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Patients with rheumatoid arthritis in clinical care
  1. J S Smolen,
  2. D Aletaha
  1. Department of Rheumatology, Internal Medicine III, Vienna General Hospital, University of Vienna, and 2nd Department of Medicine, Lainz Hospital, Vienna, Austria
  1. Correspondence to:
    Professor J S Smolen
    University of Vienna, Div of Rheumatology, Department of Internal Medicine III University of Vienna, Vienna General Hospital Vienna, A-1090, Austria;

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The challenge of following process, damage, and function

Rheumatoid arthritis (RA) differs from most other chronic inflammatory arthropathies in its high propensity towards joint destruction.1 The mechanisms leading to this destruction are not fully elucidated, but proinflammatory cytokines and activation of osteoclasts appear to have pivotal pathogenic roles.2–,4

The highly destructive nature of the disease is manifested by the development of erosions in 10–26% of patients with RA within 3 months from the onset of disease,5,6 in over 60% within 1 year,7 and within 2 years about 75% of patients with RA have erosive joint damage.8 Such data are mostly derived from patients in whom a definitive diagnosis of RA had been established. However, even in a community based inception cohort of patients with inflammatory polyarthritis, who only cumulatively fulfil classification criteria for RA, the prevalence of erosive disease was 36% within 2 years.9 The degree of joint destruction accrues with time,10,11 and increasing radiographic joint destruction correlates with decreasing function as measured by patient questionnaires.12


Functional assessment by self report questionnaires has become standard in randomised clinical trials13–,17 as well as clinical research. The most commonly used among the many questionnaires18 is the Stanford Health Assessment Questionnaire (HAQ)19 and its derivatives. These questionnaires measure primarily function and health related quality of life, the improvement of which is the most important aspect in the care for our patients. Nevertheless, these questionnaires do not allow differentiation between the degree to which an impairment in functional activity is due to current disease activity (and thus is process related and potentially reversible), and the extent to which it is a consequence of accrued, long term, largely irreversible damage (and thus constitutes a reflection of the process …

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