The results suggest that local factors influence joint inflammation over time.
INTRODUCTION
Rheumatoid arthritis is a chronic inflammatory disease that affects a person’s joints, and may cause pain and disability. Rheumatoid arthritis can affect people of all ages, but it most often starts between the ages of 40 and 50 – although this can depend on where you live. Rheumatoid arthritis is more common in women than men.
WHAT DID THE AUTHORS HOPE TO FIND?
The authors wanted to know whether joint swelling in people with rheumatoid arthritis comes back repeatedly in the same joints over time, or if the pattern of joint swelling is random. Knowing this might help to understand the underlying processes of joint swelling better.
WHO WAS STUDIED?
The study looked at 508 people who were taking part in a trial called BeSt (short for BehandelStrategieën, which is Dutch for “treatment strategies”). Everyone taking part had a recent diagnosis of rheumatoid arthritis and had received treatment according to four different strategies.
HOW WAS THE STUDY CONDUCTED?
BeSt is a randomised trial, which means that people were assigned by chance to one of four treatment groups. Using chance in this way means that the groups are similar and allow the variable or treatment under investigation to be compared objectively. The four different treatment strategies were:
1) sequential monotherapy (one drug at a time),
2) step-up combination therapy starting with methotrexate,
3) initial combination therapy with methotrexate, sulfasalazine and prednisone, or
4) initial combination therapy with methotrexate and infliximab.
In all four strategies the treatment was adjusted if the rheumatoid arthritis was too active. The participants were followed for up to 10 years, during which time they were assessed for joint swelling every 3 months.
The authors used a statistical analysis to investigate whether joints that were swollen at the start of the study were more likely to become swollen again (once or multiple times). The tests were adjusted to take into account the fact that some joints in rheumatoid arthritis are more often swollen than others.
WHAT WERE THE MAIN FINDINGS OF THE STUDY?
The main finding was that joints which were swollen at the beginning of the study were more likely to be swollen again in the following 10 years – even in this group of people who were receiving intensive treatment. This means that joint swelling tends to be locally recurrent – it is more likely to come back in the same joints than to occur in a random pattern. This information is important, because it suggests that local factors influence joint inflammation over time.
ARE THESE FINDINGS NEW?
Yes. To the best of the authors’ knowledge this study is the first to show that local joint swelling recurs in the same joints.
WHAT ARE THE LIMITATIONS OF THE STUDY?
The study did not assess whether joint tenderness – which may also reflect joint inflammation (local activity) of rheumatoid arthritis – also recurs within the same joint. However, in previous studies it was shown that joint swelling reflects local inflammation better than tenderness does.
In addition, joint swelling assessments were also not always available. During the 10-year follow-up period, some people missed study visits, which meant that 18% of the possible data points were missing. However, the authors accounted for this by looking at the data in different ways, and these analyses showed similar results. Finally, the study did not include X-rays, so it is not possible to say how much joint swelling was caused by joint damage due to other diseases such as osteoarthritis. However, the nurses who assessed the joints were trained to tell the difference between arthritis and other joint swelling, so the authors do not think the lack of X-rays will affect the findings about recurrent swelling.
WHAT DO THE AUTHORS PLAN ON DOING WITH THIS INFORMATION?
The authors are investigating whether joints that are more often swollen also tend to develop more joint damage (which can be seen on X-rays), and whether this may also be due to local mechanisms and not (only) general inflammatory activity.
WHAT DOES THIS MEAN FOR ME?
If you have rheumatoid arthritis, studies like these might help doctors to understand the reasons for your joint swelling. A better understanding of the underlying mechanisms is important, and will help improve treatment for people with rheumatoid arthritis. It could also potentially help doctors and researchers to develop preventive measures.
If you have any concerns about your disease or its treatment, you should talk to your doctor.
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Date prepared: January 2022
Summary based on research article published on: 30 August 2021
From: Heckert SL, et al. Joint inflammation tends to recur in the same joints during the rheumatoid arthritis disease course. Ann Rheum Dis 2022;81:169–174. doi:10.1136/annrheumdis-2021-220882
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