Rheumatoid Arthritis - Clinical - Comorbidity
- FRI0075: Body Composition and it's Impact in RA Patients
- OP0133: Brain Natriuretic Peptide: Biomarker for Subclinical Ventricular Dysfunction?
- OP0136: Associaion of Anti-CCP and Extra-Articular Manifestions in RA
- OP0134: Sexual Problems in RA
- OP0137: Has CV Morbidity and Mortality Improved in Recent Years?
FRI0075 Obesity is an Independent Contributor to Functional Capacity and Inflammation in Rheumatoid Arthritis and Psoriatic Arthritis
JM Kremer and G Reed.
Body composition is altered in rheumatoid arthritis (RA) and possibly psoriatic arthritis (PsA) and may play important differential effects on disease outcomes. Here, Kremer et at describe body composition characteristics of a large multicenter cohort of North American RA and PsA patients and examine the associations of body mass index (BMI) on disease activity and disability.
Methods: Subjects enrolled in CORRONA, a large prospective multicenter database of North American RA and PsA patients cared for in community practice, have periodic collection of demographic and disease specific data. The proportion of subjects meeting WHO criteria for underweight (BMI < 18.5), normal weight (BMI 18.5 - < 25), overweight (BMI 25 - < 30), and obese (BMI > 30) were calculated for RA and PsA subjects. The effects of BMI category on disease activity and functional capacity were calculated, with adjustment for pertinent confounders.
Results: 11,323 RA and PsA patients were included. Of these, 110 (1%) were classified as underweight, 2285 (20.2%) were normal weight, 3102 (27.4%) were overweight, and 3566 (31.5%) were obese. Compared to the normal weight group, overweight and obesity were associated with significantly higher MHAQ, DAS28, Patient Global Assessment of Disease, CRP, and ESR.
| Difference in Overweight vs. Normal weight | p | Difference in Obese vs. Normal weight | p | |
| MHAQ | 0.12 | 0.12 | 0.12 | <0.001 |
| DAS28 | 0.13 | 0.037 | 0.35 | <0.001 |
| Patient Global Assessment | 1.4 | 0.04 | 5.7 | <0.001 |
| CRP (log transformed) | 0.14 | 0.04 | 0.39 | <0.001 |
| ESR (log transformed) | 0.10 | 0.016 | 0.24 | <0.001 |
Conclusions: Increasing BMI is associated higher disease activity, functional disability, and systemic inflammation in RA and PsA subjects.
Editorial Comment: These findings are in stark contrast to those presented in OP0116, in which increasing BMI was associated with less radiographic progression over time. The basis for these differences is not immediately clear. However, it could indicate that with increasing BMI, standard ways of estimating RA disease activity and severity (e.g. DAS, ESR, CRP, and HAQ) may not accurately represent damage and destruction occurring at the level of the joint. Further work is needed to establish whether obesity-adjusted outcome measures are required to accurately evaluate disease in these patients.
OP0133 Brain Natriuretic Peptide in the Diagnosis of Asymptomatic Ventricular Dysfunction in Rheumatoid Arthritis Patients
S. Abou-Raya, A. Abou-Raya, M. Helmi.
An increased risk of cardiovascular disease (CV) is found in patients with rheumatoid arthritis (RA). In this study, Abou-Raya et al investigate the use of brain natriuretic peptide (BNP) as a potential biomarker for subclinical ventricular dysfunction in RA patients. BNP is a cardiac neurohormone secreted from the ventricle in response to ventricular wall stress and volume overload.
Methods: Recruited RA subjects fulfilled ACR criteria (n=50), were nonsmoking, and free of diabetes. All were in sinus rhythm with no cardiac signs or symptoms. Healthy controls (n=15) were matched for age, sex, body mass index, heart rate, arterial blood pressure. Both groups underwent 12-lead ECG and 2 dimensional, M-mode and pulse-wave Doppler echocardiography. BNP levels were sampled at rest and at the same time of day for both groups, to account for diurnal variance.
Results: Both systolic and diastolic function were impaired in RA patients compared to controls. Diastolic dysfunction was present in 36% of the RA group compared to 12% in the control group (p<0.001). Peak E (early diastolic wave) velocity, E velocity /A (late diastolic wave) velocity ratio and isovolumetric relaxation time (IRT) in RA patients were significantly different from those of the controls. In addition, LV end systolic diameter (LVESD) and volume (LVESV) were increased and ejection fraction (EF) was decreased in RA patients compared to controls. RA patients also had higher BNP levels than controls (p<0.005) with higher levels noted in RA patients with diastolic dysfunction compared to RA patients without. BNP levels were found to correlate with LVESV, LVEDV, LVEF and hsCRP(r = 0.833, p< 0.001; r = 0.758, p< 0.005; r = -0.608, p<0.001; r = 0.663, p< 0.001) respectively.
Conclusion: LV impairment is present in a significant proportion of asymptomatic RA patients. Plasma BNP level may serve as a screening tool for the early detection of ventricular dysfunction in these patients.
Editorial Comment: BNP is a marker of subclinical and clinical LV dysfunction in the general population. This study corroborates the usefulness of this hormone as a biomarker for LV dysfunction in RA patients. Despite the small number of patients and controls studied, measures of diastolic dysfunction were reported to be more frequent in RA patients compared to controls. A weakness of the study, however, is the failure to adjust for age and gender. Diastolic dysfunction is known to be considerably more common in older women than in other demographically defined groups.
OP0136 Anti-Cyclic Citrullinated Peptide (CCP) Antibodies in patients with Long-Standing Rheumatoid Arthritis (RA) and Its Relationship with Extra-Articular Manifestations
Korkmax, Us, Kasifoglu, Akgun
Extraarticular manifestations (EAM) are not uncommon in patients with RA. Since anti-CCP antibodies have been shown to correlate with disease activity, this study investigates whether there is an association between EAM and anti-CCP antibodies.
Methods: Both patients with longstanding RA (LsRA, >3 years, n=115) and early RA (ERA, < 3 years, n=39), as well as healthy controls (n=64), were evaluated. The following was measured; DAS28, anti-CCP, RF, ESR, and CRP as well as hand, chest, and feet x-rays. EAM evaluated included lung, subcutaneous nodules, ocular problems, Feltys syndrome, and amyloidosis.
Results: 45 (39%) in the LsRA group and 6 (15%) in the ERA group had EAMs. No significant differences were found between the LsRA and ERA patients in terms of EAMs. The number of anti-CCP positive patients in the LsRA and ERA groups were 86 (75%) and 25 (64%), respectively. No positive correlations were found between anti-CCP positivity and EAM, either individually or cumulatively.
Editorial Comment: Anti-CCP antibodies are a good marker for the diagnosis of RA, and for disease severity. However, they do not correlate well with disease activity. The current study examines the relationship of anti-CCP with extraarticular disease and does not find a significant association. This is somewhat surprising as patients with extraarticular manifestations tend to have more severe disease in general and, therefore by association, might be expected to exhibit a higher prevalence of anti-CCP positivity. The number of patients with EA manifestations was relatively low, however, and the study may have been underpowered to detect an association. RA clinical and comorbility.
OP0134 Sexual problems in Rheumatoid Arthritis (RA): Associations to Demographic and Disease Related Variables
Helland, Dagfinrud, Uhlig, and Kvien
Engaging in sexual activity may be problematic for patients with chronic disease, particularly painful conditions like rheumatoid arthritis (RA). The aim of this study was to investigate the prevalence of, and variables associated with, self-reported problems with sexual activity.
Methods: 830 patients from the Oslo RA register responded in 2004 to a postal question, including a question concerning sexual activity. The question asked about their perception of the influence of their health status on their sexual activity. Five levels of response were assessed: no impact; slight impact; considerable impact; almost impossible; and impossible. Disease activity variables including pain VAS, fatigue VAS, AIMS2, and HAQ were also assessed.
Results: The mean age of respondents was 58.5 (20 91), 74% were female, 68% were married, mean disease duration of 13.4 years and the mean HAQ was .98. Responses were as follows dichotomized as noted for further analysis.
| No or Slight Impact | No impact | 31% |
| Slight impact | 38% | |
| Large Impact | Considerable impact | 21% |
| Almost Impossible | 3% | |
| Impossible | 7% |
The large impact group had worse health status indicated by disease activity measures compared to the little/no impact group (p<0.001). Men were more likely than women to report health status as having a large impact on sexual activity, (27.8% vs. 40%, p=0.001). In multiple logistic regression analyses, the best model for perceived impact on sexual activity included: increasing age per year (OR 1.05, CI: 1.03,1.06), male gender (OR 3.34, CI: 2.15,5.19), fatigue pr mm increase (OR 1.01, CI: 1.01,1.02), affect component of AIMS2 (OR 1.34, CI 1.19,1.52) and HAQ(OR 2.92, CI: 2.05,4.17) (p < 0.001 for all variables).
Conclusion: Data from this study suggest 1/3 of patients with RA feel their health status impacts their sexual activity indicating the need to address this issue with patients.
Editorial Comment: This is an understudied area in RA but clearly one that is highly relevant to quality of life for patients with RA. It is surprising that so few RA patients reported significant impact of their disease on sexual activity, and may reflect relatively mild disease overall (the mean HAQ score was only 1.0). Aggressively controlling disease activity with currently available therapies and using combination approaches where appropriate will hopefully enable patients to continue an active and satisfying sexual life. In exploring Quality of Life issues with our patients, we should routinely query them regarding this aspect of their daily lives.
OP0137 Cardiovascular Morbidity and Mortality Remains Increased in patients with Rheumatoid Arthritis. Studies from a Defined Catchment Area in 1995-2002 Compared to 1978-1985.
Bergstrom, Jacobsson, and Turesson
RA is associated with an increased risk of cardiovascular (CV) morbidity and mortality. It has been speculated that tighter control of RA disease activity will lead to a decrease in CV disease. In this study, Bergstrom et al evaluate whether CV morbidity and mortality have improved in recent years.
Methods: Two previously constituted patient cohorts, 1975-1985 (n=148) and 1995-2002 (n=161), comprised the study populations. Fatal and non-fatal CV events were collected from the National Hospital Discharge Register and the National Cause of Death Register in Sweden, for both cohorts, as well as for the background populations. Rates were calculated for total CV morbidity, coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Standardized morbidity ratio (SMR) adjusted for age and sex were calculated.
Results: The two cohorts had similar gender distribution, age at disease onset, and disease duration (13-14 yr). The 1995-2002 cohort received more pharmacological treatment and had lower disease activity and disability scores than the 1975-85 cohort. Both cohorts were found to have increased cardiovascular morbidity above background, SMR=158, (95% CI, 111-225) in the 1978 cohort and SMR=168 (95% CI, 118-232) in the 1995 cohort. There was a similar trend in peripheral vascular disease but not in cerebrovascular events.
While overall mortality improved in the 8-year follow-up for the 1995-2002 cohort compared to the 1975-85 cohort, there was no change in excess cardiovascular mortality, SMR=172 (95% CI, 100-276) and SMR=175 (95% CI, 100-284), respectively.
Conclusion: These data suggest that although overall mortality is reduced in patients with RA, excess cardiovascular morbidity and mortality persist despite advancements in treatment over the last decade.
Editorial Comment: This is an interesting study that adds to the limited data currently available on trends in CV associated mortality in RA. Several previously published studies suggest improvement in CV associated mortality in patients on MTX and/or TNF inhibitors. In contrast, data from the Mayo Clinics have not shown improvement, although their cohort predated modern therapeutic approaches using biologics and combination therapies. The current study takes advantage of several prospectively assembled cohorts but suffers from small sample sizes.
It is important to remember that CV associated mortality has been steadily decreasing for men over the past 30-40 yrs (at least in the U.S.), but no such decrease has occurred for women. Given that RA is yet another risk factor for accelerated CV disease, we should be paying particularly close attention to the CV health of our RA patients especially the women and intervening to reduce conventional CV risk factors and minimizing RA disease activity. Observation of larger cohorts with well controlled disease over the next decade will hopefully show some improvement in the excess CV morbidity and mortality in our RA (and SLE) patients, as long as the benefits of tighter control are not offset by rising trends in obesity and sedentary behavior.