Is the disease course of rheumatoid arthritis becoming milder?: Time trends since 1985 in an inception cohort of early rheumatoid arthritis

Abstract

Objective. Based on comparisons of short-term cohort studies or cross-sectional samples of patients from different calendar times, it has been suggested that present patients with rheumatoid arthritis (RA) have a milder disease course compared with that of patients in past decades. This study was undertaken to investigate whether the course of disease activity and functional disability in patients with RA has become milder over the past several years.Methods. We used the Nijmegen inception cohort of early RA, which included all patients with newly diagnosed RA who had attended the department of rheumatology at Radboud University Nijmegen Medical Centre since 1985. Patients were assessed for disease activity by the Disease Activity Score in 28 joints (DAS28) every 3 months and for functional disability by the Health Assessment Questionnaire (HAQ) disability index (DI) every 6 months. Within the total cohort, 4 subcohorts were defined, based on the date of inclusion of the patients (1985-1990, 1990-1995, 1995-2000, 2000-2005). To investigate whether the course of disease activity and functional disability (over time) was different between the subcohorts, longitudinal regression analysis (linear mixed models) was used, with the DAS28 and HAQ DI over time as outcome variables, respectively, and subcohort as the independent variable, correcting for baseline demographic and clinical characteristics. The treatment strategy was compared between the subcohorts.Results. The DAS28 at baseline and over the first 5 years of disease was lower in the more recent subcohorts. The HAQ DI did not show improvement but instead a trend toward worsening functional disability. Using longitudinal regression it was shown that disease activity improved early in the disease course and stabilized thereafter, and that this improvement was greater in patients in the more recent subcohorts and in patients with a higher baseline DAS28. Initially, the HAQ DI also improved but stabilized thereafter, and this initial improvement was less pronounced in patients in the more recent subcohorts and was greater for patients with a higher baseline HAQ DI. The treatment strategy was more aggressive in the more recent subcohorts, as shown by a shorter duration from diagnosis to the start of treatment with prednisone or disease-modifying antirheumatic drugs (DMARDs), and a greater prevalence of DMARD therapy.

Has the Severity of Rheumatoid Arthritis at Presentation Diminished Over Time?

“…Patients in the more recent decades had fewer tender joints, shorter symptom duration, and were older, but reported higher levels of pain 18 . Conflicting findings were reported in a study in the Netherlands 19 . The authors grouped 525 patients into 4 cohorts depending on the date of inclusion to the study (1985-1990, 1990-1995, 1995-2000, 2000-2005).…”

“…Most of the studies that have compared patients in earlier and more recent decades at presentation have used hospital or clinic-based populations 9,18 with established disease 19 , and/or have included small samples of patients 8,18,19 . To determine whether patients with RA are presenting with milder disease, it may be more informative to focus on a larger sample of patients presenting early in the disease course and before any treatment has started.…”

Change of Psychological Distress and Physical Disability in Patients With Rheumatoid Arthritis Over the Last Two Decades

“…The current study has strengths that add to previous findings (23)(24)(25)(26)(27)(28)37,49). It is one of few population studies (25)(26)(27)(28) examining time trends of both physical functioning and psychological well-being, and the first to examine reduced disease activity as a possible mediator of these time trends.…”

“…Therefore, in contrast with other cross-sectional population studies (24 -27), the effect of year of assessment was not confounded by disease duration (50). Lastly, our data covered more recent years than previous population studies (23)(24)(25)(26)(27)(28)37,49); therefore, effects of the newest treatments were included.…”

Étude et Suivi:Rheumatoid Arthritis in the 21st Century

“…In contrast, by the same timepoint, only about 50% of patients in the NOAR group, recruited in the early 1990s, had ever received DMARD or steroid; and the drug of choice at that time was sulfasalazine. For many years, it has been argued that RA is becoming less severe, with evidence to support this dating back long before the introduction of early aggressive treatment strategies 19,20 . Nevertheless, the striking differences in disease progression and outcomes described in the ESPOIR cohort versus those from the 1980s and 1990s highlight the influence of changes in treatment guidelines.…”