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What are the consequences of early rheumatoid arthritis for the individual?

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Rheumatoid arthritis (RA) has important impacts on health that can be related to the World Health Organization's new International Classification of Functioning, Disability and Health (ICF framework). The physical consequences of RA for the individual relate to body functions and structures in the ICF framework. The functional consequences of RA are related to activity in the ICF framework, and the impact of RA on society relates to participation in the ICF framework.

Despite conventional treatment, early RA continues to result in significant physical consequences for most patients. From the patients' perspective, this primarily results from persistent pain, although symptoms such as fatigue and depression are also relevant. This is confirmed from the clinician's perspective by the infrequency of remission, persistence of disease activity and unrelenting radiographic progression in early RA. Patients with early RA often progress, within only a few years, to significant disability. This has mainly been shown in studies using the Health Assessment Questionnaire as the disability measure, although a small number of studies using generic health measures such as Short Form-36 have reached similar conclusions.

RA patients and their friends and families incur the majority of costs associated with early RA. Many patients are not able to continue to work at the same level as they would have anticipated had they not developed RA. Later on, society bears an increased load, especially in patients with higher levels of disability; this results from major social care costs and interventions such as surgery. However, the evidence favouring expensive biological therapies, even in early RA, is likely to turn this analysis on its head in the near future.

Section snippets

Assessing the impact of chronic disease

As discussed by Carr9, given our current inability to prevent or cure RA, the primary aim of care should be to reduce the impact of the disease on patients' lives. This major focus on improving quality of life and reducing or postponing disability necessitates the development of formal methods for measuring a patient's experience of disease. Such methods focus on the patient's ability to perform daily living tasks and on more global aspects of their quality of life. Various frameworks have been

Patients' perspectives: pain

Pain is a dominant concern of patients with RA, and its persistence is a highly negative consequence of disease. Drugs currently used in arthritis include analgesics, anti-inflammatory drugs, disease-modifying antirheumatic drugs (DMARDs) and biologicals to target pain relief. Unfortunately, although controlling pain is one indication of successful treatment, many early RA patients continue to suffer pain despite therapy. Pain, generally assessed using a visual analogue scale, has been examined

The functional consequences of RA: disability

Disability in RA can be measured using either generic measures, such as the SF-36 and Nottingham Health Profile, or disease-specific measures, such as the HAQ or the Arthritis Impact Measurement Score (AIMS). The advantage of generic measures is that disability can be compared with other diseases, but such measures are relatively insensitive with significant ceiling and floor effects. The disease-specific measure, AIMS, is a good measure but is complex and therefore has not been widely adopted.

Societal consequences of RA

RA has many consequences, not only for the individual but also for their friends and family and for the whole of society. The total costs of RA (both medical and societal costs, termed ‘indirect costs’) seem to have similar drivers across Western industrialized countries, although these will clearly be very different in developing nations. In the Western world, costs have been studied in detail in established RA57, although there are only limited analyses in early RA.58

A Norwegian study,

Acknowledgements

We are grateful to the ARC for supporting our programme of research.

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