Prevalence, mortality, and treatment of patients with rheumatoid arthritis: A cohort study of the French National Health Data System, 2010-2019

Disease activity during pregnancy in patients with rheumatoid arthritis or spondyloarthritis: results from the multicentre prospective GR2 study

BACKGROUND

Pregnancy may have a beneficial effect on disease activity in rheumatoid arthritis (RA) but the evidence is more conflicting in spondyloarthritis (SpA). The aim of this study was to analyse disease activity and relapse during pregnancy in women with RA and SpA.

METHODS

Consecutive pregnant women with RA or SpA were enrolled in this French multicentre observational cohort from 2014 to 2022. Women who had at least two prenatal visits (including one in the first trimester) were included in the analysis. Disease relapse was defined as treatment intensification (initiation or switch of a DMARD) or increase in disease activity scores (DAS28-CRP for RA patients; ASDAS-CRP and/or BASDAI for SpA patients).

RESULTS

Of the 124 pregnant women included, 53 had RA and 71 had SpA. A total of 18 (35%) RA and 44 (62%) SPA received a TNF inhibitor during pregnancy. At the group level, disease activity indexes remained stable in the 1st, 2nd and 3rd trimesters. Disease relapse during pregnancy occurred in 17 (32%) RA patients and 28 (39%) SpA patients, among whom 30 (24%) requiring a treatment intensification. In multivariable analysis, factors associated with disease relapse were nulliparity (odds ratio, OR: 6.5, 95%CI: 1.1 to 37.9) and a disease flare in the 12 months prior to conception (OR: 8.2, 95%CI: 1.6 to 42.7) for RA patients, and a history of bDMARD use (OR: 5.4, 95%CI: 1.1 to 27.3) for SpA patients.

CONCLUSION

Disease activity remained stable during pregnancy in women with RA and SpA but almost a quarter required major changes to their treatment.

Clinical presentation and treatment response in ACPA-negative rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease characterized by joint inflammation and potential extra-articular manifestations. This review compares the presentation and treatment response between anti-citrullinated protein antibodies (ACPA)-positive and ACPA-negative RA patients. The incidence of seronegative RA (rheumatoid factor [RF]-negative and ACPA-negative) has increased in recent decades, emphasizing the need for new diagnostic biomarkers. Diagnostically, ACPA is highly specific for RA, yet many patients remain ACPA-negative. The absence of RF and ACPA in RA should trigger further analysis to test alternative diagnosis, in particular when new symptoms arise. Emerging biomarkers like anti-PAD4 and anti-CarP antibodies provide additional diagnostic value, identifying some ACPA-negative patients. Clinically, ACPA-negative patients often exhibit higher disease activity at diagnosis, with more swollen joints and elevated CRP levels. They also tend to have fewer pulmonary and ocular manifestations compared to ACPA-positive patients. Radiographically, ACPA-positive patients are at a higher risk for joint erosions over time. Response to treatment also differs according to ACPA status. Abatacept and rituximab have demonstrated greater efficacy in ACPA-positive patients, showing better disease activity control and higher treatment retention rates. Continuous re-evaluation is crucial for ACPA-negative patients, especially when first-line treatments like methotrexate are ineffective, to rule out RA mimickers and adjust the treatment approach accordingly. These findings underscore the importance of personalized treatment strategies in RA management.

From a better knowledge of periodontal disease to Porphyromonas gingivalis target for rheumatoid arthritis disease activity

Periodontal disease (PD) and rheumatoid arthritis (RA) are both inflammatory diseases affecting the tooth and joint, with local inflammation associated with bone loss. Bacterial infections by oral bacteria are involved in periodontal inflammation, and the best known to be associated with PD is Porphyromonas gingivalis (Pg). A large body of recent data suggests a strong involvement of this specific bacteria, Pg, in PD outcomes, but also in RA. The aim of this review is to discuss the association between PD and Pg, RA and its mechanisms, and to determine whether targeting Pg bacteria could improve RA. Numerous epidemiological studies have already confirmed the association between PD and Pg, as well as between PD and RA, which is mainly associated with a common genetic background, the shared epitope. The involvement of Pg in pathogenesis of RA is supported by the induction of gingival citrullinated proteins and therefore of anti-citrullinated proteins antibodies, which constitute the most specific biomarker of RA. The prevalence of Pg in RA is still controversial, but studies should include patients with preclinical and early RA. Finally, recent data confirmed that targeting Pg is highly effective in improving RA.

A comparative assessment of rheumatoid arthritis burden: trends in China, the US, India, Europe, and globally from 1990 to 2021 and forecasts to 2030 utilizing GBD data

BACKGROUND

Rheumatoid arthritis (RA) is a pervasive chronic inflammatory condition exerting a substantial impact on global morbidity and mortality. This study provides an in-depth analysis of the epidemiological trends of RA across China, America, India, and Europe as well as at a global level from 1990 to 2021, with forward-looking projections extending to 2030.

METHODS

Leveraging data from the Global Burden of Disease (GBD) database, a comparative assessment of the age-standardized (AS) incidence rate (ASIR), prevalence rate (ASPR), mortality rate (ASMR), and disability-adjusted life years (DALYs) rate (ASDR) for RA was performed. Trends were evaluated and future burdens forecasted using Joinpoint regression and autoregressive integrated moving average (ARIMA) models.

RESULTS

Between 1990 and 2021, a global upsurge in RA incidence was observed, with India experiencing the most rapid growth and America consistently recording the highest ASIR, albeit with a diminishing increment rate. The prevalence escalated across all regions, with America exhibiting the highest ASPR. Mortality rates generally trended downward, with India registering the highest ASMR by 2021, contrasting with the lowest rates in America and Europe. Disability trends, quantified by ASDR, exhibited relative stability, yet a notable increase was observed in India. ARIMA model-based projections anticipate a continued rise in RA incidence and prevalence by 2030, with mortality and disability rates anticipated to exhibit minor oscillations.

CONCLUSION

The escalating burden of RA, particularly in developing nations, underscores an urgent need for enhanced healthcare policies focused on early diagnosis, intervention, and disability mitigation. The projections indicate enduring public health challenges attributed to RA in the forthcoming decade.

Effectiveness of nurse-led care in patients with rheumatoid arthritis: a systematic review and meta-analysis

OBJECTIVES

This study sought to assess the effectiveness of nurse-led care (NLC) in patients with rheumatoid arthritis (RA).

METHODS

We conducted a comprehensive search of the Cochrane Library, Web of Science, PubMed, Embase, CINAHL, ClinicalTrials.gov databases and the references from relevant literature published prior to May 2023. Two independent reviewers assessed the studies using population/intervention/comparison/outcome/study criteria, and quantitative tools were used to gauge the methodological quality of the included studies. Independent quality assessments were carried out using the Cochrane Collaboration's risk-of-bias tool. Effect sizes were determined using mean difference (MD) or standardised mean difference (SMD) with corresponding 95% CIs.

RESULTS

Ultimately, 14 articles were included, encompassing a total of 3369 RA patients. NLC exhibited significant advantages in the primary outcome, disease activity (MD =-0.09, 95% CI (-0.17 to -0.01)), and the secondary outcome, self-efficacy (MD=0.40, 95% CI (0.03, 0.77)). In subgroup analysis, NLC was more effective in reducing disease activity compared with usual care (MD=-0.15, 95% CI (-0.26 to -0.04)), and there was no significant difference in disease activity reduction between NLC and rheumatologist-led care (MD=-0.02, 95% CI (-0.14, 0.10)). In terms of self-efficacy, no significant difference was observed between NLC and usual care (SMD=0.56, 95% CI (-0.09, 1.21)) or between NLC and rheumatologist-led care (SMD=0.20, 95% CI (-0.19, 0.59). When comparing other secondary outcomes (pain, satisfaction, quality of life, fatigue, stiffness, physical function and psychological status), the effectiveness of NLC for RA patients was similar to that of the control group, with no statistically significant differences.

CONCLUSIONS

NLC proves highly effective in managing RA patients, surpassing usual care and equating to rheumatologist-led care in primary and some secondary outcomes. It may be feasible to allow nurses to participate in the disease management of some RA patients instead of doctors.

PROSPERO REGISTRATION NUMBER

CRD42022362071.

All-cause and cause-specific mortality in rheumatoid arthritis: a meta-analysis

OBJECTIVE

This study aimed to evaluate standardized mortality ratios (SMRs) for both all-cause and cause-specific mortality in patients with rheumatoid arthritis (RA).

METHODS

We conducted an extensive search across the Medline, Embase, and Cochrane databases to identify studies investigating SMRs for all-cause and/or cause-specific mortality in individuals with RA compared to the general population. Subsequently, we performed a comprehensive meta-analysis, examining SMRs across various categories, including all-cause, sex-specific, ethnicity-specific, and cause-specific SMRs in RA patients.

RESULTS

Seventeen studies involving 486,098 patients with RA and 63,988 deaths met the inclusion criteria. Patients with RA had a 1.522-fold increase in all-cause SMR (SMR 1.522, 95% CI 1.340-1.704, p < 0.001) compared to the general population. Stratification by ethnicity revealed that the all-cause SMR was 1.575 (95% CI 1.207-1.943) in Caucasians and 1.355 (95% CI 1.140-1.569) in Asians. The gender-specific meta-analysis revealed elevated SMR in both women and men. RA patients exhibited an increased risk of mortality attributed to cardiovascular disease (CVD), respiratory disease, infection, and cerebrovascular accidents (CVA). However, no significant increase in SMR was observed for mortality due to malignancy.

CONCLUSION

This meta-analysis study highlights a 1.522-fold increase in SMR in patients with RA compared to that in the general population, irrespective of sex or region. Additionally, a notable increase in mortality associated with specific causes, including CVD, respiratory disease, infection, and CVA, underscores the critical need for targeted interventions to manage these heightened risks in patients with RA.

Pregnancy outcomes in women with rheumatoid arthritis: an 11-year French nationwide study

BACKGROUND

Rheumatoid arthritis (RA) can affect women of childbearing age. The management of patients with RA during pregnancy has evolved over the past decades, especially with the availability of new therapeutic molecules.

OBJECTIVES

To describe pregnancy in women with RA, to compare pregnancy outcomes with those of women in the general population and to compare pregnancy outcomes in women with active and inactive RA.

METHODS

Using the French National Health Data System, we identified all pregnancies ending between 2010 and 2020 in patients with and without RA. Characteristics were described. Active RA was defined by conventional synthetic/biological/targeted synthetic disease-modifying antirheumatic drug initiation, systemic or intra-articular corticosteroid administration and/or RA-related hospitalisation. Pregnancy outcomes were compared computing multivariable logistic marginal regression model using generalised estimating equation (GEE).

RESULTS

We included 11 792 RA and 10 413 681 non-RA pregnancies. Among RA pregnancies, 74.5% ended in live births and 0.4% in stillbirths. RA pregnancies resulted more frequently in preterm births (adjusted OR (ORa) 1.84; 95% CI 1.69 to 2.00) and very preterm births (ORa 1.43; 95% CI 1.20 to 1.71), low birth weight (ORa 1.65; 95% CI: 1.52 to 1.90), caesarean section (ORa 1.46; 95% CI 1.38 to 1.55) and pregnancy-related hospitalisation (ORa 1.30; 95% CI 1.22 to 1.39). Disease activity decreased during pregnancy. Active RA had higher rates of prematurity (ORa 2.02; 95% CI 1.71 to 2.38), small for gestational age (ORa 1.53; 95% CI 1.28 to 1.83) and caesarean section (ORa 1.25; 95% CI 1.11 to 1.40) than non-active RA.

CONCLUSION

Pregnancies in women with RA were associated with more adverse outcomes, especially if the disease was active. These findings should encourage physicians to closely monitor RA during this crucial period.

Risk of cancer for patients with rheumatoid arthritis versus general population: a national claims database cohort study

Background

Older studies uncovered an increased risk of cancer in patients with rheumatoid arthritis between 10% and 30% compared to the general population, with a lack of data concerning infrequent cancers. In recent year, major therapeutic breakthroughs might have affected this risk of cancer by mitigating disease activity or on the contrary by impairing antitumoral immune response. The objectives of this study are to compare cancer risk in patients with treated rheumatoid arthritis to the general population, in all treated patients and according to treatment exposure.

Methods

This is a nationwide population-based study within the French national claims database "Système National des Données de Santé" (SNDS) between January 1st 2010 and December 31st 2020, to estimate the age and sex-standardized incidence ratios of cancer (all sites and site specific) of treated rheumatoid arthritis patients, with the French population as reference (by use of the French Network of Population-Based Cancer Registries [FRANCIM]).

Findings

During the study period, 257,074 treated patients with rheumatoid arthritis contributed to a total of 2,098,238 person-years for the main analysis. The all-cancer risk was increased in rheumatoid arthritis patients, with a SIR (Standardized Incidence Ratio) of 1.20 (95% CI [1.17-1.23]). This risk was increased particularly for lung (SIR 1.41, 95% CI [1.36-1.46], bladder (SIR 2.38 95% CI [2.25-2.51]), cervix (SIR 1.80, 95% CI [1.62-2.01]), prostate (SIR 1.08, 95% CI [1.04, 1.13]) cancers, melanoma (SIR 1.37, 95% CI [1.29-1.46]), diffuse large B cell lymphoma (SIR 1.79, 95% CI [1.63-1.96], multiple myeloma (SIR 1.42, 95% CI [1.27-1.60]) and Hodgkin's lymphoma (SIR 2.73, 95% CI [2.31-3.23]). Some cancers were less frequent than in the general population such as pancreatic (SIR 0.90, 95% CI [0.83-0.97]) as well as breast and endometrial cancers (SIR 0.91, 95% CI [0.88-0.94] and SIR 0.77, 95% CI [0.71-0.84] respectively). Although we observed a modest but significant relative increase of all-cancer risk over-time in rheumatoid arthritis patients, there was a trend towards a decrease in risk of non-Hodgkin's lymphoma. Patients treated with rituximab were the patients displaying the highest risk of cancer.

Interpretation

Compared to the general population, treated rheumatoid arthritis patients were at greater risk of all-cancer and some site specific cancers, except for breast, pancreatic and endometrial cancers which were less frequent than in the general population.

Funding

This work was supported by unrestricted grants from the InCA (national institute against cancer) and AP-HP (Assistance Publique des Hôpitaux de Paris).

Suboptimal management of rheumatoid arthritis in France: a real-world study based on data from the French National Health Data System

OBJECTIVES

The emergence of targeted therapy is changing rheumatoid arthritis (RA) management, but real-world data remain limited. This study aimed to describe real-world RA treatment patterns using data from a French national claims database.

METHODS

This longitudinal study used the French Permanent Representative Sample (Echantillon Généraliste des Bénéficiaires) claims database. Patients with RA were identified between 2013 and 2017, with treatment patterns, persistence and adherence described.

RESULTS

The study population included 2553 patients with RA. Disease-modifying antirheumatic drugs (DMARDs) were prescribed for 1512 (59.2%) patients, of whom 721 (47.6%) did not require discontinuation or treatment switch. There were 377 (24.9%) treatment discontinuations and 114 patients (7.5%) switched to a targeted DMARD (biological and synthetic (Janus kinase inhibitor) DMARDs). Among the 2315 patients with RA in 2017, almost half (n=1102, 47.6%) were not treated with a DMARD. Most (85.7%) received symptomatic treatment (analgesics (81.0%), steroids (49.2%), non-steroidal anti-inflammatory drugs (39.5%)). Of the 1142 treatment initiations identified, 713 (62.4%) were conventional synthetic DMARDs (csDMARDs), with methotrexate being the most frequent (n=553, 48.45%). One-year persistence rates varied between 55.9% (49.2-62.0%) for tumour necrosis factor inhibitors, and 63.4% (59.6-67.0%) for csDMARDs. Treatment adherence, assessed through medication possession ratio, varied between 71.9% and 90.8%, with ≥80% being the adherence cut-off. Almost half of DMARD initiations were associated with long-term (>6 months), high-dose oral steroid use (~7 mg/day prednisone equivalent).

CONCLUSION

Despite a diverse therapeutic arsenal, there remains a medical need that is not covered by current RA management, which is frequently compensated for by overprescription of steroids.