Co-morbidities in Finnish patients with rheumatoid arthritis: 15-year follow-up.

OBJECTIVES: To study the prevalence and importance of co-morbidities in patients with rheumatoid arthritis (RA) at the time of the diagnosis and after a 15-year follow-up, focusing on the relationship between co-morbidity and disease activity. METHOD: The study population comprised 87 patients with early RA (mean age 44 years, 79% female, and 65% rheumatoid factor positive) collected from the Helsinki area between 1986 and 1989. Data for co-morbidities were collected at baseline and at a 15-year examination or at the time of death, and the age-weighted Charlson co-morbidity index (CCIa) at baseline was calculated for each patient. The disease activity score based on 28 joints (DAS28) was assessed with three parameters at baseline and during the first year (DAS28 AUC0-12). The relationship between co-morbidity and activity of RA was studied in groups CCIa 0, CCIa 1-2, and CCIa ≥ 3. RESULTS: Adequate data were available in 80 patients with a mean age of 60 years and a mean disease duration of 15.4 years. At baseline, 20% of patients had at least one co-morbid condition (CC). At endpoint, 60% of the patients had some co-morbidity: 34% had one CC, 19% two, 5% three, and 2% four CCs. The most common end-point CCs were hypertension (30%), cardiovascular diseases (14%), and malignancies (11%). DAS28 AUC0-12 and DAS28 at end-point were higher in groups CCIa1-2 and CCIa ≥ 3 than in CCIa 0. CONCLUSIONS: Co-morbidities increased during the 15 years of RA and the patients with high baseline CCIa showed higher disease activity both in early disease and at end-point.

Psoriatic arthritis mutilans (PAM) in the Nordic countries: demographics and disease status. The Nordic PAM study.

OBJECTIVE: To determine the prevalence and clinical characteristics of psoriatic arthritis mutilans (PAM) in the Nordic countries. METHOD: Patients with putative PAM aged ≥ 18 years were recruited. Fifty-nine patients were included after clinical examination. RESULTS: The prevalence of PAM in the adult Nordic population was estimated to be 3.69 per million inhabitants [95% confidence interval (CI) 2.75-4.63]. The female to male ratio was close to 1:1. The mean age of skin disease onset was 25 years and the mean age of onset of joint disease was 30 years. The onset of skin disease was 2 years earlier among female patients. At inclusion, the mean duration of arthritis was 27 ± 11 years for male patients and 33 ± 11 years for female patients. PAM was most frequently seen in the distal interphalangeal (DIP) joints of the toes, followed by the IP joint of the thumb and the DIP joint of the little finger on the left hand. Female and male patients had similar numbers of painful and swollen joints. Enthesitis was found in 19 patients (32%), while 38 patients (64%) had a history of dactylitis. Twenty-three of these 38 patients (61%) had a history of dactylitis in the same finger/toe as they had PAM. At the time of inclusion, 45% of the patients were found to have clear or almost clear skin. CONCLUSIONS: PAM in the Nordic countries has a low prevalence, with only three to five cases per million inhabitants. The majority of the patients present with mild skin disease.

Cardiovascular diseases in patients with rheumatoid arthritis.

OBJECTIVES: To study cardiovascular autopsy findings and the lifetime prevalence of cardiovascular diseases (CVDs) in patients with rheumatoid arthritis (RA). METHOD: In 369 RA patients and their reference cases without any rheumatic disease (non-RA), we studied CVDs recorded on autopsy reports at consecutive autopsies from 1952 to 1991. From autopsy referrals by clinicians, we recorded lifetime CVDs. In RA patients autopsied from 1973, we evaluated clinical data. RESULTS: From 1952 to 1991, RA patients had, compared with non-RA, myocardial infarction (MI; 26% vs. 41%) and cerebral infarction (14% vs. 28%) less frequently but cardiac amyloidosis (28% vs. 3%), pericarditis (27% vs. 8%), and diffuse myocardial abnormality (21% vs. 11%) more frequently reported at autopsy. Of RA patients autopsied from 1973, 40% had had a diagnosis of congestive heart failure (CHF) and coronary heart disease (CHD) during their lifetime. The RA patients with CHF had a higher mean erythrocyte sedimentation rate (ESR) than those without CHF. In RA patients, MI or myocardial abnormality at autopsy had no such correlation. In RA, male sex, ischaemic electrocardiogram changes, diabetes, hypertensive disease, and severe radiographic changes typical for RA were associated with MI detected at autopsy. No such associations emerged with respect to diffuse myocardial abnormality. When disorders potentially causing diffuse myocardial damage were excluded, RA patients had, on autopsy reports, compared to non-RA, diffuse myocardial abnormality more frequently (21% vs. 12%, p = 0.002). Cardiac amyloidosis showed no correlation to this. CONCLUSION: RA patients seem to have an increased risk for myocardial damage. The influence of inflammation on the myocardium in RA needs further studies.

Once-monthly oral ibandronate provides significant improvement in bone mineral density in postmenopausal women treated with glucocorticoids for inflammatory rheumatic diseases: a 12-month, randomized, double-blind, placebo-controlled trial.

OBJECTIVES: To study the efficacy and safety of once-monthly oral ibandronate in the prevention of glucocorticoid (GC)-induced osteoporosis (GIOP) in postmenopausal women with inflammatory rheumatic diseases. METHOD: A randomized, double-blind, placebo-controlled, parallel-group study of 140 postmenopausal women was conducted. At baseline, the mean lumbar spine (LS) (L1-L4) bone mineral density (BMD) was normal or osteopaenic (T-score ≥ -2.0) and the patients were receiving treatment with 5-15 mg/day of prednisone equivalent. Patients were randomized 1:1 to receive either monthly oral ibandronate 150 mg or placebo for 12 months. All patients received vitamin D and calcium supplements. The primary endpoint was the relative change in mean LS BMD from baseline to 12 months. RESULTS: Mean LS BMD increased significantly by 2.6% and 3.2% from baseline to 6 and 12 months with ibandronate compared to 0.3% and -0.1% with placebo, respectively (p < 0.001). Comparable significant mean increases were also found in trochanter, femoral neck and total hip BMDs at 12 months. Reductions in the serum levels of bone turnover markers C-terminal telopeptide of type I collagen (sCTX), N-terminal propeptide of type I procollagen (P1NP), and tartrate-resistant acid phosphatase (TRACP) were significantly more marked in the ibandronate group than in the placebo group at 1, 6, and 12 months. Adverse events (AEs) were reported at a similar frequency in both groups. A higher proportion of serious AEs (SAEs) were reported in the ibandronate group without emergence of any single SAE. CONCLUSIONS: Once-monthly oral ibandronate provides a significant increase in LS and total hip BMD with an acceptable safety profile in postmenopausal women treated with low-dose GCs for inflammatory rheumatic diseases.

Impact of early radiographic remission on the 15-year radiographic outcome in patients with rheumatoid arthritis.

OBJECTIVE: To investigate the 15-year radiographic outcome in patients with rheumatoid arthritis (RA) in relation to early radiographic remission. METHODS: A cohort of 87 patients with RA, treated with early-initiated disease-modifying anti-rheumatic drug (DMARD) therapy, was followed up prospectively for 15 years. Radiographs of hands and feet were taken at baseline and at 1, 2, 3, 5, 7, 10, and 15 years, and radiographs of large joints at 15 years. Radiographic outcome was assessed by the Larsen score (LS). Early radiographic remission was defined as a change of ≤ 1 Larsen unit in a year, during the first 2 years. RESULTS: A complete set of radiographs for evaluation was available from 69 patients. Outcome was evaluated in three groups: group A comprised 18 (26%) patients with sustained early radiographic remission (at both year 1 and year 2); group B comprised 20 (29%) patients with temporary early radiographic remission (at either year 1 or year 2); and group C comprised 31 (45%) patients with no early radiographic remission. Radiographic outcome was most favourable in patients with sustained early radiographic remission. The mean change in LS over 15 years was 11 [95% confidence interval (CI) 0-22] in group A, 30 (95% CI 12-51) in group B, and 62 (95% CI 45-81) in group C (p < 0.001). A similar relationship to large joint damage (Larsen large joint score) was seen. CONCLUSIONS: Compared with patients with progressive erosions, our results indicate that early radiographic remission relates to a better long-term radiographic outcome in RA regarding both small joint and large joint changes.

Can disease-modifying anti-rheumatic drugs be discontinued in long-standing rheumatoid arthritis? A 15-year follow-up.

OBJECTIVE: To investigate the 15-year outcome of patients with early rheumatoid arthritis (ERA) with respect to the continuity of treatment. METHODS: We conducted a 15-year follow-up study of 87 patients with ERA treated since diagnosis with disease-modifying anti-rheumatic drugs (DMARDs) according to the 'sawtooth' strategy. The patients were divided into groups according to the continuity of treatment: (A) 'continuous DMARDs', (B) 'discontinued and restarted DMARDs', and (C) 'permanently discontinued DMARDs'. The main outcome measurements included the Health Assessment Questionnaire (HAQ), the Larsen score, and clinical remission according to the American Rheumatism Association (ARA) criteria. RESULTS: Seventy (80%) patients participated in the 15-year follow-up. DMARDs were discontinued in 20 (29%) patients due either to remission or to a symptom-free period of the disease. The disease flared up in nine (45%) of these patients, in some patients several years after the discontinuation. At the 15-year follow-up, 59 (84%) patients were on DMARDs; only three (4%) were using biologicals. Functional capacity remained good in all groups (mean HAQ score 0.52). The mean Larsen score was higher (54) in group A than in groups B (25) and C (12) (p =0.001). The remission rate was 64% in group C and considerably lower in groups A (6%) and B (0%) (p<0.001). CONCLUSIONS: Our results indicate that most of the patients with long-standing RA require continuous DMARD treatment. If the treatment is discontinued, patients should be followed-up closely and DMARDs readministered without delay if the disease flares up.

Causes of death in patients with rheumatoid arthritis autopsied during a 40-year period.

We studied causes of death (CoDs) between 1952 and 1991 assessed by a clinician before autopsy and then determined at autopsy by a pathologist in 369 subjects with rheumatoid arthritis (RA) and 370 subjects without RA (non-RA). We analysed clinical data for RA subjects between 1973 and 1991. In RA subjects, leading autopsy-based CoDs were RA, cardiovascular diseases and infections. Between diagnoses of CoDs by the clinician and those determined by the pathologist, RA subjects had lower agreement than did the non-RA regarding coronary deaths (Kappa reliability measure: 0.33 vs. 0.46). In non-RA subjects, autopsy-based coronary deaths showed a decline since the 1970s with no such decline in RA. Between subjects treated at any time during RA with disease-modifying anti-rheumatic drugs and those without, autopsy-based CoDs were similar. Coronary death being less accurately diagnosed in RA subjects may indicate that coronary heart disease in RA patients often remains unrecognized.

Amyloidosis as a cause of death in patients with rheumatoid arthritis.

OBJECTIVE: To study amyloidosis as a cause of death along with associated factors and frequency of pre-mortem diagnosis in patients with rheumatoid arthritis (RA) autopsied between 1952 and 1991. METHODS: We studied causes of death in 369 consecutively autopsied RA and 370 autopsied non-RA patients of the same sex, age at death, and year of autopsy. In those RA patients who died from 1973 onwards, we were also able to analyse clinical data: pre-mortem diagnosis of amyloidosis, clinical features of RA, and treatment. RESULTS: Based on autopsy, amyloidosis was determined as a cause of death in 9.5% of RA and in none of the non-RA patients (p<0.001). In our RA patients, we detected no trend in deaths from amyloidosis between 1952 and 1991. The RA patients dying of amyloidosis died younger than those dying of other causes (p=0.001). During the course of the disease, the RA patients with amyloidosis had: higher erythrocyte sedimentation rate (p=0.002), lower haemoglobin (p<0.001), more frequently proteinuria (p<0.001) and renal failure (p<0.001) than did the rest of the RA patients. Pre-mortem, amyloidosis was diagnosed by biopsy in 65% of the RA patients with amyloidosis as their cause of death. CONCLUSION: Amyloidosis may be undetected during the course of RA. Thus, it should be actively searched for in the patients with long-lasting and active disease, especially, if they have proteinuria or renal failure.

Combination drug strategy in recent-onset rheumatoid arthritis suppresses collagen I degradation and is associated with retardation of radiological progression.

OBJECTIVE: To assess whether serum C-terminal cross-linking telopeptide of type I collagen (ICTP), a marker of type I collagen degradation, has any additional value in the assessment of treatment effect in patients with early rheumatoid arthritis (RA). METHODS: A total of 182 patients were randomized to treatment either with three disease-modifying anti-rheumatic drugs (DMARDs) and low-dose prednisolone (COMBI) or with a single DMARD with or without low-dose prednisolone (SINGLE). We investigated the prognostic value of serum ICTP level for the progression of joint destruction in X-rays (Larsen's score) from baseline to 2 years. RESULTS: There was a statistically significant decrease in serum ICTP levels from baseline to 1 year. At 6 months, the serum ICTP level was lower in the COMBI patients compared to that of the SINGLE cases (p = 0.008, after adjustment for baseline ICTP). When grouping the patients according to serum ICTP tertiles at 6 months, there was a statistically significant trend for increasing median change in Larsen score from baseline to 2 years from lowest to highest ICTP tertile in the SINGLE patients [p = 0.008, after adjustment for 28-joint Disease Activity Score (DAS28) score and RF status at baseline], while in the COMBI, the change remained low in all ICTP tertiles. CONCLUSIONS: The COMBI strategy for recent-onset RA results in early suppression of type I collagen degradation, which is reflected in radiological joint damage at 2 years. Serum ICTP at 6 months may be useful for identifying those RA patients whose treatment should be intensified to prevent further joint damage.

Infectious causes of death in patients with rheumatoid arthritis: an autopsy study.

OBJECTIVE: To study mortality from infections and accuracy of pre-mortem diagnoses in patients with rheumatoid arthritis (RA) autopsied during a 40-year period. METHODS: We investigated infectious causes of death, findings at autopsy, and clinicians' estimation of cause of death in 369 consecutively autopsied RA and 371 autopsied non-RA patients with same sex, age at death, and year of autopsy. We also compiled clinical features of RA patients from medical records available and examined the association between these and infectious causes of death. RESULTS: Deaths from any infection were more frequent in RA (36%) than in non-RA (26%) patients. In both groups, respiratory and urinary tract infections were the most common infectious causes of death. More RA patients died from urinary tract infections than non-RA patients. In approximately half of the patients in both groups, infection as a cause of death was unrecognized before death, with no major change occurring over the 40-year study period. CONCLUSIONS: Infections, especially respiratory and urinary tract infections, are frequent causes of death in RA patients. The high proportion of undiscovered infections as a cause of death highlights the diagnostic difficulty. With a decreasing number of autopsies being performed at present, greater numbers of infections may be under-reported.

Polymorphism at position +896 of the toll-like receptor 4 gene interferes with rapid response to treatment in rheumatoid arthritis.

The aim of this study was to determine whether the +896 A-->G substitution of the Toll-like receptor 4 (TLR4) gene, causing the Asp299-->Gly change in the extracellular domain of TLR4, influences treatment response in recent-onset rheumatoid arthritis. 169 patients with rheumatoid arthritis were genotyped from the Finnish Rheumatoid Arthritis Combination Therapy trial, in which they were treated either with only one disease-modifying antirheumatic drug (DMARD) with or without prednisolone (single group), or with three DMARDs and prednisolone (combination group). Patients homozygotic for the wild-type +896A allele were compared with those having the polymorphic G allele in terms of early clinical response (at 6 months) by the 28-joint Disease Activity Score (DAS28). 1 of 20 (5%; (95% (confidence interval (CI) 1 to 5)) patients of the single group with TLR4 +896AG or GG and 29 of 67 (43%; (95% CI 31 to 56)) patients with AA were in remission (p = 0.001). DAS28 of the single group with TLR4 +896AG or GG was higher than with AA (p = 0.019). In the combination group, remission rates and DAS28 values were comparable between the genotypes. The polymorphic TLR4 +896G allele may impair treatment response to single DMARD treatment in recent-onset rheumatoid arthritis.

Peptidylarginine deiminase, the arginine to citrulline converting enzyme, is frequently recognized by sera of patients with rheumatoid arthritis, systemic lupus erythematosus and primary Sjögren syndrome.

OBJECTIVE: Antibodies to citrulline-containing epitopes of filaggrin are highly specific for rheumatoid arthritis (RA). We studied whether the enzyme peptidylarginine deiminase (PAD), responsible for the post-translational modification of peptide-bound arginine residues to citrulline, constitutes an antigen for patients with RA. METHODS: IgG antibodies to PAD were measured by enzyme-linked immunosorbent assay (ELISA) in sera from patients with RA, systemic lupus erythematosus (SLE), primary Sjögren syndrome (pSS), multiple sclerosis (MS) and healthy controls. RESULTS: Compared to healthy controls, raised levels of IgG antibodies to PAD were found in 50 of 57 recent-onset RA patients (88%) and in 40 (70%) of the same 57 patients 3 years later (p<0.0001 for both comparisons). Eleven of 51 (22%) patients with RA of long duration, 19/43 (44%) patients with SLE and 16/19 (84%) patients with pSS, but none of 20 patients with MS, had elevated anti-PAD levels. CONCLUSION: The arginine-citrulline converting enzyme PAD was recognized as a new antigen against which patients with inflammatory rheumatic diseases frequently show IgG class antibodies.

Mortality in patients with rheumatoid arthritis treated actively from the time of diagnosis.

OBJECTIVES: To evaluate the mortality rates among patients with early rheumatoid arthritis (RA) treated actively according to the "sawtooth" strategy. METHODS: The study included 150 early, disease modifying antirheumatic drug (DMARD) naive patients with RA from two patient cohorts. The first cohort was assembled between 1986 and 1989 (87 patients, aged 19-65 years at onset) and the second between 1991 and 1993 (63 patients, aged 27-83 years at onset). The mean duration of symptoms at the time of diagnosis was 7.1 months (range 2-24). The clinical data and the use of DMARDs were systematically recorded. The causes of death were obtained from death certificates and medical records, if available. The data were collected up to 1 November 2000. RESULTS: During a follow up time of 7-14 years, 24 patients died. The standardised mortality ratio was not increased (0.93 in the first cohort and 1.62 in the second cohort). Age adjusted mortality rates did not differ statistically significantly between the two patient cohorts. The causes of death included malignancy (8 patients); cardiovascular diseases (10); respiratory disease (4), including two patients with pneumonia; sepsis (one); and RA (one). High inflammatory activity, disease activity, and poor functional ability at study entry, and the presence of extra-articular features during the follow up were more common among the patients who had died. CONCLUSIONS: No statistically significant increase in mortality rates was seen in these actively treated early RA cohorts during the follow up. High disease activity at the onset and the development of extra-articular features seem to be associated with mortality.

Current features of peptic ulcer disease in Finland: incidence of surgery, hospital admissions and mortality for the disease during the past twenty-five years.

BACKGROUND: Medical therapy of peptic ulcer disease (PUD) has improved dramatically during the past 20 years with the introduction of modern antisecretory drugs as well as eradication therapy of Helicobacter pylori. During the 1990s, there has been a 3-fold increase in the consumption of histamine-2-receptor antagonists and proton-pump inhibitors, but also an 8-fold increase in the consumption of nonsteroidal anti-inflammatory drugs (NSAIDs) in Finland. METHODS: The incidence of surgery, hospital admissions and mortality for PUD was analysed between 1972 and 1999; the data were collected from the National Research and Development Centre for Welfare and Health and from the National Centre for Statistics. In the analysis, the codes of the Intemational Statistical Classification of Diseases 8-10 were used. RESULTS: In 1987, 11.9 elective operations (per 10(5) inhabitants) were performed (mean of 2 consecutive years), but only 1.3 in 1997, a reduction of 89%. In 1987, 5.2 emergency operations for ulcer perforation or bleeding were performed, whereas there were 7.5 in 1997, an increase of 44%. The annual hospital admission rate increased from 38.3 admissions (per 10(5) inhabitants) in 1972 (mean +/- s (standard deviation) of 5 consecutive years) to 68.7 in 1992. This 79% increase was mainly due to bleeding from gastric ulcer in elderly women. The overall annual mortality rate increased between 1972 and 1992 from 6.4 to 8.4 deaths (per 10(5) inhabitants), i.e. by 31%. The mortality rate from ulcer perforation and haemorrhage increased from 4.2 deaths in 1972 to 7.3 deaths in 1992, i.e. by 74%. CONCLUSIONS: The increasing incidence rates of emergency surgery, hospital admissions and mortality for PUD in the 1980s and 1990s have started to decrease in the most recent years in Finland. This epidemiologic change probably reflects both the demographic change and an increased consumption of NSAIDs, among the elderly people, in particular. The most recent epidemiologic change may reflect an increased consciousness about the harmful effects of conventional NSAIDs. Regardless of the constantly occurring emergency surgery, elective surgery for PUD is hardly ever required today.

Increased level of YKL-40 in sera from patients with early rheumatoid arthritis: a new marker for disease activity.

YKL-40 is a newly discovered major secretory protein of human chondrocytes and synoviocytes. We measured serum levels of YKL-40 in 52 patients with early onset rheumatoid arthritis (RA) by enzyme-linked immunosorbent assay (ELISA) during a 2-year prospective follow-up, correlating values with laboratory and clinical variables and radiographic progression. Levels at baseline before antirheumatic therapy were significantly higher in patients than in healthy controls. The levels of YKL-40 correlated with laboratory and clinical markers of disease activity both at baseline and during follow-up. Baseline YKL-40 values correlated with baseline Larsen scores but did not predict radiographic progression. Baseline and mean YKL-40 values did not differ between fast and slow radiological progressions. Mean YKL-40 levels correlated with the number of swollen joints but were not predictors of radiographic progression. These results suggest that in early RA, serum YKL-40 is an inflammatory marker correlating with disease activity. However, its levels do not predict clinical course or radiographic progression.

Focal sialadenitis in patients with ankylosing spondylitis and spondyloarthropathy: a comparison with patients with rheumatoid arthritis or mixed connective tissue disease.

OBJECTIVES: To investigate the occurrence of and risk factors for focal sialadenitis in patients with rheumatoid arthritis (RA), mixed connective tissue disease (MCTD), ankylosing spondylitis (AS), and spondyloarthropathy (SpA). METHODS: A total of 85 patients (25 with RA, 19 with MCTD, 19 with AS, 22 with SpA) participated in the study. Each patient filled out a questionnaire for eye and oral symptoms and for the use of medication, and was interviewed; other tests included Schirmer's test, laboratory tests, collection of unstimulated and stimulated whole saliva, and minor salivary gland biopsy. A focus score of > or =1 was regarded as an indicator of focal sialadenitis. RESULTS: Focal sialadenitis was observed in 68% (57/84) of all patients. It affected 80% (20/25) of the patients with RA, 94% (17/18) of those with MCTD, 58% (11/19) of those with AS, and 41% (9/22) of those with SpA (chi(2) test, p=0.0013). Salivary secretion correlated negatively with the focus scores-that is, severity of focal sialadenitis. Patients with focal sialadenitis had both decreased salivary secretion and decreased tear secretion significantly more often than did patients without (chi(2) test, p=0.0074 and p=0.048 respectively). Patients with positive rheumatoid factor (RF), antinuclear antibodies (ANA), or SSA or SSB antibodies had sialadenitis significantly more often than did patients with negative antibodies. In the subgroup of patients with AS or SpA, no associations were found between focal sialadenitis and the presence of these antibodies. CONCLUSION: In addition to patients with RA or MCTD, focal sialadenitis also affects a very high proportion of patients with AS or SpA. Focus scores are significantly higher in patients with RA or MCTD than in those with AS or SpA. A significant association exists between focal sialadenitis and RF, ANA, SSA and SSB. However, in the subgroup of patients with AS or SpA, no associations were found between focal sialadenitis and serological markers or clinical symptoms.

Effect of treatment on the outcome of very early rheumatoid arthritis.

OBJECTIVE: To evaluate the effect of treatment on the outcome of very early RA. METHODS: In a 3-year prospective study of 27 patients with very early RA (VERA) (symptoms <4 months before diagnosis) and 122 patients with early RA (symptoms between 4-24 months) the effect of active treatment on the clinical picture, functional capacity, and radiological progression was evaluated. RESULTS: Initially VERA patients had a more active clinical picture and worse functional capacity. Despite a higher number of DMARDs used in VERA patients, C-reactive protein and Ritchie index remained significantly higher in these patients (although significant improvement occurred). They also had a more rapidly progressive disease (higher Larsen score/month of symptoms) during pre-treatment period, the progression of which was retarded with early, active DMARD therapy. By the end of 3 years, the rate of progression ran parallel in both groups. CONCLUSION: Active treatment had an impact on the rate of radiological progression and clinical activity but not on the functional outcome in patients with initially active RA of short duration.

Treatment strategy, disease activity, and outcome in four cohorts of patients with early rheumatoid arthritis.

OBJECTIVE: To compare four different inception cohorts of patients with early rheumatoid arthritis (RA) with respect to treatment strategies, disease activity, and outcome during a five year follow up period. METHOD: Data from cohorts of patients with early RA, with a standardised assessment at least every six months for five years from four different centres, were included in one database. Owing to slight differences in the individual study designs, linearly interpolated values were calculated to complete the standard follow up schedule. RESULTS: Despite similar inclusion criteria, significant differences in demographic factors and baseline disease activity were found between the different cohorts. During the follow up an aggressive treatment strategy was followed in the Dutch and Finnish cohort, an intermediate strategy in the British cohort, and a conservative strategy in the Swedish cohort. A significant improvement in disease activity was seen in all cohorts, though the most rapid and striking improvement was seen in those receiving aggressive treatment. This resulted in less radiographic destruction in the long run. CONCLUSION: This observational study of cohorts of patients with early RA confirms that early aggressive treatment results not only in a more rapid reduction of disease activity but also in less radiographic progression in the long term.