When the first visit to the rheumatologist is established rheumatoid arthritis

The outlook for people living with rheumatoid arthritis (RA) has improved tremendously in a generation. Major contributions to this include recognition of the importance of early treatment initiation, improved understanding of the pathobiology, the identification of therapeutic targets and their subsequent validation in clinic trials and the realisation of the importance of ‘tight control’ of inflammatory responses. Despite these advances, many patients meeting classification criteria present for the first time to a rheumatologist with longstanding symptoms. There is no definition as to when RA becomes ‘established’. But there is evidence that a ‘window of opportunity’ exists over about 12–16 weeks symptom duration, during which treatment intervention gives rise to the most optimal outcomes. This review addresses issues regarding the management of patients presenting outside the window of opportunity in terms of heterogeneity of presentation, assessment, therapeutic goals and treatment options as well as the importance of a multidisciplinary approach to holistic care.     

Clinical significance of low titer anti-nuclear antibodies in early rheumatoid arthritis: implications on the presentation and long-term course of the disease

The objective of this study was to evaluate the clinical significance of anti-nuclear antibodies (ANA) detected in the early stages of rheumatoid arthritis (RA), by a retrospective comparison of the clinical, laboratory, and therapeutic characteristics of patients with or without ANA. The files of 99 longstanding seropositive RA patients were reviewed. Data relating to demographics, medical history, family history, physical findings, extra-articular complications, laboratory tests, drugs [dosage, duration, efficacy, combinations, adverse effects (AEs)], intra-articular injections, and surgery were recorded. Patients with or without ANA at presentation of their disease were compared using chi-square and t-tests. Fifty-two ANA positive (group 1) and 47 ANA negative (group 2) patients were enrolled in the study. All were comparable in terms of their mean age, age at diagnosis, follow-up duration (∼10.5 years), and male:female (M:F) ratio. On admission, pain complaints were more pronounced in group 1 (P = 0.004 in the feet), but the physical findings did not differ. Deformities and nodules developed in similar numbers. Extra-articular complications were evenly distributed; vasculitis, however, was significantly more prevalent in ANA positive (10/52) than in ANA negative (2/47) patients. Thyroid disease was more common in group 2 (10/47 vs 3/52). Laboratory tests (presentation and maximal values) were similar, with the exception of higher anti-DNA (but within normal ranges) and γ-globulin% in group 1. Group 1 used more drugs prior to diagnosis. Corticosteroids and disease-modifying anti-rheumatic drugs (DMARDs) were evenly used. Combination therapy, joint injections, and surgery were more prevalent in group 2. AEs to various DMARDs were more common in group 1. Although similar in many aspects, RA patients with ANA tend to present with more pain complaints, a higher risk of vasculitis and AEs relating to use of DMARDs, while those without ANA needed more aggressive therapeutic modalities. Received: 7 February 2000 / Accepted: 13 July 2000     

Double-blind,placebo-controlled study of OM-8980 in rheumatoid arthritis

Summary A total of 95 patients suffering from active rheumatoid arthritis were included in this double-blind, placebo-controlled study of the immunomodulator OM-8980. Treatment was one capsule daily of OM-8980 or placebo for 6 months. A significant improvement was observed in the OM-8980 group in comparison with the placebo group as regards the Ritchie index (P=0.002), grip strength (P=0.02) and pain (P=0.03). The number of swollen joints, duration of morning stiffness and erythrocyte sedimentation rate decreased more markedly under OM-8980 than under the placebo, without reaching the level of statistical significance. A significant difference in favour of OM-8980 was observed in the intake of non-steroidal anti-inflammatory drugs and oral corticosteroids. Clinical tolerance was on the whole good (10 cases with side effects out of 49 in the OM-8980 group and 7 out of 46 in the placebo group, ns), with the majority of the side effects concerning the gastrointestinal system. The global assessment of the therapeutic efficacy both by the physician and the patient showed a highly significant superiority of OM-8980 over the placebo (P=0.001).Other participating rheumatologists: Belgium: M. De Moor, Kortrijk; F. Ginsberg, Brussels; D. Itzkowitch, Brussels; A. Mindlin, Brussels; R. Ooghe, Kortrijk; S. Schreiber, La Louvière; P. Vroninks, Hasselt. Luxembourg: P. Hemmer, Luxembourg; C. Kemmer, Esch-sur-Alzette     

Treatment of DMARDs-resistant rheumatoid arthritis with minocycline: a local experience among the Chinese

We report a local experience with minocycline (100 mg b.i.d.) in treating Chinese patients with rheumatoid arthritis (RA) who were resistant to the conventional disease-modifying antirheumatic drug (DMARD) treatment. In contrast to a preliminary observation in seven patients with rheumatoid arthritis, minocycline was effective and safe in treating our patients when added to the previous, relatively ineffective DMARD regimen. The antirheumatic effect of minocycline was impressive early in the first month. Drug compliance was fair; all patients continued to receive the study drugs, with no obvious adverse drug reactions. The reason why minocycline showed dramatic effects in reducing disease activity remains to be determined; however, minocycline-associated immune modulation, as indicated in this study, may be one of the important mechanisms in its antiarthritic effects. Received: 9 October 1997 / Accepted: 14 January 1998     

Actualización del uso de los glucocorticoides en la artritis reumatoide

Corticosteroids are a mainstay in the therapy of rheumatoid arthritis (RA). In recent years, a number of high-quality controlled clinical trials have shown their effect as a disease-modifying anti-rheumatic drug (DMARD) and a favourable safety profile in recent-onset RA. Despite this, they are more frequently used as bridge therapy while other DMARDs initiate their action than as true disease-modifying agents. Low-dose corticosteroid use during the first two years of disease slows radiologic damage and reduces the need of biologic therapy aimed at reaching a state of clinical remission in recent-onset RA. Thus, their systematic use in this clinical scenario should be considered.     

Long-term use of mizoribine in rheumatoid arthritis patients on hemodialysis

Small doses of mizoribine (MZR) were administered to five rheumatoid arthritis (RA) patients on hemodialysis (HD). A maintenance dose of 25 mg or less was administered either once per day or once following HD. The Lansbury activity index improved in all patients. The blood concentrations of MZR before and after HD were 0.33–1.79 μg/ml and 0–0.93 μg/ml, respectively. Hence, the rate of elimination by HD ranged from 50.3% to 83.4%. As far as side effects were concerned, alopecia was seen in two patients, and one patient developed shingles. However, the severity of these symptoms was mild and, after discontinuing or reducing the dose of MZR for a certain period of time, we were able to continue its administration. These findings suggest that the long-term administration of MZR is a useful treatment for RA patients on HD. Received: July 12, 2000 / Accepted: December 7, 2000     

A survey of United States rheumatologists concerning effectiveness of disease-modifying antirheumatic drugs and prednisone in the treatment of rheumatoid arthritis

Objective . To collect the ratings of American rheumatologists regarding relative short-term and long-term effectiveness of disease-modifying anti-rheumatic drug (DMARD) therapy in the treatment of rheumatoid arthritis and to compare these data with results of a meta-analysis of randomized, controlled clinical trials (RCTs) of these drugs. Methods . A survey was mailed to 3,200 United States rheumatologists who were members of the American College of Rheumatology during the summer of 1996. The survey was completed by 645 rheumatologists. Results . Methotrexate (MTX) was rated as substantially more effective than any other DMARD after both 1 year and 4 years of therapy. At 1 year, more than 90% of rheumatologists rated MTX as “good or excellent,” compared with 35% giving a similar rating to intramuscular (IM) gold, the second-ranked DMARD. At 4 years, MTX was rated as “good or excellent” by 65%, compared with 53% for combinations, 30% for prednisone, and 11% for hydroxychloroquine, the second-ranked single DMARD. These ratings reflect results of long-term observational studies, but differ considerably from a meta-analysis of results of short-term RCTs, in which the efficacy of MTX, sulfasalazine, penicillamine, and IM gold were indistinguishable. Conclusion . The ratings of US rheumatologists regarding effectiveness of DMARD therapies are in agreement with observational data, but differ substantially from results of RCTs. These findings suggest that observational studies may yield useful and important information about treatment results, which are complementary to, but not available from, the RCT model. Regulatory agencies should consider long-term observational studies as a part of the evaluation of drugs.     

Predictive factors related to shoulder joint destruction in rheumatoid arthritis patients treated with biologics: A prospective study

Objective: The aim of this study was to assess the risk factors for shoulder joint destruction in rheumatoid arthritis (RA) patients treated with biologics.

Methods: Thirty shoulders of 29 patients with RA were assessed using 18F-fluorodeoxyglucose positron emission tomography (PET) and magnetic resonance imaging (MRI) before starting biologics and 6 months later. The mean age (range) was 54 (18–72) years, and the mean disease duration was 7 (0.8–30) years. The radiographic findings were assessed at baseline and 3 years later. The inflammation markers and RA disease activity were also assessed. These parameters were compared between the progression of joint destruction group and the no progression group.

Results: The SUVmax on PET, the rate of synovitis, and the rate of rotator cuff tear on MRI before biologic treatment were significantly higher in the progression of joint destruction group. SUVmax and synovitis on MRI after 6 months were also significantly higher in the progression of joint destruction group. On logistic regression analysis, the SUV at baseline of the shoulder joint was the main risk factor for joint destruction.

Conclusion: The detection of synovitis by imaging was more important than disease activity and inflammation markers for assessing the progression of shoulder joint destruction.     

Non traditional risk factors of carotid atherosclerosis in rheumatoid arthritis

Introduction

Cardiovascular events are markedly increased in rheumatoid arthritis, and they remain poorly understood.

Aim of work

To investigate inflammatory markers, markers of endothelial dysfunction, antioxidant vitamins and rheumatoid arthritis-related factors as non traditional risk factors for occurrence of carotid atherosclerosis in rheumatoid arthritis patients.

Patients and methods

Thirty RA patients were included in this study. All of them were females and their ages ranged from 23 to 62 years with a mean of 43.95 ± 7.2 years. All of them were subjected to full history taking, thorough clinical examination, laboratory investigations, disease activity assessment, bone erosion assessment by Modified Larsen score and functional assessment by health assessment questionnaire (HAQ) score. Carotid Duplex was done to measure the intima-media thickness (IMT) and carotid plaques. The patients who proved to have carotid atherosclerosis by ultrasound were subjected to ultrasound examination of brachial artery flow mediated dilatation (FMD) to confirm presence of endothelial dysfunction in those patients.

Results

Ten out of 30 RA patients (33.3%) had carotid atherosclerosis in whom there was impaired FMD denoting endothelial dysfunction. Among those patients, the risk factors that associated with occurrence of carotid atherosclerosis included higher levels of inflammatory markers (CRP, ESR and IL-6) and VCAM-1 (a marker of endothelial dysfunction), lower levels of antioxidant vitamins A and E, and RA-related factors as longer duration of disease, increased RF titer, increased HAQ-score, bone erosion, duration of prednisone use and prednisone cumulative dose.

Conclusion

The prevalence of carotid atherosclerosis in rheumatoid arthritis patients was 33.3%. Among those patients, a statistically significant association was found between occurrence of carotid atherosclerosis and inflammatory markers, endothelial dysfunction, antioxidant vitamins and rheumatoid arthritis related factors.     

Effects of surgical intervention on disease activity of rheumatoid arthritis: Cases of surgery for rheumatoid arthritis of the lower limbs treated with biologics

Abstract

Objectives. In order to verify combination therapy with drugs and surgery for rheumatoid arthritis (RA), we evaluated changes in clinical outcome affected by surgical intervention in the patient treated with biologics and investigated the effects of surgery on disease activity.

Methods. Fifty-five lower limb joint surgeries were performed in 48 patients under biological therapy. DAS28-ESR, modified Health Assessment Questionnaire (mHAQ) score, PtGA and serum CRP were examined just before surgery, at 6 months and at 12 months after surgery. A kind of suitable medication and its dose were investigated.

Results. Preoperative DAS28-ESR significantly decreased from 3.71 ± 1.19 (mean ± SD) to 3.37 ± 1.22 at 6 months and to 3.24 ± 1.05 at 12 months postoperatively. mHAQ score did not change, but, PtGA and serum CRP improved. In 43 (78.2%) patients in whom no change or decrease in medication during the follow-up period, excluding the effect of drugs, DAS28-ESR also decreased significantly from 3.53 ± 1.17 to 3.16 ± 1.16 at 6 months, and to 3.16 ± 0.98 at 12 months.

Conclusions. Lower limb surgery performed under biological therapy enhances the effects of not only improving joint function but also of ameliorating systemic disease activity.     

Perioperative complications in elective surgery in patients with rheumatoid arthritis treated with biologics

Abstract

We retrospectively investigated the influence of biological agents on delayed wound healing and the occurrence of postoperative surgical site infection (SSI) in patients after surgery for rheumatoid arthritis. The patients were divided into two groups—those with and without treatment with biological agents (276 and 278 joints, respectively)—and adverse events (delay in wound healing and SSI) were investigated. Wound healing was delayed in 11.4% of total knee arthroplasty (TKA) operations, 16.7% of total ankle arthroplasty operations, and 9.7% of foot surgeries in the treatment group, and in 5.5% of TKA operations, 12.5% of total elbow arthroplasty operations, and 5.7% of foot surgeries in the non-treatment group. The difference in the incidence of delayed wound healing between the two groups was not statistically significant. In the treatment group, postoperative superficial and deep infection developed in one and two joints, respectively. In the non-treatment group, superficial infection developed in one joint. There was no statistically significant difference between the two groups. These findings suggest that the use of biological agents may not affect the incidence of postoperative adverse events related to wound healing and SSI.     

Efficacy and safety of sirukumab in Japanese patients with moderate to severe rheumatoid arthritis inadequately controlled by disease modifying anti-rheumatic drugs: Subgroup analysis of a phase 3 study

Abstract

Objective: To evaluate the efficacy and safety of sirukumab in Japanese patients with active rheumatoid arthritis (RA) uncontrolled by disease-modifying antirheumatic drugs.

Methods: This subgroup analysis based on a double-blind, placebo-controlled, 52-week phase 3 study (SIRROUND-D) assessed American College of Rheumatology (ACR) 20 response at week 16 and van der Heijde-modified Sharp score (vdH-S) at week 52 (coprimary endpoints).

Results: A total of 168 (Japanese)/1670 patients received sirukumab 50?mg/4 weeks (q4w, n?=?58), 100?mg/every 2 weeks (q2w, n?=?54), or placebo (n?=?56) subcutaneously. Significantly more patients achieved ACR20 response at week 16 with sirukumab (50?mg q4w: 69.0%; 100mg q2w: 66.7%) vs. placebo (21.4%; p?<?.001). Median change from baseline in total vdH-S score at week 52 was significantly lower with sirukumab (50?mg q4w: 0.3, p?=?.024; 100?mg q2w: 0.0, p?=?.002) vs. placebo (1.3). Sirukumab consistently showed greater improvements in secondary endpoints at weeks 24 and 52. Nasopharyngitis, elevated liver enzymes, injection site erythema and upper respiratory tract infections were the common treatment-emergent adverse events (TEAEs). Incidences of TEAEs and serious AEs were consistent between sirukumab groups through week 52.

Conclusion: Sirukumab showed clinically meaningful improvements consistent with significant improvements in the global study. No new safety signals were observed.     

Long-term safety study of iguratimod in patients with rheumatoid arthritis

We conducted a 52-week clinical study of iguratimod in 394 Japanese patients with rheumatoid arthritis to evaluate the long-term safety of the drug. Iguratimod was administered orally at a daily dose of 25 mg for the first 4 weeks and 50 mg for the subsequent 48 weeks. Some of the patients continued the treatment for 100 weeks for their benefit. The cumulative incidence of adverse events for 100 weeks was 97.6%. The cumulative incidence of adverse reactions was 65.3%; unfavorable symptoms and signs (excluding abnormal laboratory data changes) accounted for 33.2% of the reactions, and abnormal laboratory data changes accounted for 50.4%. The continued treatment rate was 66.8% at week 28 and 53.6% at week 52. For reference, the American College of Rheumatology (ACR) 20 response rate was calculated for the patients who had assessable disease activity, who did not violate the study protocol, and who continued the study treatment at weeks 28 and 52. The rate was 46.9% at week 28 and 41.0% at week 52. To use iguratimod safely for a long time, patients should be observed closely for adverse reactions such as increased hepatic enzymes.     

Update on the epidemiology,risk factors,and disease outcomes of rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease characterized by joint inflammation, which affects approximately 1% of the population. The benefit of early recognition and treatment has led to an increased interest in the early phases of disease. With the aim of classifying patients earlier in their disease course, new RA classification criteria have been developed. Much attention has been devoted to the identification in the prearthritis phase of arthralgia. The discovery of new risk factors and autoantibodies has led to new theories about the putative mechanisms involved in disease development. Finally, the outcome measures have also evolved, with more emphasis on sustained drug-free remission and patient-reported outcomes.This article reviews the new developments in RA research and discusses the latest insights into epidemiology, risk factors, predisease states, and outcomes.     

Long-term safety study of iguratimod in patients with rheumatoid arthritis

Abstract

We conducted a 52-week clinical study of iguratimod in 394 Japanese patients with rheumatoid arthritis to evaluate the long-term safety of the drug. Iguratimod was administered orally at a daily dose of 25?mg for the first 4 weeks and 50?mg for the subsequent 48 weeks. Some of the patients continued the treatment for 100 weeks for their benefit. The cumulative incidence of adverse events for 100 weeks was 97.6%. The cumulative incidence of adverse reactions was 65.3%; unfavorable symptoms and signs (excluding abnormal laboratory data changes) accounted for 33.2% of the reactions, and abnormal laboratory data changes accounted for 50.4%. The continued treatment rate was 66.8% at week 28 and 53.6% at week 52. For reference, the American College of Rheumatology (ACR) 20 response rate was calculated for the patients who had assessable disease activity, who did not violate the study protocol, and who continued the study treatment at weeks 28 and 52. The rate was 46.9% at week 28 and 41.0% at week 52. To use iguratimod safely for a long time, patients should be observed closely for adverse reactions such as increased hepatic enzymes.     

Minimal disease activity,remission, and the long‐term outcomes of rheumatoid arthritis

Objective

To determine the prevalence of minimal disease activity (MDA) and remission in patients with rheumatoid arthritis (RA), to assess the effect of anti–tumor necrosis factor (anti‐TNF) therapy on MDA, and to determine the extent to which MDA status improves long‐term outcomes.

Methods

Using the Patient Activity Scale (PAS) as a surrogate, we assessed the prevalence of MDA and remission in 18,062 patients with RA using the newly developed Outcome Measures in Rheumatology Clinical Trials (OMERACT) criteria for MDA.

Results

MDA was noted in 20.2% of 18,062 patients and persistent MDA, operationally defined as having MDA during ≥2 consecutive 6‐month observation periods, occurred in 13.5% of 7,433 patients followed longitudinally. Disease activity at remission levels was noted in 7%. Among patients with MDA, 82% received disease‐modifying antirheumatic drugs or biologic agents. Following anti‐TNF initiation, the cumulative probability of achieving MDA at 2 and 6 years was 4.1% and 7.6%, respectively, and persistent MDA probabilities were 2.7% and 4.5%, respectively. Regardless of RA duration, patients with MDA had substantially better outcomes, including a 10‐fold reduction in work disability and an approximately 2‐fold reduction in total joint replacement and mortality.

Conclusion

Remission remains uncommon in RA, and the prevalence of new remission in community practice is substantially lower than noted in published trials of biologic therapy. On average, persons with MDA appear to have persistently mild RA. This might be the effect of milder RA and/or more effective treatment in early RA. The PAS had satisfactory levels of agreement with the full MDA criteria and appears suitable for use in clinical and epidemiologic research.     

The comparison of effects of biologic agents on rheumatoid arthritis damage progression is biased by period of enrolment: Data from a systematic review and meta-analysis

ObjectivesTo indirectly compare the 12-month effects of available biologic agents in slowing RA radiographic progression.MethodsA systematic review of literature of randomised, double-blind, controlled trials (RCTs) evaluating RA radiographic progression as end point was conducted using a PubMed searching of MEDLINE from January 1995 to May 2012. For each trial, the mean change from baseline of the standardised annual radiographic progression score (weighted for estimated annual progression rate) was estimated, and the effect size was calculated as the difference between biologic and non-biologic-treated groups. In order to optimise data homogeneity and improve RCTs comparison, a mixed-effect model was applied including previous responsiveness to methotrexate (MTX-experienced or MTX-naïve populations) and period of study enrolment as moderators.ResultsThe PubMed search resulted in 183 references, and 14 were eligible for the meta-analysis. The analysis of study distribution in forest plots showed a high correlation between the study period of enrolment and the impact of biological therapy in both MTX-naïve and MTX-experienced subgroups. In particular, effect size was the highest for older trials and progressively decreased in the most recent ones, suggesting a highest propensity to radiographic progression in populations enroled in older trials. Some statistically significant differences among RCTs were found in both subgroups but were significantly biased by the different propensity to radiographic progression due to period of enrolment.ConclusionsOur meta-analysis demonstrated that period of enrolment deeply influence study population propensity to radiographic progression in each trial. This finding does not allow the indirect comparison of various biologic agents, despite our mixed-model significantly reducing heterogeneity among RCTs.     

The comparison of effects of biologic agents on rheumatoid arthritis damage progression is biased by period of enrolment: Data from a systematic review and meta-analysis

Objectives

To indirectly compare the 12-month effects of available biologic agents in slowing RA radiographic progression.

Methods

A systematic review of literature of randomised, double-blind, controlled trials (RCTs) evaluating RA radiographic progression as end point was conducted using a PubMed searching of MEDLINE from January 1995 to May 2012. For each trial, the mean change from baseline of the standardised annual radiographic progression score (weighted for estimated annual progression rate) was estimated, and the effect size was calculated as the difference between biologic and non-biologic-treated groups. In order to optimise data homogeneity and improve RCTs comparison, a mixed-effect model was applied including previous responsiveness to methotrexate (MTX-experienced or MTX-naïve populations) and period of study enrolment as moderators.

Results

The PubMed search resulted in 183 references, and 14 were eligible for the meta-analysis. The analysis of study distribution in forest plots showed a high correlation between the study period of enrolment and the impact of biological therapy in both MTX-naïve and MTX-experienced subgroups. In particular, effect size was the highest for older trials and progressively decreased in the most recent ones, suggesting a highest propensity to radiographic progression in populations enroled in older trials. Some statistically significant differences among RCTs were found in both subgroups but were significantly biased by the different propensity to radiographic progression due to period of enrolment.

Conclusions

Our meta-analysis demonstrated that period of enrolment deeply influence study population propensity to radiographic progression in each trial. This finding does not allow the indirect comparison of various biologic agents, despite our mixed-model significantly reducing heterogeneity among RCTs.     

Disease activity and functional changes of RA patients receiving different DMARDs in clinical practice

The aim of this study was to compare the effectiveness of different disease-modifying anti-rheumatic drugs (DMARDs) in improving disease activity and functional status in patients with rheumatoid arthritis (RA). One hundred and fifty-two Thai RA patients treated with at least one DMARD were enrolled in this 1-year cohort. Demographic characteristics, baseline and end-of-study data on disease activity and Health Assessment Questionnaire (HAQ) Disability Index of the subjects were compared among different DMARD options. Predictors of HAQ score were investigated using regression analysis. The results showed that the studied patients had established RA with mild to moderate activity. More than 85% were prescribed methotrexate (MTX) as single or combined DMARDs. At 1 year, improvement in most activity measures was experienced. However, all patients had functional declines. Patients taking antimalarial agents had the maximal rate of functional deterioration. Patients taking MTX-based DMARDs had significantly lower rate of functional decline than patients taking DMARDs without MTX (p=0.018). Only patients receiving MTX-based DMARDs had clinically meaningful improvement in HAQ score. The predictors of HAQ score at 1 year included baseline HAQ score and patient global assessment at end of study. In conclusion, although DMARD treatment was shown to improve disease activity in RA patients, functional deterioration was evident in our cohort. Thus, measures of functional status are more appropriate than measures of disease activity to evaluate treatment effects of DMARDs in established RA in clinical practice. MTX-based DMARDs should be prescribed where possible in RA patients with persisting activity due to their ability to delay functional deterioration.     

Risk factors for depression in rheumatoid arthritis

Objective. To identify risk factors for the development of depression in persons with rheumatoid arthritis (RA). Methods. Subjects were divided into depressed versus nondepressed groups on the basis of the Center for Epidemiologic Studies-Depression Scale; a range of psychological, pain-related, disease-related, and demographic variables were analyzed to predict depression. Both cross-sectional and longitudinal predictive models were examined. Results. A series of analyses, including multiple logistic regression, found that the optimal predictors of depression in RA were average daily stressors, confidence in one's ability to cope, and degree of physical disability. The model was successfully cross-validated on separate data sets (i.e., same subjects at different time points). Conclusion. All of the identified risk factors for depression in RA are preventable to some extent and, therefore, should be addressed in comprehensive, rheumatology team care.