Adult and juvenile rheumatoid arthritis: current epidemiologic concepts

Anti-carbamylated Protein Antibodies Positivity in Rheumatoid Arthritis and Its Association With Rheumatoid Factor and Anti-cyclic Citrullinated Protein Antibodies

Background Rheumatoid arthritis (RA) is a widespread autoimmune disease affecting millions of people worldwide. The current markers include anti-cyclic citrullinated peptide (anti-CCP) antibodies and rheumatoid factor (RF), which are nonspecific and elevated in various conditions and do not have a prognostic value. They are also elevated in the later stages of the disease. Anti-carbamylated protein (anti-CarP) antibodies have been reported to be associated with joint damage in RA. Therefore, this study aimed to evaluate the sensitivity and specificity of anti-CarP antibodies in individuals with RA and their relationship with inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Methods This was a cross-sectional case-control study conducted from April 2020 to March 2021 at the Saveetha Medical College, Chennai, India. The age makeup of the three groups was evaluated: Group 1 comprised anti-CCP and RF-positive patients; Group 2 comprised anti-CCP and RF-negative patients; and Group 3 was the control group, which comprised healthy volunteers. Patient samples, including blood and serum, have been utilized to conduct various assessments aimed at evaluating biomarkers such as CRP, ESR, RF, and autoantibodies like anti-CCP and anti-CarP. Results This study examined the role of various autoantibodies and biomarkers in RA across three distinct groups. Group 1 predominantly consisted of middle-aged individuals, and women constituted the majority in both Group 1 and Group 2, consistent with higher RA prevalence among females. In Group 1, 65.7% of patients tested positive for anti-CarP, while in Group 2, 48.6% tested positive even when RF and anti-CCP antibodies were absent. This suggests a potential diagnostic role for anti-CarP antibodies in identifying RA patients early. CRP and ESR levels were significantly elevated in RA patients (Groups 1 and 2) compared to healthy controls (Group 3), indicating higher inflammatory activity in affected individuals. We also observed that anti-CarP antibodies had a specificity of 69.1% and a sensitivity of 78.2%. Positive correlations between the diagnosis of RA and anti-CarP antibody positivity were observed across the groups and correlated well with the inflammatory markers and signs such as joint damage. The data were found to be statistically significant. Conclusions Our study showed a significant correlation between joint damage and CRP levels and a positive correlation between anti-CarP antibodies and ESR and CRP values. These findings suggest that anti-CarP antibodies can offer certain advantages over RF and anti-CCP antibodies in RA diagnosis due to their early detection potential, higher specificity, complementary diagnostic role, and predictive value for disease severity.

Reliability and Validity of the Turkish Version of the ABILHAND Questionnaire in Rheumatoid Arthritis Individuals, Based on Rasch Analysis

OBJECTIVES

This study aims to assess the reliability and validity of the Turkish version of the ABILHAND questionnaire in individuals with rheumatoid arthritis (RA) [ABILHAND-RA (TR)] using the Rasch analysis.

MATERIALS AND METHODS

A total 90 individuals (15 males, 75 females; mean age 51.8±10.9 years; range, 20 to 65 years) diagnosed as RA according to the criteria of the American College of Rheumatology were included. The ABILHAND-RA (TR) was used to determine manual ability, while disease activity was evaluated by the use of Disease Activity Score 28 (DAS28). Jamar hand dynamometer and pinch-meter were used to examine grip and pinch strength of the participants. Nine Hole Peg Test (NHPT) and Duruoz Hand Index (DHI) measured hand disability level. Nottingham Health Profile (NHP) was used to assess quality of life. ABILHAND-RA (TR) results were analyzed using the Rasch analysis method.

RESULTS

Item 20 was excluded from the 27-item ABILHAND-RA (TR) as 96% of the individuals rated this item as "easy". The new set of 18 items (7 subtests and 11 items) were found to sustain item invariance and fit to the Rasch model. Significant relationships were found between ABILHAND-RA (TR) and DAS28, bilateral grip strength, NHPT dominant side results, DHI, and NHP.

CONCLUSION

Turkish version of the ABILHAND-RA was found to be clinically valid, reliable, and sensitive enough to be used in clinical evaluations, rehabilitation interventions, and for progression follow-up in individuals with RA.

Molecular Actions of Glucocorticoids in Cartilage and Bone During Health, Disease, and Steroid Therapy

Cartilage and bone are severely affected by glucocorticoids (GCs), steroid hormones that are frequently used to treat inflammatory diseases. Major complications associated with long-term steroid therapy include impairment of cartilaginous bone growth and GC-induced osteoporosis. Particularly in arthritis, GC application can increase joint and bone damage. Contrarily, endogenous GC release supports cartilage and bone integrity. In the last decade, substantial progress in the understanding of the molecular mechanisms of GC action has been gained through genome-wide binding studies of the GC receptor. These genomic approaches have revolutionized our understanding of gene regulation by ligand-induced transcription factors in general. Furthermore, specific inactivation of GC signaling and the GC receptor in bone and cartilage cells of rodent models has enabled the cell-specific effects of GCs in normal tissue homeostasis, inflammatory bone diseases, and GC-induced osteoporosis to be dissected. In this review, we summarize the current view of GC action in cartilage and bone. We further discuss future research directions in the context of new concepts for optimized steroid therapies with less detrimental effects on bone.

Damage control in rheumatoid arthritis

Right from the onset, rheumatoid arthritis is an aggressive disease that can quickly alter joint structure and integrity. Such rapid pathogenesis requires that the diagnosis be established early and aggressive therapy initiated swiftly. In this article, Drs Issa and Ruderman describe what is known about the cause, progression, and outcomes of rheumatoid arthritis. They review the steps toward its diagnosis and urge that treatment be started promptly--to both contain disease and reduce joint destruction as soon as possible.

Marital quality and self-efficacy: influence on disease management among individuals with rheumatoid arthritis

Individuals with rheumatoid arthritis (RA) struggle to maintain improved functional ability and reduced pain levels. Health education emphasizing self-efficacy helps individuals to adjust with the disease outcome and progression. As a basis to develop comprehensive evidence-based patient education programs, the aim of the study was to examine the role of marriage as a predictor of pain and functional self-efficacy among individuals with RA. Review of the regression analysis did not provide support for the relationships between marital quality and self-efficacy. Relationships were not observed between marital quality, length of marriage, and self-efficacy as predicted by the first hypothesis. Additional regression analysis examination found that marital quality, length of marriage, pain, and health assessment together reported significant variance in self-efficacy. However, only health assessment significantly predicted self-efficacy. Other nonexamined variables could have influenced the independent marital quality effects. Future longitudinal studies with larger sample sizes can further validate the current findings.

Kynurenic acid in synovial fluid and serum of patients with rheumatoid arthritis, spondyloarthropathy, and osteoarthritis

OBJECTIVE

Previously we demonstrated that kynurenic acid (KYNA), an endogenous metabolite of kynurenine, is present in the synovial fluid of patients with rheumatoid arthritis (RA). KYNA inhibits proliferation of synoviocytes in vitro. The goal of our study was to compare KYNA concentrations in synovial fluid and blood of patients with RA, inflammatory spondyloarthropathies (SpA), and osteoarthritis (OA).

METHODS

Serum and synovial fluid samples were obtained from 189 patients with RA, 56 patients with SpA, and 32 patients with OA. KYNA was separated using a high-performance liquid chromatography system and measured fluorometrically.

RESULTS

KYNA concentration in synovial fluid obtained from patients with RA and SpA was significantly lower than that in patients with OA (p < 0.05). The concentration of KYNA in serum of patients with RA, SpA, and OA did not differ among all groups studied. The positive correlation between KYNA content in synovial fluid and serum was found in patients with RA (p < 0.05). Univariate linear regression analysis demonstrated that fibrinogen was significantly associated with KYNA in synovial fluid (p < 0.05), and red blood cell counts, morning stiffness, and pain scores were significantly associated with KYNA level in serum (all p < 0.05). Multivariate regression analysis revealed correlation between the following independent variables: hemoglobin level, hematocrit, red blood cell count in conjunction with age and KYNA content in synovial fluid. A lack of correlation was observed between KYNA content in synovial fluid of patients with RA and other clinical and laboratory measures of disease activity.

CONCLUSION

Our data show a local deficit of KYNA in inflammatory states.

Coadministration of Lansoprazole and Naproxen Does Not Affect the Pharmacokinetic Profile of Methotrexate in Adult Patients With Rheumatoid Arthritis

Drugs prescribed for rheumatoid arthritis are often associated with gastrointestinal toxicity, and proton pump inhibitors may be coadministered for gastroprotection. In this open-label study, the effect of lansoprazole 30 mg qd and naproxen 500 mg bid on the pharmacokinetic profile of methotrexate was investigated. Twenty-seven adult rheumatoid arthritis patients on stable oral methotrexate doses (7.5-15 mg/week) for a minimum of 3 months were enrolled. Methotrexate pharmacokinetics were assessed on days -1 (methotrexate alone) and 7 (methotrexate with lansoprazole and naproxen). Pharmacokinetics of methotrexate and 7-hydroxymethotrexate were not altered by coadministration of methotrexate with lansoprazole and naproxen; point estimates and 90% confidence intervals for the peak plasma concentration and area under the plasma concentration-time curve of methotrexate and 7-hydroxymethotrexate were within the 0.80 to 1.25 boundaries. Therefore, coadministration of naproxen and lansoprazole for 7 days does not affect the pharmacokinetic profile of low doses of methotrexate.

State and trait pain catastrophizing and emotional health in rheumatoid arthritis

BACKGROUND

Pain catastrophizing is a powerful predictor of pain adaptation, and both stable and time-varying aspects may influence overall emotional well-being.

PURPOSE

This study aims to test the independent influences of state and trait pain catastrophizing on the relationship between daily intensity and negative affect, positive affect, and depressive symptoms.

METHODS

Daily diary data were collected for 30 days from a sample of 231 adults with a diagnosis of rheumatoid arthritis.

RESULTS

State pain catastrophizing accounted for a significant proportion of the relationship between daily pain and each of the three examined daily outcomes. Greater trait pain catastrophizing significantly increased the effect of state pain catastrophizing on the relationship between pain intensity and the outcome variables in cross-sectional and time-lagged models.

CONCLUSIONS

The results of the current study indicate that state pain catastrophizing plays a prominent role in the adaptation to daily pain fluctuations, particularly for those with a propensity to catastrophize.

Influence of Rheumatoid Arthritis on Employment, Function, and Productivity in a Nationally Representative Sample in the United States

Objective.

The Medical Expenditure Panel Survey (MEPS) was used to estimate the national influence of rheumatoid arthritis (RA) on employment, limitations in work or housework, inability to work or do housework, missed work days, days spent sick in bed, and annual wages.

Methods.

MEPS is a nationally representative survey of the US population. Multiple logistic, negative binomial, and Heckman selection regression methods were used, controlling for age, sex, race, ethnicity, smoking status, income, education, and chronic comorbidity. RA was identified using International Classification of Diseases-9 code 714.

Results.

In unadjusted descriptive statistics, individuals with RA were older, had more chronic conditions, missed more work days, spent more days sick in bed, had lower employment rates, had higher rates of limitations and inability to work, and received disability benefits at higher rates. After adjustment, multiple regression analyses showed individuals with RA were 53% less likely to be employed [OR 0.47, 95% CI 0.34–0.65], 3.3 times more likely to have limitations in work or housework (95% CI 2.35–4.64), 2.3 times more likely to be unable to work or do housework (95% CI 1.55–3.53), and spent 3.6 times as many days sick in bed as those without RA (95% CI 2.32–5.53). RA was associated with an expected loss of $8957 in annual earnings (95% CI $1881–$15,937). There was no statistically significant difference in missed work days or the level of wages.

Conclusion.

In the most recent available national data for adults, RA was associated with reductions in employment, productivity, and function.

Trends in RA patients' adherence to subcutaneous anti-TNF therapies and costs

OBJECTIVE

To examine adherence to adalimumab (ADA) and etanercept (ETA) and health care costs in rheumatoid arthritis (RA) patients, and to explore the association between adherence, utilization and costs.

RESEARCH DESIGN AND METHODS

Using administrative claims data from a large managed health care plan, RA patients treated with etanercept or adalimumab during the period from 01/01/2005 through 12/31/2005 were identified. The first dispensing date was defined as the index date. Patient adherence and costs were assessed during the 1 year post-index period.

MAIN OUTCOME MEASURES

Nonadherence (medication possession ratio <80%) was modeled using logistic regression. Hazard ratios (HR) comparing time to discontinuation were estimated using Cox proportional hazard (PH) models. Propensity score matching with multivariate generalized linear modeling adjustment was done to assess cost difference between ADA and ETA.

RESULTS

Of 3829 eligible RA patients, 1292 (765 existing, 527 naïve) and 2537 (1834 existing, 703 naïve) patients used ADA and ETA, respectively. Compared with ADA users, ETA users had longer average treatment duration (316 vs. 291 days; p < 0.0001). Unadjusted adherence rates for naïve and existing users were 63% and 70% (ADA), and 65% and 73% (ETA). Logistic regression analysis indicated that compared with ETA users, ADA users were more likely to be nonadherent (OR, naïve 1.24; existing; 1.25). Cox PH models indicated that existing ADA users were more likely to discontinue (HR = 1.11; p = 0.06) their medication than existing ETA users. Compared with ADA users, ETA users had significantly lower RA-related pharmacy costs (naïve: $10,892 vs. $12,534, p < 0.01; existing: $12,192 vs. $13,752, p < 0.01) and RA-related total costs (naïve: $11,976.42 vs. $13,511.99, p < 0.05; existing: $14,031 vs. $15,454, p < 0.05).

CONCLUSIONS

ETA users had longer treatment duration, were more likely to adhere to their medication regimen and had lower RA-related pharmacy and RA-related total costs compared with ADA users. These findings must be considered within the limitations of this database analysis.

Diagnosis and treatment of early active rheumatoid arthritis

A 59-year-old patient comes to a community pharmacy with unexplained, worsening bilateral foot pain and inflammation. Following evaluation of the situation, the pharmacist suggests that the patient has rheumatoid arthritis (RA). After a visit and consultation with her physician, the patient begins a complicated, rapidly evolving therapeutic regimen for RA. Through extensive counseling and education, the pharmacist is able to help the patient better manage her new medication regimen and understand expected outcomes. Pharmacists can play a very active role in helping patients with RA manage their therapies to optimize health outcomes.

The role of magnetic resonance imaging in the early diagnosis of rheumatoid arthritis

Rheumatoid arthritis (RA) is a common disease that affects 1% of the population. With the advent of disease-modifying therapies, it became particularly important to detect RA as early as possible. In this article, we discuss the role of magnetic resonance imaging (MRI) in the imaging of early RA. Imaging of soft tissues manifestations, which precede the development of osseous erosions, is discussed. We also review the role of MRI in establishing correct diagnosis in cases of arthritis, which do not demonstrate classical clinical presentation. The role of MRI in the follow-up of RA is addressed.

Management of established rheumatoid arthritis with an emphasis on pharmacotherapy

The goals for the management of established rheumatoid arthritis (RA) differ slightly from the goals for the management of early RA. In established RA, in most cases, joint damage will be present, therefore the main goals are aimed at keeping the disease activity as low as possible to prevent joint damage progression. Furthermore, patients with RA have a reduced life expectancy, mainly due to co-morbid conditions such as cardiovascular disease. As in early disease, pharmacotherapy is the cornerstone of the management of patients with established RA. In this article we will discuss the characteristic manifestations of established RA, the pharmacological treatment strategies available for reaching the management goals of established RA, the role of prognostic factors and the measurements available for evaluating the outcomes of the management of individual patients with established RA in daily clinical practice.

Role of ultrasound in assessment of early rheumatoid arthritis

This report reviews imaging methods used for diagnosis and monitoring of rheumatoid arthritis, with emphasis on the role of ultrasonography. Traditionally, conventional radiography has been useful in detecting and monitoring the extent of joint destruction in rheumatic disease. However, it is particularly difficult to detect pathological joint changes in the early stages. Magnetic resonance imaging is able to detect inflammation of the synovial membrane and erosions but is limited by cost and availability. Ultrasound has recently emerged as a useful and potentially reliable method for assessing the degree of joint inflammation and erosion in patients with early rheumatoid arthritis.

Adaptation of the RAQoL for use in Australia

Quality of life is an important patient-reported outcome of rheumatoid arthritis (RA) in addition to structural and functional outcomes. The RAQoL (Rheumatoid Arthritis Quality of Life questionnaire) was developed in the UK and the Netherlands as a disease-specific tool. It was adapted for use in the Australian social context and the reliability and validity was tested. A lay panel assessed the UK version and adapted the wording for use within Australia. Reliability and validity were assessed by a postal survey of the RAQoL and comparator questionnaires to 100 patients with RA. The RAQoL was easily adapted into Australian-English. Test-retest reliability was high with a Spearman rank correlation coefficient of 0.93. RAQoL scores correlated well with patient-perceived disease activity and severity--indicating good validity. The Australian version of the RAQoL is a valid and reliable tool for the assessment of quality of life. It is practical, easy to administer and has good potential for use in clinical settings and trials in Australia.

Efficacy and safety of bucillamine, a D-penicillamine analogue, in patients with active rheumatoid arthritis

Japanese rheumatologists consider bucillamine (Buc) to be a useful disease-modifying antirheumatic drug (DMARD) and often give Buc to patients with rheumatoid arthritis (RA) prior to administering methotrexate (MTX). However, no large studies on the efficacy and safety of Buc in RA patients have been published in English to date. We therefore investigated the clinical course of RA patients treated with Buc and compared the results with those for patients treated with MTX to evaluate and confirm the place of Buc in therapeutic strategies for RA in Japan. Our results suggested that Buc should be given to patients with moderately active RA either before or after the administration of MTX because its efficacy can be judged within 3 months and because serious adverse events are rare. Issues like the ability of Buc to prevent joint destruction and its efficacy and safety when combined with agents like etanercept require future study.

Measuring Process of Arthritis Care: The Arthritis Foundation’s Quality Indicator Set for Rheumatoid Arthritis

OBJECTIVE

To describe the scientific evidence that supports each of the explicit process measures in the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis.

METHODS

For each of the 27 measures in the Arthritis Foundation's Quality Indicator set, a comprehensive literature review was performed for evidence that linked the process of care defined in the indicator with relevant clinical outcomes and to summarize practice guidelines relevant to the indicators.

RESULTS

Over 7500 titles were identified and reviewed. For each of the indicators the scientific evidence to support or refute the quality indicator was summarized. We found direct evidence that supported a process-outcome link for 15 of the indicators, an indirect link for 7 of the indicators, and no evidence to support or refute a link for 5. The processes of care described in the indicators for which no supporting/refuting data were found have been assumed to be so essential to care that clinical trails assessing their importance have not, and probably never will be, performed. The process of care described in all but 2 of the indicators is recommended in 1 or more practice guidelines.

CONCLUSION

There are sufficient scientific evidence and expert consensus to support the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis, which defines a minimal standard of care that can be used to assess health care quality for patients with rheumatoid arthritis.

Cost effectiveness of tumour necrosis factor-alpha inhibitors as first-line agents in rheumatoid arthritis

BACKGROUND AND OBJECTIVE

Rheumatoid arthritis (RA) is an autoimmune disease with an unknown aetiology that results in >9 million physician visits and >250 000 hospitalisations per year in the US. Tumour necrosis factor-alpha (TNFalpha) inhibitors are effective agents in treating RA; however, their cost effectiveness as first-line agents has not been investigated. This study aimed to examine the cost effectiveness of using TNFalpha inhibitors (both as monotherapy and in combination with methotrexate) as first-line agents versus methotrexate (monotherapy) from a payer perspective.

METHODS

A Markov model was developed utilising a discount rate of 3% per annum, a cycle length of 1 year and a lifetime time-horizon for a hypothetical cohort of US females aged 55-60 years who had been diagnosed with RA. The source of data for predicted probabilities, expected mortality rates and treatment costs in year 2005 US dollars (drug, toxicity, monitoring and hospitalisation) was from the literature. These costs are assigned in 5-year cycles (calculated from initial 1-year estimates) along with the effect on quality-adjusted life-years (QALYs), which were calculated using the Health Assessment Questionnaire score. Univariate sensitivity analyses were conducted on all relevant parameters.

RESULTS

Adalimumab, etanercept, adalimumab plus methotrexate and infliximab plus methotrexate had incremental cost-effectiveness ratios (ICERs) versus methotrexate monotherapy of $US63 769, $US89 772, $US194 589 and $US409 523 per QALY, respectively. When taking into consideration age at diagnosis, the ICER for etanercept ranged from $US84 129 to $US96 225 per QALY. In considering males for the base-case age at diagnosis, the ICER for etanercept versus methotrexate was $US85 100 per QALY. The average lifetime cost across all treatment arms in a woman diagnosed between 55 and 60 years of age was $US211 702.

CONCLUSION

While these ICERs cannot be used to directly compare one biological agent with another since there are no comparative trials, they do provide a valid comparison versus methotrexate as first-line agents. Depending where the cost-effectiveness threshold is drawn (i.e. whether it is considered to be $US50 000 or $US100 000 per QALY), etanercept and adalimumab may be considered relatively cost-effective first-line treatments for RA compared with methotrexate monotherapy.

Synovial inflammatory processes in the hand

The numerous synovial articulations and tendon sheaths of the hand afford it a central role in the diagnosis and management of inflammatory arthropathies. Inflammation may be idiopathic, infectious, post-traumatic, or secondary to deposition diseases. In most cases, synovial inflammation represents the primal event in the onset of destructive arthropathies. We review the imaging features of acute and chronic synovitis in the hand. Magnetic resonance imaging is very sensitive to the earliest changes of synovitis and provides a modality for early detection of disease. Additionally, once a diagnosis is established, magnetic resonance imaging has an emerging role in rapid assessment of response to therapy. Positron emission tomography and ultrasound also show promise in the evaluation and treatment of inflammatory arthropathies. Although highly sensitive to the presence of inflammation these more advanced imaging techniques often lack specificity. Therefore, the radiographic evaluation of the pattern of bone destruction remains critical to distinguishing among the different synovial inflammatory processes.

Bone edema scored on magnetic resonance imaging scans of the dominant carpus at presentation predicts radiographic joint damage of the hands and feet six years later in patients with rheumatoid arthritis

OBJECTIVE

Magnetic resonance imaging (MRI) is capable of revealing synovitis and tendinitis in early rheumatoid arthritis (RA), as well as bone edema and erosion. These features are visible before radiographic joint damage occurs. We sought to examine whether MRI of one body region (the wrist) can be used to predict whole-body radiography scores reflecting joint damage at 6 years.

METHODS

We conducted a 6-year prospective study of a cohort of patients who fulfilled the criteria for RA at presentation, using clinical parameters, radiographs, and MRI scans of the dominant wrist. Of the 42 patients enrolled at baseline, full MRI, radiographic, and clinical data were available for 31 at 6-year followup. MRI scans were scored by 2 radiologists, using a validated scoring system. Radiographs of the hands and feet were graded using the modified Sharp scoring method. MRI and radiography scores obtained at baseline and 6 years were compared, and baseline MRI scores were examined for their ability to predict radiographic outcome at 6 years.

RESULTS

At 6 years, the total Sharp score correlated significantly with the total MRI score and the MRI erosion score (r = 0.81, P < 0.0001 and r = 0.79, P < 0.0001, respectively). The 6-year Sharp score also correlated with the baseline total MRI and MRI erosion scores (r = 0.56, P < 0.0001 and r = 0.33, P = 0.03, respectively). MRI synovitis and bone edema scores remained constant for the group as a whole over 6 years, but bone erosion scores progressed (P = 0.0001), consistent with radiographic deterioration. Erosions on 6-year MRI scans were frequently preceded by MRI bone edema at baseline (odds ratio 6.5, 95% confidence interval 2.78-18.1). Regression models indicated that the baseline MRI bone edema score was predictive of the 6-year total Sharp score (P = 0.01), as was the C-reactive protein (CRP) level (P = 0.0002). Neither shared epitope status nor swollen or tender joint counts predicted radiographic outcome in this cohort. A model incorporating baseline MRI scores for erosion, bone edema, synovitis, and tendinitis plus the CRP level and the erythrocyte sedimentation rate explained 59% of the variance in the 6-year total Sharp score (R(2) = 0.59, adjusted R(2) = 0.44).

CONCLUSION

MRI scans performed at the first presentation of RA can be used to help predict future radiographic damage, allowing disease-modifying therapy to be targeted to patients with aggressive disease.

Costs and predictors of costs in rheumatoid arthritis: a prevalence-based study

OBJECTIVE

To analyze the annual cost of rheumatoid arthritis (RA) and its predictive factors.

METHODS

Data were obtained from a 12-month retrospective cohort of 201 RA patients, randomly selected from a rheumatology registry, through a structured interview and records of the Central Information System of the hospital. Results were divided into direct, indirect, and total costs in 2001 US dollars. A sensitivity analysis was performed. Multiple linear regression models for the different types of costs were carried out.

RESULTS

The total cost was US dollars 2.2 million per year, with a cost attributable to RA of US dollars 2.07 million per year. The average cost per patient was US dollars 10419 per year (ranging from US dollars 7914 per patient per year in the best scenario to US dollars 12922 per patient per year in the worst case). Direct costs represent nearly 70% of total costs. We found an average increment in total costs of US dollars 11184 per year per unit of Health Assessment Questionnaire (HAQ) score (P < 0.0001) and an average annual increment of US dollars 621 per year of disease (P < 0.0001). After adjustment, the HAQ score, inability to perform housework tasks, and being permanently disabled for work were the only predictors of high costs.

CONCLUSION

Our data show a remarkable economic impact of RA over society and link the costs of the disease to its consequences in terms of functional disability, work disability, and housework disability.

Ingested type I interferon: a potential treatment for autoimmunity

We have proposed a unifying hypothesis of the etiopathogenesis of autoimmunity that defines autoimmunity as a type I interferon (IFN) immunodeficiency syndrome. We have examined toxicity and potential efficacy in three phase I (type 1 diabetes, rheumatoid arthritis, multiple sclerosis) and one phase II clinical trials in multiple sclerosis (MS). In a phase I open-label trial in type 1 diabetes, ingested IFN-alpha preserved residual beta cell function in recent onset patients. In a second phase I trial, treatment of rheumatoid arthritis (RA) with ingested IFN-alpha reduced the secretion of interleukin-1 (IL-1), a proinflammatory cytokine. In a third phase I trial in MS, there was a significant decrease in peripheral blood mononuclear cell (PBMC) IL-2 and IFN-gamma production after ingesting IFN-alpha. In a phase II randomized, placebo-controlled, double-blind trial in MS, 10,000 IU ingested IFN-alpha significantly decreased gadolinium enhancements compared with the placebo group at month 5. Tumor necrosis factor-alpha (TNF-alpha) and IFN-gamma cytokine secretion in the 10,000 IU group at month 5 showed a significant decrease that corresponded with the effect of ingested IFN-alpha on decreasing gadolinium enhancements. Ingested IFN-alpha was not toxic in any of these clinical trials. These studies suggest that ingested IFN-alpha may have a potential role in the treatment of autoimmunity.

Ingested type I interferon: state of the art as treatment for autoimmunity

We have proposed a unifying hypothesis of the etiopathogenesis of autoimmunity that defines autoimmunity as a type I interferon (IFN) immunodeficiency syndrome. We have examined toxicity and potential efficacy in three phase I (type 1 diabetes, rheumatoid arthritis, multiple sclerosis) and one phase II clinical trials in multiple sclerosis. In a phase I open-label trial in type 1 diabetes, ingested IFN-alpha preserved residual beta-cell function in recent onset patients. In a second phase I trial, treatment of rheumatoid arthritis with ingested IFN-alpha reduced the secretion of interleukin (IL)-1, a pro-inflammatory cytokine. In a third phase I trial in multiple sclerosis, there was a significant decrease in peripheral blood mononuclear cell IL-2 and IFN-gamma production after ingesting IFN-alpha. In a phase II randomized, placebo-controlled, double-blind trial in multiple sclerosis, 10,000 IU ingested IFN-alpha significantly decreased gadolinium enhancements compared with the placebo group at month 5. Tumor necrosis factor-alpha and IFN-gamma cytokine secretion in the 10,000 IU group at month 5 showed a significant decrease that corresponded with the effect of ingested IFN-alpha on decreasing gadolinium enhancements. Ingested IFN-alpha was not toxic in any of these clinical trials. These studies suggest that ingested IFN-alpha may have a potential role in the treatment of autoimmunity.

Treatment of rheumatoid arthritis with methotrexate and hydroxychloroquine, methotrexate and sulfasalazine, or a combination of the three medications: results of a two-year, randomized, double-blind, placebo-controlled trial

OBJECTIVE

To compare the efficacy of combination therapy with methotrexate (MTX) and hydroxychloroquine (HCQ), MTX and sulfasalazine (SSZ), and MTX, HCQ, and SSZ in patients with rheumatoid arthritis (RA).

METHODS

RA patients (n = 171) who had not previously been treated with combinations of the study medications were randomized to receive 1 of the 3 treatment combinations in this 2-year, double-blind, placebo-controlled protocol. HCQ was given at a dosage of 200 mg twice a day. The dosage of MTX was accelerated from 7.5 mg/week to 17.5 mg/week in all patients who were not in remission. Similarly, the dosage of SSZ was escalated from 500 mg twice a day to 1 gm twice a day in patients who were not in remission. The primary end point of the study was the percentage of patients who had a 20% response to therapy according to the American College of Rheumatology (ACR) criteria at 2 years.

RESULTS

Intent-to-treat analysis revealed that patients receiving the triple combination responded best, with 78% achieving an ACR 20% response at 2 years, compared with 60% of those treated with MTX and HCQ (P = 0.05) and 49% of those treated with MTX and SSZ (P = 0.002). Similar trends were seen for the ACR 50% response, with 55%, 40%, and 29% of patients in the 3 treatment groups, respectively, achieving these results at 2 years (P = 0.005 for the triple combination group versus the MTX and SSZ group). All combination treatments were well-tolerated. Fourteen patients (evenly distributed among the 3 groups) withdrew from the protocol because of symptoms that were potentially related to the study medication.

CONCLUSION

The triple combination of MTX, SSZ, and HCQ is well-tolerated, and its efficacy is superior to that of the double combination of MTX and SSZ and is marginally superior to that of the double combination of MTX and HCQ.

Psychiatric dysfunction in connective tissue diseases: association with Sjögren's syndrome

Abstract We studied 217 patients with connective tissue disease (CTD), comprising 55 patients with primary Sjögren's syndrome (SS), 34 with secondary SS, and 128 without SS. Psychiatric manifestations were investigated using three questionnaires: the Arthritis Impact Measurement Scale 2 (AIMS2), the Cornell Medical Index (CMI), and the Beck Depression Inventory (BDI). Stratified analysis revealed that the frequency of a neurotic state (levels III + IV in CMI) in both primary SS patients (53%; 29% + 24%) and secondary SS patients (67%; 41% + 26%) was significantly greater than in CTD patients without SS (34%; 20% + 14%) (P < 0.05 and P < 0.001, respectively). The median and Q1-Q3 BDI scores in secondary SS patients (7.5 and 4.0-20.0) were significantly higher than those in CTD patients without SS (5.0 and 1.0-10.0) (P < 0.05). Neither the frequency of a neurotic state nor the BDI score differed significantly between patients with primary SS and those with secondary SS. Regression analysis showed significant correlations between the AIMS2 level-of-tension scale and CMI classifications (rs = 0.676, P < 0.001), and between the AIMS2 mood scale and BDI score (rs = 0.679, P < 0.001). SS should always be borne in mind when patients with sicca syndrome and multifarious psychiatric complaints are examined.

The epidemiology of rheumatoid arthritis

Studies of the descriptive epidemiology of RA indicate a population prevalence of 0.5% to 1% and a highly variable annual incidence (12-1200 per 100,000 population) depending on gender, race/ethnicity, and calendar year. Secular trends in RA incidence over time have been shown in several studies, supporting the hypothesis of a host-environment interaction. People with RA have a significantly increased risk of death compared with age- and sex-matched controls without RA from the same community. The determinants of this excess mortality remain unclear; however, reports suggest increased risk from gastrointestinal, respiratory, cardiovascular, infectious, and hematologic diseases among RA patients compared with controls. Despite extensive epidemiologic research, the etiology of RA is unknown. Several risk factors have been suggested as important in the development or progression of RA. These include genetics, infectious agents, oral contraceptives, smoking, and formal education. Epidemiologic research is an essential contributor to our understanding of RA.

Anti-TNF agents for rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory, autoimmune disease with a prevalence of approximately 1% and an annual incidence of 0.04%. Up to 50% of patients with RA are unable to work 10 years after diagnosis. The disease is associated with significant morbidity and mortality with associated medical costs to the UK of between £240 m and £600 m per year.

Non steroidal anti-inflammatory drugs (NSAIDs) have little effect on the underlying course of RA, but they have some anti-inflammatory and analgesic properties. Disease modifying antirheumatic drugs (DMARDs) have been shown to slow progression of RA and are currently recommended early in the course of treatment of RA which is when disease progression is most rapid.

Etanercept and infliximab belong to a new group of parentally administered antitumour necrosis factor (TNF) drugs.

Etanercept is licensed in the UK for the treatment of active rheumatoid arthritis in patients who have not responded to other DMARDs and in children with polyarticular-course juvenile arthritis who have not responded to or are intolerant of methotrexate. In adults it produces significant improvements in all measures of rheumatic disease activity compared to placebo. In patients whose disease remains active despite methotrexate treatment, further improvement in control is obtained with the addition of etanercept without an increase in toxicity. In one small trial, etanercept was found to be more effective than placebo in a selected group of children.

Infliximab is a monoclonal antibody which is currently licensed in the UK for Crohn's disease and, in combination with methotrexate for the treatment of rheumatoid arthritis in patients with active disease when the response to disease-modifying drugs, including methotrexate, has been inadequate. In clinical trials infliximab produced significant improvements in all measures of rheumatic disease activity compared with placebo. Infliximab in combination with methotrexate was shown to be superior to methotrexate or infliximab alone.

There are currently no predictors of a good response to anti-TNF drugs and a percentage of patients fail to respond to treatment (25% to 38% of etanercept patients; 21% to 42% of infliximab patients). Infliximab monotherapy induces the production of anti-infliximab antibodies, which may reduce its effectiveness. Adding methotrexate to infliximab therapy may prevent this response.

Anti-TNF drugs may affect host defences against infection and malignancy; whether these agents affect the development and course of malignancies and chronic infections is unknown and safety and efficacy in patients with immunosuppression or chronic infections has not been investigated. With infliximab, upper respiratory tract infections, general infections and those requiring antimicrobial treatment were more common in patients than placebo. Likewise, upper respiratory tract infections were more common in patients treated with etanercept than with placebo. Injection site reactions occur with both infliximab (16%–20%) and etanercept (37%).

There are approximately 600 000 patients with RA in the UK, and of these between 2% and 3.5% may have severe disease which has failed to respond to conventional treatment and who might be eligible for anti-TNF therapy. If between 50% and 70% of patients treated with anti-TNF drugs respond and continue on long-term treatment then the recurrent annual cost to the NHS could be between £48 m and £129 m .

Drug treatment for rheumatoid arthritis

The general goals of drug treatment for patients with rheumatoid arthritis are to reduce morbidity and mortality. Because rheumatoid arthritis is a potentially devastating disease, a more aggressive treatment approach has emerged in the last decade. The modern treatment pyramid consists of nonsteroidal antiinflammatory drugs and glucocorticoids for symptomatic relief, and disease modifying antirheumatic drugs for reducing disease activity in the short term and joint damage in the long term. There is increasing evidence that a reduction of disease activity by disease modifying antirheumatic drugs alters the course of rheumatoid arthritis and that patients benefit from early installation of these compounds. The major problem with disease modifying antirheumatic drugs is their low efficacy to toxicity ratio, leading to marked reduction of the length of time a patient is taking a given drug. The new treatment strategies, including combination regimens and new drugs that are being investigated, promise better efficacy and tolerance in the near future. A step in this direction is the development of biologic agents targeting specific mechanisms in the immune response. Early results in clinical trials with antitumor necrosis factor-alpha monoclonal antibodies are encouraging.

Bone marrow transplantation for therapy in autoimmune disease

A variety of clinical and experimental reports have shown the interdependence between bone marrow and autoimmune diseases. Autoimmune diseases can be transferred as well as cured by bone marrow transplantation (BMT). The widespread application of this therapeutic approach is limited today by the morbidity and mortality associated with BMT, including failure of engraftment, graft-versus-host disease (GVHD) and the toxicity from lethal conditioning approaches. Mixed chimerism (with the advantage of superior immunocompetence of the host and a relative protection against GVHD) can be achieved with incomplete ablation conditioning regimens. BMT may provide a potential strategy to treat those autoimmune diseases for which today only symptomatic treatment is available.

Treatment of early rheumatoid arthritis with minocycline or placebo: results of a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To determine if minocycline is an effective therapy for seropositive rheumatoid arthritis (RA) when used within the first year of disease.

METHODS

The Rheumatoid Arthritis Investigational Network enrolled 46 patients with RA of <1 year duration into a 6-month study of minocycline (100 mg twice daily) versus placebo. All patients were rheumatoid factor positive. The primary end point of the study was successful completion of 6 months of treatment with no drug toxicity while maintaining 50% improvement in composite symptoms of arthritis.

RESULTS

Eighteen of the 46 patients who were enrolled met 50% improvement criteria at 3 months, and maintained at least a 50% improvement for 6 months with no significant drug toxicity. Among them were 15 of the 23 patients (65%) treated with minocycline and 3 of 23 patients (13%) treated with placebo (P < 0.001).

CONCLUSION

In patients with early seropositive RA, therapy with minocycline is superior to placebo.

Treatment of rheumatoid arthritis with methotrexate alone, sulfasalazine and hydroxychloroquine, or a combination of all three medications

BACKGROUND

Rheumatoid arthritis is a common disease that causes substantial morbidity and mortality. The responses of patients with rheumatoid arthritis to treatment with a single so-called disease-modifying drug, such as methotrexate, are often suboptimal. Despite limited data, many patients are treated with combinations of these drugs.

METHODS

We enrolled 102 patients with rheumatoid arthritis and poor responses to at least one disease-modifying drug in a two-year, double-blind, randomized study of treatment with methotrexate alone (7.5 to 17.5 mg per week), the combination of sulfasalazine (500 mg twice daily) and hydroxychloroquine (200 mg twice daily), or all three drugs. The dose of methotrexate was adjusted in an attempt to achieve remission in all patients. The primary and point of the study was the successful completion of two years of treatment with 50 percent improvement in composite symptoms of arthritis and no evidence of drug toxicity.

RESULTS

Fifty of the 102 patients had 50 percent improvement at nine months and maintained at least that degree of improvement for two years without evidence of major drug toxicity. Among them were 24 of 31 patients treated with all three drugs (77 percent), 12 of 36 patients treated with methotrexate alone (33 percent, P < 0.001 for the comparison with the three-drug group), and 14 of 35 patients treated with sulfasalazine and hydroxychloroquine (40 percent), P = 0.003 for the comparison with the three-drug group). Seven patients in the methotrexate group and three patients in each of the other two groups discontinued treatment because of drug toxicity.

CONCLUSIONS

In patients with rheumatoid arthritis, combination therapy with methotrexate, sulfasalazine, and hydroxychloroquine is more effective than either methotrexate alone or a combination of sulfasalazine, and hydroxychloroquine.

Multiple sclerosis and chronic inflammatory diseases. A case-control study

INTRODUCTION

Disease associations may provide useful etiological leads in relation to diseases of unknown cause.

MATERIAL AND METHODS

We conducted a hospital-based case-control study of 155 MS patients and 200 controls in Hordaland County, Norway to investigate the possible association between MS and autoimmune diseases.

RESULTS

The MS patients had a statistically significant more frequent coexistence of rheumatoid arthritis, psoriasis, and goitre when compared to the controls (OR = 2.96; 95% CI 1.23-7.66). This difference persisted when analysing the definite MS cases separately (OR = 2.90; 95% CI 1.10-7.96). The familial occurrence of chronic inflammatory diseases was not significantly different in cases and controls. A significant increased risk to develop MS occurred in first degree relatives of MS patients (OR = 12.58; 95% CI 1.73-552).

CONCLUSION

Acknowledging the low figures, the uncertain estimates with large confidence intervals, and thus the obvious role of chance in this study, the results might indicate that a generalized, genetically controlled problem of the immune system could result in aggregates of the reported diseases, all of which are partly characterized by aberrations of the immune system.

Long-term followup of patients with Sjögren's syndrome

OBJECTIVE

To assess long-term outcome in patients with isolated keratoconjunctivitis sicca (KCS), primary Sjögren's syndrome (SS), and secondary SS.

METHODS

In 112 patients referred because of dry eyes, an ophthalmologic diagnosis of KCS was made based on results of the Schirmer I test, the tear fluid lysozyme concentration, and rose bengal staining. Subsequent assessments, including sublabial salivary gland biopsy, were performed. Followup assessments were performed 10-12 years after initial diagnosis.

RESULTS

Six patients were excluded because no biopsy specimen was available. Seventy-three percent of the remaining 106 patients were female, with a mean age of 53.5 years and a mean symptom duration of 3.9 years. Application of the 1987 classification criteria of Daniels and Talal revealed a diagnosis of isolated KCS in 56 patients, primary SS in 31, and secondary SS in 19. At baseline, 2 of 56 patients with isolated KCS and 8 of 31 with primary SS exhibited mild features of organ-specific autoimmune disease. At followup, 2 of 38 patients with isolated KCS and 4 of 21 with primary SS had developed new features related to autoimmune disease, not necessitating treatment with corticosteroids; none of the patients developed major glandular complications. Three of 30 patients with primary SS died of malignant lymphoma. In 1 of these patients, the possibility could not be excluded that sicca symptoms and infiltrates seen on sublabial salivary gland biopsy had occurred concomitantly with early stages of lymphoma. Malignant lymphoma did not develop in any of the patients with isolated KCS or secondary SS.

CONCLUSION

Primary Sjögren's syndrome is characterized by a stable and rather mild course of glandular and extraglandular manifestations, in marked contrast to the increased risk of development of malignant lymphoma in these patients. Since patients with isolated KCS do not have an increased risk for development of malignant lymphoma, a presumptive diagnosis of primary SS should be confirmed in patients with sicca syndrome.

Innovative treatment approaches for rheumatoid arthritis. Combination therapy

It is accepted that combination DMARD therapy is a useful tool in current rheumatological practice. However, well-designed, large, long-term, controlled clinical trials are needed to determine which combinations, dosage schedules, and sequences of administration are most beneficial and least toxic. Until we develop treatment regimens that reliably induce and sustain acceptable control of disease manifestations in all patients for the rest of their natural lifespan, daily oral prednisone will continue to be a troublesome component of 'bridge' therapy, as it becomes the sole surviving constant in complex regimens whose other components are eventually discontinued because of toxicity, lack of efficacy, or non-compliance. We have often seen patients in whom the replacement of a well-tolerated but presumable ineffective DMARD with another DMARD has led to worsening of disease, when the modest benefits of the discontinued DMARD were lost before the hoped for onset of benefit from its replacement became evident. Since the toxicity of combinations of DMARDs has not appeared to be excessive, one can reasonably add the second DMARD to the first, while carefully monitoring for adverse effects and planning ton continue the combination until increased benefit occurs. Subsequently, if the second DMARD is not tolerated, the partial benefit from the first has not been given up, and a longer duration of treatment with the initial DMARD is sometimes associated with satisfactory improvement. If better control of rheumatoid arthritis is evident after 3-6 months of treatment with the combination of DMARDs, one must still decide whether to stop the first DMARD, stop the second, or continue with the combination. In the absence of major toxicity, we are most likely to choose to continue the combination if the patient has had a good response, thus inadvertently embarking on prolonged combined DMARD therapy (Paulus, 1990). Of course, other drugs besides those discussed above are available to control different aspects of joint damage; they should be considered in any combination therapy. Drugs which potentially protect cartilage from damage, such as orgotein, glycosaminoglycan polysulphate (Arteparon), and Rumalon, may prove useful in rheumatoid arthritis; they have been studied in osteoarthritis, but there is evidence that they protect cartilage from breakdown by inflammation in some animal models. As one of the many goals of treatment in rheumatoid arthritis is to protect cartilage, these chondroprotective agents might also be considered as part of the combinations to be studied. The combination of modest clinical efficacy with minimal toxicity reported with minocycline treatment of rheumatoid arthritis make this another potentially interesting addition to combination therapy regimens (Tilley et al, 1995). It is also important to continue the development of so-called 'biological agents', such as interleukin-2 receptor antibodies, anti-CD4 antibodies, anti-TNF-alpha agents and anti-thymocyte globulin. Combinations which include such agents have not yet been evaluated, although is seems logical considering that these agents offer the possibility of precise intervention directed at specific steps of the immuno-inflammatory process; their combination may thus be more effective than the use of single agents alone. While we await results of well-designed studies of these newer agents in RA therapy, we should continue to consider creative ways of using drugs that are already available.

Rheumatoid arthritis and connective tissue disorders: sub-Saharan Africa

Rheumatoid arthritis (RA) once a rarity in Africa, is now reported in large numbers from many parts of Africa. Although epidemiological surveys have shown that the prevalence in urban populations is similar to Western communities, it is less common in rural areas. Further epidemiological studies are needed to confirm these findings in other parts of Africa and identify factors contributing to this difference to provide a better understanding for the emergence of RA in Africa. Earlier reports suggested that in African blacks RA was a mild disease, severe radiographic changes were uncommon, deformities were rare and extra-articular features were unusual and only symptomatic therapy was necessary to control symptoms in most patients. Recent experience shows that severe disease with deformities and radiographic changes are seen and a wide spectrum of extra-articular features are noted although they may be less common than in Caucasians. African blacks with RA may have a younger age of onset and the genetic association with HLA DR4 has been confirmed. Systemic lupus erythematosus (SLE) is also recognized more often in African blacks who have a younger age of onset. SLE is also recognized less often in males. Features such as photosensitivity and serositis are less common while renal disease is more common. A reported short-term mortality of about 30% emphasizes the need for urgent efforts to improve the prognosis in SLE. The infrequent occurrence of localized systemic sclerosis and the absence of anti-centromere antibodies in blacks was noted in a recent large series of patients with systemic sclerosis. The other connective tissue diseases and systemic vasculitides are reported much less frequently and will probably be detected more often in future. Anti-cardiolipin antibodies are detected frequently in association with infections, including HIV infection. The spectrum of diseases associated with ANCA includes a variety of connective tissue diseases and infections such as HIV infection and invasive amoebiasis must be added.

The economic impact of musculoskeletal disorders

Musculoskeletal disorders have a major impact on society in terms of morbidity, long-term disability and economics. As populations increase and age, payment for medical care and indirect costs from loss of earnings will increase. Both rheumatoid arthritis and low back pain have a great economic impact on society, and the costs of these are escalating problems. Statistics are analysed from various studies in the United States and Canada, and these highlight the need for more rational and effective health care management strategies.