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Active Foot Synovitis in Patients With Rheumatoid Arthritis: Unstable Remission Status, Radiographic Progression, and Worse Functional Outcomes in Patients With Foot Synovitis in Apparent Remission
Author(s) -
Wechalekar Mihir D.,
Lester Susan,
Hill Catherine L.,
Lee Anita,
Rischmueller Maureen,
Smith Malcolm D.,
Walker Jennifer G.,
Proudman Susanna M.
Publication year - 2016
Publication title -
arthritis care and research
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 2.032
H-Index - 163
eISSN - 2151-4658
pISSN - 2151-464X
DOI - 10.1002/acr.22887
Subject(s) - medicine , synovitis , rheumatoid arthritis , adverse effect , cohort , physical therapy
Objective To determine whether foot synovitis is associated with adverse radiographic and functional outcomes after 3 years in an inception rheumatoid arthritis (RA) cohort receiving treat‐to‐target combination disease‐modifying antirheumatic drug therapy. Methods Disease activity was assessed in early RA patients (n = 266) using the Disease Activity Score in 28 joints, Clinical Disease Activity Index (CDAI), and Simplified Disease Activity Index (SDAI). Radiographic outcomes were assessed with annual hand and feet radiographs and quality of life with the Short Form 36 (SF‐36). The prevalence of remission and foot synovitis was calculated using marginal binomial generalized estimating equations, transition between remission and nonremission states by a multistate Markov model, and changes in radiographic scores by a negative binomial mixed regression log‐link model. Population‐matched SF‐36 data were analyzed by mixed‐effects linear regression. Results Disease activity scores that omit foot joints were modest in their ability to capture foot synovitis. Despite the relative stringency of the SDAI and CDAI for remission, 25–36% of patients in remission had foot synovitis. In patients in remission, foot synovitis predicted transition from remission into relapse by up to 2‐fold. The sustainability of remission markedly influenced the progression of erosion scores ( P = 0.006). After adjusting for disease activity, foot synovitis was associated with worse SF‐36 physical functioning scores ( P = 0.025). Conclusion Disease activity measures that omit foot joints capture foot synovitis poorly. When it is used to define remission, foot synovitis is found in a substantial proportion of patients, which predicts relapse and worse physical function. Foot synovitis influences the sustainability of remission, which in turn markedly influences radiographic progression. Regardless of remission status, persistent foot synovitis should prompt therapy escalation in order to improve long‐term outcomes.