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What Are The Main Indicators Of Poor Prognosis In Rheumatoid Arthritis?

Mar 15, 2008
Rheumatoid arthritis (RA) is a chronic, inflammatory, systemic, autoimmune disease that affects more than 2.1 million Americans. Because it is a systemic disease, rheumatoid arthritis can affect internal organs. There is abundant evidence indicating that the chronic inflammation leads to significant problems with mortality related to early cardiovascular events such as heart attack and stroke and lymphoma.

Morbidity- meaning the adverse effects of a disease that don't necessarily result in death is also a significant problem for patients with rheumatoid arthritis. Morbidity is most commonly manifested in disability.

When a diagnosis of rheumatoid arthritis is made, a patient will often have several questions regarding the future and what to expect. They will also wonder about their long term prognosis. Concerns about disability, crippling, and expected effects on life span often crop up.

Probably the one factor that determines long-term prognosis the best is timing of diagnosis. The earlier a patient gets diagnosed and treated, the better the prognosis. With rheumatoid arthritis, once damage occurs to the joints and/or surrounding structures and internal organs, it cannot be reversed.

Another factor governing diagnosis is age at the time of diagnosis.

Aggressive disease occurring in a young person carries a poorer prognosis than in an older person, primarily because of the length of time the disease will have to cause damage.

Co-morbid conditions, meaning other medical conditions a patient has, also weighs in. The more medical problems a patient possesses, the worse the prognosis.

How aggressive the disease is at onset also carries an impact. Aggressive disease obviously is worse than slow smoldering disease. And how well the disease is controlled on medication also has a bearing on prognosis.

There are certain objective criteria that also have been demonstrated in clinical studies to impact prognosis.

For instance, patients who have what are termed "flares"- meaning worsening of the disease, that are severe and which last a long time have a worse prognosis.

Many active joints, ie., many inflamed joints are a poor prognostic indicator.

Long term disease and disease onset at an early age both worsen prognosis.

Laboratory markers such as the erythrocyte sedimentation rate (ESR or "sed rate") and C-reactive protein (CRP), when elevated confer a poorer prognosis, particularly if they stay elevated despite aggressive treatment.

Another set of laboratory indicators is the presence of positive rheumatoid factor and positive values for anti-CCP. These tests also indicate a relatively poor prognosis.

Rheumatoid nodules are collections of inflammatory tissue that often times in patients with longstanding and poorly controlled rheumatoid arthritis grow on areas such as the elbows, Achilles tendons, low back, or even the back of the skull.

Early x-ray changes showing damage are an extremely good indicator of a less than optimal prognosis. The presence of x-ray changes early on signifies an unusually aggressive form of rheumatoid arthritis.

Low socioeconomic class is another risk factor for poor prognosis. This risk factor may be a problem because of limited access to appropriate care or to lower educational level.

Another poor prognostic factor is patient functioning as measured by different tests such as the Health Assessment Questionnaire or HAQ. Poor functioning on the HAQ is an excellent indicator of prognosis.
About the Author
Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info: Arthritis Treatment
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