Research Update: Prognosis of Outcomes for Rheumatoid Arthritis – What are the Risk Factors?
In the past, it has only been possible to explain some of the joint damage caused by rheumatoid arthritis (RA) based on known risk factors. In order to improve treatment for RA, future approaches to treatment will increasingly need to be tailored to individual patients and individually configured.
Personalized medicine in RA treatment
The goal is to develop individual treatments tailored to the needs of the individual patient, “personalized medicine” for rheumatoid arthritis diagnosis and treament (for more on the subject of personalized medicine, refer to the background article Early Detection and Personalised Medicine – What Biomarkers Tell Us on our rheumachec homepage).
The use of individual and personalized medicine should make it possible to accurately predict whether early, undifferentiated arthritis (UA) will actually develop into rheumatoid arthritis. If RA has already manifested itself, it should be possible to make an individual estimation regarding the progression of RA in the patient based on defined and evaluated risk factors. In either case, adequate (and individual) treatment could be prescribed.
Defined and evaluated RA risk factors
This type of risk factor, about which little was previously known, has now been described by scientists in the Netherlands at the Leiden University Medical Center in their article Predicting Arthritis Outcome – What Can Be Learned from the Leiden Early Arthritis Clinic? Their results were published earlier this year in the journal Rheumatology.
In their study, the group led by Diederik P. C. de Rooy and Michael P. M. van der Linden, evaluated data from over 1,200 patients. The data were obtained from the Leiden Early Arthritis Clinic Cohortand included the individual results from 676 patients with rheumatoid arthritis (RA patients) as well as 570 patients with early, undifferentiated arthritis (UA patients).
Risk factors for joint damage with RA
The parameters used for the estimation of disease progression included fulfilment of the ACR 1987 Criteria for the Classification of Rheumatoid Arthritis, the duration of the Arthritis symptoms in the patients with undifferentiated arthritis, and the degree of joint damage detectable by radiology. Achievement of persistant DMARD-free remission in the RA patients was also considered in the prognoses made by the scientists.
The results of the study by de Rooy et al.: The Leiden scientists discovered that the markers for meeting the ACR 1987 RA classification criteria (the diagnosis of rheumatoid arthritis) and the markers for the duration of arthritis in patients with undifferentiated arthritis (the manifestation of RA) are largely similar.
(At this point I feel I had to add a remark in parantheses and should clarify the terms “RA Classification Criteria” and “RA Diagnostic Criteria”: In current practice, the “Classification of arthritis according to the ACR 1987 RA criteria” is largely equivalent to the “Diagnosis of rheumatoid arthritis” by an experienced rheumatologist, because such an experienced specialist will de facto rely on the classification criteria as his or her diagnostic criteria in daily clinical practice – an approach that is uncontroversial in this field. It is thus also to be expected that the 2010 ACR/EULAR Rheumatoid Arthritis Classification Criteria will likewise be implemented not only for the Classification of RA, but also as a diagnostic tool for the Diagnosis upon suspicion of rheumatoid arthritis. It goes without saying that the doctor performing the examination must be experienced with rheumatism, ideally an experienced rheumatologist. I also refer you to my article, New ACR/EULAR 2010 Classification Criteria for Rheumatoid Arthritis (RA) on ORGENTEC’s Autoimmunity Blog, posted 24/08/2010. The section entitled Why the differentiation between classification and diagnosis?discusses the ways in which formal and rigid criteria can hinder the highly individual diagnostic process for individual patients.)
Risk factors for severe joint damage from RA
According the study, the risk factors for the manifestation of rheumatoid arthritis and the occurrence of severe joint damage are very similar to the predictors of the persistence of RA. The risk factors for severe damage to the joints, as determined by the group led by de Rooy and van der Linden, include:
- presence of ACPA in the blood (ACPA stands for antibodies against citrullinated protein antigens) – specifically the detection of anti-MCV (anti-MCV stands for antibodies against mutated citrullinated vimentin) and anti-CCP antibodies (anti-CCP stands for antibodies against cyclic citrullinated peptides) (on this subject, please refer to Section B, Serology, in The 2010 ACR/EULAR Classification Criteria for RA in tabular form)
- the age of the patient
- the sex of the patient (male is at higher risk)
- symptoms present for a long time before the first examination
- involvement of the lower extremities
- Body Mass Index (BMI): high BMI is tied to a low rate of joint destruction, but a higher risk for progression of RA
- high titre of acute-phase proteins
- detection of IgM rheumatoid factors (RF IgM)
- presence of the Shared Epitope Allele HLA-DRB1
In any case, only a portion of the progression of joint destruction in cases of rheumatoid arthritis can be accounted for by the risk factors known to date, according to the authors of the Predicting Arthritis Outcomes article from the Leiden University Medical Center. In order to improve medical intervention for individual RA patients on a completely individual level, more risk factors must be identified, the researchers state.
Recommended Literature (accessed 06/05/2011):
- Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd, Birnbaum NS, Burmester GR, Bykerk VP, Cohen MD, Combe B, Costenbader KH, Dougados M, Emery P, Ferraccioli G, Hazes JM, Hobbs K, Huizinga TW, Kavanaugh A, Kay J, Kvien TK, Laing T, Mease P, Ménard HA, Moreland LW, Naden RL, Pincus T, Smolen JS, Stanislawska-Biernat E, Symmons D, Tak PP, Upchurch KS, Vencovsky J, Wolfe F, Hawker G. The 2010 ACR-EULAR classification criteria for rheumatoid arthritis. Arthritis Rheum 2010 Sep;69(9):1580-8 – the link will open the full text article!
- Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, Healey LA, Kaplan SR, Liang MH, Luthra HS. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arth Rheum. 1988 Mar;31(3):315-24 – the link will open to the article’s abstract!
- Egerer K, Feist E, Burmester G. The Serological Diagnosis of Rheumatoid Arthritis –Antibodies to citrullinated Antigens [Serologische Diagnostik der rheumatoiden Arthritis: Antikörper gegen citrullinierte Antigene]. Dtsch Arztebl Int 2009; 106(10):159-63. Review – doi:10.3238/arztebl.2009.0159 – link will open the full text article!
- de Rooy DP, van der Linden MP, Knevel R, Huizinga TW, van der Helm-van Mil AH. Predicting arthritis outcomes – what can be learned from the Leiden Early Arthritis Clinic? Rheumatology (Oxford). 2011 Jan;50(1):93-100. – link will open to the abstract of this article!
Author of this article: Tobias Stolzenberg