Dr Doortje Krijbolder and colleagues hypothesized that the at-risk phase of symptoms and subclinical joint-inflammation is a therapeutic window in which it may be possible to permanently modify the disease course. TREAT-EARLIER was a randomized, double-blind, 2-year proof-ofconcept trial, in which 236 adults with arthralgia clinically suspected of progressing to RA and MRI-detected subclinical joint inflammation were assigned to receive either a single intramuscular glucocorticoid injection and a 1-year course of oral methotrexate, or placebo injection and placebo tablets.
The group found that, after 24 months, arthritis-free survival was similar in both groups (80% versus 82%). Physical functioning improved more in the treatment-group during the first months and remained better. Similarly, pain, morning stiffness, and presenteeism showed sustained improvement compared to placebo. MRI-detected joint-inflammation was also persistently improved.
High-risk participants in the treatment group showed a delay in clinical arthritis development: they developed the endpoint less often during treatment, but frequencies became similar at 24 months (67% in both groups). A similar delaying effect was observed in ACPA-positive participants, where 48% and 52% had developed persistent clinical arthritis at 24 months.
The findings suggest that methotrexate initiated at the pre-arthritis stage of joint symptoms and subclinical inflammation did not prevent the development of clinical arthritis – but modified the disease course as measured by sustained improvement in inflammation, symptoms, and impairments. These data could open up a new treatment landscape in a pre-arthritis phase of RA, where limitations can be just as severe as at the onset of clinical arthritis.
Another group also published findings in clinically suspect arthralgia patients. The research, presented by Dr Sarah Khidir, set out to examine the influence of socioeconomic factors on RA development. 600 patients presenting with clinically suspect arthralgia were followed for the development of inflammatory arthritis. Educational attainment was defined as low (lower general secondary education), medium, or high (college or university education).
Results showed that patients with a low level of educational attainment were older, had a higher body mass index (BMI), and smoked more often compared to patients with a high educational level. But even after adjusting the data to take into account age, BMI, and smoking status, low educational attainment was associated with increased development of inflammatory arthritis.
The group also reported that patients with a lower educational level had higher levels of subclinical inflammation at presentation, which was associated with a higher risk of progression to inflammatory arthritis.
This is the first evidence that lower educational attainment of patients with arthralgia is associated with a higher risk of developing arthritis. Further research into the role of socioeconomic factors on the development of RA is needed.