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  1. J. Gwinnutt1,
  2. S. Norton2,3,
  3. K. Hyrich1,4,
  4. M. Lunt1,
  5. B. Combe5,
  6. N. Rincheval6,
  7. A. Ruyssen-Witrand7,
  8. B. Fautrel8,9,
  9. J. Chipping10,11,
  10. A. Macgregor10,11,
  11. S. Verstappen1,4
  1. 1The University of Manchester, Centre for Epidemiology Versus Arthritis, Manchester, United Kingdom
  2. 2King’s College London, Health Psychology section, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
  3. 3King’s College London, Department of Inflammation Biology, Faculty of Life Sciences and Medicine, London, United Kingdom
  4. 4Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
  5. 5The University of Montpellier, Department of Rheumatology, CHU Montpellier, Montpellier, France
  6. 6The University of Montpellier, Laboratory of Biostatistics and Epidemiology, Montpellier, France
  7. 7Hôpital Purpan, Centre de Rhumatologie, Toulouse, France
  8. 8Pitie Salpetriere Hospital, Department of Rheumatology, Assistance Publique Hôpitaux de Paris, Paris, France
  9. 9Sorbonne University, INSERM UMRS, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
  10. 10University of East Anglia, Norwich Medical School, Norwich, United Kingdom
  11. 11Norfolk and Norwich University Hospitals NHS Trust, Rheumatology Department, Norwich, United Kingdom


Background: Long-term studies in rheumatoid arthritis (RA) have reported low inflammation yet high disability over time. It is important to determine which factors are driving this disparity, so appropriate interventions can be used to reduce this gap.

Objectives: To identify a subgroup of people with RA with low inflammation yet high disability over 10 years, and describe their characteristics.

Methods: Data came from two cohorts of inflammatory arthritis with regular assessments over 10 years: the Norfolk Arthritis Register (NOAR, inclusion: ≥2 swollen joints for ≥4 weeks) from the UK and the Etude et Suivi des Polyarthrites Indifférenciées Récentes study (ESPOIR, inclusion: early RA) from France. Participants provided demographic data and completed patient reported outcomes (PROs, including the Health Assessment Questionnaire [HAQ]). The 2-component Disease Activity Score (DAS28-2C)1, a measure of inflammation, was calculated from swollen joint counts and C-reactive protein level. Inclusion criteria for this analyis: <2 years baseline symptom duration; HAQ and DAS28-2C at baseline and one other follow-up; recruited after 1/1/2000. HAQ and DAS28-2C were modelled simultaneously using a multivariate group-based trajectory model, to identify groups of participants with similar trajectories of HAQ and DAS28-2C over 10 years. Baseline demographics and PROs were compared between the trajectory groups using logistic regression. Analyses performed separately in NOAR and ESPOIR.

Results: 1001 NOAR and 767 ESPOIR participants were included. In both cohorts, a four group trajectory model had the best fit (Figure). Two subgroups were identified in each cohort that demonstrated the hypothesised relationship: similar DAS28-2C but differing HAQ scores (red trajectories in Figure), titled “High HAQ” and “Low HAQ” (mean difference in HAQ over follow-up [95% confidence interval (CI)]: NOAR 0.76 [0.73, 0.80]; ESPOIR 0.89 [0.82, 0.96]). At baseline, the High HAQ groups in both NOAR and ESPOIR were older, had a higher proportion of women, and had higher levels of fatigue (NOAR: odds ratio [OR] 1.16 [95% CI 1.06, 1.28]; ESPOIR: OR 1.20 [95% CI 1.05, 1.36] [Table]) and pain (NOAR only).

Table 1.

Baseline characteristics / logistic regression analysis

Conclusion: There is a group of people with RA with high levels of disability, despite low inflammation. These results underline the potential need for pain and fatigue management in people with RA, even when inflammation is low.

References: [1]Hensor et al (2019). Rheumatology (Oxford) 58(8)

Acknowledgements: Thanks to the participants of NOAR and ESPOIR and those working in the recruiting centres

ESPOIR Funding: An unrestricted grant from Merck Sharp and Dohme (MSD) was allocated for the first 5 years of the cohort study. Two additional grants from INSERM supported part of the biological database. The French Society of Rheumatology, Abbvie, Pfizer, Lilly and more recently Fresenius and Biogen supported the ESPOIR cohort study.

Disclosure of Interests: James Gwinnutt Grant/research support from: Research grant from Bristol Myers Squibb unrelated to this project, Sam Norton Consultant of: Pfizer and AstraZeneca, Kimme Hyrich Consultant of: Abbvie, Grant/research support from: Pfizer and BMS, Mark Lunt: None declared, Bernard Combe: None declared, Nathalie Rincheval: None declared, Adeline Ruyssen-Witrand: None declared, Bruno Fautrel: None declared, Jacqueline Chipping: None declared, Alex MacGregor: None declared, Suzanne Verstappen: None declared

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