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Objective. The Combinatietherapie Bij Reumatoide Artritis (COBRA) trial demonstrated that stepdown combination therapy with prednisolone, methotrexate, and sulfasalazine (SSZ) was superior to SSZ monotherapy for suppressing disease activity and radiologic progression of rheumatoid arthritis (RA). The current study was conducted to investigate whether the benefits of COBRA therapy were sustained over time, and to determine which baseline factors could predict outcome.Methods. All patients had participated in the 56-week COBRA trial. During followup, they were seen by their own rheumatologists and were also assessed regularly by study nurses; no treatment protocol was specified. Disease activity, radiologic damage, and functional ability were the primary outcome domains. Two independent assessors scored radiographs in sequence according to the Sharp/van der Heijde method. Outcomes were analyzed by generalized estimating equations on the basis of intent-to-treat, starting with data obtained at the last visit of the COBRA trial (56 weeks after baseline).Results. At the beginning of followup, patients in the COBRA group had a significantly lower mean time-averaged 28-joint disease activity score (DAS28) and a significantly lower median radiologic damage (Sharp) score compared with those in the SSZ monotherapy group. The functional ability score (Health Assessment Questionnaire [HAQ]) was similar in both groups. During the 4-5 year followup period, the timeaveraged DAS28 decreased 0.17 points per year in the SSZ group and 0.07 in the COBRA group. The Sharp progression rate was 8.6 points per year in the SSZ group and 5.6 in the COBRA group. After adjustment for differences in treatment and disease activity during followup, the between-group difference in the rate of radiologic progression was 3.7 points per year. The HAQ score did not change significantly over time. Independent baseline predictors of radiologic progression over time (apart from treatment allocation) were rheumatoid factor positivity, Sharp score, and DAS28.Conclusion. An initial 6-month cycle of intensive combination treatment that includes high-dose corticosteroids results in sustained suppression of the rate of radiologic progression in patients with early RA, independent of subsequent antirheumatic therapy.Rheumatoid arthritis (RA) is a chronic, potentially disabling disease characterized by inflammation of the joints, periarticular bone resorption and cartilage

ObjectivesUveitis, psoriasis and inflammatory bowel disease (IBD) are common extra-articular manifestations (EAM) in patients with ankylosing spondylitis (AS); however, summary data of reported prevalence are lacking. The aim of the present study was to summarise the prevalence of EAMs among patients with AS and to identify underlying factors to explain potential heterogeneity of prevalence.MethodsA systematic literature search was performed (Medline, Embase and Cochrane Library) to identify relevant articles. Risk of bias was assessed and data were extracted. Pooled prevalences were calculated. Potential sources of any observed clinical or methodological heterogeneity in the estimates were explored by subgroup and metaregression analysis.ResultsIn the 156 selected articles, 143 reported the prevalence of uveitis (44 372 patients), 56 of psoriasis (27 626 patients) and 69 of IBD (30 410 patients). Substantial heterogeneity was observed in prevalence estimates among all EAMs (I2=84–95%). The pooled prevalence of uveitis was 25.8% (95% CI 24.1% to 27.6%), and was positively associated in multivariable metaregression with disease duration (β 0.05, 95% CI 0.03 to 0.08) and random selection of patients (β −0.24, 95% CI −0.43 to −0.04). The pooled prevalence of psoriasis was 9.3% (95% CI 8.1% to 10.6%). The pooled prevalence of IBD was 6.8% (95% CI 6.1% to 7.7%) and was positively associated with the percentage of women in the studies (β 0.02, 95% CI 0.00 to 0.03). Geographical area was associated in multivariable metaregressions with prevalence of all EAMs.ConclusionsEAMs are common in patients with AS. The large heterogeneity between studies can be partly explained by differences in clinical as well as methodological characteristics.

Patients with RA in lower income European countries have less access to bDMARDs and sDMARDs, with particularly striking unaffordability of bDMARDs in some of these countries. When accepting that sDMARDs and bDMARDs are equally needed across countries to treat RA, our data point to inequities in access to pharmacological treatment for RA in Europe.

Objective. To assess the efficacy of low-dose prednisolone on joint damage and disease activity in patients with early rheumatoid arthritis (RA).Methods. At the start of their initial treatment with a disease-modifying antirheumatic drug (DMARD), patients with early (duration <1 year) active RA were randomly assigned to receive either 7.5 mg/day prednisolone or no prednisolone for 2 years. Radiographs of the hands and feet were obtained at baseline and after 1 and 2 years and scored according to the Sharp score as modified by van der Heijde. Remission was defined as a Disease Activity Score in 28 joints of <2.6. Bone mineral density was measured by dual x-ray absorptiometry at baseline and after 2 years.Results. Of the 250 patients included, 242 completed the study and 225 had radiographs available both at baseline and at 2 years. At 2 years, the median and interquartile range (IQR) change in total Sharp score was lower in the prednisolone group than in the noprednisolone group (1.8 [IQR 0.5-6.0] versus 3.5 [IQR 0.5-10]; P ‫؍‬ 0.019). In the prednisolone group, there were fewer newly eroded joints per patient after 2 years (median 0.5 [IQR 0-2] versus 1.25 [IQR 0-3.25]; P ‫؍‬ 0.007). In the prednisolone group, 25.9% of patients had radiographic progression beyond the smallest detectable difference compared with 39.3% of patients in the no-prednisolone group (P ‫؍‬ 0.033). At 2 years, 55.5% of patients in the prednisolone group had achieved disease remission, compared with 32.8% of patients in the no-prednisolone group (P ‫؍‬ 0.0005). There were few adverse events that led to withdrawal. Bone loss during the 2-year study was similar in the 2 treatment groups.Conclusion. Prednisolone at 7.5 mg/day added to the initial DMARD retarded the progression of radiographic damage after 2 years in patients with early RA, provided a high remission rate, and was well tolerated. Therefore, the data support the use of low-dose prednisolone as an adjunct to DMARDs in early active RA.

Objective. To summarize the prevalence of spondyloarthritis (SpA) and its subtypes in the general population, and to identify demographic and methodologic characteristics that might explain heterogeneity in prevalence estimates. Methods. A systematic literature search was performed to identify relevant articles. Risk of bias was assessed and data were extracted. Pooled prevalences were calculated. Potential sources of heterogeneity were explored by subgroup analysis and meta-regression analysis.Results. The prevalence of SpA ranged from 0.20% (95% confidence interval [95% CI] 0.00-0.66) in South-East Asia to 1.61% (95% CI 1.27-2.00) in Northern Arctic communities; the prevalence of ankylosing spondylitis (AS) from 0.02% (95% CI 0.00-0.21) in Sub-Saharan Africa to 0.35% (95% CI 0.24-0.48) in Northern Arctic communities; and the prevalence of psoriatic arthritis (PsA) from 0.01% (95% CI 0.00-0.17) in the Middle East to 0.19% (95% CI 0.16-0.32) in Europe. The following characteristics were significantly associated with variation in prevalence of SpA, AS, and/or PsA: proportion of females, mean age of the sample, geographic area and setting (demographic characteristics), year of data collection, case finding, and case ascertainment (methodologic characteristics). For the other SpA subgroups, too few studies were available to conduct a meta-analysis, but prevalence estimates of reactive arthritis (range 0.0-0.2%), SpA related to inflammatory bowel disease (range 0.0-0.1%), and undifferentiated SpA (range 0.0-0.7%) were generally low. Conclusion. SpA is a common disease, but with large variation in reported prevalence estimates, which can partly be explained by differences in demographic and methodologic characteristics. Particularly, geographic area as well as case finding account for a substantial part of the heterogeneity.

IntroductionThe Work Productivity and Activity Impairment (WPAI) questionnaire is a well validated instrument to measure impairments in work and activities. However, its validation among patients with rheumatoid arthritis (RA) has not been well established. The present study's purpose is to evaluate the construct validity of the WPAI-general health version among RA patients and its ability to differentiate between RA patients with varying health status.MethodsPatients who were enrolled in the Early Rheumatoid Arthritis Network cohort and were employed at their most recent follow-up were recruited into this sub-study. A questionnaire battery incorporating the WPAI was administered along with a number of health outcomes including the Multidimensional Health Assessment Questionnaire, fatigue and patient assessment of disease activity. The construct validity of the WPAI was tested by the correlations between the WPAI and the health outcomes and other measures of productivity. Student's t tests were used to identify whether the WPAI outcomes differed between the two levels of heath status based on the median of health outcomes.ResultsA total of 150 patients completed the WPAI questionnaire. The average age was 52 years old and the disease duration was 37.5 months since the first rheumatology visit. Of the 137 patients who were working for pay, 26 reported missing work in the past week due to their health problem, accounting for 45.5% of their working time (absenteeism). While 123 patients were working, 24% of their work was impaired due to their health problem (presenteeism). In addition, 33% of the patients' regular daily activities (activity impairment) had been prevented due to their health problems. There were moderate correlations between the WPAI absenteeism and function, pain, fatigue, and disease severity (r = 0.34 to 0.39). The WPAI presenteeism and activity impairment were strongly correlated with the health outcomes (0.67 to 0.77). Patients with more severe disease status (for example, low/high functional disability by median) had significantly higher absenteeism (4%/15%), presenteeism (15%/39%), and activity impairment (19%/53%) than those with less severe disease status.ConclusionsThe WPAI is a valid questionnaire for assessing impairments in paid work and activities in RA patients and for measuring the relative differences between RA patients with different health status.