Rheumatoid Arthritis

A disproportionate number of U.S. adults with arthritis are obese, and the prevalence has been growing over the years, according to a report from the Centers for Disease Control and Prevention.

Obesity and arthritis have a complex relationship, the authors note. “Obesity is an independent risk factor for severe pain, reduced physical function, and disability among adults with arthritis, which might be related to both the increased mechanical stress caused by extra weight on the joints as well as inflammatory effects of elevated cytokines and adipokines that affect cartilage degradation,” according to the report.

On average, the obesity prevalence was 54% higher in adults with arthritis than in those without the condition (MMWR 2011;60:509–13).

“Efforts are needed to increase access to and availability of effective services and programs to manage both chronic conditions,” the authors wrote.

The report shows that the prevalence of obesity varied widely by state, and 14 states had a significance increase between 2003 and 2009.

There are several reasons for variations among the states, among which is the variation resulting from the underlying obesity rate in the general population of the state, Jennifer M. Hootman, Ph.D., the lead author of the study and an epidemiologist in the arthritis program at the CDC, said in an interview. “States with relatively higher rates of obesity overall tended to also be the higher states among adults with arthritis,” she added.

In 2003, the age-adjusted obesity prevalence in adults with arthritis was greater than or equal to 30% in 37 states and the District of Columbia. Two states had a prevalence of 40% or higher.

Fast-forward to 2009, and the number of states with at least 30% of their arthritic population in the obese bracket had increased to 48, 12 of which had a prevalence of 40% or more. During the same year, the obesity prevalence among U.S. adults without arthritis was 30% or higher in only two states. From 2003 to 2009, the percent change in the prevalence ranged from 26.2% in Wisconsin, to −19.2% in the District of Columbia, the only area with a sharp decline, and it stayed roughly the same in 35 states.

In 2009, nearly 50 million – or 22% – of U.S. adults had arthritis, with an estimated annual medical cost of $128 billion.

Studies have shown that small amounts of weight loss can improve symptoms and function, and can cut the risk of early mortality almost in half (Clin. Geriatr. Med. 2010;26:461–77; J. Gerontol. A Biol. Sci. Med. Sci. 2010;65: 519–25).

Other studies have shown that counseling patients with arthritis who are obese has a strong correlation with their attempt to lose weight (Am. J. Prev. Med. 2004;27:16–21).

“However, provider counseling for weight loss and physical activity for adults with arthritis is below the Healthy People 2010 target, and represents an effective but underused opportunity to improve the health of adults with arthritis,” said the authors (Ann. Fam. Med. 2011;9:136–41).

Reflecting on the trends in his practice, Dr. Larry Greenbaum, a rheumatologist in Greenwood, Ind., said that the report's findings “do have a ring of truth to them.” He said that he recommends diet and exercise to his patients, although “it is very difficult to get people to modify their lifestyle.” He added that the 15-minute office visits don't leave much time for him to delve into counseling, “but I do think it's important.”

Dr. Hootman also stressed the importance of counseling patients to lose weight. “People with arthritis and their health care providers should be encouraged to know that even small amounts of weight loss and small increases in physical activity can have important benefits in terms of reducing pain and improving function,” she said.

The study has several limitations. Because the data are self-reported, they're subject to recall bias; the survey does not include individuals in institutions or households without a landline phone; and the case-finding question in the analysis covered a range of conditions, such as rheumatoid arthritis and gout, which might have different relationships to obesity, according to the authors.

The report is based on the annual Behavioral Risk Factor Surveillance System random-digital-dialed phone survey of adults aged 18 or older in 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. The arthritis and obesity prevalence data are collected in odd-numbered years.

Dr. Greenbaum reported that he has no relevant conflicts of interest.

A disproportionate number of U.S. adults with arthritis are obese, and the prevalence has been growing over the years, according to a report from the Centers for Disease Control and Prevention.

Obesity and arthritis have a complex relationship, the authors note. “Obesity is an independent risk factor for severe pain, reduced physical function, and disability among adults with arthritis, which might be related to both the increased mechanical stress caused by extra weight on the joints as well as inflammatory effects of elevated cytokines and adipokines that affect cartilage degradation,” according to the report.

On average, the obesity prevalence was 54% higher in adults with arthritis than in those without the condition (MMWR 2011;60:509–13).

“Efforts are needed to increase access to and availability of effective services and programs to manage both chronic conditions,” the authors wrote.

The report shows that the prevalence of obesity varied widely by state, and 14 states had a significance increase between 2003 and 2009.

There are several reasons for variations among the states, among which is the variation resulting from the underlying obesity rate in the general population of the state, Jennifer M. Hootman, Ph.D., the lead author of the study and an epidemiologist in the arthritis program at the CDC, said in an interview. “States with relatively higher rates of obesity overall tended to also be the higher states among adults with arthritis,” she added.

In 2003, the age-adjusted obesity prevalence in adults with arthritis was greater than or equal to 30% in 37 states and the District of Columbia. Two states had a prevalence of 40% or higher.

Fast-forward to 2009, and the number of states with at least 30% of their arthritic population in the obese bracket had increased to 48, 12 of which had a prevalence of 40% or more. During the same year, the obesity prevalence among U.S. adults without arthritis was 30% or higher in only two states. From 2003 to 2009, the percent change in the prevalence ranged from 26.2% in Wisconsin, to −19.2% in the District of Columbia, the only area with a sharp decline, and it stayed roughly the same in 35 states.

In 2009, nearly 50 million – or 22% – of U.S. adults had arthritis, with an estimated annual medical cost of $128 billion.

Studies have shown that small amounts of weight loss can improve symptoms and function, and can cut the risk of early mortality almost in half (Clin. Geriatr. Med. 2010;26:461–77; J. Gerontol. A Biol. Sci. Med. Sci. 2010;65: 519–25).

Other studies have shown that counseling patients with arthritis who are obese has a strong correlation with their attempt to lose weight (Am. J. Prev. Med. 2004;27:16–21).

“However, provider counseling for weight loss and physical activity for adults with arthritis is below the Healthy People 2010 target, and represents an effective but underused opportunity to improve the health of adults with arthritis,” said the authors (Ann. Fam. Med. 2011;9:136–41).

Reflecting on the trends in his practice, Dr. Larry Greenbaum, a rheumatologist in Greenwood, Ind., said that the report's findings “do have a ring of truth to them.” He said that he recommends diet and exercise to his patients, although “it is very difficult to get people to modify their lifestyle.” He added that the 15-minute office visits don't leave much time for him to delve into counseling, “but I do think it's important.”

Dr. Hootman also stressed the importance of counseling patients to lose weight. “People with arthritis and their health care providers should be encouraged to know that even small amounts of weight loss and small increases in physical activity can have important benefits in terms of reducing pain and improving function,” she said.

The study has several limitations. Because the data are self-reported, they're subject to recall bias; the survey does not include individuals in institutions or households without a landline phone; and the case-finding question in the analysis covered a range of conditions, such as rheumatoid arthritis and gout, which might have different relationships to obesity, according to the authors.

The report is based on the annual Behavioral Risk Factor Surveillance System random-digital-dialed phone survey of adults aged 18 or older in 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. The arthritis and obesity prevalence data are collected in odd-numbered years.

Dr. Greenbaum reported that he has no relevant conflicts of interest.

A disproportionate number of U.S. adults with arthritis are obese, and the prevalence has been growing over the years, according to a report from the Centers for Disease Control and Prevention.

Obesity and arthritis have a complex relationship, the authors note. “Obesity is an independent risk factor for severe pain, reduced physical function, and disability among adults with arthritis, which might be related to both the increased mechanical stress caused by extra weight on the joints as well as inflammatory effects of elevated cytokines and adipokines that affect cartilage degradation,” according to the report.

On average, the obesity prevalence was 54% higher in adults with arthritis than in those without the condition (MMWR 2011;60:509–13).

“Efforts are needed to increase access to and availability of effective services and programs to manage both chronic conditions,” the authors wrote.

The report shows that the prevalence of obesity varied widely by state, and 14 states had a significance increase between 2003 and 2009.

There are several reasons for variations among the states, among which is the variation resulting from the underlying obesity rate in the general population of the state, Jennifer M. Hootman, Ph.D., the lead author of the study and an epidemiologist in the arthritis program at the CDC, said in an interview. “States with relatively higher rates of obesity overall tended to also be the higher states among adults with arthritis,” she added.

In 2003, the age-adjusted obesity prevalence in adults with arthritis was greater than or equal to 30% in 37 states and the District of Columbia. Two states had a prevalence of 40% or higher.

Fast-forward to 2009, and the number of states with at least 30% of their arthritic population in the obese bracket had increased to 48, 12 of which had a prevalence of 40% or more. During the same year, the obesity prevalence among U.S. adults without arthritis was 30% or higher in only two states. From 2003 to 2009, the percent change in the prevalence ranged from 26.2% in Wisconsin, to −19.2% in the District of Columbia, the only area with a sharp decline, and it stayed roughly the same in 35 states.

In 2009, nearly 50 million – or 22% – of U.S. adults had arthritis, with an estimated annual medical cost of $128 billion.

Studies have shown that small amounts of weight loss can improve symptoms and function, and can cut the risk of early mortality almost in half (Clin. Geriatr. Med. 2010;26:461–77; J. Gerontol. A Biol. Sci. Med. Sci. 2010;65: 519–25).

Other studies have shown that counseling patients with arthritis who are obese has a strong correlation with their attempt to lose weight (Am. J. Prev. Med. 2004;27:16–21).

“However, provider counseling for weight loss and physical activity for adults with arthritis is below the Healthy People 2010 target, and represents an effective but underused opportunity to improve the health of adults with arthritis,” said the authors (Ann. Fam. Med. 2011;9:136–41).

Reflecting on the trends in his practice, Dr. Larry Greenbaum, a rheumatologist in Greenwood, Ind., said that the report's findings “do have a ring of truth to them.” He said that he recommends diet and exercise to his patients, although “it is very difficult to get people to modify their lifestyle.” He added that the 15-minute office visits don't leave much time for him to delve into counseling, “but I do think it's important.”

Dr. Hootman also stressed the importance of counseling patients to lose weight. “People with arthritis and their health care providers should be encouraged to know that even small amounts of weight loss and small increases in physical activity can have important benefits in terms of reducing pain and improving function,” she said.

The study has several limitations. Because the data are self-reported, they're subject to recall bias; the survey does not include individuals in institutions or households without a landline phone; and the case-finding question in the analysis covered a range of conditions, such as rheumatoid arthritis and gout, which might have different relationships to obesity, according to the authors.

The report is based on the annual Behavioral Risk Factor Surveillance System random-digital-dialed phone survey of adults aged 18 or older in 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. The arthritis and obesity prevalence data are collected in odd-numbered years.

Dr. Greenbaum reported that he has no relevant conflicts of interest.

BRIGHTON, ENGLAND – Very obese patients with early rheumatoid arthritis appear to have higher disease activity at presentation, according to recent data.

In a study of 216 individuals with early, clinically diagnosed rheumatoid arthritis (RA), those with a body mass index (BMI) of 35 kg/m

As a result, by using the DAS28 to guide their clinical decision making, physicians may give disease-modifying antirheumatic drug (DMARD) therapy too early in the course of the disease, suggested Stephanie Ling, who presented the findings.

Ms. Ling, a fifth-year medical student at the University of Liverpool, England, noted that earlier, more aggressive treatment of obese RA patients might explain why some studies have suggested that obesity, somewhat paradoxically, is actually beneficial in some patients with RA.

Indeed, studies have linked obesity with reduced mortality (Arch. Intern. Med. 2005; 165:1624–9; Ann. Rheum. Dis. 2010;69:i61–4) and protection against radiographic joint damage (Ann. Rheum. Dis. 2008;67:769–74), although high levels of adiponectin – secreted from the fat tissue – are associated with increased joint inflammation (Arthritis Rheum. 2009;61:1248–56).

“Physiologically, obesity is characterized by the expansion of white adipose tissue, which is not a benign tissue,” Ms. Ling explained.

White adipose tissue secretes fatty acids, and its constituent cells, the adipocytes, also secrete proinflammatory proteins, or adipokines.

“Obesity can be thought of as a chronic inflammatory state,” said Ms. Ling, adding that studies also indicate that “obesity could have adverse effect on RA disease activity.”

In the current study, patients' baseline disease characteristics, including DAS28 scores, rheumatoid factor status, and anti-cyclic citrullinated protein antibody status, were assessed according to BMI at presentation. All patients had early RA diagnosed by a consultant rheumatologist and had symptoms lasting for less than 1 year. The mean age of participants was 57 years and 57% of the cohort was female.

Patients were grouped according to their BMI category, as defined by World Health Organization (WHO) criteria. One-third fulfilled criteria for obesity, with approximately 22% in the obese I category (BMI more than 30 kg/m

Results showed that obese II–III patients were more likely to present with elevated (5.1 or higher) DAS28 scores than their lighter counterparts. Odds ratios (OR) adjusted for age, gender, and smoking status were 4.1 for DAS28 and 3.67 for ESR when comparing the very obese patients with the other BMI groups.

Considering each component of the DAS28 separately, Ms. Ling said, a high ESR (32 mm/h or more) was the main factor that appeared to be significantly higher as body weight increased. There was no association with tender or swollen joint counts, global visual analog scale, symptom duration, or rheumatoid factor/anti-cyclic citrullinated protein antibody status, she said.

“There is a need for well-designed longitudinal studies to examine the effect of obesity on the extent of RA disease progression,” she suggested.

Ms. Ling reported no conflicts of interest.

Because obesity increases the ESR, overweight RA patients may have a higher DAS28 score than their disease merits.

Source ©geronimo/Fotolia.com

BRIGHTON, ENGLAND – Very obese patients with early rheumatoid arthritis appear to have higher disease activity at presentation, according to recent data.

In a study of 216 individuals with early, clinically diagnosed rheumatoid arthritis (RA), those with a body mass index (BMI) of 35 kg/m

As a result, by using the DAS28 to guide their clinical decision making, physicians may give disease-modifying antirheumatic drug (DMARD) therapy too early in the course of the disease, suggested Stephanie Ling, who presented the findings.

Ms. Ling, a fifth-year medical student at the University of Liverpool, England, noted that earlier, more aggressive treatment of obese RA patients might explain why some studies have suggested that obesity, somewhat paradoxically, is actually beneficial in some patients with RA.

Indeed, studies have linked obesity with reduced mortality (Arch. Intern. Med. 2005; 165:1624–9; Ann. Rheum. Dis. 2010;69:i61–4) and protection against radiographic joint damage (Ann. Rheum. Dis. 2008;67:769–74), although high levels of adiponectin – secreted from the fat tissue – are associated with increased joint inflammation (Arthritis Rheum. 2009;61:1248–56).

“Physiologically, obesity is characterized by the expansion of white adipose tissue, which is not a benign tissue,” Ms. Ling explained.

White adipose tissue secretes fatty acids, and its constituent cells, the adipocytes, also secrete proinflammatory proteins, or adipokines.

“Obesity can be thought of as a chronic inflammatory state,” said Ms. Ling, adding that studies also indicate that “obesity could have adverse effect on RA disease activity.”

In the current study, patients' baseline disease characteristics, including DAS28 scores, rheumatoid factor status, and anti-cyclic citrullinated protein antibody status, were assessed according to BMI at presentation. All patients had early RA diagnosed by a consultant rheumatologist and had symptoms lasting for less than 1 year. The mean age of participants was 57 years and 57% of the cohort was female.

Patients were grouped according to their BMI category, as defined by World Health Organization (WHO) criteria. One-third fulfilled criteria for obesity, with approximately 22% in the obese I category (BMI more than 30 kg/m

Results showed that obese II–III patients were more likely to present with elevated (5.1 or higher) DAS28 scores than their lighter counterparts. Odds ratios (OR) adjusted for age, gender, and smoking status were 4.1 for DAS28 and 3.67 for ESR when comparing the very obese patients with the other BMI groups.

Considering each component of the DAS28 separately, Ms. Ling said, a high ESR (32 mm/h or more) was the main factor that appeared to be significantly higher as body weight increased. There was no association with tender or swollen joint counts, global visual analog scale, symptom duration, or rheumatoid factor/anti-cyclic citrullinated protein antibody status, she said.

“There is a need for well-designed longitudinal studies to examine the effect of obesity on the extent of RA disease progression,” she suggested.

Ms. Ling reported no conflicts of interest.

Because obesity increases the ESR, overweight RA patients may have a higher DAS28 score than their disease merits.

Source ©geronimo/Fotolia.com

BRIGHTON, ENGLAND – Very obese patients with early rheumatoid arthritis appear to have higher disease activity at presentation, according to recent data.

In a study of 216 individuals with early, clinically diagnosed rheumatoid arthritis (RA), those with a body mass index (BMI) of 35 kg/m

As a result, by using the DAS28 to guide their clinical decision making, physicians may give disease-modifying antirheumatic drug (DMARD) therapy too early in the course of the disease, suggested Stephanie Ling, who presented the findings.

Ms. Ling, a fifth-year medical student at the University of Liverpool, England, noted that earlier, more aggressive treatment of obese RA patients might explain why some studies have suggested that obesity, somewhat paradoxically, is actually beneficial in some patients with RA.

Indeed, studies have linked obesity with reduced mortality (Arch. Intern. Med. 2005; 165:1624–9; Ann. Rheum. Dis. 2010;69:i61–4) and protection against radiographic joint damage (Ann. Rheum. Dis. 2008;67:769–74), although high levels of adiponectin – secreted from the fat tissue – are associated with increased joint inflammation (Arthritis Rheum. 2009;61:1248–56).

“Physiologically, obesity is characterized by the expansion of white adipose tissue, which is not a benign tissue,” Ms. Ling explained.

White adipose tissue secretes fatty acids, and its constituent cells, the adipocytes, also secrete proinflammatory proteins, or adipokines.

“Obesity can be thought of as a chronic inflammatory state,” said Ms. Ling, adding that studies also indicate that “obesity could have adverse effect on RA disease activity.”

In the current study, patients' baseline disease characteristics, including DAS28 scores, rheumatoid factor status, and anti-cyclic citrullinated protein antibody status, were assessed according to BMI at presentation. All patients had early RA diagnosed by a consultant rheumatologist and had symptoms lasting for less than 1 year. The mean age of participants was 57 years and 57% of the cohort was female.

Patients were grouped according to their BMI category, as defined by World Health Organization (WHO) criteria. One-third fulfilled criteria for obesity, with approximately 22% in the obese I category (BMI more than 30 kg/m

Results showed that obese II–III patients were more likely to present with elevated (5.1 or higher) DAS28 scores than their lighter counterparts. Odds ratios (OR) adjusted for age, gender, and smoking status were 4.1 for DAS28 and 3.67 for ESR when comparing the very obese patients with the other BMI groups.

Considering each component of the DAS28 separately, Ms. Ling said, a high ESR (32 mm/h or more) was the main factor that appeared to be significantly higher as body weight increased. There was no association with tender or swollen joint counts, global visual analog scale, symptom duration, or rheumatoid factor/anti-cyclic citrullinated protein antibody status, she said.

“There is a need for well-designed longitudinal studies to examine the effect of obesity on the extent of RA disease progression,” she suggested.

Ms. Ling reported no conflicts of interest.

Because obesity increases the ESR, overweight RA patients may have a higher DAS28 score than their disease merits.

Source ©geronimo/Fotolia.com

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10–15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths.

“An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA,” said Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases.

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans's research at his presentation at the meeting, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation). These patients were followed for 3,402 person-years and in that time 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87) and carotid intima-media thickness also raised the risk significantly (HR, 1.61). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a 6-fold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94), diabetes (HR, 2.24), and hypertension (HR, 1.56). Measures of RA severity, such as swollen joint counts (HR, 1.03) and cumulative prednisone dose of 20 g (HR, 2.12) also had predictive value.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10–15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths.

“An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA,” said Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases.

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans's research at his presentation at the meeting, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation). These patients were followed for 3,402 person-years and in that time 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87) and carotid intima-media thickness also raised the risk significantly (HR, 1.61). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a 6-fold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94), diabetes (HR, 2.24), and hypertension (HR, 1.56). Measures of RA severity, such as swollen joint counts (HR, 1.03) and cumulative prednisone dose of 20 g (HR, 2.12) also had predictive value.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10–15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths.

“An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA,” said Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases.

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans's research at his presentation at the meeting, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation). These patients were followed for 3,402 person-years and in that time 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87) and carotid intima-media thickness also raised the risk significantly (HR, 1.61). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a 6-fold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94), diabetes (HR, 2.24), and hypertension (HR, 1.56). Measures of RA severity, such as swollen joint counts (HR, 1.03) and cumulative prednisone dose of 20 g (HR, 2.12) also had predictive value.

Dr. Greenberg receives consulting fees from Genentech Inc.

CHICAGO – Reverse shoulder arthroplasty provides a surgical option for improving pain and ability in patients who have both arthritis and massive rotator cuff tear.

Before the procedure was approved in the United States in 2005, patients with this combination of conditions were very difficult to manage. “We didn't have a solution for this problem for many, many years, but now I think we really do,” said Dr. Matthew Saltzman, an orthopedic surgeon specializing in shoulder and elbow surgery at Northwestern University, Chicago.

Reverse shoulder arthroplasty basically changes the mechanics of the shoulder. It involves putting the ball in the socket, and putting the socket where the ball used to be, he said, adding that it's “a strange concept, but it actually works.”

“With reverse shoulder arthroplasty, you're actually medializing the center of rotation, and this can be done to varying degrees depending on the implant design,” he said, explaining that the procedure changes the tension on the deltoid muscle and allows the deltoid, rather than the irreparable rotator cuff musculature, to lift the arm.

Dr. Saltzman described two cases involving elderly women who underwent the surgery and had excellent outcomes at 6–12 months. One was an 84-year-old who presented with a massive cuff tear as well as arthritis-related joint damage and loss of the joint space. Like many patients with these conditions, she had severe pain, pseudoparalysis of the shoulder, and resulting lack of function; she was able to lift her arm to only about 20 degrees.

At 6 months after the operation, she had no pain and was able to elevate her arm and rotate the arm out to the side.

The other patient was an 86-year-old who had previously lived independently, but who had slipped on ice and sustained multiple fractures of her shoulder. Although her problem wasn't arthritis related, the reverse shoulder arthroplasty was successful, and she was able to return to independent living.

Findings from a study involving 240 consecutive reverse shoulder arthroplasty procedures in 232 patients (average age, nearly 73 years) showed that average forward elevation increased from 86 degrees to 137 degrees, and average constant score (a validated measure of shoulder function) improved from 23 to 60 at the latest follow-up, indicating substantial improvement, Dr. Saltzman said (J. Bone Joint Surg. Am. 2007;89:1476–85).

In that study, patients with cuff tear arthropathy, osteoarthritis plus cuff tear, or massive cuff tear fared better, whereas those with posttraumatic arthritis and those undergoing revision arthroplasty had worse outcomes.

Dr. Saltzman disclosed that he serves on the speakers bureau of Carefusion, has made paid presentations for DJO Surgical, and has received research support from Arthrex.

CHICAGO – Reverse shoulder arthroplasty provides a surgical option for improving pain and ability in patients who have both arthritis and massive rotator cuff tear.

Before the procedure was approved in the United States in 2005, patients with this combination of conditions were very difficult to manage. “We didn't have a solution for this problem for many, many years, but now I think we really do,” said Dr. Matthew Saltzman, an orthopedic surgeon specializing in shoulder and elbow surgery at Northwestern University, Chicago.

Reverse shoulder arthroplasty basically changes the mechanics of the shoulder. It involves putting the ball in the socket, and putting the socket where the ball used to be, he said, adding that it's “a strange concept, but it actually works.”

“With reverse shoulder arthroplasty, you're actually medializing the center of rotation, and this can be done to varying degrees depending on the implant design,” he said, explaining that the procedure changes the tension on the deltoid muscle and allows the deltoid, rather than the irreparable rotator cuff musculature, to lift the arm.

Dr. Saltzman described two cases involving elderly women who underwent the surgery and had excellent outcomes at 6–12 months. One was an 84-year-old who presented with a massive cuff tear as well as arthritis-related joint damage and loss of the joint space. Like many patients with these conditions, she had severe pain, pseudoparalysis of the shoulder, and resulting lack of function; she was able to lift her arm to only about 20 degrees.

At 6 months after the operation, she had no pain and was able to elevate her arm and rotate the arm out to the side.

The other patient was an 86-year-old who had previously lived independently, but who had slipped on ice and sustained multiple fractures of her shoulder. Although her problem wasn't arthritis related, the reverse shoulder arthroplasty was successful, and she was able to return to independent living.

Findings from a study involving 240 consecutive reverse shoulder arthroplasty procedures in 232 patients (average age, nearly 73 years) showed that average forward elevation increased from 86 degrees to 137 degrees, and average constant score (a validated measure of shoulder function) improved from 23 to 60 at the latest follow-up, indicating substantial improvement, Dr. Saltzman said (J. Bone Joint Surg. Am. 2007;89:1476–85).

In that study, patients with cuff tear arthropathy, osteoarthritis plus cuff tear, or massive cuff tear fared better, whereas those with posttraumatic arthritis and those undergoing revision arthroplasty had worse outcomes.

Dr. Saltzman disclosed that he serves on the speakers bureau of Carefusion, has made paid presentations for DJO Surgical, and has received research support from Arthrex.

CHICAGO – Reverse shoulder arthroplasty provides a surgical option for improving pain and ability in patients who have both arthritis and massive rotator cuff tear.

Before the procedure was approved in the United States in 2005, patients with this combination of conditions were very difficult to manage. “We didn't have a solution for this problem for many, many years, but now I think we really do,” said Dr. Matthew Saltzman, an orthopedic surgeon specializing in shoulder and elbow surgery at Northwestern University, Chicago.

Reverse shoulder arthroplasty basically changes the mechanics of the shoulder. It involves putting the ball in the socket, and putting the socket where the ball used to be, he said, adding that it's “a strange concept, but it actually works.”

“With reverse shoulder arthroplasty, you're actually medializing the center of rotation, and this can be done to varying degrees depending on the implant design,” he said, explaining that the procedure changes the tension on the deltoid muscle and allows the deltoid, rather than the irreparable rotator cuff musculature, to lift the arm.

Dr. Saltzman described two cases involving elderly women who underwent the surgery and had excellent outcomes at 6–12 months. One was an 84-year-old who presented with a massive cuff tear as well as arthritis-related joint damage and loss of the joint space. Like many patients with these conditions, she had severe pain, pseudoparalysis of the shoulder, and resulting lack of function; she was able to lift her arm to only about 20 degrees.

At 6 months after the operation, she had no pain and was able to elevate her arm and rotate the arm out to the side.

The other patient was an 86-year-old who had previously lived independently, but who had slipped on ice and sustained multiple fractures of her shoulder. Although her problem wasn't arthritis related, the reverse shoulder arthroplasty was successful, and she was able to return to independent living.

Findings from a study involving 240 consecutive reverse shoulder arthroplasty procedures in 232 patients (average age, nearly 73 years) showed that average forward elevation increased from 86 degrees to 137 degrees, and average constant score (a validated measure of shoulder function) improved from 23 to 60 at the latest follow-up, indicating substantial improvement, Dr. Saltzman said (J. Bone Joint Surg. Am. 2007;89:1476–85).

In that study, patients with cuff tear arthropathy, osteoarthritis plus cuff tear, or massive cuff tear fared better, whereas those with posttraumatic arthritis and those undergoing revision arthroplasty had worse outcomes.

Dr. Saltzman disclosed that he serves on the speakers bureau of Carefusion, has made paid presentations for DJO Surgical, and has received research support from Arthrex.

CHICAGO – The risk of both interstitial and obstructive lung disease is increased in patients with rheumatoid arthritis, as is mortality in affected, compared with unaffected, arthritis patients.

In a cohort of rheumatoid arthritis (RA) patients from a single county in Minnesota who have been followed since 1955, the risk of developing interstitial lung disease is about 8%, compared with less than 1% in the general population, Dr. Eric L. Matteson reported.

“The hazard ratio for developing interstitial lung disease, compared to non-RA patients, is about a ninefold increase, so this is an enormous difference,” said Dr. Matteson, professor of medicine and chair of rheumatology at the Mayo Clinic, Rochester, Minn.

Furthermore, these patients with interstitial lung disease have much higher mortality than RA patients who do not have interstitial lung disease (hazard ratio, 2.14), he said.

The findings compare well with those from a recently completed survey, which used National Center for Health Statistics data and suggested that, while mortality in RA in general has declined, the rates of interstitial lung disease are increasing.

“We're probably seeing more [interstitial lung disease in RA patients] today than we did maybe 10, 20, and certainly 30 years ago,” Dr. Matteson said.

Declines in RA mortality overall may be outpacing those from interstitial lung disease. Although biologics being used to treat RA are helping joint disease and other extra-articular manifestations of RA, there is no evidence that they influence the development of interstitial lung disease, he said.

Obstructive lung disease is also a concern in RA patients, and although the difference in incidence between RA patients and the general population is smaller than with interstitial lung disease, this finding may be more surprising, Dr. Matteson said, noting that this information from the Minnesota cohort was new to him.

“It appears that rheumatoid arthritis is a risk factor for obstructive lung disease,” he said. After correcting for age, sex, and smoking status, there is about a 50% increase in the incidence of obstructive lung disease in RA patients, compared with the general population.

The reason for this is unclear, but “intriguing new data” suggest that the cystic fibrosis genes and some related genes are risk factors for developing bronchiolitis and other forms of obstructive disease in RA, so that may be part of the biologic answer, he said.

Like interstitial lung disease, obstructive lung disease also adversely affects mortality in RA patients (hazard ratio of 1.87 for affected vs. nonaffected RA patients), he noted.

Dr. Matteson had no financial conflicts of interest to disclose.

CHICAGO – The risk of both interstitial and obstructive lung disease is increased in patients with rheumatoid arthritis, as is mortality in affected, compared with unaffected, arthritis patients.

In a cohort of rheumatoid arthritis (RA) patients from a single county in Minnesota who have been followed since 1955, the risk of developing interstitial lung disease is about 8%, compared with less than 1% in the general population, Dr. Eric L. Matteson reported.

“The hazard ratio for developing interstitial lung disease, compared to non-RA patients, is about a ninefold increase, so this is an enormous difference,” said Dr. Matteson, professor of medicine and chair of rheumatology at the Mayo Clinic, Rochester, Minn.

Furthermore, these patients with interstitial lung disease have much higher mortality than RA patients who do not have interstitial lung disease (hazard ratio, 2.14), he said.

The findings compare well with those from a recently completed survey, which used National Center for Health Statistics data and suggested that, while mortality in RA in general has declined, the rates of interstitial lung disease are increasing.

“We're probably seeing more [interstitial lung disease in RA patients] today than we did maybe 10, 20, and certainly 30 years ago,” Dr. Matteson said.

Declines in RA mortality overall may be outpacing those from interstitial lung disease. Although biologics being used to treat RA are helping joint disease and other extra-articular manifestations of RA, there is no evidence that they influence the development of interstitial lung disease, he said.

Obstructive lung disease is also a concern in RA patients, and although the difference in incidence between RA patients and the general population is smaller than with interstitial lung disease, this finding may be more surprising, Dr. Matteson said, noting that this information from the Minnesota cohort was new to him.

“It appears that rheumatoid arthritis is a risk factor for obstructive lung disease,” he said. After correcting for age, sex, and smoking status, there is about a 50% increase in the incidence of obstructive lung disease in RA patients, compared with the general population.

The reason for this is unclear, but “intriguing new data” suggest that the cystic fibrosis genes and some related genes are risk factors for developing bronchiolitis and other forms of obstructive disease in RA, so that may be part of the biologic answer, he said.

Like interstitial lung disease, obstructive lung disease also adversely affects mortality in RA patients (hazard ratio of 1.87 for affected vs. nonaffected RA patients), he noted.

Dr. Matteson had no financial conflicts of interest to disclose.

CHICAGO – The risk of both interstitial and obstructive lung disease is increased in patients with rheumatoid arthritis, as is mortality in affected, compared with unaffected, arthritis patients.

In a cohort of rheumatoid arthritis (RA) patients from a single county in Minnesota who have been followed since 1955, the risk of developing interstitial lung disease is about 8%, compared with less than 1% in the general population, Dr. Eric L. Matteson reported.

“The hazard ratio for developing interstitial lung disease, compared to non-RA patients, is about a ninefold increase, so this is an enormous difference,” said Dr. Matteson, professor of medicine and chair of rheumatology at the Mayo Clinic, Rochester, Minn.

Furthermore, these patients with interstitial lung disease have much higher mortality than RA patients who do not have interstitial lung disease (hazard ratio, 2.14), he said.

The findings compare well with those from a recently completed survey, which used National Center for Health Statistics data and suggested that, while mortality in RA in general has declined, the rates of interstitial lung disease are increasing.

“We're probably seeing more [interstitial lung disease in RA patients] today than we did maybe 10, 20, and certainly 30 years ago,” Dr. Matteson said.

Declines in RA mortality overall may be outpacing those from interstitial lung disease. Although biologics being used to treat RA are helping joint disease and other extra-articular manifestations of RA, there is no evidence that they influence the development of interstitial lung disease, he said.

Obstructive lung disease is also a concern in RA patients, and although the difference in incidence between RA patients and the general population is smaller than with interstitial lung disease, this finding may be more surprising, Dr. Matteson said, noting that this information from the Minnesota cohort was new to him.

“It appears that rheumatoid arthritis is a risk factor for obstructive lung disease,” he said. After correcting for age, sex, and smoking status, there is about a 50% increase in the incidence of obstructive lung disease in RA patients, compared with the general population.

The reason for this is unclear, but “intriguing new data” suggest that the cystic fibrosis genes and some related genes are risk factors for developing bronchiolitis and other forms of obstructive disease in RA, so that may be part of the biologic answer, he said.

Like interstitial lung disease, obstructive lung disease also adversely affects mortality in RA patients (hazard ratio of 1.87 for affected vs. nonaffected RA patients), he noted.

Dr. Matteson had no financial conflicts of interest to disclose.

BRIGHTON, ENGLAND – Patients with ankylosing spondylitis who currently smoke are likely to be headed for increased disease activity and worse quality of life outcomes.

The results of a cross-sectional, postal survey found that, compared with never smoking, current smoking is associated with higher levels of disease activity, worse functional status, greater pain, and overall poorer quality of life.

This is the largest study to date to look at the effects of smoking on disease activity and severity and associated quality of life in ankylosing spondylitis (AS), according to the study's authors.

“The influence of smoking in AS is a lot less clear, however, and [until now] there have been no studies beyond susceptibility and very few studies on smoking as a risk for more severe disease,” added Dr. Derek Mattey of Keele University and the University Hospital of North Staffordshire, England.

Questionnaires were sent to 1,000 patients with AS registered at 10 secondary-care rheumatology practices in England.

The questionnaire asked about smoking history and used several patient-reported outcome measures. These included the Bath AS disease activity and functional indices (BASDAI/BASFI); pain numeric rating scale (NRS); the AS quality of life questionnaire (ASQoL); and the evaluation of AS quality of life (EASi-QoL).

Data were looked at in terms of smoking status and in relation to the pack-year history. A pack-year is a means to quantify how much a person has smoked over a long time period. It is calculated by multiplying the number of packs smoked per day by the number of years smoked. The higher the pack-year, the longer the person has smoked.

Of 612 patients who responded to the questionnaire, 606 provided information about their smoking history. The mean age of respondents was 50.8 years, 72% were male, and the mean disease duration was 17.2 years (standard deviation = 11.7 years). Around half of the cohort had never smoked, with approximately 28% reporting that they were past smokers and 21% saying that they were current smokers.

Mean BASDAI, BASFI, pain NRS, ASQoL, and EASi-QoL scores were all higher, indicating a worse outcome, in patients that had ever smoked, compared with never smokers.

Significant, dose-dependent, correlations were also found between the number of pack-years and these disease outcome measures, with worse outcomes the higher the number of pack-years.

“High disease activity and more severe pain are most strongly associated with current smoking, while decreased function and poor quality of life are associated more closely with pack-year history,” Dr. Mattey said.

Dr. Mattey said that he had no conflicts of interest but noted that a coinvestigator, Dr. Jonathan Packham, had received an educational grant from Wyeth UK.

BRIGHTON, ENGLAND – Patients with ankylosing spondylitis who currently smoke are likely to be headed for increased disease activity and worse quality of life outcomes.

The results of a cross-sectional, postal survey found that, compared with never smoking, current smoking is associated with higher levels of disease activity, worse functional status, greater pain, and overall poorer quality of life.

This is the largest study to date to look at the effects of smoking on disease activity and severity and associated quality of life in ankylosing spondylitis (AS), according to the study's authors.

“The influence of smoking in AS is a lot less clear, however, and [until now] there have been no studies beyond susceptibility and very few studies on smoking as a risk for more severe disease,” added Dr. Derek Mattey of Keele University and the University Hospital of North Staffordshire, England.

Questionnaires were sent to 1,000 patients with AS registered at 10 secondary-care rheumatology practices in England.

The questionnaire asked about smoking history and used several patient-reported outcome measures. These included the Bath AS disease activity and functional indices (BASDAI/BASFI); pain numeric rating scale (NRS); the AS quality of life questionnaire (ASQoL); and the evaluation of AS quality of life (EASi-QoL).

Data were looked at in terms of smoking status and in relation to the pack-year history. A pack-year is a means to quantify how much a person has smoked over a long time period. It is calculated by multiplying the number of packs smoked per day by the number of years smoked. The higher the pack-year, the longer the person has smoked.

Of 612 patients who responded to the questionnaire, 606 provided information about their smoking history. The mean age of respondents was 50.8 years, 72% were male, and the mean disease duration was 17.2 years (standard deviation = 11.7 years). Around half of the cohort had never smoked, with approximately 28% reporting that they were past smokers and 21% saying that they were current smokers.

Mean BASDAI, BASFI, pain NRS, ASQoL, and EASi-QoL scores were all higher, indicating a worse outcome, in patients that had ever smoked, compared with never smokers.

Significant, dose-dependent, correlations were also found between the number of pack-years and these disease outcome measures, with worse outcomes the higher the number of pack-years.

“High disease activity and more severe pain are most strongly associated with current smoking, while decreased function and poor quality of life are associated more closely with pack-year history,” Dr. Mattey said.

Dr. Mattey said that he had no conflicts of interest but noted that a coinvestigator, Dr. Jonathan Packham, had received an educational grant from Wyeth UK.

BRIGHTON, ENGLAND – Patients with ankylosing spondylitis who currently smoke are likely to be headed for increased disease activity and worse quality of life outcomes.

The results of a cross-sectional, postal survey found that, compared with never smoking, current smoking is associated with higher levels of disease activity, worse functional status, greater pain, and overall poorer quality of life.

This is the largest study to date to look at the effects of smoking on disease activity and severity and associated quality of life in ankylosing spondylitis (AS), according to the study's authors.

“The influence of smoking in AS is a lot less clear, however, and [until now] there have been no studies beyond susceptibility and very few studies on smoking as a risk for more severe disease,” added Dr. Derek Mattey of Keele University and the University Hospital of North Staffordshire, England.

Questionnaires were sent to 1,000 patients with AS registered at 10 secondary-care rheumatology practices in England.

The questionnaire asked about smoking history and used several patient-reported outcome measures. These included the Bath AS disease activity and functional indices (BASDAI/BASFI); pain numeric rating scale (NRS); the AS quality of life questionnaire (ASQoL); and the evaluation of AS quality of life (EASi-QoL).

Data were looked at in terms of smoking status and in relation to the pack-year history. A pack-year is a means to quantify how much a person has smoked over a long time period. It is calculated by multiplying the number of packs smoked per day by the number of years smoked. The higher the pack-year, the longer the person has smoked.

Of 612 patients who responded to the questionnaire, 606 provided information about their smoking history. The mean age of respondents was 50.8 years, 72% were male, and the mean disease duration was 17.2 years (standard deviation = 11.7 years). Around half of the cohort had never smoked, with approximately 28% reporting that they were past smokers and 21% saying that they were current smokers.

Mean BASDAI, BASFI, pain NRS, ASQoL, and EASi-QoL scores were all higher, indicating a worse outcome, in patients that had ever smoked, compared with never smokers.

Significant, dose-dependent, correlations were also found between the number of pack-years and these disease outcome measures, with worse outcomes the higher the number of pack-years.

“High disease activity and more severe pain are most strongly associated with current smoking, while decreased function and poor quality of life are associated more closely with pack-year history,” Dr. Mattey said.

Dr. Mattey said that he had no conflicts of interest but noted that a coinvestigator, Dr. Jonathan Packham, had received an educational grant from Wyeth UK.

CHICAGO – Extra-articular manifestations of rheumatoid arthritis still affect more than 40% of patients, and although the incidence of some severe manifestations, such as vasculitis, has declined over time, the incidence of others has increased, and many of these manifestations can adversely affect prognosis and increase mortality.

The 10-year cumulative incidence for all extra-articular manifestations of RA was nearly 50% in a cohort of 463 patients with incident RA in 1995–2007 who were followed through the end of 2008, which is similar to the 46% incidence in a similar cohort of 197 patients who were followed from 1985 to 1994. However, severe manifestations – including ocular disease and vasculitis – occurred in about 7% and 9% of patients in the cohorts, respectively, reported Dr. Eric L. Matteson at the symposium.

The findings are from a follow-up of a retrospective, longitudinal, population-based study involving the first cohort. Both cohorts included residents from a single county in Minnesota who were at least 18 years of age and who met at least four of the American College of Rheumatology criteria for RA (J. Rheumatol. 2011 April 1 [doi:10.3899/jrheum.101133]).

The most striking finding was the reduction in the incidence of vasculitis, which affected 3.6% of patients in the earlier cohort, but only 0.6% in the recent cohort, said Dr. Matteson, professor of medicine and chair of rheumatology at the Mayo Clinic, Rochester, Minn.

Episcleritis, neuropathy, xerostomia, cervical myelopathy, pulmonary fibrosis, Sjögren's syndrome, and keratoconjunctivitis sicca (KCS) also occurred less often in the later cohort, whereas subcutaneous nodules, pleuritis, pericarditis, and bronchiolitis obliterans-organizing pneumonia (BOOP) all occurred slightly more often in the later cohort.

The study also showed that the occurrence of a second extra-articular manifestation was reduced significantly in the second cohort (hazard ratio, 0.5), and that having any extra-articular manifestation was significantly associated with an increased risk of mortality (HR, 2.0). No additional increase in mortality risk was seen with severe or second extra-articular manifestations, Dr. Matteson noted.

The reasons for the decline in severe manifestations and second manifestations likely include more aggressive treatment strategies – and perhaps the use of biologics – in recent years; more vigorous disease control throughout the course of disease; and possibly secular trends, such as reduced smoking and other as-yet unidentified factors, he said.

Predictors of extra-articular manifestations include smoking, erosive severe joint disease, the need for disease-modifying antirheumatic drugs or biologic response modifiers, and seropositivity for ANA (antinuclear antibodies) or pANCA (perinuclear antineutrophil cytoplasmic antibody). Other genetic or environmental factors that are not yet fully understood might also contribute, he said.

Management of extra-articular manifestations should be guided by the organ system involved, but steroids are a mainstay of treatment. Treatments that control synovitis, including NSAIDs, are often effective as well.

For severe manifestations, treatment with glucocorticoids is often needed for at least 2 months. The role of pulse glucocorticoids, although popular, has not been established by randomized, controlled studies, he said.

There are few data on treatment of these manifestations in general, he said, noting that cytotoxic drugs are sometimes used in patients with vasculitis or inflammatory eye disease, and that the role of newer agents – such as anti–B-cell therapy, abatacept, and tumor necrosis factor antagonists – is unclear, as there is anecdotal evidence of both successful and detrimental effects.

Dr. Matteson disclosed that he has received grant support from, and/or served as an investigator or consultant for Amgen, Biogen-IDEC, Centocor, Genentech, Hoffmann-La Roche, Human Genome Sciences, Mayo Foundation, National Institutes of Health, Novartis, Pfizer, and UCB.

CHICAGO – Extra-articular manifestations of rheumatoid arthritis still affect more than 40% of patients, and although the incidence of some severe manifestations, such as vasculitis, has declined over time, the incidence of others has increased, and many of these manifestations can adversely affect prognosis and increase mortality.

The 10-year cumulative incidence for all extra-articular manifestations of RA was nearly 50% in a cohort of 463 patients with incident RA in 1995–2007 who were followed through the end of 2008, which is similar to the 46% incidence in a similar cohort of 197 patients who were followed from 1985 to 1994. However, severe manifestations – including ocular disease and vasculitis – occurred in about 7% and 9% of patients in the cohorts, respectively, reported Dr. Eric L. Matteson at the symposium.

The findings are from a follow-up of a retrospective, longitudinal, population-based study involving the first cohort. Both cohorts included residents from a single county in Minnesota who were at least 18 years of age and who met at least four of the American College of Rheumatology criteria for RA (J. Rheumatol. 2011 April 1 [doi:10.3899/jrheum.101133]).

The most striking finding was the reduction in the incidence of vasculitis, which affected 3.6% of patients in the earlier cohort, but only 0.6% in the recent cohort, said Dr. Matteson, professor of medicine and chair of rheumatology at the Mayo Clinic, Rochester, Minn.

Episcleritis, neuropathy, xerostomia, cervical myelopathy, pulmonary fibrosis, Sjögren's syndrome, and keratoconjunctivitis sicca (KCS) also occurred less often in the later cohort, whereas subcutaneous nodules, pleuritis, pericarditis, and bronchiolitis obliterans-organizing pneumonia (BOOP) all occurred slightly more often in the later cohort.

The study also showed that the occurrence of a second extra-articular manifestation was reduced significantly in the second cohort (hazard ratio, 0.5), and that having any extra-articular manifestation was significantly associated with an increased risk of mortality (HR, 2.0). No additional increase in mortality risk was seen with severe or second extra-articular manifestations, Dr. Matteson noted.

The reasons for the decline in severe manifestations and second manifestations likely include more aggressive treatment strategies – and perhaps the use of biologics – in recent years; more vigorous disease control throughout the course of disease; and possibly secular trends, such as reduced smoking and other as-yet unidentified factors, he said.

Predictors of extra-articular manifestations include smoking, erosive severe joint disease, the need for disease-modifying antirheumatic drugs or biologic response modifiers, and seropositivity for ANA (antinuclear antibodies) or pANCA (perinuclear antineutrophil cytoplasmic antibody). Other genetic or environmental factors that are not yet fully understood might also contribute, he said.

Management of extra-articular manifestations should be guided by the organ system involved, but steroids are a mainstay of treatment. Treatments that control synovitis, including NSAIDs, are often effective as well.

For severe manifestations, treatment with glucocorticoids is often needed for at least 2 months. The role of pulse glucocorticoids, although popular, has not been established by randomized, controlled studies, he said.

There are few data on treatment of these manifestations in general, he said, noting that cytotoxic drugs are sometimes used in patients with vasculitis or inflammatory eye disease, and that the role of newer agents – such as anti–B-cell therapy, abatacept, and tumor necrosis factor antagonists – is unclear, as there is anecdotal evidence of both successful and detrimental effects.

Dr. Matteson disclosed that he has received grant support from, and/or served as an investigator or consultant for Amgen, Biogen-IDEC, Centocor, Genentech, Hoffmann-La Roche, Human Genome Sciences, Mayo Foundation, National Institutes of Health, Novartis, Pfizer, and UCB.

CHICAGO – Extra-articular manifestations of rheumatoid arthritis still affect more than 40% of patients, and although the incidence of some severe manifestations, such as vasculitis, has declined over time, the incidence of others has increased, and many of these manifestations can adversely affect prognosis and increase mortality.

The 10-year cumulative incidence for all extra-articular manifestations of RA was nearly 50% in a cohort of 463 patients with incident RA in 1995–2007 who were followed through the end of 2008, which is similar to the 46% incidence in a similar cohort of 197 patients who were followed from 1985 to 1994. However, severe manifestations – including ocular disease and vasculitis – occurred in about 7% and 9% of patients in the cohorts, respectively, reported Dr. Eric L. Matteson at the symposium.

The findings are from a follow-up of a retrospective, longitudinal, population-based study involving the first cohort. Both cohorts included residents from a single county in Minnesota who were at least 18 years of age and who met at least four of the American College of Rheumatology criteria for RA (J. Rheumatol. 2011 April 1 [doi:10.3899/jrheum.101133]).

The most striking finding was the reduction in the incidence of vasculitis, which affected 3.6% of patients in the earlier cohort, but only 0.6% in the recent cohort, said Dr. Matteson, professor of medicine and chair of rheumatology at the Mayo Clinic, Rochester, Minn.

Episcleritis, neuropathy, xerostomia, cervical myelopathy, pulmonary fibrosis, Sjögren's syndrome, and keratoconjunctivitis sicca (KCS) also occurred less often in the later cohort, whereas subcutaneous nodules, pleuritis, pericarditis, and bronchiolitis obliterans-organizing pneumonia (BOOP) all occurred slightly more often in the later cohort.

The study also showed that the occurrence of a second extra-articular manifestation was reduced significantly in the second cohort (hazard ratio, 0.5), and that having any extra-articular manifestation was significantly associated with an increased risk of mortality (HR, 2.0). No additional increase in mortality risk was seen with severe or second extra-articular manifestations, Dr. Matteson noted.

The reasons for the decline in severe manifestations and second manifestations likely include more aggressive treatment strategies – and perhaps the use of biologics – in recent years; more vigorous disease control throughout the course of disease; and possibly secular trends, such as reduced smoking and other as-yet unidentified factors, he said.

Predictors of extra-articular manifestations include smoking, erosive severe joint disease, the need for disease-modifying antirheumatic drugs or biologic response modifiers, and seropositivity for ANA (antinuclear antibodies) or pANCA (perinuclear antineutrophil cytoplasmic antibody). Other genetic or environmental factors that are not yet fully understood might also contribute, he said.

Management of extra-articular manifestations should be guided by the organ system involved, but steroids are a mainstay of treatment. Treatments that control synovitis, including NSAIDs, are often effective as well.

For severe manifestations, treatment with glucocorticoids is often needed for at least 2 months. The role of pulse glucocorticoids, although popular, has not been established by randomized, controlled studies, he said.

There are few data on treatment of these manifestations in general, he said, noting that cytotoxic drugs are sometimes used in patients with vasculitis or inflammatory eye disease, and that the role of newer agents – such as anti–B-cell therapy, abatacept, and tumor necrosis factor antagonists – is unclear, as there is anecdotal evidence of both successful and detrimental effects.

Dr. Matteson disclosed that he has received grant support from, and/or served as an investigator or consultant for Amgen, Biogen-IDEC, Centocor, Genentech, Hoffmann-La Roche, Human Genome Sciences, Mayo Foundation, National Institutes of Health, Novartis, Pfizer, and UCB.

CHICAGO – Extra-articular manifestations of rheumatoid arthritis still affect more than 40% of patients, and although the incidence of some severe manifestations, such as vasculitis, has declined over time, the incidence of others has increased, and many of these manifestations can adversely affect prognosis and increase mortality.

The 10-year cumulative incidence for all extra-articular manifestations of RA was nearly 50% in a cohort of 463 patients with incident RA in 1995-2007 who were followed through the end of 2008, which is similar to the 46% incidence in a similar cohort of 197 patients who were followed from 1985 to 1994. However, severe manifestations – including ocular disease and vasculitis – occurred in about 7% and 9% of patients in the cohorts, respectively, reported Dr. Eric Matteson at a symposium sponsored by the American College of Rheumatology.

The findings, which were published online April 1 in the Journal of Rheumatology, are from a follow-up of a retrospective, longitudinal, population-based study involving the first cohort. Both cohorts included residents from a single county in Minnesota who were at least 18 years of age and who met at least four of the American College of Rheumatology criteria for RA (J. Rheumatol. 2011 April 1 [doi:10.3899/jrheum.101133]).

The most striking finding was the reduction in the incidence of vasculitis, which affected 3.6% of patients in the earlier cohort, but only 0.6% in the recent cohort, said Dr. Matteson, chair of rheumatology at the Mayo Clinic in Rochester, Minn.

Episcleritis, neuropathy, xerostomia, cervical myelopathy, pulmonary fibrosis, Sjögren’s syndrome, and keratoconjunctivitis sicca (KCS) also occurred less often in the later cohort, whereas subcutaneous nodules, pleuritis, pericarditis, and bronchiolitis obliterans-organizing pneumonia (BOOP) all occurred slightly more often in the later cohort.

The study also showed that the occurrence of a second extra-articular manifestation was reduced significantly in the second cohort (hazard ratio, 0.5), and that having any extra-articular manifestation was significantly associated with an increased risk of mortality (HR, 2.0). No additional increase in mortality risk was seen with severe or second extra-articular manifestations, Dr. Matteson noted.

The reasons for the decline in severe manifestations and second manifestations likely include more aggressive treatment strategies – and perhaps the use of biologics – in recent years; more vigorous disease control throughout the course of disease; and possibly secular trends, such as reduced smoking and other as-yet unidentified factors, he said.

Predictors of extra-articular manifestations include smoking, erosive severe joint disease, the need for disease-modifying antirheumatic drugs or biologic response modifiers, and seropositivity for ANA (antinuclear antibodies) or pANCA (perinuclear antineutrophil cytoplasmic antibody). Other genetic or environmental factors that are not yet fully understood might also contribute, he said.

Management of extra-articular manifestations should be guided by the organ system involved, but steroids are a mainstay of treatment. Treatments that control synovitis, including NSAIDs, are often effective as well.

For severe manifestations, treatment with glucocorticoids is often needed for at least 2 months. The role of pulse glucocorticoids, although popular, has not been established by randomized, controlled studies, Dr. Matteson said.

In fact, there is a dearth of data regarding treatment of these manifestations in general, he said, noting that cytotoxic drugs are sometimes used, particularly in patients with vasculitis or inflammatory eye disease, and that the role of newer agents – such as anti–B-cell therapy, abatacept, and tumor necrosis factor antagonists – is unclear, as there is anecdotal evidence of both successful and detrimental effects.

Dr. Matteson disclosed that he has received grant support from, and/or served as an investigator or consultant for Amgen, Biogen-IDEC, Centocor, Genentech, Hoffmann-La Roche, Human Genome Sciences, Mayo Foundation, National Institutes of Health, Novartis, Pfizer, and UCB.

CHICAGO – Extra-articular manifestations of rheumatoid arthritis still affect more than 40% of patients, and although the incidence of some severe manifestations, such as vasculitis, has declined over time, the incidence of others has increased, and many of these manifestations can adversely affect prognosis and increase mortality.

The 10-year cumulative incidence for all extra-articular manifestations of RA was nearly 50% in a cohort of 463 patients with incident RA in 1995-2007 who were followed through the end of 2008, which is similar to the 46% incidence in a similar cohort of 197 patients who were followed from 1985 to 1994. However, severe manifestations – including ocular disease and vasculitis – occurred in about 7% and 9% of patients in the cohorts, respectively, reported Dr. Eric Matteson at a symposium sponsored by the American College of Rheumatology.

The findings, which were published online April 1 in the Journal of Rheumatology, are from a follow-up of a retrospective, longitudinal, population-based study involving the first cohort. Both cohorts included residents from a single county in Minnesota who were at least 18 years of age and who met at least four of the American College of Rheumatology criteria for RA (J. Rheumatol. 2011 April 1 [doi:10.3899/jrheum.101133]).

The most striking finding was the reduction in the incidence of vasculitis, which affected 3.6% of patients in the earlier cohort, but only 0.6% in the recent cohort, said Dr. Matteson, chair of rheumatology at the Mayo Clinic in Rochester, Minn.

Episcleritis, neuropathy, xerostomia, cervical myelopathy, pulmonary fibrosis, Sjögren’s syndrome, and keratoconjunctivitis sicca (KCS) also occurred less often in the later cohort, whereas subcutaneous nodules, pleuritis, pericarditis, and bronchiolitis obliterans-organizing pneumonia (BOOP) all occurred slightly more often in the later cohort.

The study also showed that the occurrence of a second extra-articular manifestation was reduced significantly in the second cohort (hazard ratio, 0.5), and that having any extra-articular manifestation was significantly associated with an increased risk of mortality (HR, 2.0). No additional increase in mortality risk was seen with severe or second extra-articular manifestations, Dr. Matteson noted.

The reasons for the decline in severe manifestations and second manifestations likely include more aggressive treatment strategies – and perhaps the use of biologics – in recent years; more vigorous disease control throughout the course of disease; and possibly secular trends, such as reduced smoking and other as-yet unidentified factors, he said.

Predictors of extra-articular manifestations include smoking, erosive severe joint disease, the need for disease-modifying antirheumatic drugs or biologic response modifiers, and seropositivity for ANA (antinuclear antibodies) or pANCA (perinuclear antineutrophil cytoplasmic antibody). Other genetic or environmental factors that are not yet fully understood might also contribute, he said.

Management of extra-articular manifestations should be guided by the organ system involved, but steroids are a mainstay of treatment. Treatments that control synovitis, including NSAIDs, are often effective as well.

For severe manifestations, treatment with glucocorticoids is often needed for at least 2 months. The role of pulse glucocorticoids, although popular, has not been established by randomized, controlled studies, Dr. Matteson said.

In fact, there is a dearth of data regarding treatment of these manifestations in general, he said, noting that cytotoxic drugs are sometimes used, particularly in patients with vasculitis or inflammatory eye disease, and that the role of newer agents – such as anti–B-cell therapy, abatacept, and tumor necrosis factor antagonists – is unclear, as there is anecdotal evidence of both successful and detrimental effects.

Dr. Matteson disclosed that he has received grant support from, and/or served as an investigator or consultant for Amgen, Biogen-IDEC, Centocor, Genentech, Hoffmann-La Roche, Human Genome Sciences, Mayo Foundation, National Institutes of Health, Novartis, Pfizer, and UCB.

CHICAGO – Extra-articular manifestations of rheumatoid arthritis still affect more than 40% of patients, and although the incidence of some severe manifestations, such as vasculitis, has declined over time, the incidence of others has increased, and many of these manifestations can adversely affect prognosis and increase mortality.

The 10-year cumulative incidence for all extra-articular manifestations of RA was nearly 50% in a cohort of 463 patients with incident RA in 1995-2007 who were followed through the end of 2008, which is similar to the 46% incidence in a similar cohort of 197 patients who were followed from 1985 to 1994. However, severe manifestations – including ocular disease and vasculitis – occurred in about 7% and 9% of patients in the cohorts, respectively, reported Dr. Eric Matteson at a symposium sponsored by the American College of Rheumatology.

The findings, which were published online April 1 in the Journal of Rheumatology, are from a follow-up of a retrospective, longitudinal, population-based study involving the first cohort. Both cohorts included residents from a single county in Minnesota who were at least 18 years of age and who met at least four of the American College of Rheumatology criteria for RA (J. Rheumatol. 2011 April 1 [doi:10.3899/jrheum.101133]).

The most striking finding was the reduction in the incidence of vasculitis, which affected 3.6% of patients in the earlier cohort, but only 0.6% in the recent cohort, said Dr. Matteson, chair of rheumatology at the Mayo Clinic in Rochester, Minn.

Episcleritis, neuropathy, xerostomia, cervical myelopathy, pulmonary fibrosis, Sjögren’s syndrome, and keratoconjunctivitis sicca (KCS) also occurred less often in the later cohort, whereas subcutaneous nodules, pleuritis, pericarditis, and bronchiolitis obliterans-organizing pneumonia (BOOP) all occurred slightly more often in the later cohort.

The study also showed that the occurrence of a second extra-articular manifestation was reduced significantly in the second cohort (hazard ratio, 0.5), and that having any extra-articular manifestation was significantly associated with an increased risk of mortality (HR, 2.0). No additional increase in mortality risk was seen with severe or second extra-articular manifestations, Dr. Matteson noted.

The reasons for the decline in severe manifestations and second manifestations likely include more aggressive treatment strategies – and perhaps the use of biologics – in recent years; more vigorous disease control throughout the course of disease; and possibly secular trends, such as reduced smoking and other as-yet unidentified factors, he said.

Predictors of extra-articular manifestations include smoking, erosive severe joint disease, the need for disease-modifying antirheumatic drugs or biologic response modifiers, and seropositivity for ANA (antinuclear antibodies) or pANCA (perinuclear antineutrophil cytoplasmic antibody). Other genetic or environmental factors that are not yet fully understood might also contribute, he said.

Management of extra-articular manifestations should be guided by the organ system involved, but steroids are a mainstay of treatment. Treatments that control synovitis, including NSAIDs, are often effective as well.

For severe manifestations, treatment with glucocorticoids is often needed for at least 2 months. The role of pulse glucocorticoids, although popular, has not been established by randomized, controlled studies, Dr. Matteson said.

In fact, there is a dearth of data regarding treatment of these manifestations in general, he said, noting that cytotoxic drugs are sometimes used, particularly in patients with vasculitis or inflammatory eye disease, and that the role of newer agents – such as anti–B-cell therapy, abatacept, and tumor necrosis factor antagonists – is unclear, as there is anecdotal evidence of both successful and detrimental effects.

Dr. Matteson disclosed that he has received grant support from, and/or served as an investigator or consultant for Amgen, Biogen-IDEC, Centocor, Genentech, Hoffmann-La Roche, Human Genome Sciences, Mayo Foundation, National Institutes of Health, Novartis, Pfizer, and UCB.

BRIGHTON, ENGLAND – Patients with ankylosing spondylitis who currently smoke are likely to be headed for increased disease activity and worse quality of life outcomes.

The results of a cross-sectional, postal survey found that, compared with never smoking, current smoking is associated with higher levels of disease activity, worse functional status, greater pain and overall poorer quality of life.

This is the largest study to date to look at the effects of smoking on disease activity and severity and associated quality of life in ankylosing spondylitis (AS), according to the study’s authors.

"We know that smoking is a risk factor for rheumatoid arthritis ... and is associated with more severe disease and worse response to therapy," said Dr. Derek Mattey on April 13 at the annual meeting of the British Society for Rheumatology.

"The influence of smoking in AS is a lot less clear, however, and [until now] there have been no studies beyond susceptibility and very few studies on smoking as a risk for more severe disease," added Dr. Mattey of Keele University and the University Hospital of North Staffordshire, England.

Questionnaires were sent to 1,000 patients with AS registered at 10 secondary-care rheumatology practices in England. The questionnaire asked about smoking history and used several patient-reported outcome measures. These included the Bath AS disease activity and functional indices (BASDAI/BASFI); pain numeric rating scale (NRS); the AS quality of life questionnaire (ASQoL) and the evaluation of AS quality of life (EASi-QoL).

Data were looked at in terms of smoking status and in relation to the pack-year history. A pack-year is a means to quantify how much a person has smoked over a long time period. It is calculated by multiplying the number of packs smoked per day by the number of years smoked. The higher the pack-year, the longer the person has smoked.

Of 612 patients who responded, 606 provided information about their smoking history. The mean age of respondents was 50.8 years, 72% were male, and the mean disease duration was 17.2 years (standard deviation = 11.7 years). Around half of the cohort had never smoked, with approximately 28% reporting that they were past smokers and 21% saying that they were current smokers.

Mean BASDAI, BASFI, pain NRS, ASQoL, and EASi-QoL scores were all higher, indicating a worse outcome, in patients that had ever smoked, compared with never smokers. Significant, dose-dependent, correlations were also found between the number of pack-years and these disease outcome measures, with worse outcomes the higher the number of pack-years.

"We’ve shown that smoking has a dose-dependent relationship with measures of disease severity in AS," Dr. Mattey said. "High disease activity and more severe pain are most strongly associated with current smoking, while decreased function and poor quality of life are associated more closely with pack-year history."

All these associations appeared to be independent of age, sex, duration, and social deprivation level.

Commenting on the findings after their presentation, Dr. Deborah Symmons of the University of Manchester, England, said: "As this is a cross-sectional study, it is possible that correlation works in the opposite direction, in that people with more active disease and more pain find it more difficult to give up smoking."

Looking at the data longitudinally might be more appropriate, she suggested.

Dr. Mattey agreed that a reverse correlation was possible, but said that most of these patients started smoking before their disease started.

Dr. Mattey said that he had no conflicts of interest but noted that a coinvestigator, Dr. Jonathan Packham, had received an educational grant from Wyeth UK.

BRIGHTON, ENGLAND – Patients with ankylosing spondylitis who currently smoke are likely to be headed for increased disease activity and worse quality of life outcomes.

The results of a cross-sectional, postal survey found that, compared with never smoking, current smoking is associated with higher levels of disease activity, worse functional status, greater pain and overall poorer quality of life.

This is the largest study to date to look at the effects of smoking on disease activity and severity and associated quality of life in ankylosing spondylitis (AS), according to the study’s authors.

"We know that smoking is a risk factor for rheumatoid arthritis ... and is associated with more severe disease and worse response to therapy," said Dr. Derek Mattey on April 13 at the annual meeting of the British Society for Rheumatology.

"The influence of smoking in AS is a lot less clear, however, and [until now] there have been no studies beyond susceptibility and very few studies on smoking as a risk for more severe disease," added Dr. Mattey of Keele University and the University Hospital of North Staffordshire, England.

Questionnaires were sent to 1,000 patients with AS registered at 10 secondary-care rheumatology practices in England. The questionnaire asked about smoking history and used several patient-reported outcome measures. These included the Bath AS disease activity and functional indices (BASDAI/BASFI); pain numeric rating scale (NRS); the AS quality of life questionnaire (ASQoL) and the evaluation of AS quality of life (EASi-QoL).

Data were looked at in terms of smoking status and in relation to the pack-year history. A pack-year is a means to quantify how much a person has smoked over a long time period. It is calculated by multiplying the number of packs smoked per day by the number of years smoked. The higher the pack-year, the longer the person has smoked.

Of 612 patients who responded, 606 provided information about their smoking history. The mean age of respondents was 50.8 years, 72% were male, and the mean disease duration was 17.2 years (standard deviation = 11.7 years). Around half of the cohort had never smoked, with approximately 28% reporting that they were past smokers and 21% saying that they were current smokers.

Mean BASDAI, BASFI, pain NRS, ASQoL, and EASi-QoL scores were all higher, indicating a worse outcome, in patients that had ever smoked, compared with never smokers. Significant, dose-dependent, correlations were also found between the number of pack-years and these disease outcome measures, with worse outcomes the higher the number of pack-years.

"We’ve shown that smoking has a dose-dependent relationship with measures of disease severity in AS," Dr. Mattey said. "High disease activity and more severe pain are most strongly associated with current smoking, while decreased function and poor quality of life are associated more closely with pack-year history."

All these associations appeared to be independent of age, sex, duration, and social deprivation level.

Commenting on the findings after their presentation, Dr. Deborah Symmons of the University of Manchester, England, said: "As this is a cross-sectional study, it is possible that correlation works in the opposite direction, in that people with more active disease and more pain find it more difficult to give up smoking."

Looking at the data longitudinally might be more appropriate, she suggested.

Dr. Mattey agreed that a reverse correlation was possible, but said that most of these patients started smoking before their disease started.

Dr. Mattey said that he had no conflicts of interest but noted that a coinvestigator, Dr. Jonathan Packham, had received an educational grant from Wyeth UK.

BRIGHTON, ENGLAND – Patients with ankylosing spondylitis who currently smoke are likely to be headed for increased disease activity and worse quality of life outcomes.

The results of a cross-sectional, postal survey found that, compared with never smoking, current smoking is associated with higher levels of disease activity, worse functional status, greater pain and overall poorer quality of life.

This is the largest study to date to look at the effects of smoking on disease activity and severity and associated quality of life in ankylosing spondylitis (AS), according to the study’s authors.

"We know that smoking is a risk factor for rheumatoid arthritis ... and is associated with more severe disease and worse response to therapy," said Dr. Derek Mattey on April 13 at the annual meeting of the British Society for Rheumatology.

"The influence of smoking in AS is a lot less clear, however, and [until now] there have been no studies beyond susceptibility and very few studies on smoking as a risk for more severe disease," added Dr. Mattey of Keele University and the University Hospital of North Staffordshire, England.

Questionnaires were sent to 1,000 patients with AS registered at 10 secondary-care rheumatology practices in England. The questionnaire asked about smoking history and used several patient-reported outcome measures. These included the Bath AS disease activity and functional indices (BASDAI/BASFI); pain numeric rating scale (NRS); the AS quality of life questionnaire (ASQoL) and the evaluation of AS quality of life (EASi-QoL).

Data were looked at in terms of smoking status and in relation to the pack-year history. A pack-year is a means to quantify how much a person has smoked over a long time period. It is calculated by multiplying the number of packs smoked per day by the number of years smoked. The higher the pack-year, the longer the person has smoked.

Of 612 patients who responded, 606 provided information about their smoking history. The mean age of respondents was 50.8 years, 72% were male, and the mean disease duration was 17.2 years (standard deviation = 11.7 years). Around half of the cohort had never smoked, with approximately 28% reporting that they were past smokers and 21% saying that they were current smokers.

Mean BASDAI, BASFI, pain NRS, ASQoL, and EASi-QoL scores were all higher, indicating a worse outcome, in patients that had ever smoked, compared with never smokers. Significant, dose-dependent, correlations were also found between the number of pack-years and these disease outcome measures, with worse outcomes the higher the number of pack-years.

"We’ve shown that smoking has a dose-dependent relationship with measures of disease severity in AS," Dr. Mattey said. "High disease activity and more severe pain are most strongly associated with current smoking, while decreased function and poor quality of life are associated more closely with pack-year history."

All these associations appeared to be independent of age, sex, duration, and social deprivation level.

Commenting on the findings after their presentation, Dr. Deborah Symmons of the University of Manchester, England, said: "As this is a cross-sectional study, it is possible that correlation works in the opposite direction, in that people with more active disease and more pain find it more difficult to give up smoking."

Looking at the data longitudinally might be more appropriate, she suggested.

Dr. Mattey agreed that a reverse correlation was possible, but said that most of these patients started smoking before their disease started.

Dr. Mattey said that he had no conflicts of interest but noted that a coinvestigator, Dr. Jonathan Packham, had received an educational grant from Wyeth UK.

NEW YORK – Tumor necrosis factor inhibitors reduced the risk of myocardial infarction, stroke and cardiovascular-related death in patients with rheumatoid arthritis, according to Dr. Jeffrey D. Greenberg, who presented the findings at a rheumatology meeting sponsored by New York University. Methotrexate was not associated with a reduced risk of cardiovascular events, and prednisone use was associated with a dose-dependent increased risk.

The findings come from CORRONA (Consortium of Rheumatology Researchers of North America), a registry of patients with RA or psoriatic arthritis. The study population involved 10,156 patients followed for a median of 23 months. A subset analysis was performed, and 88 patients were identified who had experienced nonfatal myocardial infarction (n = 26), transient ischemic attack or stroke (n = 45), or cardiovascular-related death (n = 17) (Ann. Rheum. Dis. 2011;70:576-82).

In an editorial accompanying Dr. Greenberg’s report (Ann. Rheum. Dis. 2011 70:561-2), Dr. Johan Askling of Karolinska University Hospital, Stockholm, and Dr. Will Dixon of the University of Manchester (England) praiseed Dr. Greenberg’s study in terms of its methodology and transparency. However, they point out that other studies, such as those published by the British Society for Rheumatology Biologics Register (BSRBR), have not supported a cardiovascular protective effect for TNF inhibitors.

Nonbiologic disease-modifying antirheumatic drugs (DMARDs) other than methotrexate served as the reference cohort for all therapeutic comparisons. Relative to nonbiologic DMARDs, methotrexate use was associated with a nonsignificant reduction in risk (HR 0.83, 95% CI 0.44-1.57). In contrast, patients using a TNF inhibitor had a 61% reduced risk of the primary composite cardiovascular end point (HR 0.39, 0.18-0.74).

Dr. Greenberg also showed significant reductions in risk for those taking TNF inhibitors compared with those taking nonbiological DMARDs as measured by a composite end point that included CV deaths (HR = 0.39, 0.19-0.82) and a composite end point that excluded CV deaths (HR = 0.35, 0.16-0.74), and nonfatal MI (HR = 0.24, 0.06-0.95). There was a trend toward reduced risk for nonfatal TIA/stroke (HR = 0.44, 0.18-1.09). "These data indicate that TNF antagonists may represent a therapeutic strategy to attenuate the heightened cardiovascular risk experienced by RA patients," Dr. Greenberg said.

"As expected, there was a dose-dependent increased risk of cardiovascular events with steroids," said Dr. Greenberg of New York University. Prednisone doses between 1-2.5 mg and 3-7 mg almost doubled the risk (HR 1.90 and 1.89, respectively) while doses greater than 7 mg tripled the risk (HR 3.00, 1.44-6.25) (P = .04).

Dr. Greenberg advocates a three-step strategy to decrease cardiovascular risk in RA.

The first is to adhere to recommended cardiovascular disease prevention, screening, and guidelines. This includes management of "traditional" cardiovascular risk factors such as blood pressure, diabetes, lipids, smoking, and obesity, he said.

The second component – as supported by his study’s results – is to minimize use of NSAIDs and corticosteroids, and to utilize steroid-sparing options if possible.

The third component is to aim for tighter control of RA disease activity. For patients at increased CV risk, "I would treat RA aggressively," said Dr. Greenberg. Even so, he acknowledged that it has not been proved that the strategy would alter the natural course of developing cardiovascular disease. It remains to be determined what measures should be targeted, he said, suggesting options such as a specific disease activity score, C-reactive protein levels, or other inflammatory biomarkers.

Indeed, the lack of CV risk assessment tools and evidence-based practice guidelines for improving cardiovascular risk management in RA patients is getting a lot of attention.

Dr. Sherine E. Gabriel and researcher Cynthia S. Crowson of the Mayo Clinic, Rochester, Minn., discussed the limitations of both the SCORE and Framingham Risk Scores (Ann. Rheum. Dis. 2011;70:719-21). While applauding the European League Against Rheumatism (EULAR) for formulating guidelines to improve cardiovascular management in patients with RA, the researchers point out several areas of weakness. Cardiovascular disease risk, for example, is not necessarily associated with longer disease duration. In fact, studies show there is an increased risk of cardiovascular events early in the course of RA, they noted. The risks also are unclear for patients who are RF negative or ACPA negative. Further, RA patients may respond atypically to traditional cardiovascular risk factors.

Dr. Greenberg has done consulting for Centocor, CORRONA, Novartis Pharmaceutical Corp, Roche Laboratories, and UCB. He has received research and grant support from the Arthritis Foundation and the National Institutes of Health. He receives consulting fees from, or owns stock shares in, AstraZeneca, CORRONA, Genentech, Novartis, and Pfizer.

NEW YORK – Tumor necrosis factor inhibitors reduced the risk of myocardial infarction, stroke and cardiovascular-related death in patients with rheumatoid arthritis, according to Dr. Jeffrey D. Greenberg, who presented the findings at a rheumatology meeting sponsored by New York University. Methotrexate was not associated with a reduced risk of cardiovascular events, and prednisone use was associated with a dose-dependent increased risk.

The findings come from CORRONA (Consortium of Rheumatology Researchers of North America), a registry of patients with RA or psoriatic arthritis. The study population involved 10,156 patients followed for a median of 23 months. A subset analysis was performed, and 88 patients were identified who had experienced nonfatal myocardial infarction (n = 26), transient ischemic attack or stroke (n = 45), or cardiovascular-related death (n = 17) (Ann. Rheum. Dis. 2011;70:576-82).

In an editorial accompanying Dr. Greenberg’s report (Ann. Rheum. Dis. 2011 70:561-2), Dr. Johan Askling of Karolinska University Hospital, Stockholm, and Dr. Will Dixon of the University of Manchester (England) praiseed Dr. Greenberg’s study in terms of its methodology and transparency. However, they point out that other studies, such as those published by the British Society for Rheumatology Biologics Register (BSRBR), have not supported a cardiovascular protective effect for TNF inhibitors.

Nonbiologic disease-modifying antirheumatic drugs (DMARDs) other than methotrexate served as the reference cohort for all therapeutic comparisons. Relative to nonbiologic DMARDs, methotrexate use was associated with a nonsignificant reduction in risk (HR 0.83, 95% CI 0.44-1.57). In contrast, patients using a TNF inhibitor had a 61% reduced risk of the primary composite cardiovascular end point (HR 0.39, 0.18-0.74).

Dr. Greenberg also showed significant reductions in risk for those taking TNF inhibitors compared with those taking nonbiological DMARDs as measured by a composite end point that included CV deaths (HR = 0.39, 0.19-0.82) and a composite end point that excluded CV deaths (HR = 0.35, 0.16-0.74), and nonfatal MI (HR = 0.24, 0.06-0.95). There was a trend toward reduced risk for nonfatal TIA/stroke (HR = 0.44, 0.18-1.09). "These data indicate that TNF antagonists may represent a therapeutic strategy to attenuate the heightened cardiovascular risk experienced by RA patients," Dr. Greenberg said.

"As expected, there was a dose-dependent increased risk of cardiovascular events with steroids," said Dr. Greenberg of New York University. Prednisone doses between 1-2.5 mg and 3-7 mg almost doubled the risk (HR 1.90 and 1.89, respectively) while doses greater than 7 mg tripled the risk (HR 3.00, 1.44-6.25) (P = .04).

Dr. Greenberg advocates a three-step strategy to decrease cardiovascular risk in RA.

The first is to adhere to recommended cardiovascular disease prevention, screening, and guidelines. This includes management of "traditional" cardiovascular risk factors such as blood pressure, diabetes, lipids, smoking, and obesity, he said.

The second component – as supported by his study’s results – is to minimize use of NSAIDs and corticosteroids, and to utilize steroid-sparing options if possible.

The third component is to aim for tighter control of RA disease activity. For patients at increased CV risk, "I would treat RA aggressively," said Dr. Greenberg. Even so, he acknowledged that it has not been proved that the strategy would alter the natural course of developing cardiovascular disease. It remains to be determined what measures should be targeted, he said, suggesting options such as a specific disease activity score, C-reactive protein levels, or other inflammatory biomarkers.

Indeed, the lack of CV risk assessment tools and evidence-based practice guidelines for improving cardiovascular risk management in RA patients is getting a lot of attention.

Dr. Sherine E. Gabriel and researcher Cynthia S. Crowson of the Mayo Clinic, Rochester, Minn., discussed the limitations of both the SCORE and Framingham Risk Scores (Ann. Rheum. Dis. 2011;70:719-21). While applauding the European League Against Rheumatism (EULAR) for formulating guidelines to improve cardiovascular management in patients with RA, the researchers point out several areas of weakness. Cardiovascular disease risk, for example, is not necessarily associated with longer disease duration. In fact, studies show there is an increased risk of cardiovascular events early in the course of RA, they noted. The risks also are unclear for patients who are RF negative or ACPA negative. Further, RA patients may respond atypically to traditional cardiovascular risk factors.

Dr. Greenberg has done consulting for Centocor, CORRONA, Novartis Pharmaceutical Corp, Roche Laboratories, and UCB. He has received research and grant support from the Arthritis Foundation and the National Institutes of Health. He receives consulting fees from, or owns stock shares in, AstraZeneca, CORRONA, Genentech, Novartis, and Pfizer.

NEW YORK – Tumor necrosis factor inhibitors reduced the risk of myocardial infarction, stroke and cardiovascular-related death in patients with rheumatoid arthritis, according to Dr. Jeffrey D. Greenberg, who presented the findings at a rheumatology meeting sponsored by New York University. Methotrexate was not associated with a reduced risk of cardiovascular events, and prednisone use was associated with a dose-dependent increased risk.

The findings come from CORRONA (Consortium of Rheumatology Researchers of North America), a registry of patients with RA or psoriatic arthritis. The study population involved 10,156 patients followed for a median of 23 months. A subset analysis was performed, and 88 patients were identified who had experienced nonfatal myocardial infarction (n = 26), transient ischemic attack or stroke (n = 45), or cardiovascular-related death (n = 17) (Ann. Rheum. Dis. 2011;70:576-82).

In an editorial accompanying Dr. Greenberg’s report (Ann. Rheum. Dis. 2011 70:561-2), Dr. Johan Askling of Karolinska University Hospital, Stockholm, and Dr. Will Dixon of the University of Manchester (England) praiseed Dr. Greenberg’s study in terms of its methodology and transparency. However, they point out that other studies, such as those published by the British Society for Rheumatology Biologics Register (BSRBR), have not supported a cardiovascular protective effect for TNF inhibitors.

Nonbiologic disease-modifying antirheumatic drugs (DMARDs) other than methotrexate served as the reference cohort for all therapeutic comparisons. Relative to nonbiologic DMARDs, methotrexate use was associated with a nonsignificant reduction in risk (HR 0.83, 95% CI 0.44-1.57). In contrast, patients using a TNF inhibitor had a 61% reduced risk of the primary composite cardiovascular end point (HR 0.39, 0.18-0.74).

Dr. Greenberg also showed significant reductions in risk for those taking TNF inhibitors compared with those taking nonbiological DMARDs as measured by a composite end point that included CV deaths (HR = 0.39, 0.19-0.82) and a composite end point that excluded CV deaths (HR = 0.35, 0.16-0.74), and nonfatal MI (HR = 0.24, 0.06-0.95). There was a trend toward reduced risk for nonfatal TIA/stroke (HR = 0.44, 0.18-1.09). "These data indicate that TNF antagonists may represent a therapeutic strategy to attenuate the heightened cardiovascular risk experienced by RA patients," Dr. Greenberg said.

"As expected, there was a dose-dependent increased risk of cardiovascular events with steroids," said Dr. Greenberg of New York University. Prednisone doses between 1-2.5 mg and 3-7 mg almost doubled the risk (HR 1.90 and 1.89, respectively) while doses greater than 7 mg tripled the risk (HR 3.00, 1.44-6.25) (P = .04).

Dr. Greenberg advocates a three-step strategy to decrease cardiovascular risk in RA.

The first is to adhere to recommended cardiovascular disease prevention, screening, and guidelines. This includes management of "traditional" cardiovascular risk factors such as blood pressure, diabetes, lipids, smoking, and obesity, he said.

The second component – as supported by his study’s results – is to minimize use of NSAIDs and corticosteroids, and to utilize steroid-sparing options if possible.

The third component is to aim for tighter control of RA disease activity. For patients at increased CV risk, "I would treat RA aggressively," said Dr. Greenberg. Even so, he acknowledged that it has not been proved that the strategy would alter the natural course of developing cardiovascular disease. It remains to be determined what measures should be targeted, he said, suggesting options such as a specific disease activity score, C-reactive protein levels, or other inflammatory biomarkers.

Indeed, the lack of CV risk assessment tools and evidence-based practice guidelines for improving cardiovascular risk management in RA patients is getting a lot of attention.

Dr. Sherine E. Gabriel and researcher Cynthia S. Crowson of the Mayo Clinic, Rochester, Minn., discussed the limitations of both the SCORE and Framingham Risk Scores (Ann. Rheum. Dis. 2011;70:719-21). While applauding the European League Against Rheumatism (EULAR) for formulating guidelines to improve cardiovascular management in patients with RA, the researchers point out several areas of weakness. Cardiovascular disease risk, for example, is not necessarily associated with longer disease duration. In fact, studies show there is an increased risk of cardiovascular events early in the course of RA, they noted. The risks also are unclear for patients who are RF negative or ACPA negative. Further, RA patients may respond atypically to traditional cardiovascular risk factors.

Dr. Greenberg has done consulting for Centocor, CORRONA, Novartis Pharmaceutical Corp, Roche Laboratories, and UCB. He has received research and grant support from the Arthritis Foundation and the National Institutes of Health. He receives consulting fees from, or owns stock shares in, AstraZeneca, CORRONA, Genentech, Novartis, and Pfizer.