In recent years, tremendous strides in understanding how RA develops has led to the development of targeted therapies.

The aggressive use of disease-modifying anti-rheumatic drugs (DMARDS) such as methotrexate, in combination with biologic therapies has resulted in sustained effectiveness, improved tolerability, and better response levels. The result has been a significant reduction in joint damage and work-related disability.

Remission is now the norm rather than the exception in patients who are seen early. The concept of a narrow window of opportunity- usually the first 3 to 6 months of disease- where aggressive therapy can prevent deformity and disability has also been recognized as a major reason for the improved prognosis.

Despite these advances, several problems still remain. A large number of patients stop treatment for a variety of reasons including lack of response and side effects. It is unclear whether the new drugs being used can actually help joint damage to heal. Long-term side effects also remain a concern.

So how do rheumatologists make the decision to change therapy?

The first question that needs to be resolved is “what is an inadequate response?” The definition is not an easy one.

There are actually three answers. The first is what is called primary failure where the drug doesn’t lead to any kind of improvement right from the outset. Secondary failure occurs when the drug works initially but then over time, the beneficial effects fade. Finally there are side effects and other toxicity issues to consider.

Another very important factor is the patient’s own feelings as to how they are doing. What are considered are both pain relief as well as ability to function with activities of daily living.

Added to this mix is the result of different imaging modalities such as magnetic resonance imaging, ultrasound, and plain x-ray. Of these three, plain x-ray is the least sensitive and least useful method.

Laboratory parameters that measure systemic inflammation such as the erythrocyte sedimentation rate (ESR) and C-reactive protein are also used in decision-making.

Some rheumatologists advocate the use of measuring devices of disease activity. They have the following names: Disease Activity Score (DAS), Disease Activity Index (DAI), and Global Arthritis Score(GAS). These measuring devices all involve analyzing different disease parameters, scoring them, then coming up with a number. The higher the number or score, the worse the patient is doing. These different scoring methodologies have a few things in common. They usually incorporate some count of swollen and tender joints. They also usually require adding in one of the laboratory measures of inflammation. Some also add in the results of a patient’s Health Assessment Questionnaire. This latter item tallies the patient’s ability to perform routine daily activities. Finally some methods also incorporate a patient self-assessment.

There is no consensus as far as which tool is the best to use. There is growing interest though in using the tools more often than they are being used now. Stay tuned.

Upper airway symptoms are often caused by Sjogren’s disease, an autoimmune condition that often accompanies RA. In Sjogren’s disease, the glands that make secretions such as tears, saliva, and mucus are gradually destroyed. Since mucus is necessary for the neutralization and mobilization of bacteria, people with Sjogren’s disease often develop recurrent respiratory infections.

The lungs themselves can be involved. People with RA can develop multiple problems including fibrosis (scarring of lung tissue), pleural effusion (water on the lung), pulmonary nodules (spots on the lung), and pneumonitis (inflammation of lung tissue.)

Finally, drugs used to treat rheumatoid arthritis such as methotrexate, gold, and newer biologic therapies can also adversely affect the lungs.

Also, acute lower respiratory tract infections are common in patients with rheumatoid arthritis, according to results of a study published in the September issue of the Journal of Rheumatology. Respiratory infections in this population carry a high mortality (risk of death).

”Rheumatoid arthritis…shortens life expectancy compared to a control population, and excess deaths are largely caused by accelerated vascular events and an increased propensity to infection, much of which is of respiratory origin,” researchers from Queen Elizabeth Hospital, Gateshead, UK, write.

The researchers examined whether the development of lower respiratory tract infection in patients with rheumatoid arthritis (RA) is the result of their use of the drugs used to treat the RA or the inflammatory arthritis itself.

In a population of 1,522 RA patients seen over a 12-month period, 36 patients were admitted for 43 acute respiratory episodes. A detailed drug history and data on clinical outcome were collected for each case. The team collected and analyzed past medical history and admission data to evaluate the influence of oral steroids and disease modifying anti-rheumatic drugs (DMARDS) on outcome.

The overall annual incidence of lower respiratory tract infection in RA patients was 2.3%. Eight patients died from this problem, (mortality rate of 22.2%). Risk factors that predicted lower respiratory tract infection in this population included older age and male gender. An association was observed between oral steroid therapy and not taking DMARDs and an increased risk of hospital admission with lower respiratory tract infection. The authors report that there was a trend toward increased mortality in men and in those with duration of disease.

The researchers note that they have changed their clinical practice as a result of these findings. “In addition to initiating DMARDs early in all patients with RA, we actively recommend annual vaccination against influenza and pneumonia vaccination every 5 years in all patients, independent of their treatment,” the authors write.

”Older patients with long disease duration are now actively encouraged to start DMARD therapy rather than oral steroids, although drug selection may be be altered by the presence of coexistent cardiac or pulmonary disease.”
(J Rheumatol 2007;34:1832-1836).

Authors’s note: This study underscores the severity of rheumatoid arthritis on the general health and mortality risk for patients with the disease. It is not a benign disease. It is not “just arthritis.” As more data regarding the impact of RA on life expectancy is produced, it has become quite clear that RA must be diagnosed and treated aggressively.