Characterization of a Subset of Patients With Rheumatoid Arthritis for Whom Current Management Strategies are Inadequate

Abstract

ObjectiveA subset of patients with seropositive rheumatoid arthritis (RA) do not mount a C‐reactive protein (CRP) response during flares. We hypothesize that these patients are more likely to experience poor clinical care and less likely to respond to traditional therapy. This study questioned whether this presentation was associated with worse disease outcome and distinct immunological features.MethodsUsing Power Doppler ultrasound, 48 RA patients with active synovitis were recruited; 30 had normal (n)CRP (5 mg/L or less) and 18 had high (h)CRP (more than 5 mg/L) levels. All had equivalent disease burden assessed by other clinical and laboratory parameters.ResultsTime to diagnosis and time to first disease‐modifying antirheumatic drug were significantly longer in nCRP compared with hCRP patients (P < 0.05). Significantly more nCRP patients needed escalation to biologics after 2‐year follow‐up (P = 0.01). The inflammatory milieu was also different between the two subgroups. Synergy between inflammatory cytokines observed in hCRP patients was lost in nCRP patients, and nCRP patients had significantly increased regulatory T‐cell (Treg) frequencies that correlated positively with predictors of poor disease outcome. Conversely, hCRP but not nCRP patients demonstrated a significant upregulation of alternative complement pathway factors that correlated negatively with Treg frequency.ConclusionPatients with nCRP during flares of RA had an altered immunological profile compared with hCRP patients and experienced diagnostic delays and responded less favorably to conventional treatment.

Epidemiology and clinical characteristics of interstitial lung disease in patients with rheumatoid arthritis from the JointMan database

“…a Patients from the overall study population with a 6-month follow-up period from baseline. b Binary cut-offs were anti-CCP: > 20 (anti-CCP +) = 1, ≤ 20 (anti-CCP −), and missing = 0; ESR: > 28 mm/h = 1, ≤ 28 mm/h, and missing = 0; CRP: > 5 mg/L or > 0.5 mg/dL 39 = 1, ≤ 5 mg/L or ≤ 0.5 mg/dL, and missing = 0; CDAI: moderate/high CDAI score = 1, remission/low/missing CDAI score = 0. CCP cyclic citrullinated peptide, CDAI Clinical Disease Activity Index, CI confidence interval, CRP C-reactive protein, COPD chronic obstructive pulmonary disease, ESR erythrocyte sedimentation rate, HR hazard ratio, ILD interstitial lung disease, RA rheumatoid arthritis, RA–ILD RA–associated ILD.…”

Time to modify the DAS28 to make it fit for purpose(s) in rheumatoid arthritis?

“…Although composite score components should not be so closely correlated as to be redundant, we expect them to be moderately correlated [2]. However, acute phase reactants may be normal in the presence of quite florid swollen joints, perhaps due to altered immunological profile [4]. ESR varies by sex and age, and CRP is considered a more responsive inflammatory measure than ESR [5].…”