A 10 year prospective followup of patients with rheumatoid arthritis 1986-96

To determine the 10 year outcome of hospital patients with established rheumatoid arthritis (RA) treated with disease modifying drugs (DMARD).

All patients with RA of at least a year duration and attending a single clinician were followed prospectively for 10 years. DMARD treatments changed with time but were continued throughout. Measurements of joint tenderness (Ritchie Index), morning stiffness, grip, and disability (Health Assessment Questionnaire, HAQ) and radiographs of hands and feet were documented. A record of joint surgery was maintained. Patients who stopped attending the clinic were traced and an accurate record of deaths was obtained from the National Registry of Deaths. Paired clinical indices were compared where available between 0, 5, and 10 years.

At entry there were 289 patients of variable disease duration. Within 10 years, 71 had died (standardized mortality ratio 1.3) and 92 were alive but unavailable. Median joint tenderness, morning stiffness, grip strength, and hemoglobin were not significantly different at 0, 5, and 10 years. Erythrocyte sedimentation rate (ESR) declined but not significantly. By contrast, HAQ scores and radiographs worsened between 0 and 10 years (p = 0.0004, p = 0.0001, respectively). There was a trend toward lower ESR values and less disability and the lower radiographic scores in those with 10-15 years' disease duration in 1996 compared with those of similar duration in 1986. However, worsening of radiographs occurred in patients with short, medium, and long histories of RA. Correlations between disability, radiographic scores, and joint tenderness were apparent at the start and conclusion of the study. At 10 years, 54 (19%) of the original cohort had undergone at least one large joint replacement. Significantly more women required joint replacement surgery (chi-square 5.44, p = 0.02).

Over a 10 year period patients with RA exhibited an excess of deaths and a deterioration of radiographs and function despite regular DMARD treatment and apparent clinical containment. Worsening of radiographs occurred in both relatively early and late disease. There was a steady requirement for surgical large joint replacement with time. This study suggests that in the long term. the effect of DMARD treatments may be less than the expectations derived from short term studies.