Rheumatoid arthritis prognosis
The natural course of rheumatoid arthritis
If you have rheumatoid arthritis, you may be wondering about how your condition is going to develop. It is difficult to tell because RA is different for everybody. It is estimated that in a group of people with RA, 10% will improve over a period of time, 60% will experience intermittent symptoms which gradually worsen, 20% will show severe joint erosions and require surgery, and 10% will be severely disabled. However, therapies are now improving and this may improve in the coming years.
One study looked at mortality figures over 12 years. They found that approximately 25% of patients had died during that time. This was not necessarily due to their RA, but survival rates in a control group of patients without RA were double those in the RA group. 10% of deaths were attributed to RA or RA therapy.
Another followed 100 patients with RA over 14 years. They noted that people were more likely to develop RA in the winter than the summer. 88% had a positive rheumatoid factor at some point, although this changed through the disease course. In this trial, 17% had died after 14 years, with 5% thought to be possibly due to RA.
In the study above, the blood results of the remaining patients improved, but their functional abilities decreased. Rheumatoid factor positivity and initial functional status were predictors of final functional ability, but not of survival.
Certain features will make it more likely that your disease will run a worse course. These include:
A positive rheumatoid factor blood test when you are diagnosed
Number of joints affected by RA
Severe disease assessed by ratings such as the American Rheumatic Association functional class
Slow onset of symptoms
Severe joint damage on X-ray
Older age at start of RA
Both sides of the body affected at diagnosis
Lower morale (although this may be closely linked to the severity of your disease) and living alone or lack of family support have been shown to be related to lower functional ability
Disease outside the joints
Cryoglobin or certain antibodies in the blood such as anti-citrullinated protein antibody (ACPA)
Raised C-reactive protein (CRP) or serum amyloid (SAA) levels in the blood
If you have any of these factors, you may require earlier treatment with advanced therapies such as monoclonal antibodies. This will be decided by your health care team. For instance, one study looked at a combination of infliximab and methotrexate given over 1 year. It found that even 8 years later, there were substantial benefits in terms of remission of symptoms.
Disease outside the joints
If you have RA, you may suffer from RA outside the joints, for example in the lungs, kidneys or blood. As mentioned above, people with extra-articular (outside the joint) RA have a poorer prognosis. However, this depends on the organ affected. We investigate the prognosis for these symptoms below:
There are several types of lung disease associated with RA. One reason for the increased mortality figures in people with RA is the increased risk of pneumonia. Other lung diseases associated with RA are pulmonary fibrosis (scarring of lung tissue), which may be caused by the disease itself or treatments such as methotrexate, and interstitial lung disease (ILD), which affects the lung tissue.
The prognosis for ILD is challenging, as the disease has little effective treatment. The average survival after it is diagnosed is 3 years, and it often happens early in the disease. The degree of the ILD involved is closely related to the prognosis; greater involvement has a worse prognosis. Discussions are underway to decide whether people with RA should have routine chest X-rays to screen for this condition.
Skin and eyes
Certain skin and related diseases can worsen your prognosis in RA. These include a vasculitic rash (due to blood vessel inflammation) and skin ulcers. Inflammation of the eyes known as scleritis, which causes red painful eyes, also increases the risk.
People with RA have an increased risk of heart attack and stroke, which can lead to serious illnesses and disabilities such as heart failure, recurrent angina and weakness of the limbs. This may be due to increased clotting resulting from inflammation, and is responsible for a large amount of the increased mortality in RA. If you have raised CRP or SAA levels, you are at greater risk of heart disease.
To combat this, you may be prescribed medications to control your cholesterol (such as statins), blood sugar if you have diabetes, blood pressure (such as ACE inhibitors), and advised to give up smoking if you are a smoker.
One woman talks here about her experience with rheumatoid arthritis:
If you have concerns about your health, please speak to your health care team.
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Written by Dr Anne Parfitt-Rogers, Medical Writer, UK