Rheumatoid arthritis (RA) is a chronic inflammatory disease, markedwith joint pain and erosion. The course of RA can vary considerably,from mild to crippling, and is difficult to predict. On the strength ofpatient case histories and clinical trials, rheumatologists havesuggested that the majority of today's RA patients are suffering lesssevere symptoms and less functional disability compared with RApatients in past decades.
Is the course of RA becoming milder? If so, why? Intrigued by thesequestions, researchers in The Netherlands decided to seek out theanswers through a rigorous investigation. Published in the September2005 issue of Arthritis & Rheumatism (http://www.interscience.wiley.com/journal/arthritis),their findings indicate a positive trend. "Patients with early RApresenting in recent years have less severe disease activity atpresentation, as well as a more favorable course of their disease,compared with patients in earlier years," states the study's leadingauthor, Paco M. J. Welsing, MSc.
What is the reason for this improving trend? Welsing and his colleaguesfound no clear, conclusive cause, and even uncovered some contradictoryevidence. However, the team found a concurrent tendency toward ashorter duration of symptoms at the time of diagnosis and moreaggressive use of drug therapy--for instance, methotrexate, today'spreferred disease-modifying anti-rheumatic drug (DMARD) and/orprednisone--over the course of the disease.
The study included all newly diagnosed, early RA patientsenrolled in the department of rheumatology clinic of Radboud UniversityNijmegen Medical Centre since 1985. Patients were divided into fourgroups based on the date of enrollment. Patients enrolled between 1985and 1990 (167 total) comprised Group 1. Patients enrolled between 1990and 1995 (132 total) comprised Group 2. Patients enrolled between 1995and 2000 (114 total) comprised Group 3. And patients enrolled between2000 and 2005 (112 total) comprised Group 4. In all groups, themajority of patients were women. The mean age at the time of enrollmentwas 54 years for Group 1; 55 years for both Groups 2 and 3; and 57years for group 4.
Researchers set out to compare disease activity and functionaldisability among the groups over a 5-year progression (but 4-years,maximum, for Group 4). They also compared treatment strategies amongthe groups. All patients were assessed for signs of RAactivity--namely, swelling and tenderness--in 28 joints every 3 months,a laboratory measure for inflammation and a measure of general wellbeing by the Disease Activity Score 28 (DAS28). All patients wereassessed for functional disability--covering difficulties with walkingand conducting everyday activities--using the Health AssessmentQuestionnaire disability index (HAQ DI) every 6 months. In addition,all patients were periodically evaluated for pain in general.
The DAS28 scores at baseline and over the course of the studywere consistently lower, indicating milder disease activity, in themore recent groups--that is, patients diagnosed with RA within the lastten years. At the 5-year culmination, the DAS28 scores were lowest inthe most recent, complete group--Group 3, patients diagnosed between1995 and 2000--compared with both Group 2 (1990-1995) and Group 1(1985-1990). The average disease activity over time per patient showedsimilar trends of improvement. The average DAS28 score improved from4.1 to 3.4 from the Group 1 to Group 3.
However, the HAQ DI scores at baseline and over time were notlower among patients enrolled later in the study, and even showed someevidence of a worsening trend. "This contradictory result may be partlya distinction between measures of physical examination, laboratoryresults, and patient-assessed outcomes," notes Welsing, "which can beinfluenced by internal standards or attitudes of patients."
Researchers did find a correlation between more aggressivetreatment strategies and milder disease activity in the more recentgroups of patients. While suggesting the effectiveness of earlytreatment with methotrexate, for instance, and/or prednisone formanaging RA's symptoms and destructive progression, this connectioncalls for further investigation.
Article: "Is the DiseaseCourse of Rheumatoid Arthritis Becoming Milder? Time Trends Since 1985in an Inception Cohort of Early Rheumatoid Arthritis," Paco M. J.Welsing, Jaap Fransen, and Piet L. C. M. van Riel, Arthritis &Rheumatism, September 2005; 52:9; pp. 2616-2624.
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