ACR Study Group: Rheumatiod Arthritis Morbidity and Mortality - Are we making a difference?

Paivi Miettunen, MD, Roberta Schellenberg, MD

The Mayo clinic epidemiology project has been following all Minnesota residents over the age of 18 with rheumatoid arthritis (RA), from 1955-1994. The data from this epidemiological study would suggest that the incidence of RA has decreased over time. These same data, however, also point to an unchanged mortality rate for RA patients, despite significant therapeutic developments over the past 30 years.

Poor prognostic predictors for mortality are:
 • Extra-articular manifestations
 • Steroid use
 • Concomitant chemotherapy
 • Co-morbid illness.

The primary cause of death in RA patients is cardiovascular disease (CV disease), with ~ 40% of patients dying from CV disease.

The second speaker reiterated the mortality issues and questioned whether study design impacted on mortality estimates. He noted that when one compared data from an inception cohort vs. a non-inception cohort, there was a decrease in mortality. Older vs. newer studies, and studies done in community-based practices vs. clinical practices, did not impact mortality significantly.

Better survival was associated with:
 • Younger age
 • Decreased helplessness scores
 • Better functional status
 • Increased walking time
 • Better ADL scores
 • Decreased joint counts
 • Less extra-articular features
 • Were more educated
 • Had a lower RA functional class.

This speaker commented briefly on methotrexate (MTX) and a study published in the Journal of Rheumatology in 2000, which shows decreased mortality with effective MTX therapy. Individuals with 50% improvement in their RA had a standardized mortality ratio (SMR) of 1.47, as compared to a SMR of 4.11 with <20% improvement. Abstract 321 at this conference also confirms this finding.

The last issue discussed was the impact of treatment on survival in RA. It was noted that the average time to cessation of disease-modifying anti-rheumatic drug (DMARD) therapy is ~ 80 months. As this is significantly less than the duration of disease in RA, the question remains: what is the impact of therapy on long-term mortality?

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This program has been provided through an unrestricted educational grant from McNeil Consumer Healthcare, the makers of TYLENOL*(acetaminophen).