Is rheumatoid arthritis becoming a milder disease? Or are we starting second-line therapy in patients with milder disease?

Porter, Duncan; Capell, Hilary A.; McInnes, I.; Munro, Robin; Madhok, Rajan; Hunter, John; Thomson, E A

doi:10.1093/rheumatology/35.12.1305

Cited by 10 publications

(10 citation statements)

References 19 publications

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“…Progressive disability may worsen cardiovascular risk factors such as lack of exercise, poor diet, obesity and smoking. There has been some speculation that RA is becoming less severe35 but change in disease characteristics may reflect improved resources leading to fewer patients with severe disease attending any one centre rather than a true improvement in the disease 36. It is also possible that some lifestyle changes have had a beneficial effect but these remain complex and difficult to unravel.…”

Section: Discussionmentioning

confidence: 99%

Does social disadvantage contribute to the excess mortality in rheumatoid arthritis patients?

Maiden

Capell

Madhok

et al. 1999

Annals of the Rheumatic Diseases

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Background-Socioeconomic deprivation is associated with increased mortality from cardiovascular causes and malignancy. The influence of disadvantage in patients with rheumatoid arthritis (RA), who are known to have premature mortality, has not been ascertained. Aim-To assess the relation between the level of patient deprivation and mortality in RA patients. Methods-200 RA patients, enrolled in a study comparing sulfasalazine and penicillamine in 1984-85, have been followed up prospectively for 12 years. Subjects were categorised into Carstairs groups with deprivation scores ranging from 1 (most aZuent) to 7 (most deprived). Information about deaths was obtained from the Registrar General in Scotland, death certificates and GP/hospital records. Results-There were more RA patients in the deprived areas then expected compared with the West of Scotland and England and Wales. Some 47.5% of the RA patients had died by 12 years-the majority of cardiorespiratory causes or malignancy. There were no diVerences in the median age or disease duration in the various Carstairs groups at study entry, but the percentage of deaths was higher in the more deprived groups after 12 years (36% dead in most aZuent area compared with 61% in the most deprived, that is, in groups 6 and 7). Conclusion-In patients with RA increasing deprivation was associated with premature mortality. If confirmed elsewhere these findings have implications for rheumatological management strategies, for researchers involved in collaborative studies of patients from diVerent socioeconomic backgrounds and for resource allocation. (Ann Rheum Dis 1999;58:525-529)

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Section: Discussionmentioning

confidence: 99%

Does social disadvantage contribute to the excess mortality in rheumatoid arthritis patients?

Maiden

Capell

Madhok

et al. 1999

Annals of the Rheumatic Diseases

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“…Early intervention with anti-rheumatic drugs (diseasemodifying anti-rheumatic drugs, DMARDs) was found to result in better responsiveness to the drugs [3][4][5] and extensive suppression of disease activity led patients to a better outcome. 6,7 As a result, the outcome of RA patients should have become better, and this was shown by the comparison of several cohorts in different years of investigation; [8][9][10][11][12][13] however, this has not been clearly shown in a Japanese cohort study, where the circumstances in the daily practice of RA is quite different when compared with that in western countries. Especially, it is of interest whether better control of the disease activity of RA patients leads to prevention of long-term disability in Japanese circumstances.…”

Section: Introductionmentioning

confidence: 99%

Improvement of disease activity of rheumatoid arthritis patients from 2000 to 2006 in a large observational cohort study IORRA in Japan

et al. 2007

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The objective of this study was to show whether the disease activity of rheumatoid arthritis (RA) patients had improved in Japan, and whether the improvement of disease activity had resulted in a better outcome of patients. In a single-institute-based prospective observational cohort of RA patients (Institute of Rheumatology, Rheumatoid Arthritis, IORRA), a total of 7512 patients were enrolled, and their information was collected biannually. A cross-sectional data set A that included all patients in each phase was analyzed. From October 2000 to April 2006, disease activity score DAS28 significantly improved from 4.15 to 3.63, and the frequency of patients in remission (DAS28 < 2.6) increased from 8.5% to 21.5%. During this period, the frequency of methotrexate users increased from 33.9% to 58.7% and the average dosage of methotrexate also increased from 5.59 mg/week to 6.94 mg/week; on the other hand, there was no increase in any adverse reaction among the methotrexate users. To investigate the relationship between longitudinal disease control and progression of disability, a longitudinal data set B that included 712 patients who completed all phases of the study from 2000 to 2006 was selected and was analyzed. The disability index JHAQ of a poorly controlled group (average DAS > 5.1) increased (+34.8%), that of a moderately controlled group (average DAS 3.2-5.1) also increased (+14.0%), but that of a well-controlled group (average DAS < 3.2) decreased (-13.0%). In conclusion, by using a prospective observational cohort IORRA in Japan, we demonstrate that RA disease activity improved from 2000 to 2006, which correlates with an increased use of methotrexate. The suppression of disease activity resulted in a better outcome for patients.

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“…Another limitation is that adverse events were ascertained by patient self-report, rather than by a systematic review with a health professional, as is performed in a randomized controlled trial protocol. However, the self-report approach appeared valid in another study [71], and patients generally report hypertension, diabetes and cataracts if these conditions develop.…”

Section: Discussionmentioning

confidence: 99%

“…However, as noted, almost all patients took methotrexate and/or other DMARDs according to a policy of tight control [67,68], particularly after 1990. Therefore, as noted, it is not possible to separate the possible effectiveness of prednisone versus methotrexate (or even,in part,a possible secular trend to milder RA [69,70,71,72]), as the data are not from a clinical trial to isolate a single variable. Nonetheless, the data, while not definitive, are consistent with clinical trial data indicating that improved outcomes are associated with low-dose prednisone, here on a long-term basis.…”

Section: Introductionmentioning

confidence: 99%

The Past versus the Present, 1980-2004: Reduction of Mean Initial Low-Dose, Long-Term Glucocorticoid Therapy in Rheumatoid Arthritis from 10.3 to 3.6 mg/Day, Concomitant with Early Methotrexate, with Long-Term Effectiveness and Safety of Less than 5 mg/Day

Pincus

Sokka

Cutolo

2014

Neuroimmunomodulation

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Quantitative observations are presented concerning treatment with glucocorticoids of 308 patients with rheumatoid arthritis (RA) at a weekly academic rheumatology setting over 25 years from 1980 to 2004. A database of all visits included medications and multidimensional health assessment questionnaire scores for physical function, pain and routine assessment of patient index data (RAPID3; and a surrogate RAPID3-EST), completed by each patient at each visit in routine care. Over the 5-year periods of 1980-1984, 1985-1989, 1990-1994, 1995-1999 and 2000-2004, the mean initial prednisone daily dose declined from 10.3 to 6.5, 5.1, 4.1 and 3.6 mg/day, as initial doses were >5 mg/day in 49, 16, 7, 7 and 3% of patients, 5 mg/day in 51, 80, 70, 26 and 10%, and <5 mg/day in 0, 4, 23, 67 and 86%. Reduction of prednisone doses in the respective five-year periods was accompanied by increased and earlier use of methotrexate as the first disease-modifying antirheumatic drug (DMARD) in 10, 26, 57, 71 and 78%, and methotrexate treatment in 10, 26, 74, 82 and 92% of patients within the first year of disease. Higher methotrexate doses in the respective five-year periods were used after 1990, along with lower prednisone doses. Most patients were treated indefinitely with both low-dose prednisone and methotrexate; 80% continued both medications for more than 5 years. The primary adverse events were skin-thinning and bruising. New hypertension, diabetes and cataracts were seen in fewer than 10% of patients. While efficacy and safety cannot be analyzed definitively from observational data, the data suggest that many patients with RA might be treated effectively with weekly low-dose methotrexate along with initial and long-term, low-dose prednisone of <5 mg/day.

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Is rheumatoid arthritis becoming a milder disease? Or are we starting second-line therapy in patients with milder disease?

Cited by 10 publications

References 19 publications

Does social disadvantage contribute to the excess mortality in rheumatoid arthritis patients?

Does social disadvantage contribute to the excess mortality in rheumatoid arthritis patients?

Improvement of disease activity of rheumatoid arthritis patients from 2000 to 2006 in a large observational cohort study IORRA in Japan

The Past versus the Present, 1980-2004: Reduction of Mean Initial Low-Dose, Long-Term Glucocorticoid Therapy in Rheumatoid Arthritis from 10.3 to 3.6 mg/Day, Concomitant with Early Methotrexate, with Long-Term Effectiveness and Safety of Less than 5 mg/Day

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