Understanding the reactivation pattern of rheumatoid arthritis

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Rheumatoid arthritis (RA) is a chronic and systemic inflammatory disease capable of leading to functional disability and joint deformities. In addition to the systemic factors involved, there seems to be a contribution of local factors in the affected joints: mechanical stress, differences in vascularization and invervation, specific differentiation of fibroblasts and migration of B lymphocytes to the synovial space seem to be important in this context.

To better understand whether patients are more likely to reactivate previously affected joints, Heckert et al. performed a subgroup analysis of the data from the BeSt study, which will be summarized below.

Read too: Treatment in rheumatoid arthritis: is there still a place for triple therapy?

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Methods

This is a subgroup analysis of the BeSt study, which was a multicenter study designed to assess impact of treat-to-target . This study began in 2000, with a 10-year follow-up. A total of 508 newly diagnosed patients with active RA who met the classification criteria of the 1987 ACR and had symptom duration ≤ 2 years were included.

At each visit of the original study, a total of 68 joints were analyzed for pain and swelling; in this sub-analysis, the researchers considered only edema as a marker of active synovitis.

Pisode of joint edema was defined as the presence of edema on one or multiple subsequent visits. Recurrence of joint edema was defined as a new episode of edema in a joint that was previously without edema. Persistent joint edema was defined as the presence of edema in 2 or more consecutive visits.

The statistical analysis was performed considering the joint edema in the baseline as reference. Different models and sensitivity analyzes were performed. For more details, see the original article. Results

The follow-up median of the 508 patients included was 40 (IQR 24-40) visits, that is, 10 (IQR 6-10) years.

No baseline, the mean age was 54±14 years, with a median of 23 (IQR 14-53) weeks of symptom duration . The mean DAS at baseline was 4.42±0.86, with 16±8 swollen joints. Of the 34,423 joints analyzed, 8,137 (24%) were swollen; of these, 30% remained swollen on subsequent visits (median of 1 visit, 3 months after baseline ).

The logistic regression model found that the fact that a joint was swollen in the baseline increased the chance of a new episode of edema in the same joint, with OR of 1.73 (95% CI 1.67-1.80; p

Another interesting fact is that not only the presence of edema, but also its duration, was associated with a higher probability of joint edema in the follow-up, even with the treatment treat-to -target .

Learn more:

Treat-to-target (T2T) and reduction of doses in rheumatoid arthritis (RA) in times of Covid-19

Comments
This study was the first to demonstrate that RA reactivation tends to act put swollen joints at the onset of the disease.
From the point of view of basic science, these findings are important to direct efforts that allow understand what are the local factors that can contribute to this pattern of reactivation.
From a clinical point of view, it is important that the rheumatologist be aware of the joints that the patient reports as most frequently affected. Thus, it may be important to monitor these more closely articulations and a more aggressive local treatment. Future studies will help answer these questions.

Author (The):

Professor of Rheumatology at the University Federal de Juiz de Fora • Head of the Internal Medicine Service of the University Hospital of the Federal University of Juiz de Fora • Member of the Antiphospholipid Syndrome Committee of the Brazilian Society of Rheumatology.

References:

Heckert SL, Bergstra SA, Matthijssen XME, et al. Joint inflammation tends to recur in the same joints during the rheumatoid arthritis disease course. Ann Rheum Dis. 2021;0:1–6. It hurts: 10.1136/annrheumdis-2021-220882

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