RA is Changing: Maybe for the Better, or Worse, or it is the Same

Several abstracts discussed mortality rates in RA. Mortality rates are decreasing overall but there is still a gap (and in fact, the standardized mortality ratio is not different from what was reported in the past since the general population had a shorter life span than now). This has been recognized by Dr. Gabriel’s group (Rochester, Minesota)¹, and by Ontario data (Widdifield J, et al)². Dr. Lindhardsen from Denmark showed that the mortality gap was still present in RA comparing the age- and sex-matched population of Denmark to those indentified with RA (OP0046). There was approximately 35% more deaths (Standardized Mortality Ratio of approximately 1.35) with the common excess deaths being from cardiovascular disease and cancer. Perhaps unexpectedly, there were proportionately more deaths (more than two-fold higher) from infection but the deaths from infection were uncommon so this did not account for the ongoing increased rates of mortality. So mortality may be less but the gap compared to the population is still present and nearly the same decade over decade.

We believe that RA is becoming more mild – the age of onset is older (ERA cohorts have a mean age of onset of approximately 55 years whereas 15 years ago it was at least a decade younger). Tony Zhang, an internal medicine trainee from Canada, reported that cervical spine involvement was statistically less common over time based on a meta-analysis. The reduction was from a decreasing rate over decades of the most common involvement (anterior atlantoaxial subluxation) (THU0170). So a complication such as neck involvement in RA is decreasing. However, a group from Hungary (Apathy A and Bely M, #THU0263) studied 237 RA systemic vasculitis patients who had died and had autopsies between 1969 and 2000. They did not mention if more cases had occurred since then but had not died or were not autopsied. Since 1985, the RA patients who died of vasculitis were approximately 10 years older than in the early group, but they found the rate of vasculitis compared to the number of RA patients that were followed at their institution was increased and that there was more severe vasculitis at time of death in the later years studied. The poster did not discuss if Hepatitis C was ruled out. We don't know if there were changing referral patterns and the last 15 years were not reported, so there may be a different prevalence of RA vasculitis today. This seems contrary to my experience where RA vasculitis (especially patients who are ill from it) is extremely uncommon.

References:

1. Myasoedova E, et al. Curr Rheumatol Rep. Oct 2010;12(5):379-385.

2. Widdifield J, et al. Arthritis Care Res 2015 Jan 26.

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