Background/Purpose: 1.To determine the clinical presentation, treatment and outcomes of vasculitis (RV) associated with rheumatoid arthritis (RA) in the era of biologic use. 2. To identify risk factors associated with the development of RV.
Methods: A retrospective cohort of patients with RV evaluated at Mayo Clinic Rochester in 2000-2009 was identified. RV was defined as histopathological evidence of and/or a definitive clinical or radiological diagnosis of vasculitis made by a rheumatologist in a patient meeting the 1987 ACR classification criteria for RA. In a case-control study to identify risk factors for RV, RV cases were compared in a 1:2 ratio to controls (RA without RV).
Results: Eighty-six patients (58% women, 88% white) with RV were identified. All met the 1984 Scott and Bacon criteria for systemic RV. Histopathological confirmation was available for 58%. RV manifestations included cutaneous vasculitis (65%), vasculitic neuropathy (35%), CNS vasculitis (8%), mesenteric vasculitis (2%), scleritis/episcleritis (2%), pulmonary angiitis (1%) and necrotizing glomerulonephritis (1%). Median age at RV diagnosis was 63 y (IQR 51-71 y) and median duration of RA was 10.8 y (IQR 2.7-21 y). 29% were current smokers at RV diagnosis. Majority had a positive rheumatoid factor (84%), anti-CCP antibody (67%), elevated ESR (66%) and CRP (69%). For treatment, 99% received corticosteroids, 29% cyclophosphamide, 55% other DMARDs and 28% biologic response modifiers (BRM). At 6 months, 38% patients achieved complete remission, 52% had partial improvement, while 10% noted no clinical improvement. Median follow up was 16 months (IQR 2.4 -59) during which 21% patients died and 30% had a relapse of RV. Predictors of relapse included smoking at RV diagnosis, lower mean ESR at presentation, and cyclophosphamide use. Among RV patients, those treated with a BRM for their RA were younger (56 vs 65 y, p=0.004) and had a lower incidence of vasculitic neuropathy (21% vs 47%, p = 0.015) than those treated without a BRM. In none of the 34 patients treated with a BRM prior to RV, was the BRM conclusively implicated to be a trigger for RV.
The 86 RV cases were compared to 172 RA controls. After adjusting for age and disease duration, increased RV risk was associated with male sex, current smoking at RA diagnosis, coexistent peripheral vascular disease (PVD) and cerebrovascular disease. Patients with high disease severity characterized by a composite index of erosions, nodulosis and 1 or more joint surgery had a significantly higher risk of RV (Odds ratio 2.0, 95% CI 1.1-3.7). Biologic use also increased the odds for RV while use of hydroxychloroquine (OR 0.54, p=0.03) and low dose aspirin for cardioprotection (OR 0.42, p=0.02) were associated with lower odds of developing RV.
Conclusion: In this large series of patients with RV, the predominant clinical manifestations were cutaneous vasculitis and vasculitic neuropathy. Male sex, smoking, RA severity, PVD and cerebrovascular disease increased the odds of developing RV. Among patients with RV, use of BRM was associated with a lower frequency of vasculitic neuropathy. Even in the ‘biologic era’, RV remains a serious complication of RA and is associated with significant mortality.
Disclosure:
A. Makol,
None;
C. S. Crowson,
None;
E. L. Matteson,
Centocor, Inc./Johnson and Johnson,
2,
Genentech and Biogen IDEC Inc.,
2,
Hoffmann-La Roche, Inc.,
2,
Human Genome Sciences, Inc.,
2,
Pfizer Inc,
2,
Novartis Pharmaceutical Corporation,
2,
Roche Pharmaceuticals,
2,
UCB Group,
2,
Centocor, Inc.,
5,
Horizon Pharma,
5,
Novartis Pharmaceutical Corporation,
5;
K. J. Warrington,
None.
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/clinical-correlates-treatment-outcomes-and-predictors-of-vasculitis-associated-with-rheumatoid-arthritis-in-the-biologic-era-a-case-control-study/