Methotrexate (MTX) is well-established as the "anchor drug" for patients with rheumatoi... more Methotrexate (MTX) is well-established as the "anchor drug" for patients with rheumatoid arthritis (RA), to be used early and aggressively, with higher long-term effectiveness, tolerability, and safety than any other disease-modifying antirheumatic drug (DMARD). However, about 20% to 40% of patients experience incomplete responses to MTX and require further therapy, with options including other non- biologic DMARDs, low dose glucocorticoids, and biologic agents. Non-biologic DMARDs in combination with MTX may provide similar efficacy to a biologic agent in clinical trials, with fewer adverse events and lower costs. This re- view presents a summary of 21 clinical trials documenting the efficacy and safety of MTX in combination with other non-biologic DMARDs.
Osteoarthritis (OA) may be associated with substantial work disability, morbidity, costs, and inc... more Osteoarthritis (OA) may be associated with substantial work disability, morbidity, costs, and increased mortality rates, often similar to rheumatoid arthritis (RA), documented in many published reports over the last 4 decades. However, OA generally has been viewed as less severe than RA. This discrepancy may be explained in part by:a) RA may have been considerably more severe in the past, prior to effective therapies.b) most older individuals have radiographic joint damage, which often is not associated with clinical symptoms.c) RA is associated with abnormal laboratory tests, which are regarded as conveying greater significance than symptoms of pain and disability according to a "biomedical model," the dominant paradigm of modern medicine.d) Most reports of OA and RA have emphasised differences between the 2 diseases even beyond laboratory abnormalities in pathogenesis, physical findings, and imaging.e) Even pain and functional disability seen in both diseases are assesse...
OBJECTIVES Osteoarthritis (OA) is regarded as a less severe form of arthritis than rheumatoid art... more OBJECTIVES Osteoarthritis (OA) is regarded as a less severe form of arthritis than rheumatoid arthritis (RA) by health professionals and the general public, based largely on laboratory findings of autoantibodies and acute phase reactants. Relatively few studies have reported data from the patient's perspective to compare directly OA versus RA using the same self-report questionnaire measure. We aimed to summarise reports that compare OA versus RA patient pain scores and other indicators of disease burden according to the same self-report questionnaire. METHODS A retrospective review identified 5 published reports at 8 rheumatology sites in 4 countries from 1989 to 2017 in which patients with OA versus RA completed the same patient self-report questionnaire for pain and other variables. Most comparisons involved a health assessment questionnaire (HAQ) and derivative multidimensional HAQ (MDHAQ), which include physical function, pain visual analogue scale (VAS) and patient global ...
BACKGROUND A physician global estimate of patient status (DOCGL) was designed to quantitate infla... more BACKGROUND A physician global estimate of patient status (DOCGL) was designed to quantitate inflammatory activity but may be influenced by the presence of damage and distress. Therefore, three additional 0 to 10 visual analog scales (VAS) have been developed on a RheuMetric checklist to record physician estimates of inflammation (DOCINF), damage (DOCDAM), and distress (DOCSTR) (such as fibromyalgia and somatization). We analyzed patient scores on a multidimensional health assessment questionnaire (MDHAQ) and four RheuMetric physician estimates inpatients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoarthritis (OA), and fibromyalgia (FM). METHODS All patients with all diagnoses seen by Rush University Medical Center rheumatologists complete an MDHAQ and have four RheuMetric 0 to 10 VAS estimates for DOCGL, DOCINF, DOCDAM, and DOCSTR assigned by the rheumatologist at each visit. A random visit of 205 patients with RA (N = 50), OA (N = 67), SLE (N = 66), and ...
Methotrexate has become the "anchor drug" for rheumatoid arthritis (RA), taken by many ... more Methotrexate has become the "anchor drug" for rheumatoid arthritis (RA), taken by many more patients than any other disease modifying anti-rheumatic drug (DMARD) or biological agent. Methotrexate has greater efficacy and effectiveness than any other non-biologic DMARD, and greater tolerability and safety than other DMARDs. The efficacy of methotrexate is comparable to biologic agents in parallel clinical trials of DMARD-naïve patients. Adequate responses to methotrexate monotherapy or combinations with other non-biologic DMARDs are seen in about two- thirds of patients with RA in usual care. The most efficacious treatments for RA reported in the rheumatology literature are seen in strategy trials with methotrexate as the anchor drug, without any biologic agent. Interpretation of significantly lower radiographic progression between methotrexate and biologic agents in clinical trials is over- stated regarding clinic consequences. The admonition to patients to refrain entirel...
The two articles presenting ACR committee recommendations for functional status measures and dise... more The two articles presenting ACR committee recommendations for functional status measures and disease activity indices for rheumatoid arthritis (RA) in the December 2019 issue of Arthritis Care and Research are of great interest. The recommendations are based on traditional psychometric and statistical methodology, without information from clinical experience. Possible limitations of traditional psychometric and statistical methodology in the absence of data from clinical experience may be seen in the observation that high scores for both functional status measures and "disease activity" indices, including DAS28, CDAI, and RAPID3 that may be strongly affected by fibromyalgia and/or joint damage, even with minimal inflammatory activity.
OBJECTIVE Rheumatoid synovitis is characterized by a mast cell response in which tryptase contain... more OBJECTIVE Rheumatoid synovitis is characterized by a mast cell response in which tryptase containing mast cells (MCT) associate with T lymphocyte infiltration, and tryptase and chymase containing mast cells (MCTC) correlate more closely with tissue damage or repair events. We investigated expression of the alphaEbeta7 integrin and its ligand E-cadherin in rheumatoid and normal synovium and compared this expression to synovial mast cell responses. METHODS Immunohistochemical analysis was used to determine the expression of alphaEbeta7 and E-cadherin in rheumatoid (n = 17) and normal (n = 6) synovium. The density of MCT and MCTC mast cell subsets was compared to the density of alphaEbeta7 positive mast cells. RESULTS The mean density of alphaEbeta7 positive cells in rheumatoid synovia was 25.2 cells/mm2 (range 0.3-102.9), of which 26.7% (range 0-68.6%) were mast cells. A mean of 11.9% (range 0-30.4%) of rheumatoid synovial mast cells expressed alphaEbeta7 compared to 0% in normal syno...
Background: Despite the known benefits of exercise1, patients with osteoarthritis (OA) and rheuma... more Background: Despite the known benefits of exercise1, patients with osteoarthritis (OA) and rheumatoid arthritis (RA) are reported to have low levels of physical activity2. Exercise participation is not well studied in psoriatic arthritis (PsA) cohorts. This study aims to explore which factors predict exercise participation across cohorts and specifically in the PsA cohort. Objectives: The primary aim of this study was to determine which clinical factors were predictive of self- reported physical activity levels in patients with PsA. A secondary aim was to explore differences in self-reported physical activity levels amongst patients with PsA, OA and RA. Methods: Patients with the diagnosis of PsA, RA or OA are recruited prospectively at two tertiary hospital rheumatology clinics over 12 months. Demographic data is captured by the multi-dimensional health assessment questionnaire, the international physical activity questionnaire short form captures self-reported physical activity an...
Background Delayed diagnosis is recognized in many rheumatic diseases. Early treatment is regarde... more Background Delayed diagnosis is recognized in many rheumatic diseases. Early treatment is regarded as critical for optimal clinical outcomes in patients with inflammatory rheumatic diseases. We studied possible delay in diagnosis in a usual care setting in 2013 using a simple 1-page form completed by the rheumatologist. Objectives To analyze patients seen in a teaching hospital rheumatology clinic for year of onset of symptoms and year of diagnosis and onset of treatment, using a standardized form for rheumatologists (RHEUMDOC). Methods All patients seen in one setting were evaluated according to a multidimensional health assessment questionnaire (MDHAQ) completed by the patient, and by a complementary doctor form (RHEUMDOC) completed by the physician. RHEUMDOC includes entry of 3 possible rheumatic diagnoses queried for year of onset of symptoms and year of diagnosis. For this study, patients were classified into 4 groups according to diagnosis: rheumatoid arthritis (RA), osteoarthritis (OA), other inflammatory diseases (INF), and other non-inflammatory diseases (NON); differences between groups were compared using Wilcoxon rank sum tests. Results Among 177 patients seen between February and October 2013, the mean interval from year of symptom onset to year of diagnosis was 3.7 years, 1.4 years in RA, 4.9 years in OA, and 4.6 years in other INF and other NON inflammatory diseases. Among all patients, 91 (51%) had a diagnosis within one year, including 64% with RA, 36% with OA, 49% with other INF, and 50% with other NON. The delay in RA was significantly less than in OA (p=0.004), other INF (p=0.027) and all non-RA (p=0.006). Nonetheless, 28% of RA patients received a diagnosis 1-5 years, and 8% >5 years, after symptom onset. Diagnosis Number of patients Mean (SD) # years from symptoms to diagnosis Number of patients in each group according to interval from onset of symptoms to diagnosis <1 year 1–5 years >5 years n (%) n (%) n (%) RA 53 1.4 (3.3) 34 (64%) 15 (28%) 4 (8%) OA 33 4.9 (7.8) 12 (36%) 12 (36%) 9 (27%) Other INF 73 4.6 (7.6) 36 (49%) 18 (25%) 19 (26%) Other Non-INF 18 4.6 (9.4) 9 (50%) 5 (26%) 4 (22%) Total 177 3.7 (7.0) 91 (51%) 50 (28%) 36 (20%) Conclusions A considerable delay from onset of symptoms to definitive diagnosis remains an important problem in rheumatic diseases. Delay in diagnosis is more common in patients with diseases other than RA, but remains in more than 1/3 of RA patients. Identification of specific contributors to this delay could inform education of both patients and physicians regarding the importance of early diagnosis and treatment, and health policy resources to facilitate timely management of rheumatic diseases. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3447
Background Osteoarthritis (OA) generally is regarded clinically as asymmetrical, and monoarticula... more Background Osteoarthritis (OA) generally is regarded clinically as asymmetrical, and monoarticular or pauciarticular, in contrast to symmetrical, polyarticular rheumatoid arthritis (RA). However, the risk of osteoarthritis in any joint is higher in patients who already have osteoarthritis in other joints, and many OA patients have bilateral disease (1). Therefore, we have compared the likelihood of self-report of pain and possible patterns of symmetry in specific joints and joint groups in patients seen in routine care with a diagnosis of OA or RA. Objectives To analyze the number and possible symmetry of painful joints and joint groups according to a rheumatoid arthritis disease activity index (RADAI) self-report joint count of 8 joints or joint groups, fingers, wrists, elbows, shoulders, hips, knees, ankles, and toes, in patients with RA or OA seen at 2 rheumatology settings. Methods All patients seen at 2 clinical settings, Liverpool Hospital in Liverpool, New South Wales, Australia, and Rush University Medical Center, Chicago, IL, USA, complete a multidimensional health assessment questionnaire (MDHAQ) in 5-10 minutes in the waiting area prior to seeing the rheumatologist. The MDHAQ includes a rheumatoid arthritis disease activity index (RADAI) self-report painful joint count, as well as scales for physical function, pain, patient and physician global estimates, psychological distress, and fatigue. The RADAI includes a query “Please place a tick or check (√) in the appropriate spot to indicate the amount of pain you are having today in each of the [8] joint areas listed below:” fingers, wrists, elbows, shoulders, hips, knees, ankles, and toes. The 4 response options for each of 16 queries (8 right and left joints or joint groups) are: no pain =0, mild pain =1, moderate pain =2, and severe pain =3. For analyses presented here, responses were classified as either 0=no pain or 1=1, 2, or 3 positive response for pain, collapsed to one category. Data were analyzed according to descriptive statistics for mean and median values for each joint or joint group, the total number of joint groups affected, and whether a joint group was affected by unilateral or bilateral involvement in patients with OA or RA. Results Analyses of the 16 joint groups indicated that the median number of joint groups involved was 6 at Rush and 10 at Liverpool for OA and 6 at both sites for RA. In most comparisons, the likelihood of bilateral disease was greater than for unilateral disease in OA and RA, and more than 1.5 times greater for fingers, knees, ankles, and toes in OA and RA at both settings (Table). Similar patterns were seen on the right and left side. Conclusions Patients with OA report similar numbers of painful joints as patients with RA, in routine care at 2 settings. The patients also report symmetrical joint involvement more commonly than asymmetrical involvement, similarly in both OA and RA. These findings highlight the substantial impact of OA from the patient perspective and suggest possible change in the clinical approach and resource allocation for OA. References Hirsch R, et al. Association of hand and knee osteoarthritis: evidence for a polyarticular disease subset. Ann Rheum Dis. 1996;55(1):25-9. Disclosure of Interest None declared
Background A physician estimate of a patient's global status (DOCGL) often is the most effici... more Background A physician estimate of a patient's global status (DOCGL) often is the most efficient of all 7 core data set measures to distinguish active from control treatments in clinical trials1. DOCGL is designated to assess inflammatory activity. However, DOCGL may be influenced by damage and chronic pain syndromes. Therefore, 3 new physician global (0-10) visual analog subscales (VAS) have been developed to assess subsets of physician estimates for (a) inflammation, (b) damage, and (c) “neither” (usually fibromyalgia/somatization). Objectives To analyze physician subscales for inflammation, damage and “neither” in patients with 4 rheumatic diseases, RA, OA, SLE, and FM, and to compute correlations of overall DOCGL with the 3 physician subscales and with patient global estimate (PATGL) in these 4 diagnosis groups. Methods All patients seen in routine care at one academic clinical setting by eight rheumatologists are assigned 4 global estimates ranging from 0 (none) to 10 (highest) VAS, including overall DOCGL, physician scores for inflammation, damage to any organ (e.g., joint, kidney), and “neither”. A cross-sectional analysis was performed of a random visit between September and December 2014 of consecutive patients with 4 primary diagnoses: RA (n=108), OA (n=131), SLE (n=73), and FM (n=51). Results are presented as median and interquartile range (IQR) of non-normally distributed data. Spearman correlations were calculated to estimate associations of the overall DOCGL with subscales and PATGL in the 4 diagnosis groups. Results Median DOCGL ranged from 3 to 5, highest for patients with FM (5.0), followed by OA (4), RA (3.5), and SLE (3). The highest median score for inflammation was for patients with RA (1.5), for damage in patients with OA (4.2) and for “neither” in patients with FM (5.2) (Table). The highest correlation with DOCGL was seen for the inflammation subscale in RA, damage in OA, and “neither” in FM. In patients with SLE, correlations of three subscales with DOCGL were similar. DOCGL was correlated significantly with PATGL in RA, SLE, and OA, but not in FM. Conclusions Physician estimates for inflammation, damage, and “neither” differ according to different rheumatic diagnoses. These 3 subscales supplement the overall physician global estimate as a quantitative summary of the history and physical examination, to assess and monitor patients with rheumatic diseases in usual care. References Pincus T, Richardson B, Strand V, Bergman MJ. Relative efficiencies of the 7 rheumatoid arthritis Core Data Set measures to distinguish active from control treatments in 9 comparisons from clinical trials of 5 agents. Clin Exp Rheumatol. 2014;32 Suppl 85(5):47-54. Disclosure of Interest None declared
Background RA generally is regarded by physicians and the public as a more severe problem than OA... more Background RA generally is regarded by physicians and the public as a more severe problem than OA. However, OA has been ranked as the 11th (1) and RA as the 42nd (2) highest contributor to global disability among all diseases, and costs of OA and RA each have been found to account for about 1% of the US gross domestic product (3). These similarities of OA and RA are explained in part by the higher prevalence of OA compare to RA. Nonetheless, the standardized mortality ratio (SMR) (which is independent of prevalence) for OA is 1.55 (4), and quite similar to the SMR for RA of 1.5-1.6 (5). Therefore, the severity of OA may be underestimated. Objectives To compare self-report scores of patients with a primary diagnosis of osteoarthritis (OA) or rheumatoid arthritis (RA) at 4 rheumatology clinical settings, according to data from a quantitative multidimensional health assessment questionnaire (MDHAQ)/routine assessment of patient data 3 (RAPID3) and physician global estimate. Methods Patients were seen in routine care at 4 clinical settings: Liverpool Hospital, New South Wales (NSW), Australia, Rush University Medical Center, Chicago, IL, USA, NYU Medical Center, New York, NY, USA, and Arthritis and Rheumatology, a solo private practice, Ridley Park, PA, USA. At each site, patients complete an MDHAQ at each visit in the waiting area while waiting to see the rheumatologist. The MDHAQ includes scores for physical function (0-10), pain (0-10), and patient global estimate (0-10), and RAPID3 composite scores of these 3 RA core data set measures (0-30), as well as fatigue (0-10). The physician assigns a global estimate for each patient. Patients at each site with OA versus RA were compared for mean and median MDHAQ scores for demographic measures, 5 MDHAQ patient self-report measures, and physician global estimates. Results Median scores for patients with OA were higher than for RA for 21 of 24 comparisons (6 variables, physical function, pain, patient global estimate, RAPID3, fatigue, and physician global estimate, in each of 4 settings): all 6 for Liverpool and Ridley Park, 5/6 at Rush, and 4/6 at NYU. Median physical function scores ranged from 1.7 to 2.7 for RA and 1.7 to 3.3 for OA. Median pain scores ranged from 4 to 5 for RA and 5 to 7 for OA. Median patient global estimates ranged from 4 to 5 for RA and 5 to 6 for OA. Median RAPID3 scores ranged from 9.7 to 11.8 for RA and 11.7 to 16.8 for OA. Median fatigue scores ranged from 3.5 to 5 for RA and 3.3 to 5 for OA. Median physician global scores ranged from 0 to 4 for RA and1 to 5 for OA. Conclusions Among treated patients, levels of patient pain, physical function, patient and physician global estimates, RAPID3, and fatigue reported by patients with OA are as great as or greater than for patients with RA. While the findings likely reflect in part better treatments for RA, they suggest that the severity of OA may be underestimated. Better information concerning OA may lead to improved clinical management and resource allocation for OA. References Ann Rheum Dis 2014;73(7):1323-30. Ann Rheum Dis 2014;73(7):1316-22. Arthritis Rheum 1995;38(10):1351-62. BMJ 2011;342:d1165. Clin Exp Rheumatol 2008;26(5 Suppl 51):S35-61. Disclosure of Interest None declared
Background Global estimates by both patient (PATGL) and physician (DOCGL) are concordant within 2... more Background Global estimates by both patient (PATGL) and physician (DOCGL) are concordant within 2 units on a 0-10 visual analog scale (VAS) in about 40-65% of encounters, while discordance of PATGL>DOCGL occurs in about 25-60% and DOCGL>PATGL in about 10-20%.1 DOCGL is expected to be higher if DOCGL>PATGL than if DOCGL=PATGL, and might be expected to be lower if PATGL>DOCGL. However, this matter has not been examined extensively. Objectives To analyze DOCGL and PATGL according to whether DOCGL>PATGL, DOCGL=PATGL or PATGL>DOCGL in 225 patients with various rheumatic diseases seen in a general rheumatology clinic in Australia. Methods All patients completed a multidimensional health assessment questionnaire (MDHAQ), which includes PATGL, pain (PN), and physical function (FN), each scored 0-10. RAPID3 (routine assessment of patient index data) is calculated as a 0-30 scale from 3 0-10 scores for FN, PN and PATGL. The rheumatologist assigned a DOCGL for each patient on a 0-10 VAS identical to the PATGL VAS. PATGL and DOCGL were compared for concordance or discordance in 225 individual patients, classified in 3 groups: PATGL=DOCGL, i.e., both scales within 2 units of each other; PATGL>DOCGL by ≥2 units; or DOCGL>PATGL by ≥2 units. DOCGL, PATGL and RAPID3 were compared in these 3 groups, using Kruskal-Wallis tests to analyze statistical significance. Results Among 225 encounters, PATGL>DOCGL was seen in 80 (36%), PATGL=DOCGL in 118 (52%) and DOCGL>PATGL in 27 (12%), similar to published reports.1 Median DOCGL was 3.5 in concordant encounters (PATGL=DOCGL), compared to 4.0 when DOCGL>PATGL or when PATGL>DOCGL (p=0.078). By contrast, median PATGL was 3.8 when PATGL=DOCGL, compared to 1.0 when DOCGL>PATGL and 7.0 when PATGL>DOCGL (p<0.001). The range of medians in all categories was 3.0–5.5 for DOCGL, 1.0–7.5 for PATGL and 5.8–18.3 for RAPID3. Median (IQR) values for DOCGL, PATGL and RAPID3 according to whether PATGL>DOCGL, PATGL=DOCGL or DOCGL>PATGL in all patients, RA patients, and other patients. N (%) DOCGL PATGL RAPID3 All patients PATGL>DOCGL 80 (36%) 4.0 (2.8–5.0) 7.0 (5.0–8.5) 18.3 (12.8–21.0) PATGL=DOCGL 118 (52%) 3.5 (2.0–6.0) 3.8 (2.0–5.5) 10.2 (6.3–15.5) DOCGL>PATGL 27 (12%) 4.0 (3.0–6.5) 1.0 (0.0–3.0) 7.0 (4.3–11.3) Total 225 (100%) 4.0 (2.5–5.0) 5.0 (2.5–7.0) 12.0 (7.3–18.7) P value 0.078 <0.001 <0.001 RA patients PATGL>DOCGL 20 (31%) 4.0 (3.0–5.3) 7.5 (6.0–8.5) 17.4 (13.2–20.2) PATGL=DOCGL 36 (56%) 3.0 (2.0–5.0) 3.5 (1.8–5.3) 8.7 (5.2–15.5) DOCGL>PATGL 8 (13%) 3.3 (3.0–4.0) 1.0 (0.5–1.3) 5.8 (3.4–7.2) Total 64 (100%) 3.8 (2.0–5.0) 4.3 (1.8–6.8) 9.8 (6.2–18.7) P value 0.299 <0.001 <0.001 Other patients PATGL>DOCGL 60 (37%) 4.0 (2.5–5.0) 7.0 (5.0–8.5) 18.3 (12.8–21.2) PATGL=DOCGL 82 (51%) 3.5 (2.5–6.0) 4.0 (2.0–5.5) 10.9 (6.3–15.7) DOCGL>PATGL 19 (12%) 5.5 (4.0–7.0) 2.0 (0.0–3.5) 8.0 (4.3–12.0) Total 161 (100%) 4.0 (2.5–6.0) 5.0 (3.0–7.0) 12.1 (7.8–18.7) P value 0.012 <0.001 <0.001 Conclusions Discordance between PATGL and DOCGL is driven largely by variation in PATGL rather than DOCGL. DOCGL was higher in patients in whom DOCGL>PATGL vs DOCGL=PATGL, as expected, but also was higher in encounters in which PATGL>DOCGL, which was unexpected. Efforts to understand and reduce discordance may result in better care and outcomes. References Barton JL, Imboden J, Graf J, et al. Arthritis Care Res 2010;62:857-64 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3945
Background Fibromyalgia (FM) is more prevalent than most rheumatic diseases in the general popula... more Background Fibromyalgia (FM) is more prevalent than most rheumatic diseases in the general population, and is seen as a secondary phenomenon in 20–40% of people who have inflammatory rheumatic diseases. Formal ACR criteria to identify FM using self-report questionnaire data have been established (1), but generally not applied in busy clinical settings, in which it is not feasible to use multiple different patient questionnaires. A multidimensional health assessment questionnaire (MDHAQ) is feasible for completion by patients in the waiting area, and informative in rheumatoid arthritis (RA) as well as many other rheumatic diseases, and may be useful in FM. (2) Objectives To develop a cumulative index based on specific cutpoints of individual MDHAQ measures to screen for patients with primary or secondary fibromyalgia in busy clinical settings. Methods In two rheumatology settings, patients complete an MDHAQ at each visit. Nine MDHAQ scales were analyzed: 0–10 scores for physical function, pain, patient global estimate, and fatigue; 0–3 sores for sleep quality, anxiety, and depression; a RA disease activity index (RADAI) 0–48 self-report painful joint count and symptom checklist of 60 items. Scores on all MDHAQ scales were compared in Setting A in patients with a clinical diagnosis of primary FM vs RA with no secondary FM, and in Setting B in patients who had secondary FM according to ACR FM criteria vs other patients who did not meet ACR FM criteria. Only patients with complete data for all 9 MDHAQ scales and the ACR FM scales in Setting B were included in the study. Comparisons included frequencies, t tests, cross-tabulations with various cut-points, and receiver-operator curves, as well as a kappa statistic comparing clinician diagnosis of secondary FM vs FM by ACR criteria in setting B. A possible cumulative index based on specific cutpoints of individual measures, analogous to RA classification criteria (3), was explored with several cutpoints of different numbers of MDHAQ measures. Results In Setting A, 286 patients with RA were compared to 195 with FM. In setting B, 22 patients who had other diagnoses but secondary FM by ACR criteria were compared to 68 patients who had no FM by ACR criteria. All 9 MDHAQ scales were significantly higher in patients with FM compared to patients with RA or other diagnoses in both settings according to t tests and receiver-operator curves (data not shown). In Setting B, the kappa statistic was 0.68, indicating >80% agreement between the clinician diagnosis and ACR FM criteria. The highest levels of significance were seen for symptom checklist, RADAI self-report joint count scores, and pain scores. For example, an index provided a clue to primary or secondary FM at either site, with 2 of the following 3 measures: Pain ≥5, RADAI ≥16, symptom checklist ≥16.Table 1 Setting A Setting B 1° Fibro – Clin RA Clin p 2° Fibro ACR No 2° Fibro p (n=195) (n=286) (n=22) (n=68) 156 (80%) 94 (33%) p<0.0001 18 (81%) 12 (18%) p<0.0001 Conclusions MDHAQ scales can provide clues to identify primary and secondary FM. Of course, a diagnosis requires a physician history and physical examination, but a screening tool may save time and increase recognition of FM in busy clinical settings. Disclosure of Interest None declared
Methotrexate (MTX) is well-established as the "anchor drug" for patients with rheumatoi... more Methotrexate (MTX) is well-established as the "anchor drug" for patients with rheumatoid arthritis (RA), to be used early and aggressively, with higher long-term effectiveness, tolerability, and safety than any other disease-modifying antirheumatic drug (DMARD). However, about 20% to 40% of patients experience incomplete responses to MTX and require further therapy, with options including other non- biologic DMARDs, low dose glucocorticoids, and biologic agents. Non-biologic DMARDs in combination with MTX may provide similar efficacy to a biologic agent in clinical trials, with fewer adverse events and lower costs. This re- view presents a summary of 21 clinical trials documenting the efficacy and safety of MTX in combination with other non-biologic DMARDs.
Osteoarthritis (OA) may be associated with substantial work disability, morbidity, costs, and inc... more Osteoarthritis (OA) may be associated with substantial work disability, morbidity, costs, and increased mortality rates, often similar to rheumatoid arthritis (RA), documented in many published reports over the last 4 decades. However, OA generally has been viewed as less severe than RA. This discrepancy may be explained in part by:a) RA may have been considerably more severe in the past, prior to effective therapies.b) most older individuals have radiographic joint damage, which often is not associated with clinical symptoms.c) RA is associated with abnormal laboratory tests, which are regarded as conveying greater significance than symptoms of pain and disability according to a "biomedical model," the dominant paradigm of modern medicine.d) Most reports of OA and RA have emphasised differences between the 2 diseases even beyond laboratory abnormalities in pathogenesis, physical findings, and imaging.e) Even pain and functional disability seen in both diseases are assesse...
OBJECTIVES Osteoarthritis (OA) is regarded as a less severe form of arthritis than rheumatoid art... more OBJECTIVES Osteoarthritis (OA) is regarded as a less severe form of arthritis than rheumatoid arthritis (RA) by health professionals and the general public, based largely on laboratory findings of autoantibodies and acute phase reactants. Relatively few studies have reported data from the patient's perspective to compare directly OA versus RA using the same self-report questionnaire measure. We aimed to summarise reports that compare OA versus RA patient pain scores and other indicators of disease burden according to the same self-report questionnaire. METHODS A retrospective review identified 5 published reports at 8 rheumatology sites in 4 countries from 1989 to 2017 in which patients with OA versus RA completed the same patient self-report questionnaire for pain and other variables. Most comparisons involved a health assessment questionnaire (HAQ) and derivative multidimensional HAQ (MDHAQ), which include physical function, pain visual analogue scale (VAS) and patient global ...
BACKGROUND A physician global estimate of patient status (DOCGL) was designed to quantitate infla... more BACKGROUND A physician global estimate of patient status (DOCGL) was designed to quantitate inflammatory activity but may be influenced by the presence of damage and distress. Therefore, three additional 0 to 10 visual analog scales (VAS) have been developed on a RheuMetric checklist to record physician estimates of inflammation (DOCINF), damage (DOCDAM), and distress (DOCSTR) (such as fibromyalgia and somatization). We analyzed patient scores on a multidimensional health assessment questionnaire (MDHAQ) and four RheuMetric physician estimates inpatients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoarthritis (OA), and fibromyalgia (FM). METHODS All patients with all diagnoses seen by Rush University Medical Center rheumatologists complete an MDHAQ and have four RheuMetric 0 to 10 VAS estimates for DOCGL, DOCINF, DOCDAM, and DOCSTR assigned by the rheumatologist at each visit. A random visit of 205 patients with RA (N = 50), OA (N = 67), SLE (N = 66), and ...
Methotrexate has become the "anchor drug" for rheumatoid arthritis (RA), taken by many ... more Methotrexate has become the "anchor drug" for rheumatoid arthritis (RA), taken by many more patients than any other disease modifying anti-rheumatic drug (DMARD) or biological agent. Methotrexate has greater efficacy and effectiveness than any other non-biologic DMARD, and greater tolerability and safety than other DMARDs. The efficacy of methotrexate is comparable to biologic agents in parallel clinical trials of DMARD-naïve patients. Adequate responses to methotrexate monotherapy or combinations with other non-biologic DMARDs are seen in about two- thirds of patients with RA in usual care. The most efficacious treatments for RA reported in the rheumatology literature are seen in strategy trials with methotrexate as the anchor drug, without any biologic agent. Interpretation of significantly lower radiographic progression between methotrexate and biologic agents in clinical trials is over- stated regarding clinic consequences. The admonition to patients to refrain entirel...
The two articles presenting ACR committee recommendations for functional status measures and dise... more The two articles presenting ACR committee recommendations for functional status measures and disease activity indices for rheumatoid arthritis (RA) in the December 2019 issue of Arthritis Care and Research are of great interest. The recommendations are based on traditional psychometric and statistical methodology, without information from clinical experience. Possible limitations of traditional psychometric and statistical methodology in the absence of data from clinical experience may be seen in the observation that high scores for both functional status measures and "disease activity" indices, including DAS28, CDAI, and RAPID3 that may be strongly affected by fibromyalgia and/or joint damage, even with minimal inflammatory activity.
OBJECTIVE Rheumatoid synovitis is characterized by a mast cell response in which tryptase contain... more OBJECTIVE Rheumatoid synovitis is characterized by a mast cell response in which tryptase containing mast cells (MCT) associate with T lymphocyte infiltration, and tryptase and chymase containing mast cells (MCTC) correlate more closely with tissue damage or repair events. We investigated expression of the alphaEbeta7 integrin and its ligand E-cadherin in rheumatoid and normal synovium and compared this expression to synovial mast cell responses. METHODS Immunohistochemical analysis was used to determine the expression of alphaEbeta7 and E-cadherin in rheumatoid (n = 17) and normal (n = 6) synovium. The density of MCT and MCTC mast cell subsets was compared to the density of alphaEbeta7 positive mast cells. RESULTS The mean density of alphaEbeta7 positive cells in rheumatoid synovia was 25.2 cells/mm2 (range 0.3-102.9), of which 26.7% (range 0-68.6%) were mast cells. A mean of 11.9% (range 0-30.4%) of rheumatoid synovial mast cells expressed alphaEbeta7 compared to 0% in normal syno...
Background: Despite the known benefits of exercise1, patients with osteoarthritis (OA) and rheuma... more Background: Despite the known benefits of exercise1, patients with osteoarthritis (OA) and rheumatoid arthritis (RA) are reported to have low levels of physical activity2. Exercise participation is not well studied in psoriatic arthritis (PsA) cohorts. This study aims to explore which factors predict exercise participation across cohorts and specifically in the PsA cohort. Objectives: The primary aim of this study was to determine which clinical factors were predictive of self- reported physical activity levels in patients with PsA. A secondary aim was to explore differences in self-reported physical activity levels amongst patients with PsA, OA and RA. Methods: Patients with the diagnosis of PsA, RA or OA are recruited prospectively at two tertiary hospital rheumatology clinics over 12 months. Demographic data is captured by the multi-dimensional health assessment questionnaire, the international physical activity questionnaire short form captures self-reported physical activity an...
Background Delayed diagnosis is recognized in many rheumatic diseases. Early treatment is regarde... more Background Delayed diagnosis is recognized in many rheumatic diseases. Early treatment is regarded as critical for optimal clinical outcomes in patients with inflammatory rheumatic diseases. We studied possible delay in diagnosis in a usual care setting in 2013 using a simple 1-page form completed by the rheumatologist. Objectives To analyze patients seen in a teaching hospital rheumatology clinic for year of onset of symptoms and year of diagnosis and onset of treatment, using a standardized form for rheumatologists (RHEUMDOC). Methods All patients seen in one setting were evaluated according to a multidimensional health assessment questionnaire (MDHAQ) completed by the patient, and by a complementary doctor form (RHEUMDOC) completed by the physician. RHEUMDOC includes entry of 3 possible rheumatic diagnoses queried for year of onset of symptoms and year of diagnosis. For this study, patients were classified into 4 groups according to diagnosis: rheumatoid arthritis (RA), osteoarthritis (OA), other inflammatory diseases (INF), and other non-inflammatory diseases (NON); differences between groups were compared using Wilcoxon rank sum tests. Results Among 177 patients seen between February and October 2013, the mean interval from year of symptom onset to year of diagnosis was 3.7 years, 1.4 years in RA, 4.9 years in OA, and 4.6 years in other INF and other NON inflammatory diseases. Among all patients, 91 (51%) had a diagnosis within one year, including 64% with RA, 36% with OA, 49% with other INF, and 50% with other NON. The delay in RA was significantly less than in OA (p=0.004), other INF (p=0.027) and all non-RA (p=0.006). Nonetheless, 28% of RA patients received a diagnosis 1-5 years, and 8% >5 years, after symptom onset. Diagnosis Number of patients Mean (SD) # years from symptoms to diagnosis Number of patients in each group according to interval from onset of symptoms to diagnosis <1 year 1–5 years >5 years n (%) n (%) n (%) RA 53 1.4 (3.3) 34 (64%) 15 (28%) 4 (8%) OA 33 4.9 (7.8) 12 (36%) 12 (36%) 9 (27%) Other INF 73 4.6 (7.6) 36 (49%) 18 (25%) 19 (26%) Other Non-INF 18 4.6 (9.4) 9 (50%) 5 (26%) 4 (22%) Total 177 3.7 (7.0) 91 (51%) 50 (28%) 36 (20%) Conclusions A considerable delay from onset of symptoms to definitive diagnosis remains an important problem in rheumatic diseases. Delay in diagnosis is more common in patients with diseases other than RA, but remains in more than 1/3 of RA patients. Identification of specific contributors to this delay could inform education of both patients and physicians regarding the importance of early diagnosis and treatment, and health policy resources to facilitate timely management of rheumatic diseases. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3447
Background Osteoarthritis (OA) generally is regarded clinically as asymmetrical, and monoarticula... more Background Osteoarthritis (OA) generally is regarded clinically as asymmetrical, and monoarticular or pauciarticular, in contrast to symmetrical, polyarticular rheumatoid arthritis (RA). However, the risk of osteoarthritis in any joint is higher in patients who already have osteoarthritis in other joints, and many OA patients have bilateral disease (1). Therefore, we have compared the likelihood of self-report of pain and possible patterns of symmetry in specific joints and joint groups in patients seen in routine care with a diagnosis of OA or RA. Objectives To analyze the number and possible symmetry of painful joints and joint groups according to a rheumatoid arthritis disease activity index (RADAI) self-report joint count of 8 joints or joint groups, fingers, wrists, elbows, shoulders, hips, knees, ankles, and toes, in patients with RA or OA seen at 2 rheumatology settings. Methods All patients seen at 2 clinical settings, Liverpool Hospital in Liverpool, New South Wales, Australia, and Rush University Medical Center, Chicago, IL, USA, complete a multidimensional health assessment questionnaire (MDHAQ) in 5-10 minutes in the waiting area prior to seeing the rheumatologist. The MDHAQ includes a rheumatoid arthritis disease activity index (RADAI) self-report painful joint count, as well as scales for physical function, pain, patient and physician global estimates, psychological distress, and fatigue. The RADAI includes a query “Please place a tick or check (√) in the appropriate spot to indicate the amount of pain you are having today in each of the [8] joint areas listed below:” fingers, wrists, elbows, shoulders, hips, knees, ankles, and toes. The 4 response options for each of 16 queries (8 right and left joints or joint groups) are: no pain =0, mild pain =1, moderate pain =2, and severe pain =3. For analyses presented here, responses were classified as either 0=no pain or 1=1, 2, or 3 positive response for pain, collapsed to one category. Data were analyzed according to descriptive statistics for mean and median values for each joint or joint group, the total number of joint groups affected, and whether a joint group was affected by unilateral or bilateral involvement in patients with OA or RA. Results Analyses of the 16 joint groups indicated that the median number of joint groups involved was 6 at Rush and 10 at Liverpool for OA and 6 at both sites for RA. In most comparisons, the likelihood of bilateral disease was greater than for unilateral disease in OA and RA, and more than 1.5 times greater for fingers, knees, ankles, and toes in OA and RA at both settings (Table). Similar patterns were seen on the right and left side. Conclusions Patients with OA report similar numbers of painful joints as patients with RA, in routine care at 2 settings. The patients also report symmetrical joint involvement more commonly than asymmetrical involvement, similarly in both OA and RA. These findings highlight the substantial impact of OA from the patient perspective and suggest possible change in the clinical approach and resource allocation for OA. References Hirsch R, et al. Association of hand and knee osteoarthritis: evidence for a polyarticular disease subset. Ann Rheum Dis. 1996;55(1):25-9. Disclosure of Interest None declared
Background A physician estimate of a patient's global status (DOCGL) often is the most effici... more Background A physician estimate of a patient's global status (DOCGL) often is the most efficient of all 7 core data set measures to distinguish active from control treatments in clinical trials1. DOCGL is designated to assess inflammatory activity. However, DOCGL may be influenced by damage and chronic pain syndromes. Therefore, 3 new physician global (0-10) visual analog subscales (VAS) have been developed to assess subsets of physician estimates for (a) inflammation, (b) damage, and (c) “neither” (usually fibromyalgia/somatization). Objectives To analyze physician subscales for inflammation, damage and “neither” in patients with 4 rheumatic diseases, RA, OA, SLE, and FM, and to compute correlations of overall DOCGL with the 3 physician subscales and with patient global estimate (PATGL) in these 4 diagnosis groups. Methods All patients seen in routine care at one academic clinical setting by eight rheumatologists are assigned 4 global estimates ranging from 0 (none) to 10 (highest) VAS, including overall DOCGL, physician scores for inflammation, damage to any organ (e.g., joint, kidney), and “neither”. A cross-sectional analysis was performed of a random visit between September and December 2014 of consecutive patients with 4 primary diagnoses: RA (n=108), OA (n=131), SLE (n=73), and FM (n=51). Results are presented as median and interquartile range (IQR) of non-normally distributed data. Spearman correlations were calculated to estimate associations of the overall DOCGL with subscales and PATGL in the 4 diagnosis groups. Results Median DOCGL ranged from 3 to 5, highest for patients with FM (5.0), followed by OA (4), RA (3.5), and SLE (3). The highest median score for inflammation was for patients with RA (1.5), for damage in patients with OA (4.2) and for “neither” in patients with FM (5.2) (Table). The highest correlation with DOCGL was seen for the inflammation subscale in RA, damage in OA, and “neither” in FM. In patients with SLE, correlations of three subscales with DOCGL were similar. DOCGL was correlated significantly with PATGL in RA, SLE, and OA, but not in FM. Conclusions Physician estimates for inflammation, damage, and “neither” differ according to different rheumatic diagnoses. These 3 subscales supplement the overall physician global estimate as a quantitative summary of the history and physical examination, to assess and monitor patients with rheumatic diseases in usual care. References Pincus T, Richardson B, Strand V, Bergman MJ. Relative efficiencies of the 7 rheumatoid arthritis Core Data Set measures to distinguish active from control treatments in 9 comparisons from clinical trials of 5 agents. Clin Exp Rheumatol. 2014;32 Suppl 85(5):47-54. Disclosure of Interest None declared
Background RA generally is regarded by physicians and the public as a more severe problem than OA... more Background RA generally is regarded by physicians and the public as a more severe problem than OA. However, OA has been ranked as the 11th (1) and RA as the 42nd (2) highest contributor to global disability among all diseases, and costs of OA and RA each have been found to account for about 1% of the US gross domestic product (3). These similarities of OA and RA are explained in part by the higher prevalence of OA compare to RA. Nonetheless, the standardized mortality ratio (SMR) (which is independent of prevalence) for OA is 1.55 (4), and quite similar to the SMR for RA of 1.5-1.6 (5). Therefore, the severity of OA may be underestimated. Objectives To compare self-report scores of patients with a primary diagnosis of osteoarthritis (OA) or rheumatoid arthritis (RA) at 4 rheumatology clinical settings, according to data from a quantitative multidimensional health assessment questionnaire (MDHAQ)/routine assessment of patient data 3 (RAPID3) and physician global estimate. Methods Patients were seen in routine care at 4 clinical settings: Liverpool Hospital, New South Wales (NSW), Australia, Rush University Medical Center, Chicago, IL, USA, NYU Medical Center, New York, NY, USA, and Arthritis and Rheumatology, a solo private practice, Ridley Park, PA, USA. At each site, patients complete an MDHAQ at each visit in the waiting area while waiting to see the rheumatologist. The MDHAQ includes scores for physical function (0-10), pain (0-10), and patient global estimate (0-10), and RAPID3 composite scores of these 3 RA core data set measures (0-30), as well as fatigue (0-10). The physician assigns a global estimate for each patient. Patients at each site with OA versus RA were compared for mean and median MDHAQ scores for demographic measures, 5 MDHAQ patient self-report measures, and physician global estimates. Results Median scores for patients with OA were higher than for RA for 21 of 24 comparisons (6 variables, physical function, pain, patient global estimate, RAPID3, fatigue, and physician global estimate, in each of 4 settings): all 6 for Liverpool and Ridley Park, 5/6 at Rush, and 4/6 at NYU. Median physical function scores ranged from 1.7 to 2.7 for RA and 1.7 to 3.3 for OA. Median pain scores ranged from 4 to 5 for RA and 5 to 7 for OA. Median patient global estimates ranged from 4 to 5 for RA and 5 to 6 for OA. Median RAPID3 scores ranged from 9.7 to 11.8 for RA and 11.7 to 16.8 for OA. Median fatigue scores ranged from 3.5 to 5 for RA and 3.3 to 5 for OA. Median physician global scores ranged from 0 to 4 for RA and1 to 5 for OA. Conclusions Among treated patients, levels of patient pain, physical function, patient and physician global estimates, RAPID3, and fatigue reported by patients with OA are as great as or greater than for patients with RA. While the findings likely reflect in part better treatments for RA, they suggest that the severity of OA may be underestimated. Better information concerning OA may lead to improved clinical management and resource allocation for OA. References Ann Rheum Dis 2014;73(7):1323-30. Ann Rheum Dis 2014;73(7):1316-22. Arthritis Rheum 1995;38(10):1351-62. BMJ 2011;342:d1165. Clin Exp Rheumatol 2008;26(5 Suppl 51):S35-61. Disclosure of Interest None declared
Background Global estimates by both patient (PATGL) and physician (DOCGL) are concordant within 2... more Background Global estimates by both patient (PATGL) and physician (DOCGL) are concordant within 2 units on a 0-10 visual analog scale (VAS) in about 40-65% of encounters, while discordance of PATGL>DOCGL occurs in about 25-60% and DOCGL>PATGL in about 10-20%.1 DOCGL is expected to be higher if DOCGL>PATGL than if DOCGL=PATGL, and might be expected to be lower if PATGL>DOCGL. However, this matter has not been examined extensively. Objectives To analyze DOCGL and PATGL according to whether DOCGL>PATGL, DOCGL=PATGL or PATGL>DOCGL in 225 patients with various rheumatic diseases seen in a general rheumatology clinic in Australia. Methods All patients completed a multidimensional health assessment questionnaire (MDHAQ), which includes PATGL, pain (PN), and physical function (FN), each scored 0-10. RAPID3 (routine assessment of patient index data) is calculated as a 0-30 scale from 3 0-10 scores for FN, PN and PATGL. The rheumatologist assigned a DOCGL for each patient on a 0-10 VAS identical to the PATGL VAS. PATGL and DOCGL were compared for concordance or discordance in 225 individual patients, classified in 3 groups: PATGL=DOCGL, i.e., both scales within 2 units of each other; PATGL>DOCGL by ≥2 units; or DOCGL>PATGL by ≥2 units. DOCGL, PATGL and RAPID3 were compared in these 3 groups, using Kruskal-Wallis tests to analyze statistical significance. Results Among 225 encounters, PATGL>DOCGL was seen in 80 (36%), PATGL=DOCGL in 118 (52%) and DOCGL>PATGL in 27 (12%), similar to published reports.1 Median DOCGL was 3.5 in concordant encounters (PATGL=DOCGL), compared to 4.0 when DOCGL>PATGL or when PATGL>DOCGL (p=0.078). By contrast, median PATGL was 3.8 when PATGL=DOCGL, compared to 1.0 when DOCGL>PATGL and 7.0 when PATGL>DOCGL (p<0.001). The range of medians in all categories was 3.0–5.5 for DOCGL, 1.0–7.5 for PATGL and 5.8–18.3 for RAPID3. Median (IQR) values for DOCGL, PATGL and RAPID3 according to whether PATGL>DOCGL, PATGL=DOCGL or DOCGL>PATGL in all patients, RA patients, and other patients. N (%) DOCGL PATGL RAPID3 All patients PATGL>DOCGL 80 (36%) 4.0 (2.8–5.0) 7.0 (5.0–8.5) 18.3 (12.8–21.0) PATGL=DOCGL 118 (52%) 3.5 (2.0–6.0) 3.8 (2.0–5.5) 10.2 (6.3–15.5) DOCGL>PATGL 27 (12%) 4.0 (3.0–6.5) 1.0 (0.0–3.0) 7.0 (4.3–11.3) Total 225 (100%) 4.0 (2.5–5.0) 5.0 (2.5–7.0) 12.0 (7.3–18.7) P value 0.078 <0.001 <0.001 RA patients PATGL>DOCGL 20 (31%) 4.0 (3.0–5.3) 7.5 (6.0–8.5) 17.4 (13.2–20.2) PATGL=DOCGL 36 (56%) 3.0 (2.0–5.0) 3.5 (1.8–5.3) 8.7 (5.2–15.5) DOCGL>PATGL 8 (13%) 3.3 (3.0–4.0) 1.0 (0.5–1.3) 5.8 (3.4–7.2) Total 64 (100%) 3.8 (2.0–5.0) 4.3 (1.8–6.8) 9.8 (6.2–18.7) P value 0.299 <0.001 <0.001 Other patients PATGL>DOCGL 60 (37%) 4.0 (2.5–5.0) 7.0 (5.0–8.5) 18.3 (12.8–21.2) PATGL=DOCGL 82 (51%) 3.5 (2.5–6.0) 4.0 (2.0–5.5) 10.9 (6.3–15.7) DOCGL>PATGL 19 (12%) 5.5 (4.0–7.0) 2.0 (0.0–3.5) 8.0 (4.3–12.0) Total 161 (100%) 4.0 (2.5–6.0) 5.0 (3.0–7.0) 12.1 (7.8–18.7) P value 0.012 <0.001 <0.001 Conclusions Discordance between PATGL and DOCGL is driven largely by variation in PATGL rather than DOCGL. DOCGL was higher in patients in whom DOCGL>PATGL vs DOCGL=PATGL, as expected, but also was higher in encounters in which PATGL>DOCGL, which was unexpected. Efforts to understand and reduce discordance may result in better care and outcomes. References Barton JL, Imboden J, Graf J, et al. Arthritis Care Res 2010;62:857-64 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3945
Background Fibromyalgia (FM) is more prevalent than most rheumatic diseases in the general popula... more Background Fibromyalgia (FM) is more prevalent than most rheumatic diseases in the general population, and is seen as a secondary phenomenon in 20–40% of people who have inflammatory rheumatic diseases. Formal ACR criteria to identify FM using self-report questionnaire data have been established (1), but generally not applied in busy clinical settings, in which it is not feasible to use multiple different patient questionnaires. A multidimensional health assessment questionnaire (MDHAQ) is feasible for completion by patients in the waiting area, and informative in rheumatoid arthritis (RA) as well as many other rheumatic diseases, and may be useful in FM. (2) Objectives To develop a cumulative index based on specific cutpoints of individual MDHAQ measures to screen for patients with primary or secondary fibromyalgia in busy clinical settings. Methods In two rheumatology settings, patients complete an MDHAQ at each visit. Nine MDHAQ scales were analyzed: 0–10 scores for physical function, pain, patient global estimate, and fatigue; 0–3 sores for sleep quality, anxiety, and depression; a RA disease activity index (RADAI) 0–48 self-report painful joint count and symptom checklist of 60 items. Scores on all MDHAQ scales were compared in Setting A in patients with a clinical diagnosis of primary FM vs RA with no secondary FM, and in Setting B in patients who had secondary FM according to ACR FM criteria vs other patients who did not meet ACR FM criteria. Only patients with complete data for all 9 MDHAQ scales and the ACR FM scales in Setting B were included in the study. Comparisons included frequencies, t tests, cross-tabulations with various cut-points, and receiver-operator curves, as well as a kappa statistic comparing clinician diagnosis of secondary FM vs FM by ACR criteria in setting B. A possible cumulative index based on specific cutpoints of individual measures, analogous to RA classification criteria (3), was explored with several cutpoints of different numbers of MDHAQ measures. Results In Setting A, 286 patients with RA were compared to 195 with FM. In setting B, 22 patients who had other diagnoses but secondary FM by ACR criteria were compared to 68 patients who had no FM by ACR criteria. All 9 MDHAQ scales were significantly higher in patients with FM compared to patients with RA or other diagnoses in both settings according to t tests and receiver-operator curves (data not shown). In Setting B, the kappa statistic was 0.68, indicating >80% agreement between the clinician diagnosis and ACR FM criteria. The highest levels of significance were seen for symptom checklist, RADAI self-report joint count scores, and pain scores. For example, an index provided a clue to primary or secondary FM at either site, with 2 of the following 3 measures: Pain ≥5, RADAI ≥16, symptom checklist ≥16.Table 1 Setting A Setting B 1° Fibro – Clin RA Clin p 2° Fibro ACR No 2° Fibro p (n=195) (n=286) (n=22) (n=68) 156 (80%) 94 (33%) p<0.0001 18 (81%) 12 (18%) p<0.0001 Conclusions MDHAQ scales can provide clues to identify primary and secondary FM. Of course, a diagnosis requires a physician history and physical examination, but a screening tool may save time and increase recognition of FM in busy clinical settings. Disclosure of Interest None declared
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Papers by Kathryn Gibson