Background Morbidity and mortality in patients with rheumatoid arthritis (RA) are mainly increased by extra-articular manifestations (EA-RA). Studies have suggested that only RA patients with systemic manifestations, as opposed to RA patients without systemic manifestations, have an increased mortality when compared with the general population.[1, 2]
Objectives To assess the development of extra-articular manifestations of rheumatoid arthritis (RA) - lung disease, renal disease, nodules and vasculitis - in patients receiving anti-TNF treatment.
Methods 152 patients with an established diagnosis of RA, who have received anti-TNF therapy (Infliximab, Etanercept, Adalimumab) were randomly selected from the Charing Cross Hospital (London, UK) Rheumatology department database.
Results 110 patients (72.8%) never had extra-articular manifestations of RA, whereas 42 patients (27.2%) did have one of the mentioned extra-articular manifestations of RA before or after commencing anti-TNF therapy. This represents a very high percentage compared to the prevalence of the EA-RA among the RA population previously reported in studies (8-12%).[1-4]
Only women developed lung disease, renal impairment or vasculitis, but this could be due to the high prevalence of RA among female population rather than a higher risk for extra-articular manifestations’ development in women.
In 22 cases (14.47%), a new extra-articular manifestation developed after starting anti-TNF (8 cases of lung disease; 11 cases of rheumatoid nodules; 3 cases of vasculitis). In 5 cases, there was clear evidence of progression of pre-existing EA-RA (2 lung disease, 3 nodules). Regression was found in 4 cases of nodular RA. Renal disease was found in just one case, and it had a stable evolution throughout the whole anti-TNF treatment period. In the rest of the cases, the evolution of EA-RA remains unclear.
The incidence rate of new onset of EA-RA was 7.5 cases per 1000 person-years, which gives a risk of developing new EA-RA of 2.73 cases per person-year. When relating to period of exposure to anti-TNF, the risk was 6.57 cases per person-year.
Conclusions Flares and extra-articular disease are still present in patients treated with anti-TNF. In some of the cases, this is due to treatment failure, because of high activity of the disease. In other cases, the development of extra-articular manifestations may be associated with the use of anti-TNFs.
Turesson C, O’Fallon WM, Crowson CS, et al. Occurrence of extraarticular disease manifestations is associated with excess mortality in a community based cohort of patients with rheumatoid arthritis. J Rheumatol. 2002;29:62-67.
Turesson C, Jacobsson LT. Epidemiology of extra-articular manifestations in rheumatoid arthritis. Scand J Rheumatol. 2004;33:65-72.
Turesson C, Eberhardt K, Jacobsson LT, et al. Incidence and predictors of severe extra-articular disease manifestations in an early rheumatoid arthritis inception cohort. Ann Rheum Dis. 2007;66:1543-1544.
Lindqvist E, Saxne T, Geborek P, et al. Ten year outcome in a cohort of patients with early rheumatoid arthritis: health status, disease process, and damage. Ann Rheum Dis. 2002;61:1055-1059.
Acknowledgements Sister Angela Smith designed the database. Marie Kelleher provided the hospital notes for the randomised cases. Michael Soljak and Hillary Watt helped with statistical advice.
Disclosure of Interest None Declared
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