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Crowson CS, Atkinson EJ, Kronzer VL, Kimbrough BA, Arment CA, Peterson LS, Wright K, Mason TG, Bekele DI, Davis JM, Myasoedova E. Comorbidity clusters in patients with rheumatoid arthritis identify a patient phenotype with a favourable prognosis. Ann Rheum Dis 2024; 83:556-563. [PMID: 38331589 PMCID: PMC11017091 DOI: 10.1136/ard-2023-225093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/24/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVES We aimed to cluster patients with rheumatoid arthritis (RA) based on comorbidities and then examine the association between these clusters and RA disease activity and mortality. METHODS In this population-based study, residents of an eight-county region with prevalent RA on 1 January 2015 were identified. Patients were followed for vital status until death, last contact or 31 December 2021. Diagnostic codes for 5 years before the prevalence date were used to define 55 comorbidities. Latent class analysis was used to cluster patients based on comorbidity patterns. Standardised mortality ratios were used to assess mortality. RESULTS A total of 1643 patients with prevalent RA (72% female; 94% white; median age 64 years, median RA duration 7 years) were studied. Four clusters were identified. Cluster 1 (n=686) included patients with few comorbidities, and cluster 4 (n=134) included older patients with 10 or more comorbidities. Cluster 2 (n=200) included patients with five or more comorbidities and high prevalences of depression and obesity, while cluster 3 (n=623) included the remainder. RA disease activity and survival differed across the clusters, with cluster 1 demonstrating more remission and mortality comparable to the general population. CONCLUSIONS More than 40% of patients with prevalent RA did not experience worse mortality than their peers without RA. The cluster with the worst prognosis (<10% of patients with prevalent RA) was older, had more comorbidities and had less disease-modifying antirheumatic drug and biological use compared with the other clusters. Comorbidity patterns may hold the key to moving beyond a one-size-fits-all perspective of RA prognosis.
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Affiliation(s)
- Cynthia S Crowson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth J Atkinson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Lynne S Peterson
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kerry Wright
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas G Mason
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Delamo I Bekele
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John M Davis
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elena Myasoedova
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
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Crowson LP, Davis JM, Hanson AC, Myasoedova E, Kronzer VL, Makol A, Peterson LS, Bekele DI, Crowson CS. Time Trends in Glucocorticoid Use in Rheumatoid Arthritis During the Biologics Era: 1999-2018. Semin Arthritis Rheum 2023; 61:152219. [PMID: 37172495 PMCID: PMC10330839 DOI: 10.1016/j.semarthrit.2023.152219] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To examine time trends in glucocorticoid (GC) use among patients diagnosed with rheumatoid arthritis (RA) during the biologic era. METHODS A population-based inception cohort of RA patients diagnosed during 1999 - 2018 was followed longitudinally through their medical records until death, migration or 12/31/2020. All patients fulfilled 1987 American College of Rheumatology classification criteria for RA. GC start and stop dates were collected along with dosages in prednisone equivalents. The cumulative incidence of GC initiation and discontinuation adjusted for the competing risk of death was estimated. Cox models adjusted for age and sex were used to compare trends between time periods. RESULTS The study population included 399 patients (71% female) diagnosed in 1999 - 2008 and 430 patients (67% female) diagnosed in 2009 - 2018. GC use was initiated within 6 months of meeting RA criteria in 67% of patients in 1999-2008 and 71% of patients in 2009-2018, corresponding to a 29% increase in hazard for initiation of GC in 2009-2018 (adjusted hazard ratio [HR]: 1.29; 95% confidence interval [CI]: 1.09-1.53). Among GC users, similar rates of GC discontinuation within 6 months after GC initiation were observed in patients with RA incidence in 1999 - 2008 and 2009 - 2018 (39.1% versus 42.9%, respectively), with no significant association in adjusted Cox models (HR: 1.11; 95% CI: 0.93-1.31). CONCLUSION More patients are initiating GCs early in their disease course now compared to previously. The rates of GC discontinuation were similar, despite the availability of biologics.
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Affiliation(s)
- Lisa P Crowson
- University of Health Sciences and Pharmacy, St. Louis, MO USA
| | - John M Davis
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Andrew C Hanson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Elena Myasoedova
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA; Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | - Ashima Makol
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Cynthia S Crowson
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA; Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA.
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Eggleston RH, Baqir M, Varghese C, Pennington KM, Bekele DI, Hartman TE, Ernste FC. Clinical Outcomes With and Without Plasma Exchange in the Treatment of Rapidly Progressive Interstitial Lung Disease Associated With Idiopathic Inflammatory Myopathy. J Clin Rheumatol 2023; 29:151-158. [PMID: 36729874 DOI: 10.1097/rhu.0000000000001923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND/OBJECTIVE A subset of patients with idiopathic inflammatory myopathy (IIM) develops highly fatal, rapidly progressive interstitial lung disease (RP-ILD). Treatment strategies consist of glucocorticoid and adjunctive immunosuppressive therapies. Plasma exchange (PE) is an alternative therapy, but its benefit is unclear. In this study, we aimed to determine whether PE benefited outcomes for patients with RP-ILD. METHODS In this medical records review study, we compared baseline characteristics and clinical outcomes for 2 groups of patients with IIM-related RP-ILD: those who received and did not receive PE. RESULTS Our cohort consisted of 15 patients, 9 of whom received PE. Baseline demographic characteristics and severity of lung, skin, and musculoskeletal disease between the 2 groups of patients were not significantly different. Five patients required mechanical ventilation (2, PE; 3, no PE). Plasma exchange was generally a third-line adjunctive treatment option. The PE group had a longer median (interquartile range) hospitalization (27.0 [23.0-36.0] days) than the non-PE group (12.0 [8.0-14.0] days) ( p = 0.02). There was a potential benefit in 30-day mortality improvement in those receiving PE (0% vs 33%, p = 0.14), with a statistically significant improvement in 2 important composite end points including 30-day mortality or need for lung transplant (0% vs 50%, p = 0.04) and 1-year mortality or need for lung transplant or hospital readmission for RP-ILD in those receiving PE (22% vs 83%, p = 0.04). CONCLUSIONS Plasma exchange may be an underutilized, safe salvage therapy for patients with IIM-related RP-ILD when other immunosuppressive therapies fail.
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Affiliation(s)
- Reid H Eggleston
- From the Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science
| | - Misbah Baqir
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester
| | | | - Kelly M Pennington
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester
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Cunningham KY, Hur B, Gupta VK, Arment CA, Wright KA, Mason TG, Peterson LS, Bekele DI, Schaffer DE, Bailey ML, Delger KE, Crowson CS, Myasoedova E, Zeng H, Rodriguez M, Weyand CM, Davis JM, Sung J. Patients with ACPA-positive and ACPA-negative rheumatoid arthritis show different serological autoantibody repertoires and autoantibody associations with disease activity. Sci Rep 2023; 13:5360. [PMID: 37005480 PMCID: PMC10066987 DOI: 10.1038/s41598-023-32428-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/27/2023] [Indexed: 04/04/2023] Open
Abstract
Patients with rheumatoid arthritis (RA) can test either positive or negative for circulating anti-citrullinated protein antibodies (ACPA) and are thereby categorized as ACPA-positive (ACPA+) or ACPA-negative (ACPA-), respectively. In this study, we aimed to elucidate a broader range of serological autoantibodies that could further explain immunological differences between patients with ACPA+ RA and ACPA- RA. On serum collected from adult patients with ACPA+ RA (n = 32), ACPA- RA (n = 30), and matched healthy controls (n = 30), we used a highly multiplex autoantibody profiling assay to screen for over 1600 IgG autoantibodies that target full-length, correctly folded, native human proteins. We identified differences in serum autoantibodies between patients with ACPA+ RA and ACPA- RA compared with healthy controls. Specifically, we found 22 and 19 autoantibodies with significantly higher abundances in ACPA+ RA patients and ACPA- RA patients, respectively. Among these two sets of autoantibodies, only one autoantibody (anti-GTF2A2) was common in both comparisons; this provides further evidence of immunological differences between these two RA subgroups despite sharing similar symptoms. On the other hand, we identified 30 and 25 autoantibodies with lower abundances in ACPA+ RA and ACPA- RA, respectively, of which 8 autoantibodies were common in both comparisons; we report for the first time that the depletion of certain autoantibodies may be linked to this autoimmune disease. Functional enrichment analysis of the protein antigens targeted by these autoantibodies showed an over-representation of a range of essential biological processes, including programmed cell death, metabolism, and signal transduction. Lastly, we found that autoantibodies correlate with Clinical Disease Activity Index, but associate differently depending on patients' ACPA status. In all, we present candidate autoantibody biomarker signatures associated with ACPA status and disease activity in RA, providing a promising avenue for patient stratification and diagnostics.
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Affiliation(s)
- Kevin Y Cunningham
- Bioinformatics and Computational Biology Program, University of Minnesota Twin Cities, Minneapolis, MN, 55455, USA
| | - Benjamin Hur
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN, 55905, USA
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Vinod K Gupta
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN, 55905, USA
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Courtney A Arment
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kerry A Wright
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Thomas G Mason
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Lynne S Peterson
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Delamo I Bekele
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Daniel E Schaffer
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Marissa L Bailey
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kara E Delger
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Cynthia S Crowson
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, 55905, USA
| | - Elena Myasoedova
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, 55905, USA
| | - Hu Zeng
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
- Department of Immunology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Moses Rodriguez
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Cornelia M Weyand
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
- Department of Immunology, Mayo Clinic, Rochester, MN, 55905, USA
| | - John M Davis
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Jaeyun Sung
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN, 55905, USA.
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA.
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA.
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Mangaonkar AA, Tande AJ, Bekele DI. Differential Diagnosis and Workup of Monocytosis: A Systematic Approach to a Common Hematologic Finding. Curr Hematol Malig Rep 2021; 16:267-275. [PMID: 33880680 PMCID: PMC8057007 DOI: 10.1007/s11899-021-00618-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/19/2022]
Abstract
Purpose of Review Monocytosis is a frequently encountered clinical condition that needs appropriate investigation due to a broad range of differential diagnoses. This review is meant to summarize the latest literature in the diagnostic testing and interpretation and offer a stepwise diagnostic approach for a patient presenting with monocytosis. Recent Findings Basic studies have highlighted the phenotypic and functional heterogeneity in the monocyte compartment. Studies, both translational and clinical, have provided insights into why monocytosis occurs and how to distinguish the different etiologies. Flow cytometry studies have illustrated that monocyte repartitioning can distinguish chronic myelomonocytic leukemia, a prototypical neoplasm with monocytosis from other reactive or neoplastic causes. Summary In summary, we provide an algorithmic approach to the diagnosis of a patient presenting with monocytosis and expect this document to serve as a reference guide for clinicians.
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Affiliation(s)
| | - Aaron J Tande
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
| | - Delamo I Bekele
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Bekele DI, Warrington KJ, Koster MJ. Giant cell arteritis associated with inflammatory bowel disease: a case-series and review of the literature. Rheumatol Int 2020; 41:487-492. [PMID: 33095281 DOI: 10.1007/s00296-020-04727-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/08/2020] [Indexed: 01/10/2023]
Abstract
To describe the clinical characteristics, management, and outcome of a series of patients with giant cell arteritis (GCA) and inflammatory bowel disease (IBD). Patients with both GCA and IBD evaluated between 1/1/1996 and 12/30/2018 were retrospectively identified. Clinical characteristics, laboratory parameters, radiologic features, histopathology, management and outcomes were abstracted. A systematic literature review identifying patients with IBD and GCA was performed via a Medline and EMBASE search from inception through December 31 2019. Six patients were identified with GCA and IBD (66% male). Five (83%) had ulcerative colitis (UC) and one had Crohn's disease (CD). Diagnosis of IBD preceded GCA in four patients with an average interval of 30 years (range 14-42). Average time to IBD diagnosis in those with prior GCA diagnosis was 1.5 years. During mean follow-up of 4.3 years, GCA relapse was infrequent with only one patient with relapse observed. Systematic literature review identified six additional patients with confirmed coexistence of GCA and IBD. Similar to the current series, male sex was more common and ulcerative colitis was the predominant IBD phenotype. The current study reports findings from the largest single-institution case-series of co-existent GCA and IBD. In contrast to Takayasu arteritis with co-existent IBD, which displays a predilection for female sex and Crohn's disease phenotype, both the current study and review of literature demonstrate a stronger association of GCA with male sex and ulcerative colitis. Further studies addressing a potential pathophysiologic connection between GCA and IBD are suggested.
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Affiliation(s)
- Delamo I Bekele
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic Alix School of Medicine, 200 First St. SW, Rochester, MN, 55905, USA.
| | - Kenneth J Warrington
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic Alix School of Medicine, 200 First St. SW, Rochester, MN, 55905, USA
| | - Matthew J Koster
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic Alix School of Medicine, 200 First St. SW, Rochester, MN, 55905, USA
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Albitar HAH, Bekele DI. The Crystal Crown. Mayo Clin Proc 2019; 94:1641-1642. [PMID: 31378237 DOI: 10.1016/j.mayocp.2019.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 11/22/2022]
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Baffour FI, McKenzie GA, Bekele DI, Glazebrook KN. Sonography of active rheumatoid arthritis during pregnancy: a case report and literature review. Radiol Case Rep 2018; 13:1233-1237. [PMID: 30258513 PMCID: PMC6148827 DOI: 10.1016/j.radcr.2018.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/18/2018] [Accepted: 08/26/2018] [Indexed: 11/16/2022] Open
Abstract
Disease activity in rheumatoid arthritis usually subsides in pregnancy, however a subset of patients have worsened symptoms with joint pain and swelling. Monitoring and mitigating disease activity in pregnancy is important for preventing deforming structural changes which can affect the ability of the patient to care for themselves and the newborn. Ultrasound is a safe and low-cost imaging modality for detecting active changes from an inflammatory arthritis, which can help guide management. We describe a case of an acute disease flare during pregnancy, readily detected with ultrasound, and present a review of sonographic evaluation of rheumatoid arthritis in pregnancy.
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Affiliation(s)
- Francis I. Baffour
- Division of Musculoskeletal Radiology, Department of Radiology, 200 1st Street SW, Rochester, MN 55905
- Corresponding author.
| | - Gavin A. McKenzie
- Division of Musculoskeletal Radiology, Department of Radiology, 200 1st Street SW, Rochester, MN 55905
| | | | - Katrina N. Glazebrook
- Division of Musculoskeletal Radiology, Department of Radiology, 200 1st Street SW, Rochester, MN 55905
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Gebreselassie AG, Bekele DI, Paul Y, Ngwa JS, Larbi DA. The Evaluation of Syncope in a Predominantly Black Population: Focus on Neuroimaging. N Am J Med Sci 2016; 8:279-83. [PMID: 27583235 PMCID: PMC4982356 DOI: 10.4103/1947-2714.187133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Current guidelines do not support the routine use of computed tomography (CT) scan of the head in the diagnostic workup of syncope. There is a lack of research to support whether these guidelines apply to the Black population. Aims: This study aims to evaluate the yield of neuroimaging in the evaluation of Syncope in a predominantly Black patient population and to test whether current guidelines based on studies conducted in other populations hold true in this group. Material and Methods: A retrospective review of records of 151 patients admitted to a University Hospital with Syncope from 2011 to 2014 was performed. Data collected include CT head, magnetic resonance imaging of the brain, magnetic resonance angiogram, electroencephalogram, and orthostatic vital signs. Demographic data, admitting service, and comorbid conditions were identified. Syncope was classified as cardiogenic, orthostatic, vasovagal, situational, or undetermined. Statistical analysis was performed to determine which diagnostic tools were useful in identifying the potential causes of syncope. Data analysis was conducted using the Statistical Analysis System software 9.3 (SAS Institute, Cary, NC) and Statistical Analysis and Graphics (NCSS 9.0.7, Kaysville, UT). Results: One hundred and twenty eight (84.8%) of the patients were Black. The average age was 56.62 ± 18.78 standard deviation and 68.2% (103) were female. One hundred and fourteen patients (75.5%) had a CT brain. Five out of 114 patients had an acute abnormality on CT (4.4%). Only 1 of these 5 patients had an abnormality that was related to syncope. CT brain (P = 0.978) was not found to be predictive of underlying etiology of syncope despite high frequency of use. Conclusions: CT head was not useful in determining the etiology of syncope in a predominantly Black population. Current guidelines and studies conducted in other populations have detected similar findings.
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Affiliation(s)
| | - Delamo I Bekele
- Department of Internal Medicine, Howard University Hospital, Washington DC, USA
| | - Yonette Paul
- Department of Internal Medicine, Howard University Hospital, Washington DC, USA
| | - Julius S Ngwa
- Department of Cardiovascular Physiology, Howard University Hospital, Washington DC, USA
| | - Daniel A Larbi
- Department of Internal Medicine, Howard University Hospital, Washington DC, USA
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