Outlook Brighter For People With RA
Dutch study finds patients fare better now than 20 years ago.
People with rheumatoid arthritis (RA) are likely to have a much better quality of life today than they did two decades ago, according to researchers in the Netherlands, who followed more than 1,100 patients diagnosed with RA between 1990 and 2011. They attribute the gains to earlier diagnosis, more aggressive medications and a greater emphasis on overall well-being. Their findings were published recently in Arthritis Care & Research.
Lead author Cecile Overman, a doctoral candidate at Utrecht University in the Netherlands, says she and her colleagues wanted to determine if improved treatments over the last 20 years led to better physical and psychological health for RA patients.
In RA, the body's immune system mistakenly attacks the lining of the joints, leading to body-wide inflammation that damages not only the cartilage and bones, but also organs such as the heart and lungs as well. RA is also associated with depression and anxiety, which for some can be as limiting as physical disability. No cure for RA exists, but certain medications can improve symptoms and slow disease progress.
In the current study, researchers followed several groups of mostly female patients, aged 17 to 86, who were diagnosed with RA at different times over a 20-year period. All were assessed at diagnosis and after approximately four years of treatment (follow-up).
Disease activity was measured by the DAS28, a score that takes into account blood markers of inflammation and the number of painful and swollen joints present in each patient (the lower score, the better a patient is doing). Depression, anxiety and physical functioning were measured using validated patient questionnaires.
Results showed that both mood and physical ability improved both after treatment and as the study progressed over time. For example, about 43 percent of people newly diagnosed with RA in 1990 reported feeling depressed, whereas 32 percent of those diagnosed in 2004 to 2008 did. At follow-up, the numbers were 25 and 14 percent, respectively. Physical disability was cut in half during the 20-year span.
DAS28 scores decreased over the course of the study, too. Overman says that although the research does not prove cause-and effect, results suggest that the downward trend in physical disability, anxiety and depressed mood results from reduced disease activity. And that, in turn, is probably due to better treatments.
"In our study, as insights evolved, treatment strategies changed across the decades, with pharmacological treatment becoming more intense,” she says. “For example, to keep inflammation and disease progression to a minimum, patients start with stronger medications as soon as possible, are monitored more frequently, and medications are combined for optimal efficacy. Furthermore, when new anti-inflammatory drugs such as biologics became available, their use increased."
Researchers didn't examine the effect of any particular drug, but Overman says tumor necrosis factor (TNF) inhibitors such as etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira), were commonly prescribed in the later years of the study.
She stresses, however, that nondrug treatments, such as exercise, physician encouragement and, for some patients, mental health therapies (although not included in the study) are also important aspects of treatment.
"Nowadays, the future of a newly diagnosed patient with RA looks brighter due to improved treatment possibilities, both pharmacological and non-pharmacological. Patients today are encouraged to keep physically active and the possibilities of a valued life despite RA are stressed," she points out.
Overman adds that although many studies have noted improved physical functioning among RA patients, few have focused on emotional well-being.
"Compared to the general population, patients with [RA] are more prone to experience psychological distress, such as depression and anxiety,” she explains. “Just focusing on the physical component to assess how patients are doing would be selling them short. Over the years, awareness of the importance of overall patient well-being and functioning has increased among health professionals, and the focus has widened from just trying to cure the disease to trying to find out how to improve the quality of people's lives."
She adds, "Psychological well-being is a complex concept which doesn't only depend on variables related to the disease, but also on many other variables, such as genetics and lifestyle possibilities and choices."
Overman also notes that although the study was conducted in the Netherlands, the findings likely apply to patients in the United States and other affluent countries if clinicians there follow new, evidence-based guidelines and "all patients have access to the same quality of care."
Janice McInnes, a physical therapist and clinical supervisor of rehabilitation services at Brigham and Women's Hospital in Boston, says the "positive experience of both providers and patients" at her institution confirm the Dutch findings.
"Patients who have been diagnosed with a rheumatologic condition can lead active lives and engage in a wide variety of physical activities when their condition is well-controlled," she says. “As a physical therapist who treats patients with rheumatologic conditions, it is more routine now to see a patient with RA who needs muscle strength and conditioning. In the past, more therapy time was needed to restore basic range of motion and function. Now, physical therapy is just helping them get back in the game."
Overman concurs, adding, "Patients with rheumatoid arthritis have a better opportunity of living a valued life than patients diagnosed with this disease two decades ago, and I would like to relay this hopeful message."