Background/Purpose: Measures to assess patients with rheumatoid arthritis (RA) reflect primarily inflammatory activity in patients who meet inclusion criteria for selection into clinical trials. However, many patients seen in routine care (and some in clinical trials) have structural joint damage and/or patient distress in addition to inflammatory activity, which may affect RA indices. Thus, a patient with 0 swollen joints, an erythrocyte sedimentation rate of 15, 14 tender joints and patient global assessment of 80/100 (or 8/10) would have a DAS28 of 5.1 and CDAI of at least 22 (even if physician global assessment is 0), suggesting high disease activity, although the high score results from damage and/or distress. We have added to a physician global assessment (DOCGL) 0-10 visual analog scale (VAS) 3 three 0-10 VAS for inflammation, damage, and distress, as well as estimates of the proportion of clinical management decisions attributed to each (%inflammation+ %damage+%distress, total=100%). We hypothesized that a greater proportion of clinical decisions in RA may be attributed to structural damage than to inflammation as a result of modern therapeutics, by comparing scores in routine care patients.

Methods: At one academic center, all patients complete an MDHAQ/RAPID3 prior to seeing the rheumatologist. Physicians complete 4 0-10 VAS for DOCGL, inflammation (i.e., reversible disease) (DOCINF), damage (i.e., structural irreversible disease) (DOCDAM), and distress (i.e., fibromyalgia, depression, etc.) (DOCSTR). The rheumatologist also records estimates of the proportion of clinical management decisions attributed to %inflammation, %damage, and % distress, total=100%. Patients were classified in 5 groups for DOCINF and DOCDAM VAS as 0-2, 2.1-4, 4.1-6, 6.1-8, and 8.1-10, and for % of clinical decisions as 0-20%, 21-40%, 41-60%, 61-80%, and 81-100%, and compared using t tests and analysis of variance (ANOVA).

Results: In a cross-sectional analysis of a single random visit of 98 RA patients, mean physician DOCINF 0-10 VAS was 2.8, lower than 3.8 for DOCDAM (Table). The mean proportion of management decisions attributed to inflammation was 39%, lower than 52% for damage (Table) (9% for distress- data not shown). Minimal 0-2.0 VAS scores for DOCINF were seen in 48 patients vs 30 for DOCDAM, while 4.1-10 VAS were estimated in 20 patients for DOCINF (8+2+10) vs 29 for DOCDAM (12+15+2). More than 40% of management decisions was attributed to damage in 59 patients (24+20+15) (vs 22 for 0-20%), vs to inflammation in 42 patients (18+15+9) (same as 0-20%) (Table).

Conclusion: Structural joint damage appears more prominent than inflammatory activity in physician clinical management decisions in a cross-section of RA patients at this time. Quantitative physician estimates of damage as well as inflammation may clarify management decisions in patients with RA, as damage remains a significant challenge in routine clinical care.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/is-joint-damage-due-to-secondary-osteoarthritis-oa-clinically-as-important-as-inflammation-in-contemporary-management-of-rheumatoid-arthritis-ra/