Rheumatoid arthritis should we shift the focus fr

Authors: Hani Almoallim Ashraf Kamil

Publish Date: 2013/01/06

Volume: 32, Issue: 3, Pages: 285-287

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Abstract

Rheumatoid arthritis RA is a chronic inflammatory disorder characterized by progressive inflammatory synovitis and destruction of articular cartilage and marginal bone Joint erosion can be seen within 6 months of disease onset in the majority of patients and occurs more rapidly in the first year than in latestage disease 1 Historical studies have demonstrated that moderate disability within 2 years of diagnosis is not uncommon and up to 30  of patients may be unable to work after 10 years 2 Improvement in disability as measured by Health Assessment Questionnaire HAQ disability index scores can be demonstrated in the short term with DMARD therapy but the magnitude of this improvement is substantially greater among patients with early disease than among those with more advanced disease 3 Longitudinal studies of RA patients show that there is a progressive decline in HAQ scores with time 3 4 Early interventions that prevent irreversible damage would appear to offer the best opportunities for achievement of favorable outcomes in patients with early aggressive RA In early intervention studies that measured radiographic progression this therapeutic window can be as small as a few months 5 6 In addition to early therapy combination treatment has been shown to result in more favorable shortterm and longterm outcomes than monotherapy 5 7RA poses a significant burden to patients their caregivers and employers and the government Work disability often arises early in the course of the disease According to several prospective studies 20–35  of individuals had to stop working within 2–3 years of disease onset 2 8 After 5–10 years the reported work disability rate is approximately 40  9Aggressive therapy can also help to preserve the workability of RA patients In a study by Klimes et al published in 2011 10 it was noted that patients on biologics reported less reduction of daily activities 398  than patients on DMARDs 505  reflecting around 536  higher productivity costs for the latter group Similarly we recently showed that the use of biologics improved workability scores in RA in a crosssectional study of 120 patients from three different hospitals in Saudi Arabia Janoudi N Almoallim H Husien W Noorwali A Ibrahim A 2012 Workability and work instability evaluation in Saudi patients with rheumatoid arthritis Arthritis Care Research unpublished Indeed we observed that RA patients on conventional therapy had significantly lower work quality quantity and satisfaction scores than those receiving biological therapyIn a study published in 1996 Mau et al 11 showed that the fastest decline in the employment rate among RA patients was found within the first 3 years of the disease onset with a 3year employment rate reduced to 73 ± 5  This reflects the importance of early and aggressive management of RA if workability is the main treatment goal This observation was further confirmed by Puolakka and collaborators 12 who concluded that prompt induction of remission enabled maintenance of work capacity Their results revealed that the median numbers of work disability days per patientyear from 6 through 60 months of followup were 0 for ACR70 achievers 4 for ACR 50 achievers 16 for ACR 20 achievers and 352 for ACR20 nonachieversOver the past 15 years rheumatologists have developed and witnessed many paradigmatic changes in the treatment of RA Recently a task force of rheumatologists and patients developed a set of recommendations on the basis of evidence derived from a systematic literature review and expert opinion This resulted in ten treattotarget recommendations 13 These recommendations describe the treatment goal of achieving remission with low disease activity as an alternative goal in patients with longstanding disease and either explain the extended definition of remission or suggest ways to achieve remissionOur goal as rheumatologists in Saudi Arabia goes one step further as we want to ensure that RA patients remain active working members of Saudi society Since maintenance of workability remains a major challenge in RA this is a more stringent objective that makes achieving strict remission a major goal for rheumatologists Indeed we recently observed in a crosssectional study of RA patients in Saudi Arabia that 55  of RA patients suffered from a 50  drop in their work quantity and 658  described a 50  effect on their workability Janoudi N Almoallim H Husien W Noorwali A Ibrahim A 2012 Workability and work instability evaluation in Saudi patients with rheumatoid arthritis Arthritis Care Research unpublished Only 5  of patients stated that RA had no effect on their workability In fact as would be expected work quality quantity and satisfaction were significantly correlated with active RA Zhang et al 14 found that achieving clinical remission or major improvement may be necessary to significantly affect work outcomes They observed that ACR70 responders were 72  less likely to stop working and 55  less likely to miss work than ACR20 nonresponders Furthermore patients achieving DAS28 remission were 54  less likely to stop work than those with DAS28 scores 32 Their results also revealed that moderate improvements did not appear to effect work stoppage or missed days after adjustmentsHowever valid assessment of the workability and work productivity of RA patients remains a challenge Until the early 1990s there was no quantitative measure of healthrelated work productivity loss due to health problems for the employed population The National Health Survey assessed workdays missed and whether there was any work limitation but did not quantify the amount of limitation or its effect on work productivity Some multidimensional heathrelated quality of life questionnaires assessed role impairment but these instruments did not distinguish work impairment from that in other activities such as housework or school and did not quantify the absolute amount of impairment 15 These instruments generated qualitative impairment scores but not quantitative scoresThe Work Productivity and Activity Impairment WPAI Questionnaire was created to be a patientreported quantitative assessment of the amount of absenteeism work time missed presenteeism reduced onthejob effectiveness and daily activity impairment attributable to general health WPAIGH or a specific health problem WPAISHPThe six questions in the WPAI questionnaire were generated from three main sources First a review of the work productivity literature suggested the type of items that should be tested in the questionnaire Second comments made by allergic rhinitis patients when responding to the intervieweradministered version of the WPAI items in a series of clinical studies and their responses to different work productivity questions were analyzed 16 Third cognitive debriefing of subjects following interviewer administration and selfadministration of a diseasespecific and general health version of the WPAI items and related work productivity questions helped to determine the final wording of the items The construct validity and discriminative ability of WPAIGH have been established in a study of Zhang et al 17 Thus the WPAIGH is a valid questionnaire for assessing impairment in paid work and activities among RA patients and for measuring the relative differences between RA patients with different health statuses The WPAIGH is therefore useful for measuring productivity outcomes in clinical practiceThe WPAI was designed to be generalizable to a broad range of occupations/diseases and evidence of its reliability and validity is available for many musculoskeletal and nonmusculoskeletal conditions Nevertheless occupations requiring more mobility and physical performance might result in lower WPAI scores eventually leading to the requirement of more aggressive therapies Therefore measurement of patient workability should be carefully weighed Item content is highly consistent across different versions of the measure WPAIGH versus WPAISHP which should facilitate comparison of outcome scores in different studies It has an intuitive scoring method and is compatible with economic costing orientation of response is based on the amount of time affected In addition the WPAI has low respondent burden 18 and could be easily included in regular clinical practice as it is not time consumingFinally while the new Treat to Target recommendations are widely accepted by rheumatologists worldwide we strongly believe that the target should also include workability This represents a valuable patient assessment tool which should be incorporated into the daily management of RA and monitored as a fundamental targeted outcome for all RA patients Although further research is warranted to optimize the implementation of workability measures in clinical practice tools such as WPAI should form an integral part of RA patient assessment along with DAS and HAQ thus transforming the objective of any management guidelines for RA patients into “Treat to Work”

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