Mortality Rates Improve for Patients with Rheumatoid Arthritis

Research shows that patients with RA are living longer.

Although current research shows that mortality rates remain higher in patients with rheumatoid arthritis (RA) compared with people without RA, emerging research suggests that survival is improving.

Recent data from a study presented at the British Society of Rheumatology (BSR) meeting showed a dramatic increase in life expectancy in patients with RA over the past 25 years in the United Kingdom.¹

According to lead author of the study, Sam Norton, PhD, Psychology Department, Institute of Psychiatry King’s College London, U.K., who presented the findings at the April meeting, the study found that the life expectancy for people with RA in the U.K. has increased by about 10 years over the past 25 years, similar to that seen in the general population.

Importantly, preliminary evidence suggested a reduction in excess mortality risk seen in people with RA. The study found a 27% decrease in excess all-cause mortality over 25 years, mainly seen in patients younger than 55 years old, largely driven by reductions in excess mortality due to cardiovascular morbidity.

“These findings are preliminary, and we have no clear answer for what might account for this increase in life expectancy,” he emphasizes. “We are in the process of examining whether the dramatic increase in life expectancy is due to changes in a particular cause of death, such as cardiovascular disease.”

Drilling Down

The study used outcomes data from two prospective observational cohort studies of patients not treated by disease-modifying antirheumatic drugs (DMARDs) at the time of study enrollment: the Early Rheumatoid Arthritis Study (ERAS), which recruited 1,460 patients between 1986 and 1998, and the Early Rheumatoid Arthritis Network (ERAN), which recruited 1,252 patients between 2002 and 2012.

The study found a significant association between the year of symptom onset and risk of all-cause mortality risk, with a hazard ratio of 0.96 (95% confidence interval [CI], 0.95–0.98). This represented a 3.5% reduction in the relative hazard of death from any cause per year, and translated to an increasing median age at death from 76.7 years in 1986 to 86.7 years in 2012.

Early, aggressive treatment helps RA patients beat the odds of early mortality.

The study also found that the excess morality risk in patients with RA reduced over time compared with the general population, with all-cause standardized mortality ratio (SMR) significantly increased in the ERAS cohort (SMR = 0.94; 95% CI, 1.20–1.39). No significant increase was seen in the ERAN cohort (SMR = 0.94; 95% CI, 0.78–1.13).

When looking specifically at excess cardiovascular mortality risk, the study found a similar trend with the SMR reducing, dropping from 1.96 (95% CI, 1.64–2.39) in the ERAS cohort to 1.11 (95% CI, 0.75–1.46) in the ERAN cohort.

Jenny Humphreys, clinical research fellow, ARUK Centre of Excellence for Epidemiology, University of Manchester, and lead author of another recent study that looked at mortality trends in patients with early RA over 20 years in the U.K., emphasizes the importance of the finding of the marked increases in life expectancy over the past 20 years for people with RA found in the Norton study, and she says this finding coheres with what she and her colleagues found in their single cohort study.²

She says their study also found a decreasing trend in the SMR for RA patients, and—although it did not reach statistical significance as it did in the Norton study—she doesn’t see the results as contradictory. “The difference in our results could be explained by differences in the characteristics of the study participants [inclusion of patients with inflammatory arthritis],” she says.

Other Noteworthy Findings

Norton and colleagues also found that people are developing RA at a later age. The study found that the age at symptom onset increased by about two months per year, from 54.2 years in 1986 to 58.5 years in 2012. The gain in life expectancy, says Dr. Norton, was only partially offset by patients developing RA at a later age.

“While this is good news, since the gain in life expectancy was greater than the delay in onset, these findings suggest that people with rheumatoid arthritis are living longer with their condition.” The clinical implication of this for rheumatologists is the need for better and longer management of RA.

“Management of RA should continue to focus on treating patients to achieve low disease activity, thereby reducing the likelihood that the condition results in severe disability,” he says.

Clinical Implications—Importance of Early Aggressive Treatment

Emphasizing that emerging evidence does suggest that survival is improving for people with RA, Sherine Gabriel, MD, professor of epidemiology and medicine, Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minn., says the cause of this improvement remains difficult to determine, given the observational nature of the data.

However, she says treatment of RA has become more aggressive over recent years, suggesting that recent changes in the therapeutic approach to RA may be responsible for the improved outcomes.

She also says, though, that recent research suggests that people with RA may age at an accelerated rate compared with those without RA, adding fuel to the need for early aggressive treatment.

“The systemic inflammation that characterizes RA puts people with the disease at risk of accelerated aging and early mortality,” she says. “Early, aggressive treatment is our best means of addressing these risks.”

Mary Beth Nierengarten is a freelance medical journalist based in St. Paul, Minn.

References

1. Norton S, et al. Excess mortality in rheumatoid arthritis: Gains in life expectancy over 25 years. BSR. 2014; Abstract O34.
2. Humphreys JH, Warner A, Chipping J. Mortality trends in patients with early rheumatoid arthritis over 20 years: Results from the Norfolk Arthritis Register. Arthritis Care Res (Hoboken). 2014 Sep;66(9):1296–1301.