Disease Outcome In Rheumatoid Arthritis Research Articles

Socioeconomic deprivation and its relationship with worse disease outcomes in rheumatoid arthritis: impact beyond traditional risk factors.

Socioeconomic deprivation and its relationship with worse disease outcomes in rheumatoid arthritis: impact beyond traditional risk factors.

P109 Personalised comprehensive care packages for people with rheumatoid arthritis: a survey-based study

Abstract Background/Aims Socioeconomic and clinical factors are closely associated with long-term disease outcomes in rheumatoid arthritis (RA). There is increasing evidence for holistic, targeted management of people with RA, including at first presentation. This study aimed to determine how people with, and those involved in the treatment of RA, benefit from personalised care packages and treatment programmes. Methods An online survey was developed by an expert panel comprising physicians, psychologists, epidemiologists and patients, following three multidisciplinary workshops which included patients. Questions were designed to evaluate participants’ views on multidisciplinary Team (MDT) involvement in the care of patients at early-stage RA and onwards. The online survey underwent extensive revisions by patients and clinicians, before dissemination to patients and healthcare professionals (HCPs) in the UK. Results We received 41 complete responses: 23 (57.5%) rheumatology consultants/trainees, seven (17.5%) rheumatology specialist nurses, five (12.5%) occupational therapists, three (7.5%) physiotherapists, one dietician (2.5%) and one patient (2.5%). 82.9% of respondents agreed that people with RA need access to the same “early” care package (comprising a core MDT) at time of diagnosis. On subsequent clinical reviews, 85.4% of respondents agreed that the care package for people with early RA may need to be tailored to an individual’s clinical, psychological and social needs. 58.5% of respondents confirmed that a standard core packaging with input from a consultant rheumatologist, clinical nurse specialist/patient educator, general practitioner and pharmacist is appropriate for patients with early RA, irrespective of patient or disease-related factors; 36.6% disagreed and 4.9% were unsure. Of those disagreeing with this statement, 36.7% agreed not all of these healthcare professionals are relevant to patient care at time of diagnosis, whilst 53.3% gave another reason and 10% were unsure. 68.3% of participants suggested additional involvement of 1-6 MDT members in patient care, specifically occupational therapists, physiotherapists and psychologists. Other posited that primary care may be included occasionally, and additional MDT members’ expertise in early disease may be overwhelming and require frequent review. There was strong agreement (median 10/10 on Likert scale) for the following two statements: ‘A care package with core members of the multidisciplinary rheumatology team need to be available to people newly diagnosed with RA’; ‘Personalised comprehensive care packages, comprising a core plus various additional members of the multidisciplinary team, need to be offered and adapted according to a person’s individual disease characteristics and socio-economic circumstances’. Conclusion HCPs caring for people with RA overwhelmingly agree with a tailored MDT involvement from an early stage of disease, reviewed regularly and adapted. Care packages need to be personalised to account for bio-psycho-social factors. HCPs need to acknowledge that the “ideal” care package may vary markedly between patients to maximise impact and benefit for patients. Disclosure M. Dey: None. A.D. Busby: None. H. Lempp: None. E. Nikiphorou: None.

Socioeconomic Status and Medication Use in Rheumatoid Arthritis: A Scoping Review.

Socioeconomic status (SES) influences disease outcomes in rheumatoid arthritis (RA) patients. Differences in medication use may partly explain this association. A scoping review was used to identify research conducted on this topic and determine what knowledge gaps remain. Medline, Embase, and PsychInfo were searched from their inception until February 2022 for studies that assessed SES and medication use as an outcome variable. Data was extracted on the use of specific SES measures, medication use, and whether differences in SES variables were associated with differences in medication use. We identified 2,103 studies, of which 81 were selected for inclusion. Included studies originated most frequently from the US (42%); the mean ± SD age of participants was 55.9 ± 6.8 years, and most were female (75%). Studies measured a median of 4 SES variables (interquartile range 3-6), with educational, area-level SES, and income being the most frequent measurements used. Patients' race and/or ethnicity were documented by 34 studies. Studies primarily assessed the likelihood of prescription of disease-modifying antirheumatic drugs or dispensation, medication adherence, or treatment delays. A majority of studies documented at least 1 SES measure associated with a difference in medication use. There is some evidence that SES affects use of medications in patients with RA; however, multiple definitions of SES have been utilized, making comparisons between studies difficult. Prospective studies with consistently defined SES will be needed to determine whether differences in medication use accounts for the poorer outcomes experienced by patients of lower SES.

Exploring drug cost and disease outcome in rheumatoid arthritis patients treated with biologic and targeted synthetic DMARDs in Norway in 2010\u20132019 \u2013 a country with a national tender system for prescription of costly drugs

BackgroundIn Norway, an annual tender system for the prescription of biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) has been used since 2007. This study aimed to explore annual b/tsDMARDs costs and disease outcomes in Norwegian rheumatoid arthritis (RA) patients between 2010 and 2019 under the influence of the tender system.MethodsRA patients monitored in ordinary clinical practice were recruited from 10 Norwegian centers. Data files from each center for each year were collected to explore demographics, disease outcomes, and the prescribed treatment. The cost of b/tsDMARDs was calculated based on the drug price given in the annual tender process.ResultsThe number of registered RA patients increased from 4909 in 2010 to 9335 in 2019. The percentage of patients receiving a b/tsDMARD was 39% in 2010 and 45% in 2019. The proportion of b/tsDMARDs treated patients achieving DAS28 remission increased from 42 to 67%. The estimated mean annual cost to treat a patient on b/tsDMARDs fell by 47%, from 13.1 thousand euros (EUR) in 2010 to 6.9 thousand EUR in 2019. The mean annual cost to treat b/tsDMARDs naïve patients was reduced by 75% (13.0 thousand EUR in 2010 and 3.2 thousand EUR in 2019).ConclusionsIn the period 2010–2019, b/tsDMARD treatment costs for Norwegian RA patients were significantly reduced, whereas DAS28 remission rates increased. Our data may indicate that the health authorities’ intention to reduce treatment costs by implementing a tender system has been successful.

Integrative lncRNA–mRNA co‐expression network analysis identifies novel lncRNA E2F3‐IT1 for rheumatoid arthritis

Integrative lncRNA–mRNA co‐expression network analysis identifies novel lncRNA E2F3‐IT1 for rheumatoid arthritis

Does biologic survival depend on co-prescribed methotrexate dose in established rheumatoid arthritis? A real-world study.

Several seminal studies have suggested that a combination therapy of biologics with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) improve disease outcomes in rheumatoid arthritis (RA). Hence, most guidelines reflect this practice. It has also been shown that methotrexate (MTX) at a dose of 8-10 mg/week is perhaps sufficient to achieve better outcomes in early RA. However, it is not clear whether this strategy enhances biologic retention in the patients with established RA. We present a real-world retrospective study to investigate whether csDMARD co-prescription improves biologic retention and the optimal dose to preserve such response. All patients prescribed biologic therapy for RA at our center between 2003 and 2017 were identified through the departmental database. They were split into five groups based on a weekly MTX dose (≤7.5 mg, 10-17.5 mg, ≥20 mg), other csDMARD prescription, or biologic monotherapy. The one-way analysis of variance model for independent values was utilized to ascertain the significance of data. The Mann-Whitney two-tailed U test was employed to determine the significance of relationship between the monotherapy group and other arms. The significance level was predefined at 0.05. A total of 168 patients with 198 biologic events were included. The mean age was 59.4 years (range, 24-90 years). 78% were women. The mean disease duration was 155.6 months (range, 15-491). There was a statistically significant difference (p=0.03) in biologic retention among the five arms. Compared to monotherapy, the data remained significant for ≥20 mg MTX and csDMARD groups; however, the biologic retention in the other two MTX arms was not significant. There was no significant relationship among groups for DAS28 improvement (p=0.24). Our results suggest that to improve biologic retention, the MTX dose should be increased to 20 mg a week or more, and, in people with MTX intolerance, csDMARDs co-presciption can be an alternative strategy. Maintenance with a low-to-moderate MTX dose can lead to poorer retention rates.

The Mediterranean diet, fish oil supplements and Rheumatoid arthritis outcomes: evidence from clinical trials.

The impact of dietary interventions such as specific types of diet or nutritional supplements in rheumatoid arthritis (RA) has been subject to increased attention in recent years. The recognition of the unmet need to better understand the effects of specific dietary interventions on disease outcomes in RA, along with the growing patient interest on lifestyle interventions beyond pharmacotherapy, have informed the undertaking of this narrative literature review. The benefits of the Mediterranean Diet (MD) have been shown in various studies, although only a limited number of trials focus specifically on RA. Based on the studies reviewed, the MD may provide benefits in reducing pain and swollen and tender joints in RA patients. There is more and better evidence that n-3 polyunsaturated fat (PUFA) supplementation has the potential to reduce inflammation and provide clinical benefit, possibly slowing progression to pharmacotherapy. Yet, many of these studies to date are limited in their methodology; this being partly a reflection of the complexity of the research questions being addressed. Consequently, the conclusions that can be robustly drawn from their results are restricted. With a focus on clinical trials on the MD and fish oil supplementation, this review critically appraises the evidence, discussing the findings of studies in the wider context of impact on RA outcomes, methodological challenges, and practical points to consider as part of the routine care of RA patients.

PSY93 - Effect of Patient Involvement in Treatment Decision Making on Disease Outcomes in Rheumatoid Arthritis in the EU5

PSY93 - Effect of Patient Involvement in Treatment Decision Making on Disease Outcomes in Rheumatoid Arthritis in the EU5

Rheumatoid Arthritis Patients' Motivations for Accepting or Resisting Disease-Modifying Antirheumatic Drug Treatment Regimens.

Patient refusal of and nonadherence to treatment with disease-modifying antirheumatic drugs (DMARDs) can adversely affect disease outcomes in rheumatoid arthritis (RA). This qualitative study describes how RA patients' feelings in response to experiences and information affected their decisions to accept (agree to adopt, initiate, and implement) or resist (refuse, avoid, and discontinue) DMARD treatment regimens. A total of 48 RA patients were interviewed about their experiences making decisions about DMARDs. The interviews were transcribed, coded, and analyzed for themes related to their internal motivations for accepting or resisting treatment regimens, using a narrative analysis approach. In addition to feelings about the necessity and dangers of medications, patients' feelings towards their identity as an ill person, the act of taking medication, and the decision process itself were important drivers of patient's decisions. For patients' motivations to accept treatment regimens, 2 themes emerged: a desire to return to a normal life, and fear of future disability due to RA. For motivations to resist treatment regimens, 5 themes emerged: fear of medications, maintaining control over health, denial of sick identity, disappointment with treatment, and feeling overwhelmed by the cognitive burden of deciding. Feelings in response to experiences and information played a major role in how patients weighed the benefits and costs of treatment options, suggesting that addressing patients' feelings may be important when rheumatologists counsel about therapeutic options. Further research is needed to learn how best to address patients' feelings throughout the treatment decision-making process.

Prognostic significance of high-mobility group box protein 1 genetic polymorphisms in rheumatoid arthritis disease outcome.

Rheumatoid arthritis (RA) is a systemic inflammatory disease that causes chronic inflammation of the joints. Analysis of genetic variants offers promise for guiding treatment and improving outcomes in RA. High-mobility group box protein 1 (HMGB1) is a ubiquitous nuclear protein found in all mammal eukaryotic cells that participates in several biological functions including immune response, cell survival and apoptosis. We investigated the effects of HMGB1 gene polymorphisms on the risk of RA disease progression in a cohort of Chinese Han individuals. Four single nucleotide polymorphisms (SNPs) from the HMGB1 gene were selected and genotyped in 232 patients with RA and 353 healthy controls. We found that having one C allele in rs1360485 and one G allele in rs2249825 polymorphisms lowered the risk of RA in females. Moreover, among healthy controls, those who bore the C/G/T haplotype at SNPs rs1360485, rs2249825 and rs1412125 were at reduced risk of developing RA by 0.13-fold (p <0.05). This is the first report to examine the risk factors associated with HMGB1 SNPs in the development of RA disease in the Chinese Han population.

Effect of early treatment with disease-modifying anti-rheumatic drugs and treatment adherence on disease outcome in rheumatoid arthritis patients

Aim of the workTo evaluate the effects of early and regular treatment with Disease Modifying Anti-Rheumatic Drugs (DMARDs) on disease outcome in rheumatoid arthritis (RA) patients and factors affecting adherence to treatment. Patients and methodsSixty-four RA patients (83% females, mean age 42.9±11.9 and disease duration 4.5±2years) were divided into Group A (n=31) who received DMARDs within 6months of symptom onset and Group B (n=33) who received DMARDs later in the disease course. Patients were assessed by the disease activity score DAS28, the Modified Health Assessment Questionnaire-Disability Index (MHAQ-DI), the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Short Form-36 and scoring of radiological damage by modified Larsen’s method. Adherence was assessed by self-report and physician judgment. A questionnaire including the most important factors that may affect early and regular treatment by DMARDs/appointment keeping of follow up visits was administered to the patients. ResultsThe adherence rate was 62.5%. Group A patients had significantly lower DAS28, MHAQ-DI, radiological scores (P=0.001 for all), higher PCS (P=0.001) and MCS (P=0.003) scores than group B patients. Among groups A and B, adherent patients had significantly lower DAS28 (P=0.001 for both) and higher PCS (P=0.002 and 0.04, respectively) than non-adherent patients. Rural residence, lack of awareness about the disease and lack of belief in medication effectiveness were the most important factors associated with non-adherence (p=0.04, 0.03 and 0.045, respectively). ConclusionEarly treatment and adherence to DMARDs have an important impact on disease outcome in RA patients.

A disintegrin and metalloprotease-17 and galectin-9 are important regulators of local 4-1BB activity and disease outcome in rheumatoid arthritis.

Co-stimulatory T cell cytokines are important in the progression of RA. This study investigates the interplay between 4-1BB, a disintegrin and metalloprotease-17 (ADAM17) and galectin-9 (Gal-9) in RA. Stimulated mononuclear cells from patients with chronic RA (n = 12) were co-incubated with tissue inhibitor of metalloproteinase, 4-1BB ligand and Gal-9. Plasma samples were examined for soluble 4-1BB (s4-1BB) in newly diagnosed, treatment-naïve patients with RA (n = 97). The 28-joint DAS with CRP (28DAS-CRP), total Sharp score, erosion score and joint space narrowing were used to evaluate treatment outcome serially over a 2-year period. RA CD4(+) and CD8(+) synovial T cells express high levels of 4-1BB. The addition of TNF-α to cultured synovial mononuclear cells increased shedding of 4-1BB. 4-1BB ligand only increased TNF-α shedding in combination with Gal-9. RNA interference-mediated knockdown of ADAM17 or the addition of an ADAM17 inhibitor reduced the 4-1BB shedding. Shedding of 4-1BB was not influenced by Gal-9. Plasma levels of s4-1BB were increased in early RA and correlated with the number of swollen joints at baseline. After 3 months of treatment, the plasma levels of s4-1BB were equal to those of the controls. Baseline plasma levels of s4-1BB were inversely correlated with DAS28-CRP after 2 years of treatment, but not with total Sharp score, erosion score or joint space narrowing. ADAM17 induces 4-1BB shedding in RA. Gal-9 is pivotal for the function of 4-1BB and induction of TNF-α. Furthermore, high plasma levels of s4-1BB were associated with the number of swollen joints, but also with a low DAS28-CRP after 2 years treatment in early RA.

Challenges and opportunities in the early diagnosis and optimal management of rheumatoid arthritis in Africa and the Middle East

Early diagnosis and early initiation of disease-modifying antirheumatic drug (DMARD) therapy slow the progression of joint damage and decrease the morbidity and mortality associated with rheumatoid arthritis (RA). According to the European League Against Rheumatism (EULAR) guidelines, treatment should be initiated with methotrexate and addition of biological DMARDs such as tumour necrosis factor (TNF) inhibitors should be considered for RA patients who respond insufficiently to methotrexate and/or other synthetic DMARDs and have poor prognostic factors. Africa and the Middle East is a large geographical region with varying treatment practices and standards of care in RA. Existing data show that patients with RA in the region are often diagnosed late, present with active disease and often do not receive DMARDs early in the course of the disease. In this review, we discuss the value of early diagnosis and remission-targeted treatment for limiting joint damage and improving disease outcomes in RA, and the challenges in adopting these strategies in Africa and the Middle East. In addition, we propose an action plan to improve the overall long-term outlook for RA patients in the region.

SAT0049 Obesity is Associated with Reduced Improvement in Functional Disability After 1 Year of Treatment: Results from an Inception Early Rheumatoid Arthritis Cohort

BackgroundDisease outcomes in rheumatoid arthritis (RA) may be influenced by a patient’s body mass index (BMI). Previous work has shown improved radiographic outcomes in obese RA patients1. However, obesity is...

The Swindon Foot and Ankle Questionnaire: Is a Picture Worth a Thousand Words?

Objectives. Despite increased awareness of the high prevalence and significance of foot and ankle problems in rheumatoid arthritis (RA), feet remain neglected. Reasons may include the perception that feet are difficult to assess, they are not included in the DAS28, and lack of freely available foot screening tools specific for RA. Methods. The Swindon Foot and Ankle Questionnaire (SFAQ) is a simply worded 10-point foot and ankle screening questionnaire with diagrams of feet and ankles for use in general rheumatology outpatients. All RA patients on our electronic database were invited to complete the questionnaire and attend clinic for assessment. Patients assessed clinically were scored out of 10 using the parameters from the questionnaire. The SFAQ was compared to the Manchester Foot Pain and Disability Index (MFPDI), DAS28, HAQ, HAD, and OSRA scores. Results. 597 questionnaires were sent, 301 (50%) returned, and 137 seen in clinic. There was good correlation between the postal SFAQ score, clinic score (r = 0.63), and the MFPDI (r = 0.65). Neither of the foot scores correlated with other RA disease outcome measures. 75% patients completed the picture. 73% corresponded to clinical findings. 45% of patients required an intervention following clinical review and trended towards higher scores. Conclusions. The SFAQ was quick to complete and correlated with the MFPDI. Lack of association with standard RA outcome measures suggests that relying on these scores alone may miss foot pathology. The diagrams were a useful complement. This simple screening tool could aid identification of RA foot and ankle problems.

Une alopécie diffuse

Early diagnosis and immediately started appropriate treatment are mandatory for the prevention of radiographic progression, functional disability and unfavourable disease outcome in rheumatoid arthritis (RA). The current classification criteria for RA include two different types of biomarkers representing inflammatory processes, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) or immune processes including autoantibodies, such as rheumatoid factor (RF) and antibodies against citrullinated proteins (ACPA). After the discovery of RF, the recent recognition of various autoantibodies against post-translationally modified proteins opened new avenues to diagnosing RA and predicting the course of the disease. Citrullination and carbamylation of amino acids generate new epitopes that can potentially promote the production of novel autoantibodies. In spite of growing knowledge, the pathogenic role of these autoantibodies is still not fully elucidated in RA. In this paper, we review the currently available and novel promising immune biomarkers, which may help in early diagnosis and estimating prognosis in RA.

Measures of Rheumatoid Arthritis Disease Activity: Figure 1.

The article by Pincus and colleagues1 and the accompanying editorial by Neogi and Felson2 debate the relative merits of individual and composite measures of disease outcome in rheumatoid arthritis (RA). Composite indices have clear merits. Pincus and colleagues reported that the physician global assessment performed well, and it gains some support from Neogi and Felson, as to them it represents a form of composite index. However, the … E-mail: john.kirwan{at}bristol.ac.uk. Address reprint requests to Prof. Kirwan.

Association of matrix metalloproteinase 3 promoter genotype with disease outcome in rheumatoid arthritis

Matrix metalloproteinases (MMPs) are implicated in joint destruction in rheumatoid arthritis (RA). We investigated whether the 5A/6A polymorphism within the MMP-3 (stromelysin-1) gene promoter region is associated with disease outcome in 254 patients with established RA. Patients homozygous for the MMP-3 6A allele had more radiographic damage (measured by Larsen score) than those with other genotypes (109.8 vs 91.1, P=0.04). Patients with the 6A/6A genotype also had more functional impairment and higher serum proMMP-3 levels, although only the latter was significant (P=0.002). A possible association was found between homozygosity for the 6A allele and carriage of the RA-associated HLA-DRB1 shared epitope (SE). Combination of these factors was associated with more severe disease than the SE alone. The data suggest that the MMP-3 6A/6A genotype is associated with worse RA outcome, and that this genotype may have an additive effect with the SE on disease severity.

Influence of cigarette smoking on disease outcome in rheumatoid arthritis.

Cigarette smoking is a well-known risk factor for rheumatoid arthritis. However, the influence of smoking on disease outcome has only been investigated very recently, and the data are not clear-cut. Smoking has a number of important effects on the immune system and sex hormones that may influence disease pathogenesis. Smoking has also been shown to affect disease outcome in other inflammatory diseases. The major focus of this review is to explore the relationship between smoking and severity of rheumatoid arthritis in detail.

Human leukocyte antigen-DQ and DR polymorphisms predict rheumatoid arthritis outcome better than DR alone

Conflicting data have been published on the value of the shared epitope (SE) hypothesis in predicting disease outcome in rheumatoid arthritis (RA). Recently we have proposed an alternative hypothesis, referred to as the RA protection (RAP) model. In this model, the HLA-DQ loci carry predisposition while HLA-DRB1 alleles encoding the motif DERAA provide protection against severe RA. In the present study, we have compared the respective values of the models in predicting both remission and erosions in early RA patients. We made use of an early arthritis clinic in which 158 RA patients and 138 patients with undifferentiated arthritis were enrolled. Patients were typed for HLA-DQ and -DR using high resolution DNA typing methods. Homozygosity for predisposing HLA-DQ alleles was associated with no remission and high erosion score. The presence of DERAA-bearing DRB1 alleles was negatively associated with erosions in otherwise predisposed individuals and increased the chance of being in remission. We found that the RAP model was significantly better than the SE model in predicting remission rate and erosion scores at one and two years in early RA patients. We conclude that HLA polymorphism does not only affect RA susceptibility, but also protects against severe disease at early stage.