Background Patients with rheumatoid arthritis (RA) have an increased mortality compared to the general population. Previous studies have shown that this is attributable to cardiovascular and respiratory disease. Over recent years earlier and more aggressive treatment with higher dosage of methotrexate and the earlier use of biologic drugs has improved disease outcomes. The effect on cause of death is unknown. In this retrospective cohort study we found the major cause of death was infection followed by malignancy and found no correlation with seropositivity or gender.
Objectives To analyse the causes of death in RA patients treated with aggressive disease modifying anti rheumatic drugs (DMARD) and Biologic therapies in Berkshire, UK.
Methods Patients with RA who died between 2010 and 2016 were identified using the DAWN software DMARD monitoring database. A cohort of 3106 patients with RA are monitored using DAWN software in Berkshire, UK. The causes of death were identified from medical records, general practice records or the local coroners office.
Results 198 patients on DAWN monitoring died during the 6 year study period. Treatment details and cause of death was identified for 131 RA patients. 71% were seropositive for rheumatoid factor and 61% were female.
91 patients (69%) were treated with methotrexate, 28 hydroxychloroquine (21%), 14 sulphasalazine (21%) and 7 with leflunomide (5%). The majority of patients (81) were on monotherapy (61%), 32 were on 2 DMARDS (24%) and only one was on triple therapy.
4 patients with RA who died were on biologic monotherapy, 10 were treated with biologic and combination DMARD. The most commonly prescribed biologics were etanercept (35%) and rituximab (35%).
The leading causes of death in this cohort were pneumonia (39 patients 29%), cerebrovascular disease (16 patients 12%), septicaemia (11 patients 8%) and lung cancer (6 patients 4%).
Infection accounted for 57 patients' deaths (43%) followed by malignancy in 24 patients (18%). Cerebrovascular disease (20 patients, 15%) and cardiovascular disease (13 patients, 9%) were less frequent causes of death in our cohort.
Comorbidity data for the cohort was recorded premortem. 49 patients (37%) had cardiovascular disease of any kind. 25% had respiratory disease and 23% had an endocrine comorbidity (predominantly diabetes).
Conclusions In our large cohort of aggressively treated RA patients, infection followed by malignancy and not cardiovascular disease, was the leading cause of death. Larger prospective studies will be required to see if cumulative drug toxicity of more aggressive early treatment improves outcome from RA but changes mortality from comorbidities over time.
Disclosure of Interest None declared