Rheumatoid Arthritis: Killer Disease?
ABSTRACT & COMMENTARY
Synopsis: After more than 20 years of follow-up, a group of patients with rheumatoid arthritis had almost three times as many deaths as expected for an age- and gender-matched population of similar size.
Source: Symmons DPM, et al. J Rheumatol 1998;25:1072-77.
How does one quantify the notion that a patient's illness increases his or her risk of dying prematurely? One way is to divide the number of deaths in a group of patients by the number of expected deaths in similar-sized group of people from the general population with the same age and gender distribution over the same period of time. This figure is the standardized mortality ratio (SMR). Symmons and colleagues used death certificates to assess the number and the causes of death in a group of 489 patients with rheumatoid arthritis (RA). These patients presented to tertiary care, hospital-based rheumatologists in the 1960s and 1970s and, by the time the data collection was complete, had been followed to the time of death, or a mean of 21.5 years. Patients who presented for evaluation to a rheumatologist within the first five years of illness were included in an "early" group, while those who presented after more than five years were designated as belonging to a "late" group. The mean age of the "early" group was 45.4 years at presentation, while the late group had a mean age of 50.3 years. A total of 59% of the entire group of patients with RA died. The SMR for RA patients was 2.7. For men, the SMR was 2.3 at 10 years of follow-up and 2.04 at 20 years of follow-up. For women, the SMRs were 3.5 and 2.78 at 10 and 20 years follow-up, respectively. When analyzed by "early" vs. "late" presentation, and including all causes of death, the "early" group had an SMR of 2.5 in the first decade of follow-up and 1.8 in the second decade, while the "late" group had an SMR of 3.6 in the first decade after presentation. With the caveat that causes of death were used as listed on death certificates and that there was no independent medical record review, there was a strikingly increased SMR for lymphoid and bone marrow-derived neoplasms, with the greatest SMR being 35 for non-Hodgkin's lymphoma. However, the largest number of excess deaths was assigned to the circulatory system, with an SMR for cardiovascular deaths of 2.2. The SMR for respiratory deaths was 3.6, which the authors reported included deaths due to pneumonia. For digestive system disorders, the SMR was 5.0, and for the musculoskeletal system, the SMR was 80.
COMMENT BY JERRY M. GREENE, MD
Rheumatoid arthritis, at least RA that is bad enough to get an English patient to a tertiary care center to see a rheumatologist in London, increases the risk of premature death. Unfortunately, this study, depending as it does upon death certificates for the causes of death, does not shed much light on the ways in which having RA shortens some patients' lives. Particularly intriguing to me is why so many deaths were ascribed to the musculoskeletal system (15% of all deaths; SMR of 80). The authors can only address it by saying: "In the great majority of cases, the death certificate was not completed by the rheumatologist but by the attending physician, usually the GP." Regardless of the mechanism, this study puts physicians on notice that RA, its treatment, or both can shorten lives. We should do what we can to minimize immunosuppression and its infectious and neoplastic consequences. We should address known risk factors for coronary heart disease and try to minimize the use of systemic corticosteroids such as prednisone to reduce the effects of impaired glucose tolerance and deleterious effects upon serum lipids that may accelerate atherosclerosis. We should consider use of anti-ulcer drugs such as omeprazole, famotidine, or misoprostol in those at risk of non-steroidal drug-induced gastric damage to prevent ulcer complications, such as bleeding and perforation. Finally, and despite possible disincentives to primary care physicians to do so, early referral to a rheumatologist may help to reduce the risk of premature death. Evidence for this last point is the lower SMR for the "early" vs. the "late" presenting group of RA patients-a difference that persisted even when an adjustment was made for potential lead time bias by comparing the second decade of follow-up for the "early" group with the first decade of follow-up for the "late" group.
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