Current issues of ACP Journal Club are published in Annals of Internal Medicine


Prognosis

Long-term prognosis, measured by health status, disease process, and damage, varied in early rheumatoid arthritis

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ACP J Club. 2003 May-Jun;138:77. doi:10.7326/ACPJC-2003-138-3-077


Source Citation

Lindqvist E, Saxne T, Geborek P, Eberhardt K. Ten year outcome in a cohort of patients with early rheumatoid arthritis: health status, disease process, and damage. Ann Rheum Dis. 2002;61:1055-9. [PubMed ID: 12429534] (All 2003 articles were reviewed for relevancy, and abstracts were last revised in 2009.)


Abstract

Questions

In patients with early rheumatoid arthritis (RA), what are the long-term outcomes (as measured by health status, disease process, and damage), and what are the prognostic factors?

Design

Inception cohort followed for 10 years.

Setting

A university hospital in southern Sweden.

Patients

183 patients > 18 years of age (mean age at disease onset 51 y, 63% women) with definite RA (American Rheumatism Association criteria) and disease duration < 2 years. 92% of patients had follow-up for 10 years.

Assessment of prognostic factors

Prognostic factors included age, sex, genotype, rheumatoid factor, Health Assessment Questionnaire (HAQ) score, erythrocyte sedimentation rate, and active joint counts. Possible predictors of outcome were assessed using logistic multiple-regression analyses.

Main outcome measures

Health status, measured by the HAQ and functional class; disease process, measured by clinical and laboratory measures of disease activity, and disease course; and damage, quantified as need for large joint replacements and occurrence of major extra-articular complications.

Main results

During the 10-year follow-up, 5% of patients had died, 75% had been treated with disease-modifying antirheumatic drugs, and 46% had been treated with low-dose oral glucocorticoids. After 10 years, 94% of patients managed daily life activities independently. Based on HAQ scores, 20% of patients had almost no disability, 28% were mildly disabled, and 10% were seriously disabled. All measures of disease activity decreased during the study. 79% of patients had a relapsing–remitting disease course, and 18% were in remission at 10 years. 17% of patients had large joint replacements, and 8% had developed serious extra-articular complications. Only mean HAQ score (mildly disabled or not) during the first 3 months predicted 10-year disability.

Conclusions

In patients with early rheumatoid arthritis, the long-term prognosis, as measured by health status, disease process, and damage, is variable. Poor health status during the first 3 months predicted disability at 10 years.

Sources of funding: Swedish Medical Research Council; Österlund and Kock Foundations; King Gustaf V 80 year Fund; Reumatikerförbundet.

For correspondence: Dr. E. Lindqvist, Lund University Hospital, Lund, Sweden. E-mail elisabet.lindqvist@reum.lu.se.


Commentary

Long-term follow-up studies in RA are difficult to maintain, and this study by Lindqvist and colleagues including 183 patients (of whom 168 had 10-y follow-up) is a substantial achievement. The most useful information in the study is confirmation of the variable course of the disease in a cohort of patients treated before the advent of biological agents. At the end of this period of observation, nearly half of the patients were either slightly disabled or functionally unaffected by the disease. This is important information for encouraging patients and their caregivers. A hint that energetic early treatment helps to maintain normal function and reduces cumulative joint damage is also apparent. In contrast, destructive disease progressed in approximately 10%, despite optimal management in this era.

This study, however, does not allow any conclusions about the efficacy of individual drug treatment. The authors do not state the indications for starting a specific drug, the stage at which treatment began, or the duration of treatment. In comparison with most series, a high percentage received steroids in unspecified doses. Many of the drugs used, such as Auronofin (oral gold), are now redundant.

In general terms, the results support the modern belief that early definitive treatment is beneficial (1). However, this study also emphasizes the persistent difficulty in identifying reliable prognostic markers. Disease heterogeneity was an important problem, and only 75% of the patients were rheumatoid factor–positive. The limited prognostic value of genetic markers is apparent in this study, as in others (2). Accurate clinical documentation provided the most useful guide. Continuous, nonremitting disease presaged the most severe functional impairment.

A. Michael Denman, MD, FRCP
Northwick Park NHS Trust Hospital
Middlesex, England, UK


References

1. Emery P, Breedveld FC, Dougados M, et al. Early referral recommendation for newly diagnosed rheumatoid arthritis: evidence based development of a clinical guide. Ann Rheum Dis. 2002;61:290-7. [PubMed ID: 11874828]

2. Moxley G, Cohen HJ. Genetic studies, clinical heterogeneity, and disease outcome studies in rheumatoid arthritis. Rheum Dis Clin North Am. 2002;28:39-58. [PubMed ID: 11840697]