Occurrence and Effect of Lower Extremity Ulcer in Rheumatoid Arthritis — A Population-based Study

Abstract

To assess the occurrence, risk factors, morbidity, and mortality associated with lower extremity (LE) ulcers in patients with rheumatoid arthritis (RA). Retrospective review of Olmsted County, Minnesota, USA, residents who first fulfilled the 1987 American College of Rheumatology criteria for RA in 1980-2007 with followup to death, migration, or April 2012. Only LE ulcers that developed after the diagnosis of RA were included. The study included 813 patients with 9771 total person-years of followup. Of them, 125 developed LE ulcers (total of 171 episodes), corresponding to a rate of occurrence of 1.8 episodes per 100 person-years (95% CI: 1.5, 2.0 per 100 person-yrs). The cumulative incidence of first LE ulcers was 4.8% at 5 years after diagnosis of RA and increased to 26.2% by 25 years. Median time for the LE ulcer to heal was 30 days. Ten of 171 episodes (6%) led to amputation. LE ulcers in RA were associated with increased mortality (HR 2.42; 95% CI 1.71, 3.42), adjusted for age, sex, and calendar year. Risk factors for LE ulcers included age (HR 1.73 per 10-yr increase; 95% CI 1.47, 2.04), rheumatoid factor positivity (HR 1.63; 95% CI 1.05, 2.53), presence of rheumatoid nodules (HR 2.14; 95% CI 1.39, 3.31), and venous thromboembolism (HR 2.16; 95% CI 1.07, 4.36). LE ulcers are common among patients with RA. The cumulative incidence increased by 1% per year. A significant number require amputation. Patients with RA who have LE ulcers are at a 2-fold risk for premature mortality.