Effect of rheumatoid arthritis on work status and social and leisure time activities in patients followed 8 years from onset.

OBJECTIVE: To evaluate the development of handicap in patients with rheumatoid arthritis (RA) followed 8 years from onset. METHODS: The study group consisted of 106 patients participating in a prospective early RA study. The mean duration of joint symptoms at inclusion was one year. The patients were assessed at least once annually. Disability was measured with the Health Assessment Questionnaire (HAQ) and emotional distress with a self-administered test (Symptom Checklist). Work status and different social measures were registered. A structured interview regarding work capacity, leisure time, and social activities was performed about 8 years after disease onset. RESULTS: Compared to study start, disease activity had decreased, emotional distress was unchanged, disability had increased somewhat, and radiographic changes had increased markedly. The prevalence of work disability at the end of the study was 37%. The majority of patients that eventually got disability pension had stopped working the first year after onset. Seventy-eight percent of the patients who continued to work had to adjust their work conditions to stay employed. The 3 most important predictors for work disability were higher HAQ at study start, lower educational level, and older age. Three-quarters of the patients had to alter leisure time activities and half of them were not satisfied with their recreation. Many patients experienced difficulties in their roles as spouse and parent. Higher levels of emotional distress were associated with these handicaps. CONCLUSION: In this cohort of patients with RA we found a high frequency of different types of handicaps at an early stage. Slightly more than 1/3 were work disabled. The majority had stopped working during the first year. Patients perceived handicaps in terms of changed leisure time activities, and difficulties performing different social roles were frequent. Patients with these handicaps felt more emotional distress.

Clinical course and remission rate in patients with early rheumatoid arthritis: relationship to outcome after 5 years.

OBJECTIVE: To investigate the clinical course in early rheumatoid arthritis (RA) patients followed prospectively, to relate course to outcome after 5 yr, and to try to identify prognostic features. METHODS: A total of 183 patients with definite RA and a mean disease duration of 11 months were included. Of these, 75% were rheumatoid factor (RF) positive; 85% carried the shared epitope, 32% on both alleles. Most patients were assessed every 6 months. Disability was evaluated with the Health Assessment Questionnaire (HAQ) and radiographic findings according to Larsen. Remission was defined in two ways: with the American Rheumatism Association (ARA) criteria and as 'no arthritis at least at one follow-up visit'. RESULTS: Twenty per cent achieved ARA-defined remission periods of at least 6 months duration; 21 were spontaneous and 18 drug induced. Average length of remission was 20.5 months. The remission periods constituted 7% of follow-up for all patients. Another 36% achieved remission according to the second definition. All 56% were considered to have a relapsing-remitting disease pattern, in contrast to the remaining 44% with a persistent disease pattern. More patients with persistent disease were treated with disease-modifying anti-rheumatic drugs (DMARDs) and had also received a larger number of different drugs. Outcome after 5 yr regarding disability, joint inflammation and joint damage was worse for patients with persistent disease. Neither ARA-defined remission nor disease pattern could be accurately predicted. CONCLUSIONS: Long-term ARA-defined remission was rare, constituting 7% of follow-up for the entire cohort. For those 20% achieving remission, this period represented 34% of their follow-up. A total of 56% had a relapsing-remitting disease pattern and 44% had a persistent disease pattern. This classification had prognostic implications with persistency being a bad prognostic sign.

Tissue-derived macromolecules and markers of inflammation in serum in early rheumatoid arthritis: relationship to development of joint destruction in hands and feet.

We have previously shown that serum concentrations of cartilage oligomeric matrix protein (COMP) are increased early in rheumatoid arthritis (RA) patients who subsequently develop advanced large-joint destruction. A prognostic value for joint damage of serum concentrations of hyaluronan (HA) is also suggested by previous studies. In contrast, serum concentrations of bone sialoprotein (BSP) have not been useful for identifying patients with progressive large-joint destruction. In the present study, we have examined the hypothesis that serum concentrations of these tissue-derived markers are of prognostic value in RA for the development of radiographically detectable joint damage in hands and feet. Serum concentrations of COMP, HA and BSP were quantified in samples obtained from 62 patients within the first year after onset of RA and were related to the development of radiographically detectable damage in these joints after 5 yr. Neither the serum concentrations of COMP nor of BSP at inclusion predicted joint damage in hands and feet after 5 yr, and the concentration of these proteins did not change over the 5 yr period. However, the serum concentration of HA at inclusion correlated with the radiographic score at the 5 yr follow-up (r = 0.425, P < 0.01), but was not a better predictor in this respect than the erythrocyte sedimentation rate or C-reactive protein levels at inclusion. Thus, serum concentrations of the three studied tissue-derived macromolecules were in this study not useful for identifying patients prone to small-joint destruction.

Development of radiographic damage during the first 5-6 yr of rheumatoid arthritis. A prospective follow-up study of a Swedish cohort.

The objective of this study was to describe the development of radiographic damage in patients with RA and to search for predictors of radiographic progression over 5 yr. One hundred and thirteen patients, 75 female and 38 male, mean age 53 yr, with definite RA and mean disease duration of 11.4 months, were followed prospectively for 5 yr at an out-patient clinic. Radiographs of the hands and feet were performed annually, and evaluated according to Larsen. The predictive value of demographic, clinical and laboratory variables at study start was evaluated. A stepwise logistic regression model was applied. We found that radiological joint damage occurred early and was significantly progressive during the 5 study years. The rate of progression was most prominent during the first 2 yr. At study start, 53% of the patients had no detectable erosions, but only 11% remained non-erosive. Twenty-six per cent of the patients with the initial presence of erosions did not progress substantially and needed no aggressive therapy. High joint damage progression during the first year, female gender and high baseline ESR could predict 57% of the patients with high total radiographic progression. Age, disease duration, rheumatoid factor, genetic factors, active joint count and the presence of erosions at study start had no predictive value.

D-penicillamine in early rheumatoid arthritis: experience from a 2-year double blind placebo controlled study.

OBJECTIVE: To evaluate the usefulness of early treatment with D-Penicillamine (DPA) in rheumatoid arthritis. METHODS: The patients were recruited from a Swedish early RA cohort comprising 180 patients. All patients experiencing active and/or erosive disease 2 years from onset were asked to participate in a 2-year placebo-controlled DPA trial. Previous treatment with slow-acting anti-rheumatic drugs (SAARDs) or oral corticosteroids was not allowed. The main outcome variable was radiographic progression in the hands and feet evaluated according to Larsen. Clinical assessment including the Ritchie index, active joint count, and the HAQ-disability index was performed every 6th month. Patients were included in the analyses of efficacy until the endpoint of therapy. RESULTS: 111/180 patients were eligible for treatment, and 74 agreed to participate in the trial. 21/33 patients on DPA and 22/41 on placebo completed the study. More patients taking placebo stopped due to lack of response (p < 0.01). 27% of the patients on DPA were withdrawn due to side effects. Radiographic deterioration increased but most clinical variables improved in both trial arms. A large inter-individual variation was observed. The only significant difference in trend over 2 years between DPA and placebo was found for joint tenderness. However, the median trends for most clinical variables showed a more positive effect for DPA. The 37 patients who refused to participate in the trial in general fared somewhat worse than patients taking DPA and somewhat better than patients taking placebo. The remission rate was about the same in all 3 groups (12-13.5%). CONCLUSIONS: About two-thirds of all early definite RA patients were eligible for treatment using current criteria. Psychological readiness for early therapy was fairly modest with a high refusal rate. The difference in efficacy between DPA and placebo was small, but was in favour of DPA for most clinical variables. However, only joint tenderness showed a significantly better trend. No significant slowing of radiographic progression by DPA was found.

Associations of HLA-DRB and -DQB genes with two and five year outcome in rheumatoid arthritis.

OBJECTIVE: To evaluate the clinical usefulness of genomic HLA typing during the first five years of established rheumatoid arthritis (RA). METHODS: The HLA-DRB and -DQB alleles were determined by restriction length polymorphisms and polymerase chain reaction amplification with sequence specific primers in 99 Swedish patients with RA. Clinical features after two and five years disease duration were related to the genetic pattern. Seventy four patients were seropositive, 25 had nodules, 90 developed erosions, and 15 required joint replacements. Twelve patients were in remission after five years. Disability was assessed by health assessment questionnaire, and radiographic damage in hands and feet by the Larsen method. RESULTS: Eighty seven per cent of the patients carried the conserved third hypervariable region sequence (HVR3), 32% had DRB1*04 on one allele, and 26% had DRB1*04 on both alleles (all frequencies significantly greater than in controls). Frequencies of DRB1*04 associated DQB*0301 and *0302 were normal. Patients carrying DRB1*04 on both alleles tended to have more radiographic changes after two years, but this difference had diminished after five years. Disability did not vary with regard to the genotype. Homozygous HVR3 patients had about three times greater risk of undergoing joint replacement. Homozygosity for HVR3 and presence of DQB*0302 both tended to be associated with erosive disease. CONCLUSIONS: We confirmed a strong association of disease with the presence of the shared epitope on one or two alleles. However, genotype was not strongly associated with disease severity after two and five years disease duration, and thus the value of genomic typing to select patients for early aggressive therapy is questionable.

Functional impairment and disability in early rheumatoid arthritis--development over 5 years.

OBJECTIVE: To evaluate the development of functional impairment and disability in early rheumatoid arthritis (RA). METHODS: Sixty-three patients with definite RA with mean disease duration of about 1 year were followed for 5 years. Joint inflammation was evaluated with an active joint count, and radiographic changes in hands and feet with the Larsen method. Functional impairment of particular joint systems was assessed with a performance index, Signals of Functional Impairment Index, and disability with the Health Assessment Questionnaire (HAQ). RESULTS: During the observation time the disease activity decreased, and the radiographic changes of hands and feet increased significantly. Joint replacement in 10 hips, 1 knee, and 1 shoulder were performed in 9 patients after median 43 months. At study start almost half the patients had impaired hand function, mostly affecting finger flexion and pincer grip. The most marked deterioration of joint function had occurred already after 2 years in metatarsophalangeal joints (55%), elbow joints (35%), ankle joints (30%), shoulder joints (28%), and hip joints (25%). The median HAQ level at study start was 0.8, and the median change of HAQ over 5 years was 0.1. (not significant). The progression of dysfunction was not linear but followed a highly variable course over the years. Patients with higher HAQ scores at study end could be correctly classified in 75% of the cases by the 3 factors, baseline HAQ score, female sex, and a low educational level. Presence of a replaced joint did not contribute significantly, but patients with joint replacement tended to be more disabled. CONCLUSION: Functional outcome of RA after about 6 years of disease was fairly good. Functional impairment of different joints had progressed, but most patients were still mildly disabled. A subgroup of 9 patients had a worse disease course with rapidly progressing large joint destruction.

Hip involvement in early rheumatoid arthritis.

OBJECTIVE: To study early hip involvement in rheumatoid arthritis (RA) and to evaluate the usefulness of ultrasonography in the detection of hip joint synovitis in RA. METHODS: Study I: The number of hip joint replacements was recorded in a cohort of 113 patients with RA of at least five years disease duration followed from an early stage. Study II: Ultrasonography was evaluated as a method to identify hip joint synovitis in 76 patients with RA of shorter disease duration, by relating it to radiograms and clinical findings. RESULTS: Study I: Twenty one hip joint replacements were performed in 15 of the 113 patients. The median disease duration at the time of first arthroplasty was 48 (range 10-76) months; the annual incidence was approximately constant between two and six years. High disease activity at the start of the study was predictive of requirement for hip prosthesis. Study II: Hip ultrasonography was pathological in 13 of the 76 patients studied, bilaterally in nine. Hip joint synovitis could not be confirmed on clinical grounds only as seven of the patients with positive ultrasonographic findings were asymptomatic, and the remaining six patients had only mild symptoms of hip involvement. Also, six of the 63 patients with normal ultrasonography had mild symptoms. There was no difference regarding demographic, clinical, and laboratory findings in patients with and without hip synovitis. CONCLUSIONS: Early hip joint destruction giving symptoms mostly at a very late stage is frequent in RA. Ultrasonography rather than signs or symptoms could identify patients with hip joint involvement and provide a rationale for early treatment.