Background/Purpose: A physician estimate of global status (DOCGL) on a 0-10 visual analog scale (VAS) was developed initially to assess inflammation in patients with rheumatoid arthritis (RA), particularly to assess change in clinical trials, in which DOCGL has greater relative efficiency than the other 6 RA Core Data set measures to distinguish active from control treatments. Some rheumatologists interpret DOCGL as based entirely on inflammation, while others also may consider joint damage and/or psychological distress as in fibromyalgia, in addition to inflammation, in formulating a 0-10 DOCGL VAS estimate. One approach to clarifying this matter is for physicians to estimate 3 additional 0-10 VAS for inflammation, damage, and distress. We analyzed scores at 2 academic rheumatology sites for 4 VAS estimated by rheumatologists, for overall DOCGL, inflammation, damage, and distress, compared to high, moderate, low, and near-remission according to RAPID3 on an MDHAQ in patients in RA seen in routine care.

Methods: All patients seen at 2 academic sites complete an MDHAQ/RAPID3 at each visit. Rheumatologists complete 4 0-10 VAS for DOCGL, inflammation or reversible disease, damage or irreversible disease, and distress explained by neither inflammation nor damage. Mean estimates for overall status, inflammation, damage, and distress or fibromyalgia, were analyzed in patients according to RAPID3 categories for high (=≥12), moderate (=6.1-12), low (=3.1-6), and near-remission (=≤3), with statistical significance computed by analysis of variance (ANOVA). Differences between damage and inflammation estimates also were calculated. 

Results: Site A included 71 RA patients, mean age 59 years, formal education 11 years, and 76% female; site B included 137 RA patients, mean age 57 years, formal education 14 years, 88% female. The mean DOCGL at both sites A and B was 3.8. DOCGL was 1.5 and 1.6 for patients in remission, at Sites A and B respectively, 1.4 and 3.7 for those in low severity, 3.4 and 3.1 for patients in moderate severity, and 5.3 and 5.4 in patients with high severity (all p ≤ 0.01) (Table). Scores for damage were higher than scores for inflammation at both sites, 3.5 versus 2.3 at site A, and 2.7 versus 2.2 at site B for all patients, as well as in all 4 RAPID3 severity groups at both sites (Table); damage scores were 0.2-1.2/10 units higher than inflammation scores (Table). Scores for distress were somewhat higher for all patients than for inflammation but lesser than for damage at site A and lower than both inflammation and damage at site B for all patients.

Conclusion: Joint damage appears to be a more significant clinical problem than inflammation in RA patients at 2 sites. These findings may explain in part why most RA patients are not in remission despite a “treat to target” of remission with powerful biologic agents. Joint damage may be a more severe problem than inflammation in the management of RA at this time.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/joint-damage-appears-as-severe-as-inflammation-according-to-physician-visual-analog-scales-in-patients-with-rheumatoid-arthritis-regardless-of-disease-severity-at-2-sites-which-may-limit-results-of-a/