Background Early treatment of rheumatoid arthritis (RA) with treat-to-target strategies aims to reduce disease activity and to prevent joint damage. Assessment of the quality of care is commonly based on measurements of disease activity, functioning and well being. In clinical trials, radiographic scores are widely used to assess structural joint damage, but these are not applicable in routine care and limited to hands and feet. Only a few studies evaluated clinical assessment of irreversible joint damage (e.g. surgery) as outcome. The RA articular damage (RAAD) score counts structural damage in all joints that that are affected by RA1. It correlates with radiographic damage2. We have applied this score since 2014 in routine care.
Objectives Evaluate the feasibility of a simple clinical joint damage score and describe the increment over time in RA patients with varying disease duration.
Methods Cross-sectional study in all patients with a clinical diagnosis of RA visiting the outpatient clinic in 2015 and 2016. Rheumatologists and nurses from the outpatient department of a large regional hospital received a single training to perform the RAAD score. Scores of 0 (no damage), 1 (mild) or 2 (severe: ankylosis, luxation or joint surgery) were assigned to 35 joints (maximum score: 70) with a disease activity score, and stored in the electronic patient record system. Baseline data including ACR 2010 criteria were also registered.
Results In 1007 (67.3%) of 1496 RA patients seen over 2 years RAAD-scores were performed. 652 (64.7%) were female, average age (SD, range) was 62.6 (13.1, 19–95), disease duration 9.9 (9.6, 0–65) years. Rheumatoid factor and ACPA were positive in 70.6% and 70.3% respectively.
RAAD scores related to disease duration illustrate that at disease onset 86%, and after 20 years 37% of the patients has no joint damage (Table). Distribution over joints shows the classical predominance of damage in MCP, PIP and MTP joints (Image). Structural damage in shoulders or elbows was present in 8.3% and 12.5%, in knees and hips in 10,3% each. Despite current treatment strategies, irreversible joint damage of more than 5 joints is present in 6.3% within 10 years.
Conclusions Clinical assessment of joint damage is a feasible parameter of long term outcome in RA. Reflecting overall joint damage, the RAAD-score provides a broader view than radiographic scoring of hands and feet and is easy to apply in routine care. Given the slow increment a single assessment per 5 years may suffice to compare structural joint damage across cohorts of patients.
Zijlstra T, Bernelot Moens H, Bukhari M. The rheumatoid arthritis articular damage score: first steps in developing a clinical index of long term damage in RA. Ann Rheum Dis. 2002;61:20–3.
Hammer H, Odegard S, Fagerhol M, et al. Calprotectin is strongly and independently correlated with joint inflammation and damage in rheumatoid arthritis. Ann Rheum Dis 2007;66:1093–7.
Disclosure of Interest None declared