Cervical spine involvement early in the course of rheumatoid arthritis

ObjectivesCervical spine involvement in rheumatoid arthritis (RA) is considered a feature of long-standing disease. We describe two patients who presented with cervical symptoms as early features of RA.MethodsWe report two RA cases with cervical spine involvement as early features and use MEDLINE to review the literature concerning the frequency and disease duration of this manifestation and its imaging with plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI).ResultsAn 80-year-old man with cervical myelopathy from a C1–C2 rheumatoid pannus underwent decompression surgery before development of peripheral synovitis from RA. A 63-year-old woman presented with neck pain and polyarthritis at RA diagnosis, with imaging that confirmed a C1–C2 rheumatoid pannus. Onset of cervical spine involvement in RA is generally after 10 years of disease duration, ranging from 3 months to 45 years after peripheral synovitis among patients with seropositive erosive RA. Occurring in 9–88% of RA patients, cervical spine involvement may result in cervical instability due to either mechanical compression or vascular impairment of the spinal cord. Bone erosions and atlanto-axial subluxation on standard radiographs are two major signs of cervical spine involvement in RA. MRI identifies earlier signs of RA and has a higher sensitivity in detecting bone erosions compared to conventional radiography.ConclusionsCervical spine involvement in RA is not an uncommon condition but is rare at early disease onset. Symptoms of cervical pain and myelopathy should prompt a thorough neurological examination accompanied by imaging.     

Atlantoepistrophic magnetic resonance imaging involvement in early rheumatoid arthritis: an aggressive tight control therapy not fully arresting the disease

Objective

Rheumatoid arthritis (RA) is the most common inflammatory disorder affecting the cervical spine. The purpose of this study was to characterize the atloaxial involvement with magnetic resonance imaging (MRI) in patients with early RA at the moment of diagnosis and after 18 months of a tight control therapy.

Methods

Twenty consecutive patients with early RA without cervical symptoms and 20 healthy controls were enrolled. The patients underwent unenhanced and enhanced gadolinium MRI study of the upper cervical spine at diagnosis and after 18 months of therapy. The presence of pannus tissue at MRI was considered active synovitis.

Results

Five (25%) of the 20 patients presented craniocervical involvement with active synovitis at MRI. At onset, patients with cervical involvement presented higher levels of erythrocyte sedimentation rate, a higher swollen joint count, and a higher Disease Activity Score in 44 joints level. All 5 patients (100%) with cervical involvement presented already peripheral erosions. After 18 months, 1 of 5 patients with atloepistrophic synovial involvement at baseline presented complete regression of the enhancement of synovial periodontoid process, and 1 presented a decrease of this enhancement. None of the patients developed erosive process at the odontoid. The only patient with complete regression of the enhancement presented a very early disease (<3 months).

Conclusion

Our study demonstrates involvement of the atloaxial junction in 25% of early RA patients, in particular in patients with active and erosive arthritis. An early diagnosis and aggressive treatment with a combination therapy, aiming for remission, does not always reduce atlantoaxial synovitis.     

The relationship between focal erosions and generalized osteoporosis in postmenopausal women with rheumatoid arthritis

Objective

Among rheumatoid arthritis (RA) patients who have had the disease for 10 years, more than half have focal erosions, and the risk of fracture is doubled. However, there is little information about the potential relationship between focal erosions and bone mineral density (BMD). The aim of this study was to determine whether lower BMD is associated with higher erosion scores among patients with RA.

Methods

We enrolled 163 postmenopausal women with RA, none of whom were taking osteoporosis medications. Patients underwent dual x‐ray absorptiometry at the hip and spine and hand radiography, and completed a questionnaire. The hand radiographs were scored using the Sharp method, and the relationship between BMD and erosions was measured using Spearman's correlation coefficients and adjusted linear regression models.

Results

Patients had an average disease duration of 13.7 years, and almost all were taking a disease‐modifying antirheumatic drug. Sixty‐three percent were rheumatoid factor (RF) positive. The median modified Health Assessment Questionnaire score was 0.7, and the average Disease Activity Score in 28 joints was 3.8. The erosion score was significantly correlated with total hip BMD (r = −0.33, P < 0.0001), but not with lumbar spine BMD (r = −0.09, P = 0.27). Hip BMD was significantly lower in RF‐positive patients versus RF‐negative patients (P = 0.02). In multivariable models that included age, body mass index, and cumulative oral glucocorticoid dose, neither total hip BMD nor lumbar spine BMD was significantly associated with focal erosions.

Conclusion

Our results suggest that hip BMD is associated with focal erosions among postmenopausal women with RA, but that this association disappears after multivariable adjustment. While BMD and erosions may be correlated with bone manifestations of RA, their relationship is complex and influenced by other disease‐related factors.

     

Radiological cervical spine involvement in patients with rheumatoid arthritis: a cross sectional study

OBJECTIVE: To investigate the frequency and the severity of radiological cervical spine involvement in patients with rheumatoid arthritis (RA). METHODS: We investigated 165 consecutive unselected patients with RA who fulfilled the revised American College of Rheumatology criteria for RA. All patients had a complete physical and laboratory evaluation. Patients had a radiological evaluation that included hand and wrist radiographs, as well as cervical spine radiographs in anteroposterior, lateral, and lateral in full flexion views. Hand radiographs were evaluated according to the Larsen criteria, while cervical radiographs were evaluated according to Winfield classification. RESULTS: There were 143 women and 22 men, with a mean age of 59.6 +/- 12.5 and disease duration 12.3 +/- 13.9 years. Positive rheumatoid factor was found in 63.6% of patients. One hundred forty-six patients presented radiological findings related to cervical spine involvement: atlantoaxial subluxations were found in 20.6% and erosions of the odontoid process in 2.4%; none presented vertical subluxation. Subaxial subluxations were found in 43.6%, disc space narrowing at C2-C3, C3-C4, C4-C5 levels in 66.1%, and vertebral plate sclerosis and erosions in 43.6%. CONCLUSION: Cervical spine radiological involvement is a frequent finding in our patients with RA, but the severity of the disease is rather mild, possibly related to the ethnic background.     

Magnetic resonance imaging of the craniovertebral junction in rheumatoid arthritis

Conventional radiography and magnetic resonance imaging (MRI) of the craniovertebral junction were evaluated in 12 patients with longstanding rheumatoid arthritis (RA) and neck pain with or without other neurologic signs or symptoms of cervical myelopathy. MRI demonstrated abnormal soft tissue masses thought to represent pannus in 9 patients. Three patients showed cord or brainstem compression due to pannus or atlantoaxial subluxation. The 3 patients with MRI evidence of cord or brainstem compression had neurologic signs or symptoms of cervical myelopathy, and appropriate therapy was instituted based on these findings. This study indicates that MRI is able to detect abnormal soft tissue masses which probably represent pannus and their relationship to the spinal cord or brainstem, and confirms the utility of the procedure in the management of craniovertebral involvement in RA.     

Risk of cervical myelopathy in rheumatoid arthritis patients with neck pain

BackgroundCervical spine (CS) evaluation in rheumatoid arthritis (RA) is challenging since subtle neurological insult is usually masked by the severe peripheral joint affection or muscle atrophy. Neglected CS lesions could end up with cervical myelopathy. Magnetic resonance imaging (MRI) has been the modality of choice in assessing CS in RA.Aim of the workTo evaluate CS in RA using MRI and detect the risk factors for its involvement.Patients and methodsForty RA patients with neck pain were assessed using disease activity score (DAS28), Ranawat classification of rheumatoid myelopathy, simple erosion narrowing score (SENS), bilateral hand and wrist musculoskeletal ultrasound (MSKUS) for early erosion detection and CS MRI.ResultsThe mean age of patients was 44.3 ± 10.1 years, disease duration 7.9 ± 6.6 years and the DAS28 was 4.8 ± 1.6. 70% of patients were in Ranawat class I, 30% in class II, and none in class III. 70% of patients had CS lesions where synovitis occurred in 67.5% of patients, odontoid erosions in 15%, atlanto-axial marrow edema in 5%, atlanto-occipital marrow edema in 5% and none had atlanto-axial subluxation (AAS), subaxial subluxation (SAS), spinal cord/brain stem compression. CS involvement was significantly related to peripheral joint erosion, high SENS and positive RF (p = 0.01, p < 0.0001, p < 0.0001 respectively).ConclusionCS involvement is remarkable in RA especially in those with peripheral joint erosions, high SENS and positive RF. RA patients with persistent neck pain, even in absence of objective neurological deficit should be evaluated early for detection and management of CS lesions before irreversible neurological damage takes place.     

Heart involvement in rheumatoid arthritis: Multimodality imaging and the emerging role of cardiac magnetic resonance

Objectives

Patients with rheumatoid arthritis (RA) exhibit a high risk of cardiovascular disease (CVD). CVD in RA can present in many guises, commonly detected at a subclinical level only.

Methods

Modern imaging modalities that allow the noninvasive assessment of myocardial performance and are able to identify cardiac abnormalities in early asymptomatic stages may be useful tools in terms of screening, diagnostic evaluation, and risk stratification in RA.

Results

The currently used imaging techniques are echocardiography, single-photon emission computed tomography (SPECT), and cardiac magnetic resonance (CMR). Between them, echocardiography provides information about cardiac function, valves, and perfusion; SPECT provides information about myocardial perfusion and carries a high amount of radiation; and CMR—the most promising imaging modality—evaluates myocardial function, inflammation, microvascular dysfunction, valvular disease, perfusion, and presence of scar. Depending on availability, expertise, and clinical queries, “right technique should be applied for the right patient at the right time.”

Conclusions

In this review, we present a short overview of CVD in RA focusing on the clinical implication of multimodality imaging and mainly on the evolving role of CMR in identifying high-risk patients who could benefit from prevention strategies and early specific treatment targeting the heart. Advantages and disadvantages of each imaging technique in the evaluation of RA are discussed.     

Impact of hepatitis C virus infection on disease activity,functional status and ultrasonography findings in Egyptian rheumatoid arthritis patients

Background

Hepatitis C virus (HCV) infection is one of the most frequently encountered public health problems in Egypt. It is associated with many autoimmune diseases such as rheumatoid arthritis.

Spine fractures in ankylosing spondylitis: A case report and review of imaging as well as predisposing factors to falls and fractures

Background

Ankylosing spondylitis (AS), an inflammatory arthritis that affects the axial skeleton, predisposes patients with severe disease to falls and spinal fractures. Advanced imaging has improved the process of fracture detection. In spite of increased knowledge about early diagnosis and management of AS, little attention is being paid to the environmental hazards that pose a risk for patient outcome.

Objectives

To identify risk factors for falls and fractures and evaluate imaging modalities in the detection of fractures in AS patients.

Methods

A case report and review of the literature using PubMed for English articles from 2000 to 2013 regarding AS patients? risk factors for falls and fractures and imaging modalities used to diagnose fracture in this population.

Results

Potential impairments in balance and coordination in the AS population include vestibular dysfunction, thoracolumbar kyphosis, and deficits in proprioception. A common and significant environmental risk factor for falls includes the use of a tub–shower arrangement. Furthermore, osteoporosis is a well-known complication of AS, which can predispose to a fracture. Lastly, there are no comprehensive studies that have evaluated the ability of advanced imaging modalities to identify an acute spine fracture in this patient population.

Conclusions

AS patients with advanced disease are at an increased risk of falls and fractures due to many factors including but not limited to a rigid spine and difficulty with peripheral vision. A tub–shower arrangement commonly found in homes and hotel rooms is a major hazard. A consistent approach to diagnosis of fractures involving advanced imaging recommendations should be considered.     

The impact of rheumatoid arthritis on quality-of-life assessed using the SF-36: A systematic review and meta-analysis

Objective

The assessment of health-related quality-of-life (HRQoL) in rheumatoid arthritis (RA) is becoming increasingly common in both research and clinical practice. One of the most widely used tools for measuring HRQoL is the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). We conducted a systematic review examining the impact of RA on HRQoL, measured through the SF-36.

Methods

MEDLINE and Embase were searched for observational studies reporting mean and standard deviation scores for each domain of the SF-36 in adult RA patients. Studies were reviewed in accordance with PRISMA guidelines, and a random-effects meta-analysis was performed.

Results

In total, 31 studies were eligible for inclusion in the meta-analysis, including 22,335 patients. Meta-analyses found that pooled mean HRQoL score for the SF-36 physical component summary was 34.1 (95% CI: 22.0–46.1) and mental component summary was 45.6 (95% CI: 30.3–60.8). Increased age was associated with reduced physical function and physical component summary (PCS) scores but improved mental health and mental component summary (MCS) scores. Female gender was associated with improved scores on role physical, bodily pain and PCS but reduced mental health and MCS scores. Longer disease duration was associated with improved MCS. Patients with RA have a substantially reduced HRQoL in comparison to both other physical illnesses and in comparison to normative datasets from UK and USA populations.

Conclusions

RA has a substantial impact on HRQoL. This supports recent NICE guidelines stipulating that RA patients should be regularly assessed for the impact their disease has on HRQoL and appropriate management provided.     

Decreases in rates of hospitalizations for manifestations of severe rheumatoid arthritis, 1983–2001

Objective

To determine whether the rates of hospitalization for 4 manifestations of severe rheumatoid arthritis (RA), which are used as indicators of long‐term health outcomes, have changed from 1983 to 2001.

Methods

Data on all patients with RA who were hospitalized with rheumatoid vasculitis or to undergo splenectomy for Felty's syndrome, cervical spine fusion for myelopathy, or total knee arthroplasty at hospitals in California were abstracted from a state hospitalization database. Changes in rates of hospitalization from 1983 to 2001 were examined in this serial cross‐sectional study.

Results

Rates of hospitalization for rheumatoid vasculitis and splenectomy in Felty's syndrome decreased progressively over time. The risk of hospitalization for rheumatoid vasculitis was one‐third lower in 1998–2001 than in 1983–1987. The risk of hospitalization for splenectomy in Felty's syndrome was 71% lower in 1998–2001 than in 1983–1987. There were no significant decreases in the rates of hospitalization for cervical spine surgery or total knee arthroplasty (primary and revision), although in 1998–2001 there was a reversal of the trend of increasing rates of total knee arthroplasty. The risk of hospitalization for primary total knee arthroplasty was significantly lower in 1998–2001 than in 1990–1993 (rate ratio 0.90, 95% confidence interval 0.86–0.95; P < 0.0001).

Conclusion

Rates of hospitalization for rheumatoid vasculitis and splenectomy in Felty's syndrome have decreased over the past 19 years, and there has been a recent decrease in the rates of primary total knee arthroplasty in patients with RA. Although several factors may account for these decreases, these findings suggest that since the early 1980s, the long‐term health outcomes of patients with RA have improved.

     

Magnetic resonance imaging and miniarthroscopy of metacarpophalangeal joints: Sensitive detection of morphologic changes in rheumatoid arthritis

Objective

To evaluate and characterize magnetic resonance imaging (MRI) findings in the metacarpophalangeal (MCP) joints of rheumatoid arthritis (RA) patients macroscopically, using miniarthroscopy (MA; needle arthroscopy).

Methods

The second MCP joint of the dominant hand of 22 RA patients (13 with various RA activities/stages; 9 with early RA [≤1.5 years' duration]) was examined by MRI followed by MA. Findings were evaluated by standardized semiquantitative measures of synovial and bony pathologic changes of the MCP joint, and were compared with the clinical and conventional radiologic findings.

Results

Erosions and pre‐erosions were detected in 17 of 22 patients by MRI; 2 of the other 5 patients (all early RA) displayed bony changes on MA. All 10 joints with pre‐erosions on MRI (grade I bony alterations on MRI) exhibited significant cartilaginous and bony pathology on MA. Synovial membrane pathology was detected in all but 1 patient by MRI and in all patients by MA, although findings of plain radiography were normal in 6 of the 22 patients and another 9 patients had a Larsen score of 1. Semiquantitative analysis of synovial findings of MRI revealed gadolinium diethylenetriaminepentaacetic acid enhancement as a significant marker of macroscopically varied synovial vascularity and hyperemia, both of which strongly correlated with clinical activity (as measured by the Disease Activity Score). The extent of synovitis/synovial proliferation shown by MA and MRI were significantly correlated with each other, but not with any other activity or damage parameter analyzed.

Conclusion

In RA, both MRI and MA findings support early detection and staging of synovial changes. Ongoing longitudinal studies are aimed at evaluating the value of synovial proliferation as visualized by both methods.

     

Heart involvement in Rheumatoid Arthritis: Systematic review and meta-analysis

Objective

The aim of our study was to conduct a systematic review with meta-analysis of the current case–control studies about the valvular and pericardial involvement in patients with Rheumatoid Arthritis (RA), asymptomatic for cardiovascular diseases.

Methods

Case–control studies were identified by searching PubMed (1975–2010) and the Cochrane Central Register of Controlled Trials (CENTRAL) (1975–2010). Participants were adult patients with RA asymptomatic for cardiovascular diseases, and the outcome measure was the presence of cardiac involvement.

Results

Quantitative synthesis included 10 relevant studies out of 2326 bibliographic citations that had been found. RA resulted significantly associated to pericardial effusion (OR 10.7; 95% CI 5.0–23.0), valvular nodules (OR 12.5; 95% CI 2.8–55.4), tricuspidal valve insufficiency (OR 5.3; 95% CI 2.4–11.6), aortic valve stenosis (OR 5.2; 95% CI 1.1–24.1), mitral valve insufficiency (OR 3.4; 95% CI 1.7–6.7), aortic valve insufficiency (OR 1.7; 95% CI 1.0–2.7), combined valvular alterations (OR 4.3; 95% CI 2.3–8.0), mitral valve thickening and/or calcification (OR 5.0; 95% CI 2.0–12.7), aortic valve thickening and/or calcification (OR 4.4; 95% CI 1.1–17.4), valvular thickening and/or calcification (OR 4.8; 95% CI 2.2–10.5), and mitral valve prolapse (OR 2.2; 95% CI 1.2–4.0).

Conclusions

Our systematic review pointed out the strength and the grade of both pericardial and cardiac valvular involvement in RA patients. Our findings underscore the importance of an echocardiographic assessment at least in clinical research when RA patients are involved. Moreover, further research is needed to understand the possible relationship of our findings and the increased cardiovascular mortality.     

The spectrum of atlanto axial facet joint involvement in rheumatoid arthritis

Six hundred fifty outpatients with rheumatoid arthritis (RA) were evaluated and followed up during a 7-year period. As part of their routine evaluation or because of neck-shoulder girdle symptoms, 48% of the patients underwent routine cervical spine radiography. Sixty-one RA patients (9% of the total population) had C1-C2 involvement. Compared with the 589 patients with no evidence of C1-C2 involvement, these 61 patients were significantly more likely to be younger, female, and seropositive, and they had significantly more nodules and erosions, as well as a longer disease duration. Based on radiographic evidence of C1-C2 disease severity, 3 groups emerged. Group 1 (28 patients) had lateral mass collapse, group 2 (27 patients) had lateral facet joint sclerosis, erosion, or loss of joint space with no collapse, and group 3 (6 patients) had lateral subluxation with no bone or cartilage changes. Nine patients in group 1 had severe pain, and 25 had a nonreducible rotational tilt of the head. None of the patients in the other 2 groups had either of these signs or symptoms. Moreover, patients in group 1 were more likely to have other C1-C2 or subaxial subluxations and were more likely to have myelopathy. C1-C2 lateral facet joint involvement is common in RA, correlates with disease severity generally and specifically with that in the cervical spine, and, when severe, causes nonreducible rotational tilt of the patient's head.     

Regional variation and differential response to therapy for knee synovitis adjacent to the cartilage–pannus junction and suprapatellar pouch in inflammatory arthritis: Implications for pathogenesis and treatment

Objective

To use magnetic resonance imaging (MRI) to investigate the importance of knee joint synovitis at the cartilage–pannus junction (CPJ) in rheumatoid arthritis (RA) as compared with synovitis at a distant site in the suprapatellar pouch (SPP) and as compared with CPJ synovitis in the spondylarthropathies (SpA), and to assess the relative response of knee joint synovitis to therapy at the CPJ and SPP sites.

Methods

Dynamic contrast‐enhanced MRI (DEMRI) of actively involved knee joints in 24 patients (13 with RA and 11 with SpA) was undertaken. The area of synovitis was calculated at the CPJ and SPP regions of interest in patients with RA and in patients with SpA. Differences in CPJ and SPP synovitis were determined using calculated DEMRI parameters which included the initial rate of contrast enhancement (IRE) and the maximal enhancement (ME). Changes in the synovial area at the CPJ and SPP were also measured in 10 patients with early RA, following treatment with disease‐modifying antirheumatic drugs (DMARDs) (either methotrexate or leflunomide).

Results

In patients with RA or SpA, the area of synovitis was significantly larger immediately adjacent to the CPJ compared with a distant site at the SPP (in RA, mean synovitis area 162 mm² at the CPJ versus 114 mm² at the SPP [P = 0.010]; in SpA, mean synovitis area 214 mm² at the CPJ versus 143 mm² at the SPP [P = 0.002]), but the differences in the areas of synovitis at these sites were not significant between the RA and SpA patients. The IRE and ME values were also higher at the CPJ compared with the SPP, both in the RA patients (IRE P = 0.054, ME P = 0.018) and in the SpA patients (IRE P = 0.002, ME P = 0.001). A larger reduction in the area of synovitis was seen at the SPP compared with the CPJ following DMARD therapy in the RA patients (mean reduction 35% at the SPP [P = 0.023] and 12% at the CPJ [P not significant]).

Conclusion

The non–disease‐specific variations in synovitis and the differential responses to therapy in RA patients have implications for improving our understanding of CPJ synovitis. The results suggest that the pathophysiologic events at the CPJ reflect common anatomic, immune system, or biomechanical factors that play a role in modulating the severity of arthritis, and these events are not specific to RA since the same process was observed in other arthritides.

     

The spectrum of atlantoaxial facet joint involvement in rheumatoid arthritis

Six hundred fifty outpatients with rheumatoid arthritis (RA) were evaluated and followed up during a 7-year period. As part of their routine evaluation or because of neck-shoulder girdle symptoms, 48% of the patients underwent routine cervical spine radiography. Sixty-one RA patients (9% of the total population) had C1-C2 involvement. Compared with the 589 patients with no evidence of C1-C2 involvement, these 61 patients were significantly more likely to be younger, female, and seropositive, and they had significantly more nodules and erosions, as well as a longer disease duration. Based on radiographic evidence of C1-C2 disease severity, 3 groups emerged. Group 1 (28 patients) had lateral mass collapse, group 2 (27 patients) had lateral facet joint sclerosis, erosion, or loss of joint space with no collapse, and group 3 (6 patients) had lateral subluxation with no bone or cartilage changes. Nine patients in group 1 had severe pain, and 25 had a nonreducible rotational tilt of the head. None of the patients in the other 2 groups had either of these signs or symptoms. Moreover, patients in group 1 were more likely to have other C1-C2 or subaxial subluxations and were more likely to have myelopathy. C1-C2 lateral facet joint involvement is common in RA, correlates with disease severity generally and specifically with that in the cervical spine, and, when severe, causes nonreducible rotational tilt of the patient's head.     

Effects of disease modifying anti-rheumatic drugs on subclinical atherosclerosis and endothelial dysfunction which has been detected in early rheumatoid arthritis: 1-year follow-up study

Objective

The study was designed to explore the effect of disease modifying anti-rheumatic drugs (DMARDs) on synovial inflammation as well as on atherosclerotic indices in patients with early rheumatoid arthritis (RA).

Methods

The study included 35 early RA patients (disease duration <12 months). Inflammatory variables, like erythrocyte sedimentation rate (ESR) and high sensitivity C-reactive protein (hsCRP) were measured. Carotid intima-media thickness (cIMT) and endothelial dependent flow-mediated vasodilatation (ED-FMD) were measured by high-resolution ultrasonography. Disease activity of RA was assessed by disease activity score (DAS28) and quality of life was determined by Health Assessment Questionnaire-Disability Index (HAQ-DI) Score. All the above parameters were assessed both at baseline and follow-up after 1 year. Patients were treated with methotrexate (MTX), hydroxycholoroquine (HCQ) and sulfasalazine (SSZ) depending on their disease activity.

Results

After a year of treatment, variables like ESR, hsCRP, DAS28 and HAQ-DI showed significant improvement (p < 0.0001 for each variable). However, there was no such significant change observed in the lipid profile after 1 year from the baseline. Average body mass index (BMI) of patients remained same at the one year follow-up. The cIMT values after 1 year decreased significantly [0.43 ± 0.08 mm] from the baseline [0.50 ± 0.16 mm] [p = 0.002]. Similarly, in case of FMD%, the post-1-year treatment values [7.57 (4.04–13.03)] improved significantly from the baseline [5.26 (2.9–10.6)] [p = 0.041].

Conclusion

Subclinical atherosclerosis and endothelial dysfunction are demonstrable features even in early RA which improved after therapy. Early intervention of RA with DMARDs not only controls the disease but also retards the atherosclerotic progression.     

Burden of disease in treated rheumatoid arthritis patients: Going beyond the joint

Objective

The disease burden in rheumatoid arthritis (RA) extends beyond the joint. This article evaluates the physical and psychosocial extra-articular burden of treated RA and relationships among diverse disease manifestations.

Methods

MEDLINE searches identified papers published in English from January 2003 to December 2012 that evaluated systemic complications and psychosocial aspects associated with RA. Preference was given to studies with randomized cohorts and large (>100) sample sizes. Of 378 articles identified in the initial search, 118 were selected for inclusion.

Results

RA is associated with multiple comorbidities and psychosocial impairments, including cardiovascular disease, osteoporosis, interstitial lung disease, infection, malignancies, fatigue, depression, cognitive dysfunction, reduced work performance, work disability, and decreased health-related quality of life. The etiology of the extra-articular burden may reflect the systemic inflammation and immune system alteration associated with RA, metabolic imbalances and side effects related to treatment, or the influence of comorbidities. Strategies that may help to reduce the extra-articular disease burden include personalized medicine and the potential introduction of treatments with new mechanisms of action.

Conclusion

Despite improvements in treating joint disease, the extra-articular burden in RA remains substantial, encompassing multiple comorbidities and psychosocial impairments.