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Matsui T, Yoshida T, Nishino T, Yoshizawa S, Sawada T, Tohma S. Trends in treatment for patients with late-onset rheumatoid arthritis in Japan: Data from the NinJa study. Mod Rheumatol 2024; 34:881-891. [PMID: 38252503 DOI: 10.1093/mr/roae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/27/2023] [Accepted: 01/13/2024] [Indexed: 01/24/2024]
Abstract
OBJECTIVES Our objective was to investigate trends in the treatment of patients with late-onset rheumatoid arthritis (LORA) using data from the National Database of Rheumatic Diseases in Japan (NinJa). METHODS Patients registered in the National Database of Rheumatic Diseases in Japan were classified according to the disease onset: at <65 years (young-onset rheumatoid arthritis); at 65-74 years (early LORA); and at ≥75 years (late LORA). Chronological changes in the treatment and disease activity were compared. RESULTS A total of 7178, 13,171, 15,295, and 15,943 patients were evaluated in 2010, 2013, 2016, and 2019, respectively. In all groups, the use of methotrexate gradually decreased, whereas that of biological/targeted synthetic disease-modifying antirheumatic drugs (DMARDs) increased; the use of tumor necrosis factor inhibitors decreased, whereas that of non-tumor necrosis factor inhibitors increased. LORA was characterized by more single DMARD use and less methotrexate and biological/targeted synthetic DMARD use. Tumor necrosis factor inhibitors and interleukin-6 inhibitors were used less frequently, whereas abatacept was utilized more frequently in late versus early LORA. Conventional synthetic DMARD (excluding methotrexate) and glucocorticoid use was higher in late versus early LORA. CONCLUSIONS This analysis revealed chronological changes in the treatment of LORA in Japan. Differences between early and late LORA suggest that patients are not a homogeneous population.
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Affiliation(s)
- Toshihiro Matsui
- Department of Rheumatology Research, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | - Tomoya Yoshida
- Department of Rheumatology Research, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | - Takahiro Nishino
- Department of Rheumatology Research, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | - Shigeru Yoshizawa
- Department of Rheumatology, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Tetsuji Sawada
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Shigeto Tohma
- Department of Rheumatology, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
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Dibrov DA, Avdeeva AS, Rybakova VV, Demidova NV, Nasonov EL. Clinical Features of ACPA-Negative and ACPA-Positive Variants of Rheumatoid Arthritis. DOKL BIOCHEM BIOPHYS 2024; 517:243-249. [PMID: 39002008 DOI: 10.1134/s1607672924700996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 04/20/2024] [Accepted: 04/20/2024] [Indexed: 07/15/2024]
Abstract
The aim of the study was to investigate the features of the clinical picture of the disease in patients with ACPA-negative and ACPA-positive variants of rheumatoid arthritis. MATERIALS AND METHODS : The study included patients with a reliable diagnosis of rheumatoid arthritis (RA) according to the criteria of ACR/EULAR 2010. Depending on the ACPA values, two groups of patients were recruited: ACPA-positive and ACPA-negative, comparable in gender, age, duration of the disease, and therapy. The nature of the onset and course of the disease and the activity of RA were evaluated (according to the DAS28, SDAI, CDAI indices). RESULTS AND DISCUSSION : The study involved 79 patients with ACPA-negative variant of RA and 79 ACPA-positive patients. The age of patients (Me [IR] (in years)) with the ACPA(-) variant was 52 [39; 62]; with the ACPA(+) variant, 54 [42; 62]; the duration of the disease (in months) was 59 [23; 122] and 48 [17; 84], respectively. In ACPA(+) patients, a higher disease activity was determined (by the indices DAS 28crp, DAS28esr, SDAI, CDAI), higher values of C-reactive protein and erythrocyte sedimentation rate, and a greater number of painful and swollen joints (p < 0.05). According to the localization of the involved joints, arthritis of the proximal interphalangeal, metacarpal, wrist and shoulder joints was more often determined in ACPA(+) patients. Systemic manifestations of RA at the time of examination and in the anamnesis were statistically significantly more common in ACPA(+) (32.9%) than in ACPA(-) (17.7%) patients. Of the systemic manifestations, rheumatoid nodules were more common in ACPA(+) patients, whereas a tendency to a higher frequency of neuropathy, sclerites, and episcleritis was revealed in ACPA(-) patients. CONCLUSIONS . In patients with ACPA(-) subtype, clinical signs of joint damage and the inflammatory component are less pronounced compared to ACPA(+). However, the mixed picture of manifestation, the less "bright" course of the disease, the absence of characteristic immunological biomarkers necessitate long-term and careful monitoring of this group of patients. At the same time, the subjective severity of the disease and dysfunction due to ankylosing joints do not differ from the ACPA(+) variant of RA.
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Affiliation(s)
- D A Dibrov
- Nasonova Research Institute of Rheumatology, Moscow, Russia.
| | - A S Avdeeva
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - V V Rybakova
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - N V Demidova
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - E L Nasonov
- Nasonova Research Institute of Rheumatology, Moscow, Russia
- Sechenov First Moscow State Medical University of the Ministry of Health Care of the Russian Federation (Sechenov University), Moscow, Russia
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Sugihara T, Tanaka E, Matsui T. Low-Dose Glucocorticoids in Older Patients with Rheumatoid Arthritis: What Does the Evidence Say? Drugs Aging 2024:10.1007/s40266-024-01133-w. [PMID: 39066877 DOI: 10.1007/s40266-024-01133-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 07/30/2024]
Abstract
The short-term use of glucocorticoids (GCs) in combination with methotrexate was recommended for the initial treatment of rheumatoid arthritis by the European League Against Rheumatism. A randomized controlled trial (GLORIA) showed that treatment of older patients with low-dose GCs in combination with disease-modifying anti-rheumatic drugs was more efficacious than disease-modifying anti-rheumatic drugs plus placebo in terms of disease activity control and prevention of joint destruction. Glucocorticoid-related adverse events were likely to increase relative to placebo, with no increase in serious adverse events and fractures over 2 years. Observational studies showed an increased risk of serious infections, cardiovascular events, and fractures associated with long-term continuation of GCs in older patients, but the adverse events may be associated not only with GC toxicity but also with poor disease control of rheumatoid arthritis. In the GLORIA study, low-dose GCs during 2 years could be tapered off safely, but many patients had a flare of disease activity after discontinuation of GCs. In the two representative large Japanese registries (IORRA and NinJa), the proportion of patients using GCs and non-tumor necrosis factor inhibitors increased with increasing age at disease onset, with a decreasing trend in methotrexate use. The proportion of patients in remission with GC treatment also increased with increasing age at onset. These suggested that it is not easy to discontinue GCs in older patients. If GCs cannot be terminated in the short term, it may be acceptable to use GCs to control disease activity for up to 2 years.
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Affiliation(s)
- Takahiko Sugihara
- Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Eiichi Tanaka
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Toshihiro Matsui
- Department of Rheumatology Research, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
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Pavlov-Dolijanovic S, Bogojevic M, Nozica-Radulovic T, Radunovic G, Mujovic N. Elderly-Onset Rheumatoid Arthritis: Characteristics and Treatment Options. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1878. [PMID: 37893596 PMCID: PMC10608066 DOI: 10.3390/medicina59101878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/01/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Abstract
Elderly-onset rheumatoid arthritis (EORA) is a distinct clinical entity defined as the onset of rheumatoid arthritis (RA) in individuals aged over 60 years. EORA presents unique clinical features, including a more equitable distribution of sexes, a potential predilection for male involvement, a higher incidence of acute onset characterized by constitutional symptoms, a propensity for systemic manifestations, elevated sedimentation rates at disease onset, a reduced occurrence of rheumatoid factor positivity, increased titers of anti-citrullinated protein antibodies, a preference for involvement of large joints, elevated disease activity, the presence of bone erosions, and heightened patient disability. RA is recognized to consist of three partially overlapping subsets. One subset mirrors the classical RA clinical presentation, while the remaining subsets exhibit either a polymyalgia rheumatica-like phenotype or present with remitting seronegative symmetrical synovitis accompanied by pitting edema syndrome. In the initial stages of EORA management, non-steroidal anti-inflammatory drugs (NSAIDs) are not typically the first-line treatment choice, because seniors are much more prone to develop side effects due to NSAIDs, and the use of NSAIDs is in reality contraindicated to the majority of seniors due to comorbidities. Disease-modifying antirheumatic drugs (DMARDs), frequently methotrexate, are introduced immediately after the diagnosis is made. In cases where elderly patients demonstrate resistance to conventional DMARD therapy, the introduction of biological or targeted synthetic DMARDs becomes a viable treatment option. EORA presents a unique clinical profile, necessitating tailored treatment strategies. Our study emphasizes the challenges of NSAID use in seniors, highlighting the imperative shift toward DMARDs such as methotrexate. Future research should explore personalized DMARD approaches based on disease activity, comorbidities, and safety considerations, aiming to optimize treatment outcomes and minimize glucocorticoid reliance, thereby enhancing the quality of care for EORA patients.
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Affiliation(s)
| | - Milan Bogojevic
- Clinical Centre of Montenegro, Department of Rheumatology, 81000 Podgorica, Montenegro;
| | - Tatjana Nozica-Radulovic
- Faculty of Medicine, Institute for Physical Medicine and Rehabilitation and Orthopedic Surgery “Dr. Miroslav Zotovic”, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina;
| | - Goran Radunovic
- University of Belgrade, Faculty of Medicine, Institute of Rheumatology, 11000 Belgrade, Serbia;
| | - Natasa Mujovic
- University of Belgrade, Faculty of Medicine, Center for Physical Medicine and Rehabilitation, University Clinical Centre of Serbia, 11000 Belgrade, Serbia;
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Goto Y, Nagafuchi H, Kaga Y, Kawahata K. Association between glucocorticoid discontinuation and incidence of infection in older adults with rheumatoid arthritis: A retrospective cohort study. Int J Rheum Dis 2023; 26:1987-1995. [PMID: 37504066 DOI: 10.1111/1756-185x.14851] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/24/2023] [Accepted: 07/16/2023] [Indexed: 07/29/2023]
Abstract
AIM Old age and glucocorticoid (GC) use increase the susceptibility to infection in patients with rheumatoid arthritis (RA). Accordingly, we investigated whether GC discontinuation reduces the incidence of infection in older adults with RA and analyzed factors associated with GC discontinuation. METHODS Medical records of patients with RA aged ≥60 years were retrieved, and the association between GC use and the incidence of infection was investigated. The participants were divided into three groups: GC-continued, GC-discontinued, and non-GC; the incidence of infection was statistically analyzed. Furthermore, patient treatments and comorbidities were examined. RESULTS Among 389 patients with RA included in the study (n = 122, n = 126, and n = 141 in the GC-discontinued, GC-continued, and non-GC groups, respectively), 65 (16.7%) patients developed infection, and the incidence of infection was significantly higher in the GC-continued group than in the GC-discontinued (p = .021) and non-GC (p = .0003) groups; there was no significant difference between the non-GC and GC-discontinued groups (p = .659). The GC-discontinued group was more likely to require biologic use throughout the disease course than the other two groups. Comorbidities, especially malignancies (p = .004), were more common in the GC-continued group than in the GC-discontinued group (p = .007). CONCLUSION In patients with RA aged ≥60 years receiving GCs, GC discontinuation reduced the incidence of infection. Therefore, a further analysis of factors that help reduce GC use is necessary.
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Affiliation(s)
- Yutaka Goto
- Division of Rheumatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hiroko Nagafuchi
- Division of Rheumatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yasuyuki Kaga
- Department of Practical Management of Medical Information, St. Marianna University School of Medicine, Kawasaki, Japan
- EPS Corporation, Tokyo, Japan
| | - Kimito Kawahata
- Division of Rheumatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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Nawata M, Someya K, Kosaka S, Aritomi T, Funada M, Fujita Y, Nagayasu A, Fujino Y, Saito K, Tanaka Y. Usefulness of ultrasound as a predictor of elderly-onset rheumatoid arthritis with polymyalgia rheumatica-like onset. Mod Rheumatol 2023; 33:318-322. [PMID: 35286376 DOI: 10.1093/mr/roac024] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/25/2021] [Accepted: 03/09/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Differentiation between polymyalgia rheumatica (PMR) and elderly-onset rheumatoid arthritis (EORA), especially in elderly patients, is often difficult due to similarities in symptoms and serological kinetics. In this study, we aimed to analyse the predictors of EORA with PMR-like onset. METHODS Seventy-two patients diagnosed with PMR, who attended our hospital for routine care and underwent musculoskeletal ultrasonography at that time were evaluated. Synovitis was evaluated semi-quantitatively (0-3) by grey scale (GS) and power Doppler (PD) in 24 joints [both hands (wrist, metacarpophalageal, and proximal interphalangeal joints) and both shoulder joints]. RESULTS Overall, 18 patients had rheumatoid arthritis (25.0%); the mean age was 75.0 years, and 34.7% and 65.3% were male and female, respectively. In PMR and PMR/EORA groups, multivariate logistic analysis showed that rheumatoid factor positivity, GS ≥2 of hand joints, and PD ≥1 of hand joints were independent factors with significant differences. At least one of the three factors had a sensitivity of 88.9% and specificity of 92.6%. CONCLUSIONS The presence of at least one of the criteria: rheumatoid factor positivity, GS ≥ 2, and PD ≥ 1 of hand joints, suggested the possibility of developing EORA within 1 year of PMR diagnosis.
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Affiliation(s)
- Masao Nawata
- Department of Clinical Immunology and Rheumatology, Tobata General Hospital, Kitakyushu, Japan.,The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazuki Someya
- Department of Clinical Immunology and Rheumatology, Tobata General Hospital, Kitakyushu, Japan.,The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shunpei Kosaka
- Department of Clinical Immunology and Rheumatology, Tobata General Hospital, Kitakyushu, Japan.,The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Takafumi Aritomi
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Masashi Funada
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yuya Fujita
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Atsushi Nagayasu
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshihisa Fujino
- Department of Environmental Epidemiology, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazuyoshi Saito
- Department of Clinical Immunology and Rheumatology, Tobata General Hospital, Kitakyushu, Japan.,The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Li X, Cesta A, Movahedi M, Bombardier C. Late-onset rheumatoid arthritis has a similar time to remission as younger-onset rheumatoid arthritis: results from the Ontario Best Practices Research Initiative. Arthritis Res Ther 2022; 24:255. [DOI: 10.1186/s13075-022-02952-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/04/2022] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background
The prevalence of rheumatoid arthritis (RA) in persons 60 years or older is estimated to be 2%. Late-onset rheumatoid arthritis (LORA) is traditionally defined as the onset of RA after the age of 60 years. Compared to younger-onset rheumatoid arthritis (YORA) which occurs before the age of 60 years, LORA has unique characteristics and disease manifestations. To date, few reports have addressed LORA and the prognosis of LORA patients remains unclear. We compared the clinical characteristics, time to remission and treatment regimen at remission between LORA and YORA patients.
Methods
This prospective cohort study used a registry database in Ontario, Canada from 2008 to 2020. Patients were included if they had active rheumatoid arthritis (RA) disease (≥1 swollen joint) and were enrolled within 1 year of diagnosis. LORA was defined as a diagnosis of RA in persons 60 years and older and YORA as a diagnosis of RA in persons under the age of 60. Remission was defined by Disease Activity Score 28 (DAS28) ≤2.6. A multivariable Cox proportional hazards model was used to estimate time to remission.
Results
The study included 354 LORA patients and 518 YORA patients. The mean (standard deviation) baseline DAS28 score was 5.0 (1.3) and 4.8 (1.2) in LORA and YORA patients, respectively (p=0.0946). Compared to YORA patients, the hazard ratio for remission in LORA patients was 1.10 (95% confidence interval 0.90 to 1.34 p=0.36) after adjusting for other prognostic factors. For patients who reached remission, LORA patients were less likely to be on a biologic or Janus kinase (JAK) inhibitor (16% vs. 27%) and more likely to be on a single conventional synthetic disease-modifying anti-rheumatic drugs (csDMARD) (34% vs. 27%) than YORA patients (p=0.0039).
Conclusion
LORA and YORA patients had similar prognosis in terms of time to remission. At remission, LORA patients were more likely to be on a single csDMARD without a biologic or JAK inhibitor.
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How does age determine the development of human immune-mediated arthritis? Nat Rev Rheumatol 2022; 18:501-512. [PMID: 35948692 PMCID: PMC9363867 DOI: 10.1038/s41584-022-00814-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/08/2022]
Abstract
Does age substantially affect the emergence of human immune-mediated arthritis? Children do not usually develop immune-mediated articular inflammation during their first year of life. In patients with juvenile idiopathic arthritis, this apparent ‘immune privilege’ disintegrates, and chronic inflammation is associated with variable autoantibody signatures and patterns of disease that resemble adult arthritis phenotypes. Numerous mechanisms might be involved in this shift, including genetic and epigenetic predisposing factors, maturation of the immune system with a progressive modulation of putative tolerogenic controls, parallel development of microbial dysbiosis, accumulation of a pro-inflammatory burden driven by environmental exposures (the exposome) and comorbidity-related drivers. By exploring these mechanisms, we expand the discussion of three (not mutually exclusive) hypotheses on how these factors can contribute to the differences and similarities between the loss of immune tolerance in children and the development of established immune-mediated arthritis in adults. These three hypotheses relate to a critical window in genetics and epigenetics, immune maturation, and the accumulation of burden. The varied manifestation of the underlying mechanisms among individuals is only beginning to be clarified, but the establishment of a framework can facilitate the development of an integrated understanding of the pathogenesis of arthritis across all ages. In this Review, the authors discuss age-related arthropathy and the similarities and differences between childhood loss of immune tolerance and adult development of immune-mediated arthritis, and develop three hypotheses describing age-related mechanisms that contribute to the onset of arthritis. The arthritis-free ‘immune privilege’ of early childhood is overridden by multiple mechanisms, progressively and age-dependently, generating recognizable patterns of chronic inflammatory arthritis. The emergence of arthritis involves interconnected mechanisms related to immune priming, to a situational susceptibility and to the accumulation of an inflammatory burden. The accumulation of epigenetic drift may contribute to differences across ages. The exposome is expected to contribute to arthritis emergence in adults as well as in children.
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Sugihara T, Kawahito Y, Morinobu A, Kaneko Y, Seto Y, Kojima T, Ito H, Kohno M, Nakayama T, Sobue Y, Nishida K, Matsushita I, Murashima A, Mori M, Tanaka E, Hirata S, Kishimoto M, Yamanaka H, Kojima M, Harigai M. Systematic review for the treatment of older rheumatoid arthritis patients informing the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis. Mod Rheumatol 2022; 32:313-322. [PMID: 33853484 DOI: 10.1080/14397595.2021.1912922] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To provide an evidence base for clinical practice guidelines (CPG) for the management of rheumatoid arthritis (RA) in older adults. METHODS PubMed, Cochrane library, and Japan Centra Revuo Medicina databases were searched for articles published between 1990 and 2019. Quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation system, with some modifications. RESULTS Among 702 identified articles, there were 5 post-hoc analyses of randomized controlled trials and 10 observational studies. Meta-analysis of the former yielded a mean difference of the van der Heijde-modified total Sharp score of -2.79 (95% confidence interval [CI] - 3.74 to -1.84) for treatment with tumor necrosis factor inhibitors. The risk ratio (RR) for the American College of Rheumatology 50% response rate, and for serious adverse events was 2.83 (95%CI 1.90-4.21) and 1.32 (95%CI 0.53-3.31), respectively, for Janus kinase inhibitors. Meta-analysis of the observational studies yielded an RR for disease activity score-28 remission and serious infections of 0.76 (95%CI 0.64-0.91) and 1.92 (95%CI 1.31-2.81) for older-versus-younger patients receiving biological disease-modifying antirheumatic drugs, respectively. CONCLUSION This systematic review provides the necessary evidence for developing CPG for the management of RA in older adults.
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Affiliation(s)
- Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yutaka Kawahito
- Department of Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuko Kaneko
- Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Seto
- Department of Rheumatology, Yachiyo Medical Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiromu Ito
- Department of Advanced Medicine for Rheumatic Diseases and Orthopedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masataka Kohno
- Department of Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Yasumori Sobue
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Orthopedic Surgery, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Keiichiro Nishida
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Density and Pharmaceutical Sciences, Okayama, Japan
| | - Isao Matsushita
- Department of Rehabilitation Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine/Japan Drug Information Institute in Pregnancy, National Center for Child Health and Development, Tokyo, Japan
| | - Masaaki Mori
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eiichi Tanaka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Mitsumasa Kishimoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | | | - Masayo Kojima
- Department of Frailty Research, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu City, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Sugihara T. Treatment strategies for elderly-onset rheumatoid arthritis in the new era. Mod Rheumatol 2021; 32:493-499. [PMID: 34791359 DOI: 10.1093/mr/roab087] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022]
Abstract
Elderly-onset rheumatoid arthritis (EORA) is characterized by acute onset and clinical features of high disease activity. Anti-cyclic citrullinated peptide antibody (ACPA) positivity or the presence of bone erosions predicts a radiological joint destruction of EORA, but ACPA-negative EORA with a polymyalgia rheumatica (PMR) phenotype may also present. Biological disease-modifying antirheumatic drugs (bDMARDs) and Janus kinase inhibitors were beneficial both in older and in younger patients in terms of risk-benefit balance. Implementation of a treat-to-target strategy could improve EORA outcomes, but older patients have more age-related comorbidities and interstitial lung disease than younger patients. Baseline comorbidities, more frequent methotrexate dose-dependent adverse events, serious infections, cardiovascular disease events, and malignancy all influence the choice of treatment and the treatment goals for older patients. Based on articles reviewed here, it is suggested that current treatment strategies for younger patients are also useful for ACPA-positive EORA and for ACPA-negative EORA with bone erosion. Differential diagnosis of ACPA-negative EORA without erosive arthritis and PMR with peripheral manifestations is challenging, and the treatment strategy of patients presenting with this overlap phenotype remained unclear. An appropriate treatment strategy for all patients with EORA still needs to be developed.
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Affiliation(s)
- Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Internal Medicine, Division of Rheumatology and Allergy, St. Marianna University School of Medicine, Kawasaki, Japan
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11
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Andersen KM, Schieir O, Valois MF, Bartlett SJ, Bessette L, Boire G, Haraoui B, Hazlewood G, Hitchon C, Keystone EC, Pope J, Tin D, Throne JC, Bykerk VP. A Bridge Too Far? Real-World Practice Patterns of Early Glucocorticoid Use in the Canadian Early Arthritis Cohort. ACR Open Rheumatol 2021; 4:57-64. [PMID: 34708574 PMCID: PMC8754017 DOI: 10.1002/acr2.11334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/05/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To describe patterns of glucocorticoid use in a large real-world cohort with early rheumatoid arthritis (RA) and assess the impact on disease activity and treatment. METHODS Data are from adults with new RA (≤1 year) recruited to the Canadian Early Arthritis Cohort (CATCH) and are stratified on the basis of whether a person was prescribed oral glucocorticoids within 3 months of study entry. Disease activity was compared over 24 months. Mixed-effects logistic regression was used for adjusted odds ratios (aORs) of escalation to biologics separately for 12 and 24 months, with random effects terms to account for prescribing patterns clustering by study site. RESULTS Among 1891 persons, 30% received oral steroids. Users were older, were less often employed, and had shorter disease duration and higher disease activity. Disease activity improved over time, with early glucocorticoid users starting at higher levels of disease activity. Participants with early oral glucocorticoids were more likely to be on a biologic at 12 months (aOR = 2.4; 95% confidence interval [CI], 1.5-3.7) and 24 months (aOR = 1.9; 95% CI, 1.3-3.0). Despite Canadian clinical practice guidelines to limit corticosteroid use to short-term or 'bridge' therapy, 30% of patients who used oral glucocorticoids still used them 2 years later. CONCLUSION Early steroids were prescribed sparingly in CATCH and were often indicative of more active baseline disease as well as the need for progression to biologics.
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Affiliation(s)
| | | | | | - Susan J Bartlett
- McGill University, Montreal, Quebec, Canada, and Johns Hopkins University, Baltimore, Maryland
| | - Louis Bessette
- Centre Hôspitalier Universitairé de Québec-Université Laval, Québec, Québec, Canada
| | - Gilles Boire
- Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Boulos Haraoui
- Institut de Rhumatologie de Montreal, Montreal, Quebec, Canada
| | | | | | | | - Janet Pope
- St. Joseph's Health Care London and University of Western Ontario, London, Ontario, Canada
| | - Diane Tin
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - J Carter Throne
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Vivian P Bykerk
- Hospital for Special Surgery and Weill Cornell Medicine, New York City, New York
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12
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Ebina K. Drug efficacy and safety of biologics and Janus kinase inhibitors in elderly patients with rheumatoid arthritis. Mod Rheumatol 2021; 32:256-262. [PMID: 34894239 DOI: 10.1093/mr/roab003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/21/2021] [Accepted: 05/24/2021] [Indexed: 11/14/2022]
Abstract
Elderly patients with rheumatoid arthritis (RA) are frequently associated with higher disease activity and impaired physical function, although they show intolerance for conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), such as methotrexate, because of their comorbidities. However, the present treatment recommendation based on randomized controlled trials is not distinguished by age or comorbidities. Therefore, this review aimed to investigate the efficacy and safety of biological DMARDs (bDMARDs) and Janus kinase inhibitors (JAKi) in elderly patients. Present bDMARDs, including tumor necrosis factor inhibitors (TNFi), cytotoxic T lymphocyte-associated antigen-4-immunoglobulin (abatacept), interleukin (IL)-6 receptor antibody (tocilizumab and salirumab), and anti-CD20 antibody (rituximab), may be similarly or slightly less effective or safe in elderly patients compared with younger patients. Oral glucocorticoid use, prolonged disease duration, and very old patients appear to be associated with an increased risk of adverse events, such as serious infection. Some recent cohort studies demonstrated that non-TNFi showed better retention than TNFi in elderly patients. Both TNFi and non-TNFi agents may not strongly influence the risk of adverse events such as cardiovascular events and malignancy in elderly patients. Regarding JAKi, the efficacy appears to be similar, although the safety (particularly for serious infections, including herpes zoster) may be attenuated by aging.
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Affiliation(s)
- Kosuke Ebina
- Department of Musculoskeletal Regenerative Medicine, Osaka University, Graduate School of Medicine, Osaka 565-0871, Japan
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13
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Nilsson J, Andersson MLE, Hafström I, Svensson B, Forslind K, Ajeganova S, Leu Agelii M, Gjertsson I. Influence of Age and Sex on Disease Course and Treatment in Rheumatoid Arthritis. Open Access Rheumatol 2021; 13:123-138. [PMID: 34079395 PMCID: PMC8163636 DOI: 10.2147/oarrr.s306378] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/07/2021] [Indexed: 12/19/2022] Open
Abstract
Objective More than 50% of patients with rheumatoid arthritis (RA) are >65 years at diagnosis. Age of onset and sex may influence the disease course, outcome and treatment. This study follows a large cohort of patients with early RA to assess contributions of age and sex to disease outcomes. Methods Patients from the BARFOT cohort, n=2837 (68% women), were followed for eight years at predefined time points to assess inflammation, function, joint destruction and treatment with disease modifying anti-rheumatic drugs (DMARDs) and glucocorticoids (GC). The patients were divided by sex and age at inclusion (<40, 40–54, 55–69 and ≥70 years). Results For both sexes, disease activity, function and pain improved over time, significantly more in men than in women in all age groups. In men, those <40 years displayed significantly lower DAS28 compared with all other groups. This group was also the least represented group in the study. The Sharp van der Heijde Score (SHS) increased over time in both sexes and all age groups. Women ≥70 years showed less improvement in disability and the highest progression of SHS mainly due to increased joint space narrowing. Patients <40 years were more likely to receive biological DMARDs, while those ≥70 years more often received only GC treatment. Conclusion There were significant age- and sex-dependent differences in the medical treatment and in outcome of RA 8 years after diagnosis. The differences were most pronounced in men<40 and women ≥70 years, but whether they are due to disease phenotype or treatment is unclear.
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Affiliation(s)
- Jenny Nilsson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Maria L E Andersson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden.,Spenshult Research and Development Center, Halmstad, Sweden
| | - Ingiäld Hafström
- Division of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Björn Svensson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden
| | - Kristina Forslind
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden.,Spenshult Research and Development Center, Halmstad, Sweden
| | - Sofia Ajeganova
- Division of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Sciences, Rheumatology Division. Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Monica Leu Agelii
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Inger Gjertsson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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14
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Ke Y, Dai X, Xu D, Liang J, Yu Y, Cao H, Chen W, Lin J. Features and Outcomes of Elderly Rheumatoid Arthritis: Does the Age of Onset Matter? A Comparative Study From a Single Center in China. Rheumatol Ther 2021; 8:243-254. [PMID: 33315188 PMCID: PMC7991049 DOI: 10.1007/s40744-020-00267-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/28/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The aim of this work is to investigate the clinical and radiological characteristics of elderly rheumatoid arthritis and compare the outcomes between the two subgroups, elderly- and young-onset rheumatoid arthritis (EORA and YORA, respectively). METHODS We conducted a retrospective case-control study on the elderly rheumatoid arthritis patients in our medical center. EORA was defined as the patient whose onset age was above 60. RESULTS A total of 142 elderly rheumatoid arthritis patients were admitted, with 79 patients in EORA and 63 in YORA group. Inflammatory parameters including C-reactive protein, D-dimer, serum ferritin, and platelet count levels were all higher in the EORA group than those in YORA. EORA patients showed a higher score of health assessment questionnaire's disability index (p = 0.01) and patient global health assessment (p = 0.049), but a lower status of modified total sharp score (p = 0.001). Bivariate logistic regression analysis revealed that elderly onset of the disease (OR 2.30, 95% CI [1.45-3.77]), age (OR 2.04, 95% CI [1.22-3.41]), high disease activity (OR 1.90, 95% CI [1.17-3.32]), and red blood cell distribution width (OR 1.81, 95% CI [1.03-3.19]) were independent prognostic factors of disability. Age (OR 0.25, 95% CI [0.07-0.91]), disease duration (OR 2.73, 95% CI [0.97-7.70]), and co-morbid diabetes mellitus (OR 118.10, 95% CI [3. 50-3985.57]) independently contributed to radiographic joint damage in the elderly population. EORA patients showed increased death incidents and worse prognosis than YORA. Cox regression analysis reveals that comorbid hypertension (HR 12.02, 95% CI [1.08-133.54]), interstitial lung disease (ILD) (HR 85.04, 95% CI [4.11-1759.19]), and compressive fracture (HR 85.04, 95% CI [4.11-1759.19]) are independent predictors of mortality, and that ILD (HR 50.21, 95% CI [5.56-335.33]) and pulmonary hypertension (HR 25.37, 95% CI [3.03-265.81]) are independent predictors of no disease remission in the EORA patients. CONCLUSIONS The distinct features of EORA patients make EORA a unique entity different from "classic rheumatoid arthritis". EORA patients develop an upgraded systemic inflammatory status, more declined life quality, and worse prognosis than the elderly YORA. Better control of the comorbidities like ILD and diabetes mellitus may benefit the management of elderly rheumatoid arthritis. Further investigation regarding the pathogenesis and therapeutic strategies of EORA is urgently warranted.
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Affiliation(s)
- Yini Ke
- Department of Rheumatology and Immunology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaona Dai
- Department of Rheumatology, Zhejiang Hospital, Hangzhou, China
| | - Danyi Xu
- Department of Rheumatology and Immunology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junyu Liang
- Department of Rheumatology and Immunology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ye Yu
- Department of Rheumatology and Immunology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Heng Cao
- Department of Rheumatology and Immunology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Weiqian Chen
- Department of Rheumatology and Immunology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
| | - Jin Lin
- Department of Rheumatology and Immunology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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15
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Kumagai K, Okumura N, Amano Y, Yayama T, Mimura T, Maeda T, Kubo M, Mori K, Barrett-Jolley R, Imai S. Consideration of differences in drug usage between young-onset and elderly-onset rheumatoid arthritis with target of low disease activity. Mod Rheumatol 2021; 31:1094-1099. [PMID: 33538619 DOI: 10.1080/14397595.2021.1883251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Elderly-onset rheumatoid arthritis (EORA) is reported to differ from young-onset rheumatoid arthritis (YORA) with regard to patient background and drug treatment. We examined the amount of drug administered to patients who achieved low disease activity (LDA) for rheumatoid arthritis at our hospital. METHODS Demographics, clinical history, and treatments were compared between patients with EORA (n = 70) and YORA (n = 190). RESULTS There was a significant difference in the average age (73.8 vs. 57.8 years), disease duration (6.66 vs. 14.7 years), and sex (62.9% males vs. 83.7% females), but no difference in rheumatoid factor positivity (85.3% vs. 80.7%), anti-citrullinated peptide antibody positivity (86.5% vs. 87.7%), simplified disease activity index (4.28 vs. 4.59), or disease activity score 28-CRP (1.99 vs. 2.04) in the EORA and YORA groups, respectively. There were also no significant differences in prednisolone use (37.1% vs. 36.3%), amount of methotrexate administered (MTX) (1.45 vs. 1.41 mg), and MTX use (55.7% vs. 65.3%). However, the MTX dose (2.89 vs. 4.09 mg/week, p = .011) and overall biologics use (32.9% vs. 56.3%, p = .0012) were significantly lower in patients with EORA than in those with YORA. CONCLUSION Patients with EORA may be able to achieve LDA with lower drug dosage than those with YORA.
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Affiliation(s)
- Kosuke Kumagai
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Noriaki Okumura
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Otsu, Japan.,Department of Orthopaedics, Kyoto Okamoto Memorial Hospital, Kyoto, Japan
| | - Yasutaka Amano
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Takafumi Yayama
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Tomohiro Mimura
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Tsutomu Maeda
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Mitsuhiko Kubo
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Kanji Mori
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Richard Barrett-Jolley
- Institute of Ageing and Chronic Disease, Musculoskeletal Biology II, University of Liverpool, Liverpool, UK
| | - Shinji Imai
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Otsu, Japan
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16
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Romão VC, Fonseca JE, Pitzalis C. Elderly-onset rheumatoid arthritis is a unique disease subset associated with poor overall outcomes: Response to the letter by Haroon and Ayamer. Semin Arthritis Rheum 2020; 51:e11-e12. [PMID: 33358004 DOI: 10.1016/j.semarthrit.2020.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Vasco C Romão
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, United Kingdom; Department of Rheumatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal; Rheumatology Research Unit, Faculdade de Medicina, Universidade de Lisboa, Instituto de Medicina Molecular, Av. Prof. Egas Moniz, 1649-028 Lisbon, Portugalv
| | - João Eurico Fonseca
- Department of Rheumatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal; Rheumatology Research Unit, Faculdade de Medicina, Universidade de Lisboa, Instituto de Medicina Molecular, Av. Prof. Egas Moniz, 1649-028 Lisbon, Portugalv
| | - Costantino Pitzalis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, United Kingdom.
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17
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Romão VC, Humby F, Kelly S, Di Cicco M, Mahto A, Lazarou I, Hands R, Rocher-Ros V, van der Heijde D, Fonseca JE, Pitzalis C. Treatment-resistant synovitis and radiographic progression are increased in elderly-onset rheumatoid arthritis patients: findings from a prospective observational longitudinal early arthritis cohort study. Semin Arthritis Rheum 2020; 50:735-743. [PMID: 32531503 DOI: 10.1016/j.semarthrit.2020.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/26/2020] [Accepted: 03/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Clinical outcomes in elderly-onset rheumatoid arthritis (EORA), starting after the age of 60, are conflicting. Thus, we aimed to investigate in a unique biopsy-driven, treatment-naïve early arthritis cohort, the relationship between synovial pathobiology of elderly- (EORA) and younger-onset rheumatoid arthritis (YORA) patients through clinical, imaging and treatment response outcome-measures. METHODS Patients (n = 140) with early RA (<12months) starting before (YORA, n = 99) or after (EORA, n = 41) age 60 had an ultrasound-guided synovial biopsy prior to conventional immunosuppressive therapy and after 6 months. Clinical, ultrasound and radiographic data were collected prospectively and compared between groups and against immunohistological features. Using multivariate logistic regression, we determined predictors of clinical response (disease activity score-28-erythrocyte sedimentation rate [DAS28-ESR]<3.2) at 6 months and radiographic progression (≥1-unit-increase in Sharp van der Heijde [SvdH] score) at 12 months. RESULTS EORA patients were more frequently male and presented most commonly with an abrupt, polymyalgia rheumatica-like onset and extra-articular features. Both before and after treatment, DAS28-ESR was similar but ultrasound synovial-thickening (p<0.05) and power-Doppler (p<0.01) synovitis and SvdH (p<0.001) scores were higher in EORA patients. EORA was independently associated with poor treatment response at 6 months (OR=0.28, p = 0.047) and radiographic progression at 12 months (OR=4.08, p = 0.029). Synovial pathotype, synovitis scores and cellular infiltration were similar before treatment, but a pauci-immune-fibroid pathotype tended to be more common in YORA at 6 months (p = 0.093). Moreover, YORA patients had a marked improvement of all synovitis parameters (p<0.001), whereas EORA presented only mild decreases in synovitis (p<0.05), sublining macrophage (p<0.05) and T cell scores (p<0.05), with no significant changes in lining macrophages, B cells or plasma cells. CONCLUSION Early EORA presents differently and has a worse overall prognosis than YORA, with poorer clinical, histological, ultrasonographic and radiographic outcomes.
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Affiliation(s)
- Vasco C Romão
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK; Department of Rheumatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre; Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal; Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028, Lisbon, Portugal
| | - Frances Humby
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Stephen Kelly
- Rheumatology Department, Mile End Hospital, Barts Health NHS Trust, 275 Bancroft Road, London E1 2DG, UK
| | - Maria Di Cicco
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Arti Mahto
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Ilias Lazarou
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Rebecca Hands
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Vidalba Rocher-Ros
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Désirée van der Heijde
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - João Eurico Fonseca
- Department of Rheumatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre; Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal; Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028, Lisbon, Portugal
| | - Costantino Pitzalis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.
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18
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Oka S, Furukawa H, Shimada K, Hashimoto A, Komiya A, Tsunoda S, Saisho K, Tsuchiya N, Katayama M, Shinohara S, Matsui T, Fukui N, Sano H, Migita K, Tohma S. Association of HLA-DRB1 genotype with younger age onset and elder age onset rheumatoid arthritis in Japanese populations. Medicine (Baltimore) 2019; 98:e18218. [PMID: 31770283 PMCID: PMC6890270 DOI: 10.1097/md.0000000000018218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by joint destructions and human leukocyte antigen (HLA)-DRB1 is an important genetic risk factor for RA and influences the phenotype of RA. The clinical features of elder age onset RA (EORA) were known to be different from those of younger age onset RA (YORA). Previous studies reported the different association pattern of DRB1 alleles with YORA or EORA. The associations of DRB1 genotype with these RA subsets remained almost unknown. We investigated the genotype association of DRB1 with YORA or EORA in Japanese populations.HLA genotyping was performed in Japanese RA patients and the association of allele or genotype carrier frequencies were analyzed.The genotype frequency of DRB104:05/DRB104:06 (P = .0204, OR 7.69, 95%CI 1.39-42.72), DRB104:05/DRB112:01 (P = .0050, OR 5.53, 95%CI 1.71-17.88), and DRB104:05/DRB115:01 (P = .0124, OR 3.34, 95%CI 1.39-8.02) in YORA was higher than EORA. However, the frequencies of DRB101:01/DRB104:05 in YORA was tended to be lower than EORA (P = .0784, OR 0.14, 95%CI 0.01-2.42). The gene dosage effect of the shared epitope alleles was detected in EORA, but not in YORA. Trans-complementing DQ heterodimer molecules, formed by DQA1 and DQB1 of the haplotypes with and without shared epitope alleles, might explain the higher genotype frequencies of "shared epitope /not shared epitope". Linear regression analyses showed the primary role of DQB104:01 allele for the age at onset of RA.This is the first report for the associations of DRB1 genotype with YORA or EORA in the Japanese population and the differential distribution of the genotypes was noted between these RA subsets. The involvement of DQ molecules for the age at onset of RA was suggested.
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Affiliation(s)
- Shomi Oka
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara
- Molecular and Genetic Epidemiology Laboratory, Faculty of Medicine, University of Tsukuba, Tsukuba
- Tokyo National Hospital, National Hospital Organization, Kiyose
| | - Hiroshi Furukawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara
- Molecular and Genetic Epidemiology Laboratory, Faculty of Medicine, University of Tsukuba, Tsukuba
- Tokyo National Hospital, National Hospital Organization, Kiyose
| | - Kota Shimada
- Department of Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Fuchu
| | - Atsushi Hashimoto
- Department of Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara
| | - Akiko Komiya
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara
- Department of Clinical Laboratory, National Hospital Organization Sagamihara National Hospital, Sagamihara
| | - Shinichiro Tsunoda
- Division of Rheumatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya
- Department of Rheumatology, Sumitomo Hospital, Osaka
| | - Koichiro Saisho
- Department of Orthopedics/Rheumatology, Miyakonojo Medical Center, National Hospital Organization, Miyakonojo
- Tanimura Hospital, Nobeoka
| | - Naoyuki Tsuchiya
- Molecular and Genetic Epidemiology Laboratory, Faculty of Medicine, University of Tsukuba, Tsukuba
| | - Masao Katayama
- Department of Internal Medicine, Nagoya Medical Center, National Hospital Organization, Nagoya
| | | | - Toshihiro Matsui
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara
| | - Naoshi Fukui
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara
| | - Hajime Sano
- Division of Rheumatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya
| | - Kiyoshi Migita
- Clinical Research Center, Nagasaki Medical Center, National Hospital Organization, Omura
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shigeto Tohma
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara
- Tokyo National Hospital, National Hospital Organization, Kiyose
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19
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Murata K, Ito H, Hashimoto M, Nishitani K, Murakami K, Tanaka M, Yamamoto W, Mimori T, Matsuda S. Elderly onset of early rheumatoid arthritis is a risk factor for bone erosions, refractory to treatment: KURAMA cohort. Int J Rheum Dis 2018; 22:1084-1093. [PMID: 30415498 DOI: 10.1111/1756-185x.13428] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/31/2018] [Accepted: 10/04/2018] [Indexed: 01/23/2023]
Abstract
AIM Age at disease onset has been implicated as an indicator of disease activity and severity in rheumatoid arthritis (RA). This study aimed to investigate how old age at disease onset affects patient treatment and prognosis in early RA. METHODS Data from the Kyoto University Rheumatoid Arthritis Management Alliance (KURAMA) cohort was analyzed. From 2011 to 2015, a total of 2182 patients with RA were enrolled in the cohort; 239 patients were newly diagnosed with RA and were followed up for 2 years. The patients were divided into the following two groups: the young-onset RA (YORA) which included patients <60 years old (n = 117) and elderly-onset RA (EORA) which comprised patients ≥60 years old (n = 122). The clinical and laboratory data were compared at baseline, at 1 year, and at 2 years after onset. RESULTS Disease activity was higher in EORA than in YORA at baseline. Although disease activity was equivalent between EORA and YORA at 1 or 2 years, more EORA patients had bone erosions at baseline and at 2 years. More than 25% of the anti-citrullinated protein autoantibody (ACPA)-positive EORA patients without erosions at baseline had bone erosions even if they attained clinical remission at 1 or 2 years, while ~10% of YORA patients had erosions. CONCLUSION Bone erosions were more frequently found in EORA. Clinical remission at 1 or 2 years was not enough to protect bone erosions in the ACPA-positive EORA patients. Optimal treatment strategies preventing radiological damage should be considered for EORA.
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Affiliation(s)
- Koichi Murata
- Department of Advanced Medicine for Rheumatic Diseases, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiromu Ito
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Motomu Hashimoto
- Department of Advanced Medicine for Rheumatic Diseases, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kohei Nishitani
- Department of Advanced Medicine for Rheumatic Diseases, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kosaku Murakami
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masao Tanaka
- Department of Advanced Medicine for Rheumatic Diseases, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Wataru Yamamoto
- Department of Advanced Medicine for Rheumatic Diseases, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Health Information Management, Kurashiki Sweet Hospital, Kurashiki, Japan
| | - Tsuneyo Mimori
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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20
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Steffen A, Holstiege J, Klimke K, Akmatov MK, Bätzing J. Patterns of the initiation of disease-modifying antirheumatic drugs in incident rheumatoid arthritis: a German perspective based on nationwide ambulatory drug prescription data. Rheumatol Int 2018; 38:2111-2120. [PMID: 30306254 PMCID: PMC6208685 DOI: 10.1007/s00296-018-4161-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 09/24/2018] [Indexed: 12/12/2022]
Abstract
This study aimed at providing a current and nearly complete picture of the patterns of the initiation of disease-modifying antirheumatic drugs (DMARDs) in patients with newly diagnosed RA. Based on ambulatory drug prescription data and physician billing claims data covering 87% of the German population, we assembled a cohort of incident RA patients aged 15-79 years (n = 54,896) and assessed the prescription frequency of total DMARDs, conventional synthetic (csDMARDs) and biologic DMARDs (bDMARDs) within the first year of disease. Using multiple logistic regression, we estimated the chance of early DMARD receipt based on age, sex, serotype and specialty of prescribing physician while controlling for region of residence. In total, 44% of incident RA patients received a DMARD prescription within the first year of disease. In multiple regression, younger patients (< 35 years) had 1.7-fold higher chances of receiving a csDMARD than patients aged ≥ 65 years [odds ratio (OR): 1.65 with 95% confidence interval (CI) 1.51-1.80] and almost tenfold higher chances to receive a bDMARD [OR (95% CI) 9.5 (8.0-11.3)]. Seropositivity and a visit to a rheumatologist were positively associated with DMARD initiation [OR (95% CI) 2.8 (2.6-2.9) and 5.9 (5.6-6.2) for csDMARDs, respectively]. Based on data covering 87% of the German population, the present study revealed that less than half of incident RA patients receive DMARDs within the first year of disease and that marked differences exist according to age. The study highlights the importance of involving a rheumatologist early in the management of RA.
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Affiliation(s)
- Annika Steffen
- Central Research Institute of Ambulatory Health Care in Germany (Zi), Salzufer 8, 10587 Berlin, Germany
| | - Jakob Holstiege
- Central Research Institute of Ambulatory Health Care in Germany (Zi), Salzufer 8, 10587 Berlin, Germany
| | - Kerstin Klimke
- Central Research Institute of Ambulatory Health Care in Germany (Zi), Salzufer 8, 10587 Berlin, Germany
| | - Manas K. Akmatov
- Central Research Institute of Ambulatory Health Care in Germany (Zi), Salzufer 8, 10587 Berlin, Germany
| | - Jörg Bätzing
- Central Research Institute of Ambulatory Health Care in Germany (Zi), Salzufer 8, 10587 Berlin, Germany
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21
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Jung SM, Kwok SK, Ju JH, Lee SW, Song JJ, Yoon CH, Park YB, Park SH. Risk factors associated with inadequate control of disease activity in elderly patients with rheumatoid arthritis: Results from a nationwide KOrean College of Rheumatology BIOlogics (KOBIO) registry. PLoS One 2018; 13:e0205651. [PMID: 30325962 PMCID: PMC6191131 DOI: 10.1371/journal.pone.0205651] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 09/29/2018] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The proportion of elderly patients with rheumatoid arthritis (RA) is continuously growing as a result of the increasing aging population. We compared disease activity between different age groups, and evaluated the clinical factors associated with high disease activity. METHODS This cross-sectional study analyzed the data of RA patients enrolled in the Korean College of Rheumatology Biologics registry (KOBIO-RA) between 2012 and 2014. Disease activity between elderly (age ≥ 65 years) and non-elderly patients (age < 65 years) was compared, and the association of clinical factors with high disease activity was assessed using a multivariate logistic regression model. RESULTS Of 1,227 patients in KOBIO-RA, 244 patients with RA were aged 65 years or over. In elderly patients, the proportion of men was higher (P = 0.012), and the duration of disease was longer (P < 0.001) compared with non-elderly patients. The elderly group showed a higher incidence of comorbidity (P < 0.001), and less use of methotrexate (P = 0.004). Assessment of disease activity using various composite measures showed a higher proportion of high disease activity in elderly patients than non-elderly patients. Longer disease duration, presence of comorbidity, and non-use of methotrexate were independently associated with high disease activity (P = 0.002, P < 0.001, and P = 0.029, respectively). CONCLUSIONS At enrollment of KOBIO-RA, elderly patients showed higher disease activity compared with non-elderly patients. Disease duration, use of methotrexate, and comorbidity are associated with disease activity control in Korean patients with RA.
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Affiliation(s)
- Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Ki Kwok
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Hyeon Ju
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Chong-Hyeon Yoon
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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22
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Safety and Efficacy of Biological Disease-Modifying Antirheumatic Drugs in Older Rheumatoid Arthritis Patients: Staying the Distance. Drugs Aging 2017; 33:387-98. [PMID: 27154398 DOI: 10.1007/s40266-016-0374-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The population of older individuals with rheumatoid arthritis (RA) is rapidly expanding, mainly due to increased life expectancy. While targeted biological therapies are well established for the treatment of this disease, their use may be lower in older patients (age > 65 years) and very old patients (age > 75 years) as a result of perceived higher risks for adverse events in this population, taking into account comorbidity, polypharmacy, and frailty. In this review, we discuss the available evidence for the use of biological therapies in this growing patient group with specific attention towards the eventual reasons for biological treatment failure or withdrawal. The majority of data is found in secondary analyses of clinical trials and in retrospective cohorts. The most information available is on tumor necrosis factor (TNF) blockers. Older patients seem to have a less robust response to anti-TNF agents than a younger population, but drug survival as a proxy for efficacy does not seem to be influenced by age. Despite an overall rate of adverse effects comparable to that in younger patients, older RA patients are at higher risk of serious infections. Other biologics appear to have an efficacy similar to anti-TNF agents, also in older RA patients. Again, the drug survival rates for tocilizumab, rituximab, and abatacept resemble those in young RA patients with good general tolerability and safety profiles. The cardiovascular risk and the risk of cancer, increased in RA patients and in the older RA patients, do not appear to be strongly influenced by biologicals.
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23
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Twigg S, Hensor EMA, Emery P, Tennant A, Morgan AW. Patient-reported Outcomes as Predictors of Change in Disease Activity and Disability in Early Rheumatoid Arthritis: Results from the Yorkshire Early Arthritis Register. J Rheumatol 2017; 44:1331-1340. [PMID: 28668806 DOI: 10.3899/jrheum.161214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To assess patient-reported variables as predictors of change in disease activity and disability in early rheumatoid arthritis (RA). METHODS Cases were recruited to the Yorkshire Early Arthritis Register (YEAR) between 1997 and 2009 (n = 1415). Predictors of the 28-joint Disease Activity Score (DAS28) and the Health Assessment Questionnaire-Disability Index (HAQ-DI) at baseline and change over 12 months were identified using multilevel models. Baseline predictors were sex, age, symptom duration, autoantibody status, pain and fatigue visual analog scales (VAS), duration of early morning stiffness (EMS), DAS28, and HAQ-DI. RESULTS Rates of change were slower in women than men: DAS28 fell by 0.19 and 0.17 units/month, and HAQ-DI by 0.028 and 0.023 units/month in men and women, respectively. Baseline pain and EMS had small effects on rates of change, whereas fatigue VAS was only associated with DAS28 and HAQ-DI at baseline. In patients recruited up to 2002, DAS28 reduced more quickly in those with greater pain at baseline (by 0.01 units/mo of DAS28 per cm pain VAS, p = 0.024); in patients recruited after 2002, the effect for pain was stronger (by 0.01 units/mo, p = 0.087). DAS28 reduction was greater with longer EMS. In both cohorts, fall in HAQ-DI (p = 0.006) was greater in patients with longer EMS duration, but pain and fatigue were not significant predictors of change in HAQ-DI. CONCLUSION Patient-reported fatigue, pain, and stiffness at baseline are of limited value for the prediction of RA change in disease activity (DAS28) and activity limitation (HAQ-DI).
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Affiliation(s)
- Sarah Twigg
- From the Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds; National Institute for Health Research - Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals UK National Health Service (NHS) Trust, Leeds, UK; Swiss Paraplegic Research, Nottwil, Switzerland.,S. Twigg, MD, Clinical Lecturer, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; E.M. Hensor, PhD, Biostatistician, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; P. Emery, PhD, Arthritis Research UK Professor of Rheumatology, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; A. Tennant, PhD, Senior Advisor, LIRMM, School of Medicine, University of Leeds, and Swiss Paraplegic Research; A.W. Morgan, PhD, Professor of Molecular Rheumatology/Hon. Consultant Rheumatologist, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust
| | - Elizabeth M A Hensor
- From the Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds; National Institute for Health Research - Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals UK National Health Service (NHS) Trust, Leeds, UK; Swiss Paraplegic Research, Nottwil, Switzerland.,S. Twigg, MD, Clinical Lecturer, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; E.M. Hensor, PhD, Biostatistician, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; P. Emery, PhD, Arthritis Research UK Professor of Rheumatology, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; A. Tennant, PhD, Senior Advisor, LIRMM, School of Medicine, University of Leeds, and Swiss Paraplegic Research; A.W. Morgan, PhD, Professor of Molecular Rheumatology/Hon. Consultant Rheumatologist, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust
| | - Paul Emery
- From the Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds; National Institute for Health Research - Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals UK National Health Service (NHS) Trust, Leeds, UK; Swiss Paraplegic Research, Nottwil, Switzerland.,S. Twigg, MD, Clinical Lecturer, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; E.M. Hensor, PhD, Biostatistician, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; P. Emery, PhD, Arthritis Research UK Professor of Rheumatology, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; A. Tennant, PhD, Senior Advisor, LIRMM, School of Medicine, University of Leeds, and Swiss Paraplegic Research; A.W. Morgan, PhD, Professor of Molecular Rheumatology/Hon. Consultant Rheumatologist, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust
| | - Alan Tennant
- From the Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds; National Institute for Health Research - Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals UK National Health Service (NHS) Trust, Leeds, UK; Swiss Paraplegic Research, Nottwil, Switzerland.,S. Twigg, MD, Clinical Lecturer, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; E.M. Hensor, PhD, Biostatistician, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; P. Emery, PhD, Arthritis Research UK Professor of Rheumatology, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; A. Tennant, PhD, Senior Advisor, LIRMM, School of Medicine, University of Leeds, and Swiss Paraplegic Research; A.W. Morgan, PhD, Professor of Molecular Rheumatology/Hon. Consultant Rheumatologist, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust
| | - Ann W Morgan
- From the Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds; National Institute for Health Research - Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals UK National Health Service (NHS) Trust, Leeds, UK; Swiss Paraplegic Research, Nottwil, Switzerland. .,S. Twigg, MD, Clinical Lecturer, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; E.M. Hensor, PhD, Biostatistician, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; P. Emery, PhD, Arthritis Research UK Professor of Rheumatology, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust; A. Tennant, PhD, Senior Advisor, LIRMM, School of Medicine, University of Leeds, and Swiss Paraplegic Research; A.W. Morgan, PhD, Professor of Molecular Rheumatology/Hon. Consultant Rheumatologist, LIRMM, School of Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust.
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24
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Calip GS, Adimadhyam S, Xing S, Rincon JC, Lee WJ, Anguiano RH. Medication adherence and persistence over time with self-administered TNF-alpha inhibitors among young adult, middle-aged, and older patients with rheumatologic conditions. Semin Arthritis Rheum 2017; 47:157-164. [PMID: 28410817 DOI: 10.1016/j.semarthrit.2017.03.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 02/01/2017] [Accepted: 03/15/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Self-injectable TNF inhibitors are increasingly used early in the chronic treatment of moderate to severe rheumatologic conditions. We estimated medication adherence/persistence over time following initiation in young adult and older adult patients with rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis. METHODS We conducted a retrospective cohort study of patients aged 18+ years newly initiating etanercept, adalimumab, certolizumab pegol, or golimumab using the Truven Health MarketScan Database between 2009 and 2013. Pharmacy dispensing data were used to calculate 12-month medication possession ratios (MPR) and determine adherence (MPR ≥ 0.80) for up to 3 years after starting therapy. Persistence over each 12-month interval was defined as not having a ≥92-day treatment gap. Multivariable generalized estimating equation models were used to calculate odds ratios (OR) and robust 95% confidence intervals (CI) for associations between patient characteristics and repeated adherence/persistence measures over time. RESULTS Among 53,477 new users, 14% were young adults (18-34 years), 49% middle-aged (35-54 years), and 37% older adults (55+ years). Overall, 37% of patients were adherent and 83% were persistent in the first year of therapy. The lowest adherence (17%) and persistence (70%) were observed among young adult patients by Year +3. Compared to older adults, middle-aged (OR = 0.73, 95% CI: 0.71-0.76) and young adults (OR = 0.50, 95% CI: 0.47-0.53) were less likely to be adherent. Higher Charlson comorbidity scores, hospitalizations, and emergency department visits were associated with non-adherence/non-persistence. CONCLUSIONS We observed low adherence to self-administered TNF inhibitors but most patients remained persistent over time. Further efforts to improve adherence in young adults and patients with greater comorbidity are needed.
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Affiliation(s)
- Gregory S Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 S. Wood St. MC 871, Chicago, IL 60612; Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA.
| | - Sruthi Adimadhyam
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 S. Wood St. MC 871, Chicago, IL 60612
| | - Shan Xing
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 S. Wood St. MC 871, Chicago, IL 60612
| | - Julian C Rincon
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 S. Wood St. MC 871, Chicago, IL 60612
| | - Wan-Ju Lee
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 S. Wood St. MC 871, Chicago, IL 60612
| | - Rebekah H Anguiano
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL
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25
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Hitchon CA, Boire G, Haraoui B, Keystone E, Pope J, Jamal S, Tin D, Thorne C, Bykerk VP. Self-reported comorbidity is common in early inflammatory arthritis and associated with poorer function and worse arthritis disease outcomes: results from the Canadian Early Arthritis Cohort. Rheumatology (Oxford) 2016; 55:1751-62. [DOI: 10.1093/rheumatology/kew061] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Indexed: 12/31/2022] Open
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26
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Okely JA, Cooper C, Gale CR. Wellbeing and Arthritis Incidence: the Survey of Health, Ageing and Retirement in Europe. Ann Behav Med 2016; 50:419-26. [PMID: 26769022 PMCID: PMC4869763 DOI: 10.1007/s12160-015-9764-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND A number of studies provide evidence for an association between psychosocial factors and risk of incident arthritis. Current evidence is largely limited to the examination of negative factors such as perceived stress, but positive factors such as subjective wellbeing may also play a role. PURPOSE The purpose of the current study was to investigate whether people with higher subjective wellbeing have a lower risk of developing arthritis. METHODS We used Cox proportional hazards regression to examine the prospective relationship between wellbeing (measured using the CASP-12) and incidence of arthritis over a 9-year period. The sample consisted of 13,594 participants aged ≥50 years from the Survey of Health, Ageing and Retirement in Europe. RESULTS There was a significant association between greater wellbeing and reduced incident arthritis that was stronger at younger ages. In sex-adjusted analyses, for a standard deviation increase in CASP-12 score, the hazard ratios (95 % confidence intervals) for incident arthritis in people aged <65 and ≥65 years were 0.73 (0.69-0.77) and 0.80 (0.77-0.85), respectively. After further adjustment for other established risk factors, these associations were attenuated but remained significant in both age groups: the fully adjusted hazard ratios were 0.82 (0.77-0.87) and 0.88 (0.82-0.95), respectively. CONCLUSIONS These results provide evidence for an association between greater wellbeing and reduced risk of incident arthritis and, more generally, support the theory that psychosocial factors are implicated in the aetiology of this disease. Future research needs to delineate the mechanisms underlying the association between wellbeing and arthritis risk.
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Affiliation(s)
- Judith A Okely
- Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, 7 George Square, Edinburgh, EH8 9JZ, UK.
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Catharine R Gale
- Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, 7 George Square, Edinburgh, EH8 9JZ, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
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27
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van Onna M, Boonen A. The challenging interplay between rheumatoid arthritis, ageing and comorbidities. BMC Musculoskelet Disord 2016; 17:184. [PMID: 27118031 PMCID: PMC4845363 DOI: 10.1186/s12891-016-1038-3] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 04/15/2016] [Indexed: 11/30/2022] Open
Abstract
Background The incidence of rheumatoid arthritis (RA) is expected to increase over the next 10 years in the European Union because of the increasing proportion of elderly people. As both RA and ageing are associated with emerging comorbidities such as cardiovascular disease, malignancies and osteoporosis, these factors will have a profound effect on the management of RA. In addition, both increasing age and comorbidities may independently alter commonly used RA-specific outcome measures. Discussion Age-related decline in immune cell functions (immunosenescence), such as a decrease in T-cell function, may contribute to the development of RA, as well as comorbidity. The chronic immune stimulation that occurs in RA may also lead to premature ageing and comorbidity. The interplay between RA, ageing and (emerging) comorbidities is interesting but complex. Cardiovascular disease, lung disease, malignancies, bone and muscle wasting and neuropsychiatric disease all occur more frequently in RA patients as compared to the general population. It is unclear how RA should be managed in ‘today’s world of multiple comorbidities’. Evidence that treatment of RA improves comorbidities is currently lacking, although some promising indirect observations are available. On the other hand, there is limited evidence that medication regularly prescribed for comorbidities, such as statins, might improve RA disease activity. Both ageing and comorbidity have an independent effect on commonly used outcome measures in the RA field, such as the Health Assessment Questionnaire (HAQ) and the clinical disease activity index (CDAI). Prospective studies, that also account for the presence of comorbidity in (elderly) RA patients are therefore urgently needed. To address gaps in knowledge, future research should focus on the complex interdependencies between RA, ageing and comorbidity. In addition, these findings should be integrated into daily clinical practice by developing and testing integrated and coordinated health care services. Adaptation of management recommendations is likely required. Summary The elderly RA patient who also deals with (emerging) comorbidities presents a unique challenge to treating clinicians. A paradigm shift from disease-centered to goal-oriented approach is needed to develop adequate health care services for these patients.
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Affiliation(s)
- Marloes van Onna
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center, School for Public Health and Primary Care (CAPHRI), Maastricht University, P. Debyelaan 25, Maastricht, 6202 AZ, The Netherlands.
| | - Annelies Boonen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center, School for Public Health and Primary Care (CAPHRI), Maastricht University, P. Debyelaan 25, Maastricht, 6202 AZ, The Netherlands
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Ozen G, Inanc N, Unal AU, Bas S, Kimyon G, Kisacik B, Onat AM, Murat S, Keskin H, Can M, Mengi A, Cakir N, Balkarli A, Cobankara V, Yilmaz N, Yazici A, Dogru A, Sahin M, Sahin A, Gok K, Senel S, Pamuk ON, Yilmaz S, Bayindir O, Aksu K, Cagatay Y, Akyol L, Sayarlioglu M, Yildirim-Cetin G, Yasar-Bilge S, Yagci I, Aydin SZ, Alibaz-Oner F, Atagunduz P, Direskeneli H. Assessment of the New 2012 EULAR/ACR Clinical Classification Criteria for Polymyalgia Rheumatica: A Prospective Multicenter Study. J Rheumatol 2016; 43:893-900. [DOI: 10.3899/jrheum.151103] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2015] [Indexed: 11/22/2022]
Abstract
Objective.To assess the performance of the new 2012 provisional European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) polymyalgia rheumatica (PMR) clinical classification criteria in discriminating PMR from other mimicking conditions compared with the previous 5 diagnostic criteria in a multicenter prospective study.Methods.Patients older than 50 years, presenting with new-onset bilateral shoulder pain with elevated acute-phase reactants (APR), were assessed for the fulfillment of the new and old classification/diagnostic criteria sets for PMR. At the end of the 1-year followup, 133 patients were diagnosed with PMR (expert opinion) and 142 with non-PMR conditions [69 rheumatoid arthritis (RA)]. Discriminating capacity, sensitivity, and specificity of the criteria sets were estimated.Results.Discriminating capacity of the new clinical criteria for PMR from non-PMR conditions and RA as estimated by area under the curve (AUC) were good with AUC of 0.736 and 0.781, respectively. The new criteria had a sensitivity of 89.5% and a specificity of 57.7% when tested against all non-PMR cases. When tested against all RA, seropositive RA, seronegative RA, and non-RA control patients, specificity changed to 66.7%, 100%, 20.7%, and 49.3%, respectively. Except for the Bird criteria, the 4 previous criteria had lower sensitivity and higher specificity (ranging from 83%–93%) compared with the new clinical criteria in discriminating PMR from all other controls.Conclusion.The new 2012 EULAR/ACR clinical classification criteria for PMR is highly sensitive; however, its ability to discriminate PMR from other inflammatory/noninflammatory shoulder conditions, especially from seronegative RA, is not adequate. Imaging and other modifications such as cutoff values for APR might increase the specificity of the criteria.
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Affiliation(s)
- Tsuyoshi TAKEDA
- Department of Internal Medicine, Japan Organization of Occupational Health and Safety, Hokkaido Spinal Cord Injury Center
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The influence of age at disease onset on disease activity and disability: results from the Ontario Best Practices Research Initiative. Clin Rheumatol 2015; 35:759-63. [PMID: 26245721 DOI: 10.1007/s10067-015-3031-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/28/2015] [Accepted: 07/20/2015] [Indexed: 12/16/2022]
Abstract
This study aims to compare characteristics between late-onset rheumatoid arthritis (RA) and young-onset RA and determine the association between age at disease onset and disease severity. We cross-sectionally studied 971 patients at the time of entry into the Ontario Best Practices Research Initiative, a registry of RA patients followed up in routine care. We restricted patients to ≤5 years of disease duration. Late-onset RA was defined as an onset ≥60 years of age and young-onset RA <60 years. Group differences were compared, and multivariate linear regression models were used to test the influence of age at onset on Disease Activity Score in 28 Joints with erythrocyte sedimentation rate (DAS28-ESR), Clinical Disease Activity Index (CDAI), and Health Assessment Questionnaire (HAQ) scores. The swollen joint count (6.2 vs. 5.3), acute phase reactants (C-reactive protein (CRP) 17.4 vs. 11.8 mg/L, ESR 30.6 vs. 21.5 mm/h), and comorbidity burden were higher in late-onset RA compared to young-onset RA (p < 0.01). Mean DAS28-ESR (4.6 vs. 4.3) and HAQ (1.2 vs. 1.1) scores were higher in late-onset RA patients (p < 0.05). Late-onset RA patients received more initial disease-modifying antirheumatic drug (DMARD) monotherapy and corticosteroids in comparison to greater DMARD/biologic combination therapy in young-onset RA patients (p < 0.05). Adjusted multivariate analyses showed that late-onset RA was independently associated with higher mean DAS28-ESR and HAQ scores, but not CDAI. Late-onset RA patients have greater disease activity that may contribute to disability early in the disease course. Despite this, initial treatment consists of less combination DMARD and biologic use in late-onset RA patients. This may have implications for future response to therapy and development of joint damage, disability, and comorbidities in this group.
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Wong LE, Huang WT, Pope JE, Haraoui B, Boire G, Thorne JC, Hitchon CA, Tin D, Keystone EC, Bykerk VP. Effect of age at menopause on disease presentation in early rheumatoid arthritis: results from the Canadian Early Arthritis Cohort. Arthritis Care Res (Hoboken) 2015; 67:616-23. [PMID: 25303739 DOI: 10.1002/acr.22494] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 09/30/2014] [Accepted: 10/07/2014] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Studies suggest that hormonal states affect disease characteristics in women with rheumatoid arthritis (RA). This study investigated how age at menopause affects disease in women presenting with early RA. METHODS This was a cross-sectional study of postmenopausal women with early RA under age 65 years at time of enrollment in the Canadian Early Arthritis Cohort. RA-related disease characteristics in women who had early age at menopause (EM; age at menopause <45 years) were compared to those who had usual age at menopause (age at menopause ≥45 years). The t-test was applied to continuous variables and the chi-square test to categorical variables. Multivariate logistic regression analysis was used to adjust for age at menopause, smoking, and use of exogenous hormones. RESULTS A total of 534 women were included; 93 were in the EM group. The age at RA onset was similar between groups. The EM group had higher mean patient global and pain scores and was more likely to be rheumatoid factor (RF) positive and meet the 1987 American College of Rheumatology criteria for RA. Using multivariate logistic regression, the EM group was more likely to be RF positive (odds ratio 2.2 [95% confidence interval 1.3-3.8], P = 0.005). Symptom duration, joint counts, Disease Activity Score in 28 joints, Health Assessment Questionnaire scores, and inflammatory markers did not differ between groups. CONCLUSION These data suggest that early age at menopause, compared to usual age at menopause, is associated with seropositivity in women with early RA.
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Affiliation(s)
- Lauren E Wong
- Hospital for Special Surgery/Weill Cornell Medical College, New York, New York
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