What Factors Determine Poor Prognosis With Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronic, inflammatory autoimmune disorder. In RA, the immune dysfunction leads to painful, progressive crippling arthritis. RA is a systemic disorder and can affect internal organs including the eyes, lungs, heart, muscles, skin, and blood vessels.
If undiagnosed or not treated aggressively it can lead to a substantial loss of mobility due to pain and joint destruction. Roughly, 60% of RA patients are unable to work 10 years after the onset of their disease.
So what factors determine a poor outcome?
Certainly, late diagnosis is a chief reason. There is a narrow window of opportunity during the first 3 to 6 months of disease, in which aggressive treatment can slow down and even stop disease progression. However, if a patient is not treated within that period of time, the likelihood is quite high that they will have already experienced some degree of joint damage and deformity.
When a patient is first seen, there are other factors that point towards a less favourable prognosis.
First, patients who satisfy the American College of Rheumatology criteria for rheumatoid arthritis (RA) have a worse prognosis than those who do not. These criteria have been formulated and validated and are known by rheumatologists who see patients with RA. They include:
* Morning stiffness lasting longer than 1 hour
* Arthritis involving more than 3 joints
* Arthritis affecting the hands
* Symmetric arthritis
* Rheumatoid nodules
* Rheumatoid factor
* X-ray changes
The next criterion is the presence of swollen and tender joints. Obviously, the more joints that are inflamed the worse the situation. Generally if a patient has more than eight tender and eight swollen joints at presentation, their prognosis is worse.
Clinical findings pointing towards the presence of internal organ involvement early suggest a poor prognosis. For instance, a patient presenting with eye or lung disease due to their RA early on have a poor outlook
The presence of vasculitis, inflammation of blood vessels, is also a good indicator of a poor outcome. Patients who have rheumatoid nodules also have aggressive disease, as a rule.
Patients are sometimes asked to fill out a Health Assessment Questionnaire (HAQ). This is a standardized form that asks a patient about their ability to function with activities of daily living. The worse the score, the worse the prognosis.
Laboratory test results also can point towards whether a patient has a poor prognosis.
Patients who have very high levels of erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) have a poor prognosis. ESR and CRP are tests used to measure the amount of inflammation a patient has.
High levels of rheumatoid factor, an antibody that is found in 80 percent of patients with RA points towards worse disease.
Another type of antibody, anti-cyclic citrullinated peptide (anti-CCP) antibodies, are present in around 55% of patients with early RA and have been found to predict the development and progression of erosions within the first 2 years of disease (Forslind K, et al. Ann Rheum Dis. 2004;63:1090-1095).
Erosions are areas of cartilage and bone destruction seen on x-ray.
A recent study showed that some patients who are negative for RF but who have elevated levels of anti-CCP also are at risk for developing erosions (Bukhari M, et al. Arthritis Rheum 2007; 56: 2929-2935).
One note: if erosions are seen on x-ray, the cat is out of the bag. Earlier detection of inflammation and erosion can be seen using magnetic resonance imaging (MRI) and ultrasound. These should be used in the assessment of patients rather than x-ray.
So why the fixation on prognosis? It is now known that patients with poor prognosis related to RA have a significantly shortened lifespan. The shortened life span is related to an increased risk of lymphoma, increased risk of cardiovascular events such as heart attack and stroke, as well as to the progressive disability leading to inability to perform activities of daily living.
So what can you do as a patient?
Make sure that if you have RA or suspect you have RA, see a rheumatologist as soon as possible… and make sure that rheumatologist is aggressive in making treatment decisions. Aggressive management is the key to altering the outcome of disease from a poor prognosis to a good prognosis.
About the author:
Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info: Arthritis Treatment
