tissue in ACPA+ patients with arthralgia. The presence of ACPA is detectable even years before the first manifestation of RA. The pre-clinical phase of RA is the period preceding clinically apparent RA with ACPA contributing to the symptoms without subclinical inflammation. While the combination of ACPA and RF increases the risk of progression to RA by up to 10 times, increasing numbers of novel autoantibodies are to be investigated to contribute to the increased risk and pathogenesis of RA. With growing knowledge about the course of RA, new aspiration emerges to cure and even prevent RA, shifting the "window of opportunity" to the pre-clinical phases of RA. The clinical definition of individuals at risk of developing RA (clinically suspect arthralgia, CSA) makes it possible to unify these at-risk individuals' clinical characteristics for "preventive" treatment in ongoing clinical trials using mostly biological or conventional synthetic disease-modifying drugs. However, the combination of symptoms, laboratory, and imaging biomarkers may be the best approach to select the correct target at-risk population. The current review aims to explore different phases of RA and discuss the potential of (non)pharmacological intervention aiming to prevent RA.
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7
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Armstrong D, Dregan A, Ashworth M, White P, McGee C, de Lusignan S. Influence of prior antibiotic use on risk of rheumatoid arthritis: case control study in general practice. Rheumatology (Oxford) 2019; 59:1281-1287. [DOI: 10.1093/rheumatology/kez452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/26/2019] [Indexed: 01/07/2023] Open
Abstract
Abstract
Objectives
To test the hypothesis that prior antibiotics influences the risk of developing RA.
Methods
A case–control study was conducted over 15 years using the UK’s Royal College of General Practitioners Research and Surveillance Centre database. The frequency and type of antibiotic prescription for patients who subsequently developed RA were compared with antibiotic prescriptions in a control group of patients who remained free of RA. Cases, defined as patients with a new diagnosis of RA made between 2006 and 2018, were matched with up to four RA-free controls on practice, age, gender and date of diagnosis. Exposure was measured by the number and type of prescriptions for antibiotics prior to the RA diagnosis or to the index date in controls.
Results
A total of 8482 patients with a new diagnosis of RA between 2006 and 2018 were compared with 22 661 controls. There was a higher likelihood of an RA diagnosis after antibiotic prescriptions within 1 year, 5 years and ever with a strong dose–response. Patients receiving >10 antibiotics in a 5 year period were more than twice as likely to receive an RA diagnosis as controls [adjusted odds ratio 2.65 (CI 2.40, 2.93)].
Conclusion
Exposure to antibiotics prior to the diagnosis was a significant risk factor for RA. This could reflect an immunological response to a compromised microbiome. Alternatively, patients with pre-symptomatic or early undiagnosed RA may have been more likely to present to their general practitioner with infections due to an unrecognized effect of RA.
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Affiliation(s)
- David Armstrong
- Department of Population Health Sciences, King’s College London
| | - Alex Dregan
- Department of Psychological Medicine, Institute of Psychiatry, Psychological, and Neurosciences, King’s College London, London
| | - Mark Ashworth
- Department of Population Health Sciences, King’s College London
| | - Patrick White
- Department of Population Health Sciences, King’s College London
| | - Chris McGee
- Department of Clinical and Experimental Medicine, Surrey University, Guildford
- Royal College of General Practitioners Research and Surveillance Centre, London, UK
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, Surrey University, Guildford
- Royal College of General Practitioners Research and Surveillance Centre, London, UK
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8
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De Cock D, Van der Elst K, Stouten V, Peerboom D, Joly J, Westhovens R, Verschueren P. The perspective of patients with early rheumatoid arthritis on the journey from symptom onset until referral to a rheumatologist. Rheumatol Adv Pract 2019; 3:rkz035. [PMID: 32083241 PMCID: PMC7018614 DOI: 10.1093/rap/rkz035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/05/2019] [Indexed: 12/25/2022] Open
Abstract
Objective Timely treatment of patients with early RA (ERA) favours a beneficial disease outcome. However, individuals often delay their contact with a health-care professional (HCP) after ERA-related symptom onset. The aim of this study was to investigate the perspective of patients on the journey of a patient from RA symptom onset until referral to a specialist. Methods A subgroup of patients with ERA from the Care in ERA (CareRA) trial were interviewed retrospectively to discuss their initial ERA-related experiences preceding diagnosis, using a bespoke assessment form. The first section of the form focused on initial symptoms and help-seeking behaviour by the patients. The second part probed the actions of the HCPs consulted. Additional notes derived from the patient stories were analysed thematically. Results Among 94 patients, pain (97%), swelling (73%) and stiffness (52%), typically in multiple joints, were reported as initial ERA symptoms. The general practitioner (GP) was generally the first HCP to be contacted (87%). Frequently reported reasons to visit an HCP were intense pain (90.4%) and difficulties in performing daily activities (69%). In 44.1% of patients, the HCP suspected ERA at the first visit. Approximately 25% of patients needed more than five visits before detection of ERA. GPs mainly referred patients to rheumatologists (71%). Thematic analysis uncovered that multiple HCPs were often involved in the journey to RA detection and referral. Conclusion Pain is the most commonly reported initial symptom of ERA and the main reason to visit an HCP, usually a GP. These GPs play a pivotal role in early detection and correct referral. Furthermore, the journey of a patient seems complex, often with multiple HCPs being involved.
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Affiliation(s)
- Diederik De Cock
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, University of Leuven, Leuven, Belgium
| | - Kristien Van der Elst
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, University of Leuven, Leuven, Belgium
| | - Veerle Stouten
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, University of Leuven, Leuven, Belgium
| | - Donna Peerboom
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, University of Leuven, Leuven, Belgium
| | - Johan Joly
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, University of Leuven, Leuven, Belgium
| | - Rene Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, University of Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, University of Leuven, Leuven, Belgium
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9
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Raza K, Holers VM, Gerlag D. Nomenclature for the Phases of the Development of Rheumatoid Arthritis. Clin Ther 2019; 41:1279-1285. [PMID: 31196657 DOI: 10.1016/j.clinthera.2019.04.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/27/2019] [Accepted: 04/10/2019] [Indexed: 12/26/2022]
Abstract
Rheumatoid arthritis (RA) is a common immune-mediated inflammatory disease. Research on RA is increasingly focused on the earliest stages of the disease, and has provided strong evidence that clinical signs and symptoms may be preceded by a preclinical phase during which evidence of systemic autoimmunity may be present. To facilitate research in this area, a number of international initiatives have proposed definitions of the phases of disease leading up to RA. The first of these initiatives was the European League Against Rheumatism's (EULAR) set of recommendations on terminology in persons at risk for RA, which suggested that the "at-risk phases" be described in terms of patients variably having: (A) genetic risk factors for RA; (B) environmental risk factors for RA; (C) systemic autoimmunity associated with RA; (D) symptoms without clinical arthritis; and (E) unclassified arthritis. The phrase clinically suspect arthralgia (CSA) is now widely used and can be regarded as describing a subgroup of patients in phase D. A definition of CSA was recently proposed by a EULAR taskforce, and primary research has begun to explore the full range of symptoms, as well as their sensitivity and specificity alone and in combination with other factors, that characterize this phase. Similarly, immune abnormalities at mucosal and others sites that precede and/or are associated with the onset of musculoskeletal symptoms are being increasingly studied and understood. Whether some of these at-risk phases, in particular CSA, represent entities meriting their own classification criteria is an essential area for consensus and will be discussed.
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Affiliation(s)
- Karim Raza
- Institute of Inflammation and Ageing, Arthritis Research UK Rheumatoid Arthritis Centre of Excellence, Medical Research Council Arthritis Research UK Centre for Musculoskeletal Ageing, University of Birmingham, Birmingham, United Kingdom; Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.
| | - V Michael Holers
- Division of Rheumatology, University of Colorado-Denver, Aurora, CO, USA
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10
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Falahee M, Finckh A, Raza K, Harrison M. Preferences of Patients and At-risk Individuals for Preventive Approaches to Rheumatoid Arthritis. Clin Ther 2019; 41:1346-1354. [PMID: 31196645 DOI: 10.1016/j.clinthera.2019.04.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/22/2019] [Accepted: 04/10/2019] [Indexed: 02/07/2023]
Abstract
Effective treatments for rheumatoid arthritis (RA) are available and can lead to remission for some patients, but most patients remain on potentially toxic and expensive medications in the long term. Interest is increasingly turning to the disease phases preceding the development of RA that represent opportunities for preventive interventions. At-risk target populations include individuals with genetic and environmental risk factors, those who have developed systemic autoimmunity, and those who have developed clinically suspect symptoms (eg, arthralgias without synovitis, or an early arthritis). Ongoing prospective studies will inform the development of increasingly accurate predictive tools to identify individuals at risk of developing RA. Furthermore, a range of preventive approaches has been suggested, including lifestyle modification (eg, smoking cessation) and pharmacologic interventions (eg, hydroxychloroquine, methotrexate, abatacept, rituximab) that are currently the subject of randomized controlled trials. As prediction and prevention of RA evolve, it is increasingly likely that individuals at risk (including asymptomatic individuals) may be faced with complex decisions about whether to accept assessment of their risk status or to take a preventive intervention associated with risk of serious adverse events and uncertain benefit. Acceptance of preventive medication in other contexts can be low. For example, <25% of women at high risk of breast cancer are willing to take preventive hormonal treatments. Actual uptake is lower still. Patients' beliefs and preferences predict treatment uptake and adherence. Before the dream of preventing RA can become reality, health care providers need to understand the perspectives of individuals in the target population and to identify barriers and facilitators for this approach. This commentary reviews what is currently known about the perspectives of patients and individuals at risk about predictive and preventive approaches for RA and identifies gaps to be addressed to inform the development of efficient preventive strategies.
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Affiliation(s)
- Marie Falahee
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.
| | - Axel Finckh
- Department of Rheumatology, Geneva University Hospital, Geneva, Switzerland
| | - Karim Raza
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Rheumatology, Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom; Arthritis Research UK Rheumatoid Arthritis Pathogenesis Centre of Excellence, MRC Arthritis Research UK Centre for Musculoskeletal Ageing Research, NIHR Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada; Arthritis Research Centre of Canada, Richmond, British Columbia, Canada
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11
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Muller S, Hider S, Machin A, Stack R, Hayward RA, Raza K, Mallen C. Searching for a prodrome for rheumatoid arthritis in the primary care record: A case-control study in the clinical practice research datalink. Semin Arthritis Rheum 2019; 48:815-820. [PMID: 30072114 DOI: 10.1016/j.semarthrit.2018.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/08/2018] [Accepted: 06/18/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Rheumatoid arthritis (RA) has articular and non-articular manifestations. Early, intensive treatment has substantial benefit for both. This requires patients be identified as soon as symptoms develop. OBJECTIVES To determine whether selected signs and symptoms can be identified in the primary care records of patients prior to a formal diagnosis of RA being made and, if so, how early they can be identified. METHODS A case-control study was constructed within the UK Clinical Practice Research Datalink (CPRD). 3577 individuals with 'definite' RA, were matched to 14,287 individuals without inflammatory arthritis. An index date was established (i.e., date general practitioner (GP) first appeared to suspect RA). Rates of consultation and consultations for suspected early RA symptoms were compared in cases and controls in the two years prior to the index date using conditional logistic regression, adjusted for number of consultations. RESULTS The mean (standard deviation) age of participants was 58.8 (14.5) years and 66.8% were female. Rates of any consultation were significantly higher in RA cases than in controls for at least two years prior to the index date. Cases were more likely to have a pre-diagnosis coded consultation for joint, and particularly hand symptoms (aOR 11.44 (9.60, 13.63)), morning stiffness (8.10 (3.54, 18.5)), carpal tunnel syndrome (4.57 (3.54, 5.88)) and other non-articular features. CONCLUSIONS In patients who develop RA, GP consultation rates are higher for at least two years prior to the first recorded suspicion of RA. This study highlights symptoms that should raise a GP's index of suspicion for RA.
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Affiliation(s)
- Sara Muller
- Research Institute for Primary Care & Health Sciences, David Weatherall Building, Keele University, Keele, Staffordshire ST5 5BG, UK.
| | - Samantha Hider
- Research Institute for Primary Care & Health Sciences, David Weatherall Building, Keele University, Keele, Staffordshire ST5 5BG, UK; Haywood Academic Rheumatology Centre, Haywood Hospital, Stoke-on-Trent, UK.
| | - Annabelle Machin
- Research Institute for Primary Care & Health Sciences, David Weatherall Building, Keele University, Keele, Staffordshire ST5 5BG, UK
| | - Rebecca Stack
- College of Business Law & Social Sciences, Nottingham Trent University, Nottingham, UK
| | - Richard A Hayward
- Research Institute for Primary Care & Health Sciences, David Weatherall Building, Keele University, Keele, Staffordshire ST5 5BG, UK
| | - Karim Raza
- Institute of Inflammation and Ageing, Arthritis Research UK Rheumatoid Arthritis Pathogenesis Centre of Excellence and MRC Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, UK; Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Christian Mallen
- Research Institute for Primary Care & Health Sciences, David Weatherall Building, Keele University, Keele, Staffordshire ST5 5BG, UK
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12
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Holla JFM, van Beers-Tas MH, van de Stadt LA, Landewé R, Twisk JWR, Dekker J, van Schaardenburg D. Depressive mood and low social support are not associated with arthritis development in patients with seropositive arthralgia, although they predict increased musculoskeletal symptoms. RMD Open 2018; 4:e000653. [PMID: 30018798 PMCID: PMC6045698 DOI: 10.1136/rmdopen-2018-000653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/06/2018] [Accepted: 04/21/2018] [Indexed: 11/29/2022] Open
Abstract
Objective Studies on the role of psychosocial vulnerability in the development of arthritis must be performed early in the disease course to exclude the reverse explanation that arthritis leads to psychological symptoms. Therefore, the objective of this study was to investigate the longitudinal (5-year) association between depressive mood, daily stressors, avoidance coping and social support as predictors, and the development of arthritis and other clinical parameters as outcomes, in persons with seropositive arthralgia at risk of developing rheumatoid arthritis. Methods Five-year follow-up data of 231 patients from the Reade seropositive arthralgia cohort were used. Clinical and psychological data were collected using physical examinations and questionnaires. Mixed models and Cox regression analyses were used to assess the 5-year associations between depressive mood, daily stressors, avoidance coping or social support, and the development of arthritis or clinical parameters (tender joint count, Visual Analogue Scale (VAS) pain, VAS morning stiffness and erythrocyte sedimentation rate (ESR)). Results Higher scores for depressive mood and lower scores for social support were not associated with the development of arthritis nor with ESR. However, they were longitudinally associated with an increase in pain (p<0.001), morning stiffness (p<0.01) and tender joint count (p<0.001). No consistent associations were found between daily stressors, avoidance coping and the development of arthritis or other clinical parameters. Conclusion Although an effect on the development of arthritis could not be demonstrated, a strong longitudinal association was found between high depressive mood, low social support and clinical parameters. In persons with seropositive arthralgia, depressive symptoms and low social support may increase musculoskeletal symptoms.
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Affiliation(s)
- Jasmijn F M Holla
- Amsterdam Rehabilitation Research Center, Reade, Amsterdam, The Netherlands
| | | | - Lotte A van de Stadt
- Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Robert Landewé
- Amsterdam Rheumatology and immunology Center, Academic Medical Center, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Joost Dekker
- Amsterdam Rehabilitation Research Center, Reade, Amsterdam, The Netherlands.,Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, The Netherlands.,Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands.,Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Dirkjan van Schaardenburg
- Amsterdam Rheumatology and immunology Center, Reade, Amsterdam, The Netherlands.,Amsterdam Rheumatology and immunology Center, Academic Medical Center, Amsterdam, The Netherlands
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13
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van Beers-Tas MH, Ter Wee MM, van Tuyl LH, Maat B, Hoogland W, Hensvold AH, Catrina AI, Mosor E, Stamm TA, Finckh A, Courvoisier DS, Filer A, Sahbudin I, Stack RJ, Raza K, van Schaardenburg D. Initial validation and results of the Symptoms in Persons At Risk of Rheumatoid Arthritis (SPARRA) questionnaire: a EULAR project. RMD Open 2018; 4:e000641. [PMID: 29862044 PMCID: PMC5976102 DOI: 10.1136/rmdopen-2017-000641] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 04/06/2018] [Accepted: 04/11/2018] [Indexed: 11/04/2022] Open
Abstract
Objectives To describe the development and assess the psychometric properties of the novel 'Symptoms in Persons At Risk of Rheumatoid Arthritis' (SPARRA) questionnaire in individuals at risk of rheumatoid arthritis (RA) and to quantify their symptoms. Methods The questionnaire items were derived from a qualitative study in patients with seropositive arthralgia. The questionnaire was administered to 219 individuals at risk of RA on the basis of symptoms or autoantibody positivity: 74% rheumatoid factor and/or anticitrullinated protein antibodies positive, 26% seronegative. Validity, reliability and responsiveness were assessed. Eighteen first degree relatives (FDR) of patients with RA were used for comparison. Results Face and content validity were high. The test-retest showed good agreement and reliability (1 week and 6 months). Overall, construct validity was low to moderate, with higher values for concurrent validity, suggesting that some questions reflect symptom content not captured with regular Visual Analogue Scale pain/well-being. Responsiveness was low (small subgroup). Finally, the burden of symptoms in both seronegative and seropositive at risk individuals was high, with pain, stiffness and fatigue being the most common ones with a major impact on daily functioning. The FDR cohort (mostly healthy individuals) showed a lower burden of symptoms; however, the distribution of symptoms was similar. Conclusions The SPARRA questionnaire has good psychometric properties and can add information to currently available clinical measures in individuals at risk of RA. The studied group had a high burden and impact of symptoms. Future studies should evaluate whether SPARRA data can improve the prediction of RA in at risk individuals.
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Affiliation(s)
- Marian H van Beers-Tas
- Amsterdam Rheumatology and Immunology Center, Reade, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Marieke M Ter Wee
- Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Lilian H van Tuyl
- Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Bertha Maat
- Amsterdam Rheumatology and Immunology Center, Reade, Amsterdam, The Netherlands
| | - Wijnanda Hoogland
- Amsterdam Rheumatology and Immunology Center, Reade, Amsterdam, The Netherlands
| | | | | | - Erika Mosor
- Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria.,Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Tanja A Stamm
- Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Axel Finckh
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland.,Department of Medical Specialties, University of Geneva, Geneva, Switzerland
| | - Delphine S Courvoisier
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland.,Department of Medical Specialties, University of Geneva, Geneva, Switzerland
| | - Andrew Filer
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ilfita Sahbudin
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Rebecca J Stack
- Department of Psychology, Nottingham Trent University, Nottingham, UK
| | - Karim Raza
- Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Dirkjan van Schaardenburg
- Amsterdam Rheumatology and Immunology Center, Reade, Amsterdam, The Netherlands.,Amsterdam Rheumatology and Immunology Center, Amsterdam Medical Center, Amsterdam, The Netherlands
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14
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Twigg S, Nikiphorou E, Nam JL, Hunt L, Mankia K, Pentony PE, Freeston JE, Tan AL, Emery P. Comorbidities in Anti-Cyclic Citrullinated Peptide Positive At-Risk Individuals Do Not Differ from Those Patients with Early Inflammatory Arthritis. Front Med (Lausanne) 2018. [PMID: 29516000 PMCID: PMC5825886 DOI: 10.3389/fmed.2018.00035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Objectives To compare comorbidities in a cohort of cyclic citrullinated peptide (CCP) antibody positive patients without or prior to onset of inflammatory arthritis (IA) to those in patients with early IA. Methods Baseline data from two established cohorts were used. The first recruited people at risk of IA: CCP antibody positive cases without IA (CCP Cohort, n = 296). The second cohort [the Inflammatory Arthritis CONtinuum study (IACON)] recruited patients with early IA (n = 725). Proportions of patients with given comorbidities were compared between cohorts and then logistic regression was used to determine odds ratios (OR) for the CCP cohort having specific comorbidities, compared to IACON patients. Analyses adjusted for gender, age, smoking status, and body mass index. Results Patients from the CCP cohort were younger (mean age 50, compared to 53 years). The proportion of patients with at least one comorbidity was higher in the IACON than the CCP cohort: (40% compared to 24%, respectively). Results of logistic regression analyses suggested the odds of hypertension, taking a lipid-lowering agent, ischemic heart disease, cerebrovascular disease, lung disease, and diabetes were not increased in either cohort. However, patients in the CCP cohort were more likely to be taking an antidepressant (OR = 1.62, 95% CI 1.03, 2.56, p = 0.037). Conclusion There was no significant difference in comorbidities among people with CCP antibodies but without IA, compared to those of patients with established IA.
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Affiliation(s)
- Sarah Twigg
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom.,Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Elena Nikiphorou
- Academic Rheumatology Department, King's College London, London, United Kingdom
| | - Jackie L Nam
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Laura Hunt
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Kulveer Mankia
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Peta Elizabeth Pentony
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Jane E Freeston
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Ai Lyn Tan
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Paul Emery
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
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15
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Jutley GS, Latif ZP, Raza K. Symptoms in individuals at risk of rheumatoid arthritis. Best Pract Res Clin Rheumatol 2017; 31:59-70. [PMID: 29221599 DOI: 10.1016/j.berh.2017.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 08/04/2017] [Accepted: 08/04/2017] [Indexed: 11/27/2022]
Abstract
An increasing interest in treating individuals at risk of rheumatoid arthritis (RA) to prevent the development of this chronic condition has focussed attention on the identification of risk factors of this disease. Most patients who develop RA progress through a preceding symptomatic phase that may take the form of arthralgia, palindromic rheumatism or unclassified arthritis before a disease currently classifiable as RA is established. An understanding of symptoms that identify individuals as being at risk of RA is a critical issue. Constellations of relevant symptoms could (1) form the basis of public health campaigns to encourage rapid consultation, (2) inform primary health care providers regarding which patients to perform additional tests in or whom to refer to a rheumatologist and (3) be included in algorithms to predict RA development. In this review, we present qualitative and quantitative data summarising current understanding of the symptoms experienced by individuals at risk of RA.
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Affiliation(s)
- Gurpreet Singh Jutley
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT UK
| | - Zahira P Latif
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT UK
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT UK.
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16
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Ten Brinck RM, van Steenbergen HW, Mangnus L, Burgers LE, Reijnierse M, Huizinga TW, van der Helm-van Mil AH. Functional limitations in the phase of clinically suspect arthralgia are as serious as in early clinical arthritis; a longitudinal study. RMD Open 2017; 3:e000419. [PMID: 28879045 PMCID: PMC5574454 DOI: 10.1136/rmdopen-2016-000419] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/04/2017] [Accepted: 02/14/2017] [Indexed: 12/22/2022] Open
Abstract
Introduction A phase of arthralgia may precede the emergence of rheumatoid arthritis (RA). Although several studies have focused on biomarkers, the relevance of this phase for patients is less studied. It is unknown if patients already have functional limitations and if this is correlated to the extent of subclinical inflammation. Therefore, we assessed functional disability in patients with clinically suspect arthralgia (CSA), its association with MRI-detected subclinical inflammation and its course during progression to clinical arthritis. Methods From April 2012 to March 2015, 241 patients had arthralgia for <1 year and were, based on clinical presentation, considered at risk for RA by their rheumatologists. At baseline, Health Assessment Questionnaire (HAQ) scores were determined and unilateral 1.5 T MRI of metacarpophalangeal, wrist and metatarsophalangeal joints were made. Presence of MRI-detected subclinical inflammation was assessed by summing synovitis, tenosynovitis and bone marrow oedema scores (range 0–189). Patients were followed on arthritis development and HAQ scores were repeated when clinical arthritis had developed. Results The median HAQ score at presentation with CSA was 0.50. Higher MRI-inflammation scores were associated with higher HAQ scores (β=0.017, 95% CI=0.004 to 0.030). During median 103 weeks follow-up, 44 patients progressed to clinical arthritis. HAQ scores ≥1.0 were associated with arthritis development (HR=2.50, 95% CI=1.03 to 6.10). Within converters, median HAQ scores did not increase from presentation with CSA to arthritis development (0.88 and 0.75, p=0.36). Conclusions HAQ scores ≥1.0 at presentation were associated with the development of clinical arthritis. Functional limitations in the prearthritis phase of CSA were as serious as in the early clinical phase, demonstrating the relevance of CSA from patients’ perspectives.
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Affiliation(s)
- Robin M Ten Brinck
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Lukas Mangnus
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Leonie E Burgers
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique Reijnierse
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom Wj Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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17
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van Steenbergen HW, Aletaha D, Beaart-van de Voorde LJJ, Brouwer E, Codreanu C, Combe B, Fonseca JE, Hetland ML, Humby F, Kvien TK, Niedermann K, Nuño L, Oliver S, Rantapää-Dahlqvist S, Raza K, van Schaardenburg D, Schett G, De Smet L, Szücs G, Vencovský J, Wiland P, de Wit M, Landewé RL, van der Helm-van Mil AHM. EULAR definition of arthralgia suspicious for progression to rheumatoid arthritis. Ann Rheum Dis 2016; 76:491-496. [DOI: 10.1136/annrheumdis-2016-209846] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 08/18/2016] [Accepted: 09/17/2016] [Indexed: 12/22/2022]
Abstract
BackgroundDuring the transition to rheumatoid arthritis (RA) many patients pass through a phase characterised by the presence of symptoms without clinically apparent synovitis. These symptoms are not well-characterised. This taskforce aimed to define the clinical characteristics of patients with arthralgia who are considered at risk for RA by experts based on their clinical experience.MethodsThe taskforce consisted of 18 rheumatologists, 1 methodologist, 2 patients, 3 health professionals and 1 research fellow. The process had three phases. In phase I, a list of parameters considered characteristic for clinically suspect arthralgia (CSA) was derived; the most important parameters were selected by a three-phased Delphi approach. In phase II, the experts evaluated 50 existing patients on paper, classified them as CSA/no-CSA and indicated their level of confidence. A provisional set of parameters was derived. This was studied for validation in phase III, where all rheumatologists collected patients with and without CSA from their outpatient clinics.ResultsThe comprehensive list consisted of 55 parameters, of which 16 were considered most important. A multivariable model based on the data from phase II identified seven relevant parameters: symptom duration <1 year, symptoms of metacarpophalangeal (MCP) joints, morning stiffness duration ≥60 min, most severe symptoms in early morning, first-degree relative with RA, difficulty with making a fist and positive squeeze test of MCP joints. In phase III, the combination of these parameters was accurate in identifying patients with arthralgia who were considered at risk of developing RA (area under the receiver operating characteristic curve 0.92, 95% CI 0.87 to 0.96). Test characteristics for different cut-off points were determined.ConclusionsA set of clinical characteristics for patients with arthralgia who are at risk of progression to RA was established.
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