Mortality in rheumatoid arthritis: the impact of disease activity, treatment with glucocorticoids, TNFα inhibitors and rituximab
Top Cited Papers
Open Access
- 29 November 2013
- journal article
- research article
- Published by BMJ in Annals Of The Rheumatic Diseases
- Vol. 74 (2), 415-421
- https://doi.org/10.1136/annrheumdis-2013-204021
Abstract
Objectives To investigate the impact of disease activity, the course of the disease, its treatment over time, comorbidities and traditional risk factors on survival. Methods Data of the German biologics register RABBIT were used. Cox regression was applied to investigate the impact of time-varying covariates (disease activity as measured by the DAS28, functional capacity, treatment with glucocorticoids, biologic or synthetic disease modifying antirheumatic drugs (DMARDs)) on mortality after adjustment for age, sex, comorbid conditions and smoking. Results During 31 378 patient-years of follow-up, 463 of 8908 patients died (standardised mortality ratio: 1.49 (95% CI 1.36 to 1.63)). Patients with persistent, highly active disease (mean DAS28 > 5.1) had a significantly higher mortality risk (adjusted HR (HRadj)=2.43; (95% CI 1.64 to 3.61)) than patients with persistently low disease activity (mean DAS28 < 3.2). Poor function and treatment with glucocorticoids > 5 mg/d was significantly associated with an increased mortality, independent of disease activity. Significantly lower mortality was observed in patients treated with tumour necrosis factor α (TNFα) inhibitors (HRadj=0.64 (95% CI 0.50 to 0.81), rituximab (HRadj=0.57 (95% CI 0.39 to 0.84), or other biologics (HRadj=0.64 (95% CI 0.42 to 0.99), compared to those receiving methotrexate. To account for treatment termination in patients at risk, an HRadj for patients ever exposed to TNFα inhibitors or rituximab was calculated. This resulted in an HRadj of 0.77 (95% CI 0.60 to 0.97). Conclusions Patients with long-standing high disease activity are at substantially increased risk of mortality. Effective control of disease activity decreases mortality. TNFα inhibitors and rituximab seem to be superior to conventional DMARDs in reducing this risk.Keywords
This publication has 33 references indexed in Scilit:
- Adalimumab: long-term safety in 23 458 patients from global clinical trials in rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, psoriatic arthritis, psoriasis and Crohn's diseaseAnnals Of The Rheumatic Diseases, 2012
- Treatment benefit or survival of the fittest: what drives the time-dependent decrease in serious infection rates under TNF inhibition and what does this imply for the individual patient?Annals Of The Rheumatic Diseases, 2011
- No evidence of association between anti–tumor necrosis factor treatment and mortality in patients with rheumatoid arthritis: Results from the British Society for Rheumatology Biologics RegisterArthritis & Rheumatism, 2010
- Associations of disease activity and treatments with mortality in men with rheumatoid arthritis: results from the VARA registryRheumatology, 2010
- Treating rheumatoid arthritis to target: recommendations of an international task forceAnnals Of The Rheumatic Diseases, 2010
- Different Methods of Balancing Covariates Leading to Different Effect Estimates in the Presence of Effect ModificationAmerican Journal of Epidemiology, 2009
- Treatment with TNF blockers and mortality risk in patients with rheumatoid arthritisAnnals Of The Rheumatic Diseases, 2007
- Modified disease activity scores that include twenty-eight-joint counts development and validation in a prospective longitudinal study of patients with rheumatoid arthritisArthritis & Rheumatism, 1995
- The mortality of rheumatoid arthritisArthritis & Rheumatism, 1994
- The american rheumatism association 1987 revised criteria for the classification of rheumatoid arthritisArthritis & Rheumatism, 1988