The increasing disease duration of patients at the time of orthopaedic surgery for rheumatoid arthritis

Abstract

In recent years, disease-modifying antirheumatic drugs (DMARDs), including biological agents, have been used to inhibit or halt the underlying immune process and prevent long-term damage in rheumatoid arthritis (RA). The introduction of biological DMARDs has increased treatment options for RA, and clinical remission is now considered to be the primary goal of RA treatment. Despite the availability of such aggressive therapies, ongoing progressive destruction of joints occurs in a subgroup of RA patients, who eventually require joint surgery [1]. Orthopaedic procedures can substantially improve the overall function and quality of life in such patients. However, some reports have suggested that improvements in medical treatment might partially explain the reduction in the incidence of orthopaedic joint surgery, resulting in a worldwide trend towards better long-term outcomes [2–5]. In this study, we investigated the disease duration at the time of orthopaedic surgery among RA patients who participated in a large observational cohort study established by our institute (IORRA) [4]. Outpatients who fulWlled the American College of Rheumatology criteria for RA and/or 2010 rheumatoid arthritis classiWcation criteria were registered in this cohort study [6, 7]. An average of 4,990 outpatients with RA were seen each month from 2003 to 2009. Patient information was collected biannually (April/May and October/November) when the patients visited the outpatient unit of the Institute of Rheumatology, Tokyo Women’s Medical University [8]. Figure 1a shows the average RA disease activity from 2003 to 2009. As previously reported, disease activity decreased during this period [9]. Figure 1b shows the disease duration trend at the time of surgery. Surprisingly, the disease duration of patients who underwent total knee arthroplasty (TKA) gradually increased during this period. In addition, the disease duration of patients who underwent any type of surgery, including TKA, total hip arthroplasty, wrist and Wnger joint surgeries, and foot surgeries, was also increased. The reason for the observed increase in disease duration at the time of RA-associated surgery may be related to the decreased number of synovectomies and suppression of disease activity that has resulted from the use of methotrexate (MTX) and biological agents [9]. MTX was approved for the treatment for RA by the Japanese Ministry of Health, Labor and Welfare in 1999, while inXiximab was approved in 2003, etanercept was approved in 2005, adalimumab and tocilizumab were approved in 2008, and abatacept was approved in 2009. In addition, the use and dosage of MTX and the number of use of biological agents have been increasing every year [9]. Conversely, disease activity score (CDAI: clinical disease activity index, SDAI: simpliWed disease activity index) has been decreasing. Therefore, the recent implementation of medical therapy in RA patients may have suppressed and delayed the progression of destruction in arthritic joints, thereby resulting in postponement of surgery. We believe that these clinical results also provide evidence that these recently introduced medical therapies result in better long-term outcomes for RA patients. However, further studies, including analyses of RA databases that collect long-term data on a variety of surgical interventions, are required to conWrm this hypothesis. S. Momohara (&) · K. Ikari · K. Kawakami · T. Iwamoto · E. Inoue · K. Yano · Y. Sakuma · R. Hiroshima · A. Tokita · A. Taniguchi · H. Yamanaka Institute of Rheumatology, Tokyo Women’s Medical University, 10-22 Kawada, Shinjuku, Tokyo 162-0054, Japan e-mail: smomohara@ior.twmu.ac.jp