How can the risk of long-term consequences of rheumatoid arthritis be reduced?

Physical Therapists' Ability to Distinguish Between Inflammatory and Noninflammatory Arthritis and to Appropriately Refer Patients to a Rheumatologist

OBJECTIVE

To investigate whether physical therapists (PTs) can correctly identify new-onset inflammatory arthritis; to assess whether PTs are aware that cases of new-onset inflammatory arthritis should be referred to a rheumatologist; to explore the comfort level of PTs to refer to medical specialists; and to determine factors associated with correctly identifying inflammatory arthritis and referring to a rheumatologist.

METHODS

We sent a questionnaire to PTs in 2 Canadian provinces describing 4 case scenarios (new-onset rheumatoid arthritis [RA], knee osteoarthritis [OA], new-onset ankylosing spondylitis [AS], and low back pain [LBP]). Participants were asked to identify probable medical diagnoses and indicate their plan of action. We described the frequencies of our outcomes and used logistic regression to explore associated factors.

RESULTS

A total of 352 PTs responded. The proportions who correctly identified each of the 4 cases were 90%, 83%, 77%, and 100%, respectively, for RA, OA, AS, and LBP. Among those, 77%, 30%, 73%, and 3%, respectively, indicated that it was "very important" or "extremely important" to refer to a rheumatologist. Approximately two-thirds felt "extremely comfortable" or "quite comfortable" to refer to a specialist. PTs working in rural areas were less likely to refer.

CONCLUSION

Most PTs correctly identified the clinical cases and were aware of the importance of prompt referral to a rheumatologist for inflammatory disease. Most indicated that it was not very important to refer those with OA and LBP. This implies that many PTs can distinguish between inflammatory and noninflammatory conditions and appropriately refer patients with suspected inflammatory arthritis to a rheumatologist.

Systemic Diseases and Conditions Affecting Jaws

This article discusses the radiographic manifestation of jaw lesions whose etiology may be traced to underlying systemic disease. Some changes may be related to hematologic or metabolic disorders. A group of bone changes may be associated with disorders of the endocrine system. It is imperative for the clinician to compare the constantly changing and dynamic maxillofacial skeleton to the observed radiographic pathology as revealed on intraoral and extraoral imagery.

An interesting finding of multiple calcified pulmonary nodules in a patient with rheumatoid arthritis

Calcified pulmonary (lung parenchymal) densities can occur in a number of conditions. A patient with rheumatoid arthritis presented with new right lung base nodules and left long base soft-tissue densities on his chest X-ray. These findings did not exist on his chest X-ray performed 2 years earlier. A subsequent thoracic CT scan showed multiple pleural-based irregular nodules of soft-tissue density that were partially calcified. There was also mediastinal and hilar lymphadenopathy. Following a discussion at the respiratory multidisciplinary team meeting, a CT-guided nodal biopsy was performed that showed necrotic lung tissue with palisaded histiocytes and fibrosis with chronic inflammation. No vasculitis or granulomata were seen and no there was evidence of malignancy. Appearances were consistent with a rheumatoid nodule. No mycobacteria or fungi were seen on Ziehl–Neelsen, Wade–Fite or periodic acid–Schiff stains. We concluded that this patient had unusual calcified rheumatoid lung nodules. Previously, calcified pulmonary nodules have been reported in the setting of Caplan’s syndrome in miners.

Disability and health‐related quality of life among patients with rheumatoid arthritis: association with radiographic joint damage, disease activity, pain, and depressive symptoms

OBJECTIVE

To study the associations between disability and health-related quality of life (HRQoL), respectively, and radiographic joint damage, disease activity, pain, and depressive symptoms among patients with rheumatoid arthritis (RA).

METHODS

Data were collected through questionnaires and clinical examinations at baseline (1997) and at 2 years' follow-up among patients with RA (n = 307). Disability was measured with a validated Dutch questionnaire, derived from the Health Assessment Questionnaire (HAQ), and HRQoL with a validated Dutch version of the RAND-36, using physical (PCS) and mental (MCS) component summary scales. Multivariate linear regression analyses were performed to assess the relationship between disability or HRQoL and radiographic damage, disease activity, pain, and depressive symptoms.

RESULTS

Pain, with respect to disability and PCS, and depressive symptoms, with respect to MCS, were more important predictors than radiographic damage and disease activity.

CONCLUSIONS

Daily RA practice needs to be broadened by regular assessment of disease burden from the patients' perspectives. Patient-reported measures, such as disability or HRQoL, should be incorporated for monitoring health outcomes of individual patients and for initiating and evaluating therapy.

Dose escalation of infliximab therapy in arthritis patients is related to diagnosis and concomitant methotrexate treatment: observational results from the South Swedish Arthritis Treatment Group register

OBJECTIVE

To study frequency of dose escalation in infliximab-treated patients and to identify possible predictors thereof.

METHODS

Patients with chronic arthritis initiating their first course of anti-TNF treatment with infliximab at Lund University Hospital were included in a structured clinical follow-up protocol. Information on diagnosis, drug dosage, disease duration, previous and ongoing DMARDs, treatment start and cessation were prospectively collected during the period March 1999 through February 2007. All patients were started on a dose of 3 mg/kg at time 0, week 2, week 6 and then every eighth week independent of diagnosis and were followed for a period of 2 yrs.

RESULTS

A total of 206 patients were included in the study. Thirty-two of the patients had PsA, 25 had AS and 149 patients had RA. A minor dose escalation, defined as less than doubling of the dosage, was observed for 53, 48 and 42% of the patients with PsA, AS and RA, respectively. The corresponding values for major dose escalation was observed for 19, 8 and 15% of the patients, respectively. Regression analysis showed that patients with a diagnosis of PsA (P = 0.03), longer follow-up period (P < 0.01), and lack of concomitant MTX treatment (P = 0.03) were significantly associated with risk of dose escalation.

CONCLUSION

Dose escalations were performed in 59% of all infliximab-treated patients during the first 2 yrs of treatment. Our data suggest that PsA patients might require higher dosages than RA and AS patients.

Measures of outcome in patients with inflammatory arthritis

BACKGROUND

Musculoskeletal disorders account for 15-20% of general practitioner (GP) consultations and cause significant morbidity and disability. Although rheumatology nursing is regarded as a partnership between the practitioner and patient, it remains a relatively tough task to generate a letter summarizing the outcome of clinical assessment and decisions made regarding the patients' management.

OBJECTIVE

To assess the validity of a developed pro forma letter that summarizes the outcome measures of patients suffering from inflammatory arthritis, as assessed in secondary care, and to assess the comprehensibility of this new model.

METHODS

The outcome measures of 184 patients with rheumatoid arthritis (99), as well as seronegative inflammatory arthritis (85) were reviewed. A pro forma was designed to summarize the outcome of the clinical assessment.

RESULTS

Fifty-five males (29.9%) and 129 (70.1%) females were included with a mean age of 44.3 years and standard deviation of 14.5 (age range 22-81 years); duration of illness was variable and ranged between 4 months and 28 years. The pro forma showed a strong validity when compared to patients' data records (range 0.89-0.97). All GPs rated it as comprehensible (comprehensibility rate 80.8%).

CONCLUSION

The pro forma is a valid instrument that can be used in clinical practice. It offers an option that is well accepted by rheumatology nurses, rheumatologists, as well as GPs. The letter was found to be a significantly better tool for informing GPs about patients' medical condition, possible risks and management plan.

Impact of concomitant DMARD therapy on adherence to treatment with etanercept and infliximab in rheumatoid arthritis. Results from a six-year observational study in southern Sweden

The objective of this work is to compare the adherence to therapy of patients receiving etanercept and infliximab during first tumour necrosis factor (TNF)-blocking treatment course in rheumatoid arthritis. Special emphasis is placed on potential predictors for treatment termination and the impact of concomitant methotrexate (MTX) or other disease-modifying antirheumatic drugs (DMARDs). Patients (n = 1,161) with active rheumatoid arthritis, not responding to at least two DMARDs including MTX starting etanercept or infliximab therapy for the first time, were included in a structured clinical follow-up protocol. Information on diagnosis, disease duration, previous and ongoing DMARDs, treatment start and termination, as well as cause of withdrawal was prospectively collected during the period of March 1999 through December 2004. Patients were divided into six groups according to TNF-blocking drugs and concomitant DMARDs. Five-year level (one-year) of adherence to therapy was 36% (69%) for patients receiving infliximab in combination with MTX compared with 65% (89%) for patients treated with etanercept and MTX (p < 0.001). Cox regression models showed that the risk for premature treatment termination of patients treated with infliximab was threefold higher than for etanercept (p < 0.001). Also, the regression analysis showed that patients receiving concomitant MTX had better treatment continuation than patients treated solely with TNF blockers (p < 0.001). Moreover, patients receiving concomitant MTX had superior drug survival than patients receiving other concomitant DMARDs (p < 0.010). The superior effect of MTX was associated primarily with fewer treatment terminations because of adverse events. In addition, the study identifies low C-reactive protein level, high age, elevated health assessment questionnaire score, and higher previous number of DMARDs as predictors of premature treatment termination. In summary, treatment with etanercept has higher adherence to therapy than treatment with infliximab. Concomitant MTX is associated with improved treatment continuation of biologics when compared with both TNF blockers as monotherapy and TNF blockers combined with other DMARDs.

Is three selected parameters adequate to monitor rheumatoid arthritis?

This pilot study was done to choose which among the five core set criteria will have more discriminating ability and which is easy to administer in a clinical setting. Forty-eight patients recently diagnosed to have rheumatoid arthritis (RA) were recruited for the study. They were assessed by a rheumatologist in each visit (initial and after 2 months of treatment), for five core measures: patient assessment, pain (measured on VAS scale), number of tender joints, health assessment questionnaire (HAQ) score, and erythrocyte sedimentation rate (ESR). All patients were treated with methotrexate 7.5 mg per week and hydroxychloroquin 400 mg per day with adequate dose of NSAIDs. Patients with associated conditions like stroke, ischemic heart disease, and other physical comorbidity were excluded. They were categorized as 20, 50, and 70% improvement, if four of the five criteria occur. The Wilcoxon signed rank test and discriminant function analysis were done to identify the order of importance of measures on influencing the outcome. The ESR followed by patient improvement scale showed the least changes, while HAQ showed the highest changes. Discriminate function analysis has been carried out to see which factors influenced in grouping them for responses with post hoc analyses of finding the order of importance of these factors in classifying the response. Pain scale, ESR, HAQ score, patient improvement scale, and tender score were in the decreasing value of importance. The pain scale, HAQ, and ESR, which are more objective and discriminate measures, are useful as measures in RA.

The LUNDEX, a new index of drug efficacy in clinical practice: Results of a five-year observational study of treatment with infliximab and etanercept among rheumatoid arthritis patients in southern Sweden

OBJECTIVE

To describe the use of the LUNDEX, a new index for comparing the long-term efficacy and tolerability of biologic therapies in rheumatoid arthritis (RA) patients treated in clinical practice.

METHODS

Patients (n = 949) with active RA that had not responded to at least 2 disease-modifying antirheumatic drugs (DMARDs) including methotrexate, in whom biologic therapy was being initiated, were included in a structured clinical followup protocol. The protocol included collection of data on diagnosis, disease duration, previous and ongoing DMARD treatment, and dates on which biologic treatment was started and terminated. In addition, data on efficacy measures used for calculating validated response criteria, i.e., the European League Against Rheumatism and American College of Rheumatology response criteria, were collected at fixed time points. Data were prospectively registered from March 1999 through January 2004. The LUNDEX, a new index combining the proportion of patients fulfilling a selected response criteria set with the proportion of patients adhering to a particular therapy, was designed to compare the efficacy of the different therapies.

RESULTS

Etanercept had higher overall LUNDEX values compared with infliximab, mostly because of a lower rate of adherence to therapy with infliximab. The relationship between the drugs was consistent irrespective of the response criteria used.

CONCLUSION

The LUNDEX is a valuable tool for evaluating drug efficacy in observational studies. It has the advantage of integrating clinical response as well as adherence to therapy in a composite value. Moreover, the LUNDEX has a practical and potentially universal application independent of diagnosis and response criteria.

Predictive factors of work disability in rheumatoid arthritis: a systematic literature review

BACKGROUND

Work disability-a common outcome of rheumatoid arthritis (RA)-is a societal (for example, financial costs) and individual problem (for example, loss of status, income, social support, and distraction from pain and distress). Until now, factors that predict work disability in RA have not been systematically reviewed.

OBJECTIVE

To determine predictive factors of work disability in RA as reported in the literature.

METHODS

A systematic literature search in Cinahl (1988-2004), Embase (1988-2004), and Medline (1989-2004) was followed by the application of two sets of criteria related to: (a) methodological quality, and (b) measurement of the predictive factor. Based on the quality and the consistency of the findings, a rating system was used to assess the level of evidence for each predictive factor.

RESULTS

Nineteen publications (17 cohorts) were identified, of which 13 met the general methodological quality criteria. Results provided strong evidence that physical job demands, low functional capacity, old age, and low education predict work disability in RA. Remarkably, biomedical variables did not consistently predict work disability. Moreover, owing to the lack of high quality studies no evidence was found for personal factors such as coping style, and work environmental factors such as work autonomy, support, work adjustments that are presumed crucial in the work disablement process.

CONCLUSIONS

The results indicate that work disability in RA is a biopsychosocially determined misfit between individual capability and work demands.

"The rheumatologist can see you now": Successful implementation of an advanced access model in a rheumatology practice

OBJECTIVE

To provide rheumatologic care to patients in a timely and patient-centered manner.

METHODS

We developed and implemented processes to measure and help eliminate backlog, created access time for same-day patients, and retooled the appointments process to be more efficient and patient focused. In addition, we developed a protocol to be used by our primary care colleagues to care for osteoarthritis of the knee in a standardized manner.

RESULTS

The third available rheumatology appointment fell from about 60 days to <2 days. Cancellations fell from 40% to <20%. Patient satisfaction measures (composite score, physician score, and accessibility score) improved significantly. The number of new patients seen for knee osteoarthritis decreased by 6.7%, whereas the number of new rheumatoid arthritis referrals increased by 50.4%. Financial performance improved as well.

CONCLUSIONS

This advanced access model in a busy academic rheumatology practice demonstrated considerable improvement in access, patient satisfaction, and finances. Using a team approach, we are now able to give the patient the rheumatologic care they want and need at a time they want and need it.

A home-based two-year strength training period in early rheumatoid arthritis led to good long-term compliance: a five-year followup

OBJECTIVE

To evaluate the impact of a 2-year home-based strength-training program on physical function in patients with early rheumatoid arthritis (RA) after a subsequent 3-year followup.

METHODS

Seventy patients with early RA were randomized to perform either strength training (experimental group [EG]) or range-of-motion exercises (control group [CG]). Maximal strength values were recorded by dynamometers. The Modified Disease Activity Score (DAS28), pain, Health Assessment Questionnaire (HAQ), walking speed, and stair-climbing speed were also measured.

RESULTS

The maximum strength of assessed muscle groups increased by 19-59% in the EG during the training period and remained at the reached level throughout the subsequent 3 years. Muscle strength improved in the CG by 1-31%, but less compared with the EG. During the 2-year training period, DAS28 decreased by 50% and 45% and pain by 67% and 39% in the EG and CG, respectively. The differences in muscle strength, DAS28, and HAQ were significantly in favor of the EG both at the 2-year and 5-year followup assessments.

CONCLUSIONS

The improvements achieved during the 2-year strength-training period were sustained for 3 years in patients with early RA.

Etanercept, infliximab, and leflunomide in established rheumatoid arthritis: clinical experience using a structured follow up programme in southern Sweden

OBJECTIVE

To explore the feasibility of prospectively monitoring treatment efficacy and tolerability of infliximab, etanercept, and leflunomide over a two year period in patients with established rheumatoid arthritis (RA) in clinical practice using a structured protocol.

METHODS

All patients with RA at seven centres in southern Sweden, for whom at least two disease modifying antirheumatic drugs, including methotrexate, had failed or not been tolerated, who started treatment with either infliximab, etanercept, or leflunomide were included. They were evaluated at predefined times using a standardised protocol including items required for evaluating response to the American College of Rheumatology (ACR) or EULAR criteria. All adverse events were recorded using World Health Organisation terminology. Concomitant treatment and survival while receiving a drug were recorded.

RESULTS

During the study 166 patients were treated with etanercept, 135 with infliximab, and 103 with leflunomide. Treatment response as determined by the ACR and EULAR response criteria was similar for the tumour necrosis factor (TNF) blockers. The TNF blockers performed significantly better than leflunomide both as determined by the response criteria and by survival on drug analysis. Thus 79% and 75% continued to receive etanercept or infliximab compared with 22% of patients who started leflunomide after 20 months. The spectrum of side effects did not differ from those previously reported in the clinical trials. The initial two year experience of a protocol for postmarketing surveillance of etanercept, infliximab, and leflunomide shows that a structured protocol with central data handling can be used in clinical practice for documenting the performance of newly introduced drugs.

CONCLUSIONS

Efficacy data for the TNF blockers comply with results in clinical trials, whereas leflunomide appeared to perform worse than in clinical trials. Prolonged monitoring is required to identify possible rare side effects.