Very early treatment with infliximab in addition to methotrexate in early, poor-prognosis rheumatoid arthritis reduces magnetic resonance imaging evidence of synovitis and damage, with sustained benefit after infliximab withdrawal: results from a twelve-month randomized, double-blind, placebo-contro Reduction in long-term disability in patients with rheumatoid arthritis by disease-modifying antirheumatic drug-based treatment strategies. Perioperative factors associated with septic arthritis after arthroplasty. Prospective multicenter study of 362 knee and 2,651 hip operations. Interleukin-6, procalcitonin and TNF-alpha: markers of peri-prosthetic infection following total joint replacement. UK consultant rheumatologists' access to biological agents and views on the BSR Biologics Register. Longterm safety, efficacy, and radiographic outcome with etanercept treatment in patients with early rheumatoid arthritis. Serious infections during anti-TNFalpha treatment in rheumatoid arthritis patients. Perioperative Anti-Tumor Necrosis Factor Therapy Does Not Increase the Rate of Early Postoperative Complications in Crohn’s Disease The risk of post‐operative complications associated with infliximab therapy for Crohn's disease: a controlled cohort study Serious infections under treatment with TNF-α antagonists compared to traditional DMARDs in patients with rheumatoid arthritis Infectious and Healing Complications after Elective Orthopaedic Foot and Ankle Surgery during Tumor Necrosis Factor-Alpha Inhibition Therapy Predictors of infection in rheumatoid arthritis. Radiographic, clinical, and functional outcomes of treatment with adalimumab (a human anti-tumor necrosis factor monoclonal antibody) in patients with active rheumatoid arthritis receiving concomitant methotrexate therapy: a randomized, placebo-controlled, 52-week trial. Time-dependent increase in risk of hospitalisation with infection among Swedish RA patients treated with TNF antagonists Progression of radiographic joint damage in different eras: trends towards milder disease in rheumatoid arthritis are attributable to improved treatment.
OBJECTIVE Anti-tumor necrosis factor alpha agents are among the most effective therapies for rheumatoid arthritis ( RA ) . However , their optimal use is yet to be determined . This 12-month double-blind study attempted remission induction using st and ard therapy with or without infliximab in patients with early , poor-prognosis RA . The primary end point was synovitis ( measured by magnetic resonance imaging [ MRI ] ) . Clinical observations continued to 24 months . METHODS All patients had fewer than 12 months of symptoms . Assessment s included full metrologic evaluation , laboratory tests , radiographs , functional evaluation using the Health Assessment Question naire ( HAQ ) , and quality of life measurement using the RA Quality of Life ( RAQoL ) question naire . MRI was performed at 0 , 4 , 14 , and 54 weeks ; MR images were scored blindly . Patients received methotrexate ( MTX ) and were r and omized to receive either infliximab or placebo for 12 months . RESULTS Twenty patients were recruited ( mean age 52 years , mean symptom duration 6 months , mean C-reactive protein level 42 mg/liter , and 65 % rheumatoid factor positive ) . At 1 year , all MRI scores were significantly better , with no new erosions in the infliximab plus MTX group ; a greater percentage of infliximab plus MTX-treated patients fulfilled the American College of Rheumatology ( ACR ) 50 % and 70 % improvement criteria ( 78 % versus 40 % in the placebo plus MTX group and 67 % versus 30 % , respectively ) and had a greater functional benefit ( P < 0.05 for all comparisons ) . Importantly , at 1 year after stopping induction therapy , response was sustained in 70 % of the patients in the infliximab plus MTX group , with a median Disease Activity Score in 28 joints ( DAS28 ) of 2.05 ( remission range ) . At 2 years , there were no significant between-group differences in the DAS28 , ACR response , or radiographic scores , but differences in the HAQ and RAQoL scores were maintained ( P < 0.05 ) . CONCLUSION Remission induction with infliximab plus MTX provided a significant reduction in MRI evidence of synovitis and erosions at 1 year . At 2 years , functional and quality of life benefits were sustained , despite withdrawal of infliximab therapy . These data may have significant implication s for the optimal use of expensive biologic therapies OBJECTIVE Therapeutic strategies for rheumatoid arthritis ( RA ) have been evolving from the traditional " pyramid " approach toward one based upon early and sustained use of disease-modifying antirheumatic drugs ( DMARDs ) , in the hope of improving long-term health outcomes . However , few data to have been presented to document the effects of this approach . We sought to directly assess associations between consistent DMARD use and long-term functional outcomes . METHODS We studied 2,888 RA patients who were followed up prospect ively for up to 20 years ( average 9 years ) at 8 data bank centers . The independent variable was the proportion of patient encounters that result ed in treatment with > or = 1 DMARD ( hydroxychloroquine , sulfasalazine , auranofin , intramuscular gold , D-penicillamine , methotrexate , and /or azathioprine ) . The dependent variable was each patient 's last recorded Disability Index value from the Health Assessment Question naire ( HAQ ) . RESULTS Increased DMARD use was strongly associated with better long-term Disability Index values ( P < 0.0001 ) . The association was strengthened when restricted to more seriously affected ( rheumatoid factor (RF)-positive ) patients . The magnitude of the effect , unadjusted , was a difference of 0.53 HAQ Disability units ( scale 0 - 3 ) between 100 % DMARD use and 0 % . Correlation coefficients ranged up to 0.26 . Effects were similar for all disease duration periods ( 0 - 4 , 5 - 9 , 10 - 14 , 15 - 19 , and 20 + years ) . " Control " correlations , with variables computed to represent the proportion of time in which patients were taking either nonsteroidal anti-inflammatory drugs or prednisone , failed to show positive associations . A multiple linear regression model , which controlled for age , disease duration , sex , RF positivity , proportion of visits under a prednisone regimen , and initial disability level , included the proportion of time in which patients were taking DMARDs ( P < 0.0001 ) , with a model R2 of 0.54 . These results were obtained despite an adverse selection bias in which more severely affected individuals were given DMARDS more frequently , and despite absence of data on drug use early in the disease course of many patients . Thus , these results , which suggest up to a 30 percent reduction in long term disability with consistent DMARD use , are most likely conservative . CONCLUSION An association between consistent DMARD use and improvement in long-term functional outcomes in RA is supported by these data Perioperative factors associated with late septic arthritis after knee and hip arthroplasties were prospect ively investigated . All patients received a short course of perioperative cefuroxime . After a follow-up of 1 year , septic arthritis was diagnosed in 9/362 patients ( 2.5 percent ) after knee arthroplasty and in 17/2651 patients ( 0.64 percent ) after hip arthroplasty . For the knee , factors associated with septic arthritis after arthroplasty were rheumatoid arthritis , wound infection , an unhealed wound , and a painful , limited knee function at discharge from the hospital . For the hip , corresponding risk factors were diabetes , failed fracture osteo synthesis , a breakdown of sterility during operation , wound infection , postoperative urinary tract infection , and an unhealed wound at discharge from the hospital or a difficult rehabilitation course . Reoperation after knee and hip arthroplasty was also clearly associated with a higher incidence of septic arthritis This prospect i ve study evaluates the role of new laboratory markers in the diagnosis of deep implant infection in 78 patients ( 41 men and 37 women ) with a revision total knee or hip replacement . The mean age at the time of operation was 64.0 years ( 19 to 90 ) . Intra-operative cultures showed that 21 patients had a septic and 57 an aseptic total joint replacement . The  white blood cell count , the erythrocyte sedimentation rate and levels of C-reactive protein , interleukin-6 , procalcitonin and tumour necrosis factor (TNF)-alpha  were measured in blood sample s before operation . The diagnostic cut-off values were determined by Received Operating Characteristic curve analysis . C-reactive protein ( > 3.2 md/dl ) and interleukin-6 ( > 12 pg/ml ) have the highest sensitivity ( 0.95 ) . Interleukin-6 is less specific than C-reactive protein ( 0.87 vs 0.96 ) . Combining C-reactive protein and interleukin-6 identifies all patients with deep infection of the implant . Procalcitonin ( > 0.3 ng/ml ) and TNF-alpha ( > 40 ng/ml ) are very specific ( 0.98 vs 0.94 ) but have a low sensitivity ( 0.33 vs 0.43 ) . The combination of C-reactive protein and interleukin-6 measurement provide excellent screening tests for infection of a deep implant . A highly specific marker such as procalcitonin and pre-operative aspiration of the joint might be useful in identifying patients with true positive C-reactive protein and /or interleukin-6 levels OBJECTIVES The British Society for Rheumatology Biologics Register ( BSRBR ) is a prospect i ve cohort study to determine the efficacy and toxicity of biological agents in rheumatoid arthritis ( RA ) patients compared with RA controls . Entry of patients to the register is a condition of use of anti-tumour necrosis factor ( anti-TNF ) therapy in the UK , but little is known of clinicians ' views of its usefulness . Data from the register suggest uneven provision of anti-TNF-alpha therapy . METHODS A question naire was sent on behalf of the BSRBR to all UK consultant rheumatologists concerning provision and use of anti-TNF-alpha therapy and their experience of working with the BSRBR . RESULTS  Response rate was 49.5 % representing 252 consultants . Fourty-six per cent had some limitation of access to anti-TNF-alpha drugs , usually a financial cap ( 70 % ) , even for RA patients meeting National Institute for Health and Clinical Excellence ( NICE ) criteria . Sixty-seven per cent could prescribe for ankylosing spondylitis ( AS ) or psoriatic arthritis ( PsA ) in some circumstances but only 25 and 35 % , respectively , could prescribe according to BSR guidance . More than 50 % found the workload involved in su bmi tting data to the registry at least difficult , but most had favourable impressions of the BSRBR and thought similar registries desirable or essential for PsA , AS and rituximab . CONCLUSIONS Access to anti-TNF therapy for patients with inflammatory arthritis is variable in the UK , even for RA where it is NICE-approved . Access is more limited for conditions where NICE has not yet issued guidance . The BSRBR generates a significant workload for rheumatology staff but is generally well-regarded OBJECTIVE To evaluate safety , efficacy , and radiographic progression in patients with early rheumatoid arthritis ( RA ) undergoing longterm treatment with etanercept .  METHODS Patients with early RA ( disease duration of 3 years or less ) who had completed a 2-year efficacy study comparing etanercept and methotrexate ( MTX ) were followed in an extension where they received 25 mg etanercept twice weekly . Safety was summarized descriptively and compared with data from the efficacy study . Efficacy and radiographic progression were assessed using American College of Rheumatology response criteria , disease activity scores , and Total Sharp Score ( TSS ) . RESULTS Rates of serious adverse events and serious infections did not increase with longterm exposure to etanercept , and were similar to rates reported for the blinded portion of the efficacy study . Efficacy was sustained in patients who completed 5 years of etanercept treatment at the time of this report ( N = 201 ) , even in those who decreased or discontinued use of MTX or corticosteroids . No radiographic progression ( change in TSS < or = 0 ) was seen in 55 % of patients with 5-year radiographs ; negative change ( TSS < 0 ) was seen in 11 % . CONCLUSION Etanercept treatment in patients with early RA was generally well tolerated for up to 5 years . The results indicate sustained efficacy and decreased rate of radiographic progression . The rate of radiographic progression was low compared with other studies , emphasizing the benefit gained in patients with early aggressive RA who undergo longterm treatment with etanercept The objective was to estimate the incidence of serious infections in the patients treated with anti-TNFalpha agents for rheumatoid arthritis ( RA ) recorded in the Lombardy Rheumatology Network ( LORHEN ) registry . The study inclusion criteria were met by 1064 of the 1114 patients with long-st and ing RA , 519 treated with infliximab , 303 with adalimumab , and 242 with etanercept ; their mean age was 55.8 years and the mean duration of RA 9.4 years . Seventy-three patients ( 6.9 % ) experienced a total of 74 serious infections , an incidence rate for all treatment courses of 35.9 per 1000 patient-years ( 95 % confidence interval [ 95 % CI ] 27.66 - 44.13 ) . Most were lower respiratory tract ( 34.2 % ) or skin and soft tissue infections ( 20.5 % ) . Of the 1064 patients , the 790 treated with anti-TNFalpha after March 2002 underwent screening tests for LTBI ; five patients developed active tuberculosis . Three patients died of septic shock . The type of anti-TNFalpha agent did not seem to affect the incidence or site of the infections . Both univariate and multivariate analyses identified age at the start of anti-TNFalpha treatment ( p=0.008 ) , baseline erythrocyte sedimentation rate ( [ ESR ] p=0.014 ) , and the concomitant use of corticosteroids ( p=0.029 ) as significant predictors of infections . There was no statistically significant difference in risk between the anti-TNFalpha agents Background There have been numerous studies with conflicting results regarding the use of anti-tumor necrosis factor ( TNF ) therapy and its relationship to postoperative outcome in Crohn disease . The aim of our study was to examine the rate of postoperative morbidity in patients receiving anti TNF therapy in the perioperative period . Methods All patients undergoing surgery for Crohn disease from 2005 till 2008 were abstract ed from a prospect i ve data base . Patients undergoing surgery which included a suture or staple line at risk for leaking were selected for the study . A retrospective review of medical records was performed . The study group comprised patients treated with perioperative anti TNF therapy ( defined as treatment within 8 weeks preoperatively or up to 30 days postoperatively ) . The remainder of the patients did not receive perioperative anti TNF therapy .  Patient characteristics , disease severity , medication use , operative intervention and 30-day complication were compared between the two groups . Results Three hundred and seventy patients were selected for analysis in this study , of which 119 received perioperative anti TNF therapy and 251 did not . The groups were similar in baseline characteristics , perioperative risk factors and procedures . The group who received perioperative anti TNF therapy had a more severe disease overall as measured by the American College of Gastroenterology ( ACG ) categories of disease ( 50 % severe fulminant disease in the perioperative anti-TNF therapy group versus 18 % in the group that did not receive perioperative anti-TNF therapy , p < 0.001 ) . There was no significant association of perioperative anti TNF therapy and any postoperative complications ( 27.9 % in anti-TNF group versus 30.1 % in no anti-TNF group , p = 0.63 ) nor intra-abdominal infectious complications ( 5.0 % in anti-TNF group versus 7.2 % in no anti-TNF group , p = 0.44 ) . Univariate analysis showed that the only factors associated with an increase in postoperative intra-abdominal infections were age and penetrating disease . Conclusions The use of anti-TNF therapy in the perioperative period is safe and is not associated with an increase in overall or infectious complications in Crohn disease patients undergoing surgery Background : By temporarily suppressing the immune response , the anti‐tumour necrosis factor agent , infliximab , may increase the risk of peri‐operative complications Biological treatments aim ing to neutralize TNF-α ( tumour necrosis factor alpha ) ( infliximab , adalimumab and etanercept ) are increasingly used to treat rheumatoid arthritis ( RA ) . Although increased frequency has not been observed in r and omized clinical trials with TNF-α antagonist agents , postmarketing surveillance suggests that infections might be serious consequences of these therapies . Our aim was to compare infections in patients with RA under treatment with disease-modifying antirheumatic drugs ( DMARDs ) and TNF-α antagonists in a university outpatient rheumatology clinic in Turkey . A total of 130 RA patients treated with DMARDs and 48 treated with TNF-α antagonists were analysed for the incidence of infections  . Patients taking TNF-α antagonists  were also review ed for infections before these therapies . The incidence of serious infections was 7/100 patient-years before TNF-α antagonists and 8.6/100 patient-years in DMARDs group . The incidence rose to 17/100 patient-years during therapy with TNF-α antagonists . In patients with RA on routine follow-up , treatment with TNF-α antagonists seems to carry an increased risk of infections compared to traditional DMARDs Background : Biologic response modifiers are assuming a larger role in the management of patients with rheumatoid arthritis . The tumor necrosis factor-alpha ( TNF-α ) inhibitors etanercept and infliximab improve patient symptoms and function . However , these agents have been associated with a risk for healing and infectious complications due to systemic blockade of TNF-α , a ubiquitous mediator required in the normal inflammatory response in tissue healing and infection surveillance . This study analyzed the risk of healing/infectious complications in patients undergoing elective foot and ankle surgery while being treated with TNF-α inhibitors etanercept and infliximab . Methods : Patients with rheumatoid arthritis undergoing elective foot and ankle surgery over a 12-month period were prospect ively followed for the development of complications in the postoperative period . All patients continued their antirheumatic medication schedule unaltered in the perioperative period . Data collected included sex , age , all medications used to treat rheumatoid arthritis , smoking history , and number of orthopaedic foot and ankle procedures performed . Patients were then stratified into two groups based on the use of immunomodulation via TNF-α inhibition ( group 1 ) versus patients who did not receive TNF-α inhibition therapy ( group 2 ) . Groups 1 and 2 were followed and compared for the development of infectious/healing complications . Results : Thirty-one patients were enrolled in the study . Group 1 ( n = 16 ) and group 2 ( n = 15 ) patients were comparable for sex distribution , number of orthopaedic procedures performed , and use of steroids , methotrexate , leflunamide , and nonsteroidal anti-inflammatory drugs . Group 1 contained six times the number of smokers in group 2 . At mean follow-up of 10.6 months ( group 1 ) and 9.7 months ( group 2 ) , healing or infectious complications were similar in both groups . However , when total complications ( healing + infection ) were analyzed , group 1 ( TNF-α inhibition , “ higher risk ” ) patients demonstrated a lower complication rate ( p = .033 ) . Conclusions : The data suggest that in patients with rheumatoid arthritis undergoing elective foot and ankle surgery , the use of TNF-α inhibition agents may be safely undertaken in the perioperative period without increasing the risk of healing or infectious complications OBJECTIVE Patients with rheumatoid arthritis ( RA ) have been shown to have an increased susceptibility to the development of infections . The exact causes of this increased risk are unknown , but may relate to immunologic disturbances associated with the disease or to the immunosuppressive effects of agents used in its treatment . This study was undertaken to identify predictors of serious infections among patients with RA . Identification of such factors is the necessary first step in reducing the excess risk of infection in RA . METHODS Members of a population -based incidence cohort of Rochester , Minnesota residents ages > or=18 years , who had been diagnosed with RA between 1955 and 1994 , were followed up longitudinally through their complete medical records until January 1 , 2000 . We examined potential risk factors for the development of all objective ly confirmed ( by microbiology or radiology ) infections and for infections requiring hospitalization . Potential risk factors included RA severity measures ( rheumatoid factor positivity , elevated erythrocyte sedimentation rate , extraarticular manifestations of RA , and functional status ) , comorbidities ( diabetes mellitus , alcoholism , and chronic lung disease ) , and other risk factors for infection ( presence of leukopenia , smoking ) . Predictors were identified using multivariate time-dependent Cox proportional hazards modeling . RESULTS The 609 RA patients in the cohort had a total followup time of 7,729.7 person-years ( mean 12.7 years per patient ) . A total of 389 patients ( 64 % ) had at least 1 infection with objective confirmation , and 290 ( 48 % ) had at least 1 infection requiring hospitalization . Increasing age , presence of extraarticular manifestations of RA , leukopenia , and comorbidities ( chronic lung disease , alcoholism , organic brain disease , and diabetes mellitus ) , as well as use of corticosteroids , were strong predictors of infection ( P < 0.004 ) in both univariate and multivariate analyses . Notably , use of disease-modifying antirheumatic drugs was not associated with increased risk of infection in multivariate analyses , after adjustment for demographic characteristics , comorbidities , and disease-related variables . CONCLUSION We identified a number of strong predictors of infections in a population -based cohort of patients with RA . These results can be used to prospect ively identify high-risk patients , who may benefit from closer followup and implementation of preventive strategies OBJECTIVE Tumor necrosis factor ( TNF ) is an important proinflammatory cytokine that mediates inflammatory synovitis and articular matrix degradation in rheumatoid arthritis ( RA ) . We investigated the ability of adalimumab , a human anti-TNF monoclonal antibody , to inhibit the progression of structural joint damage , reduce the signs and symptoms , and improve physical function in patients with active RA receiving concomitant treatment with methotrexate ( MTX ) .  METHODS In this multicenter , 52-week , double-blind , placebo-controlled study , 619 patients with active RA who had an inadequate response to MTX were r and omized to receive adalimumab 40 mg subcutaneously every other week ( n = 207 ) , adalimumab 20 mg subcutaneously every week ( n = 212 ) , or placebo ( n = 200 ) plus concomitant MTX . The primary efficacy end points were radiographic progression at week 52 ( total Sharp score by a modified method [ TSS ] ) , clinical response at week 24 ( improvements of at least 20 % in the American College of Rheumatology core criteria [ ACR20 ] ) , and physical function at week 52 ( disability index of the Health Assessment Question naire [ HAQ ] ) . RESULTS At week 52 , there was statistically significantly less radiographic progression , as measured by the change in TSS , in the patients receiving adalimumab either 40 mg every other week ( mean + /- SD change 0.1 + /- 4.8 ) or 20 mg weekly ( 0.8 + /- 4.9 ) as compared with that in the placebo group ( 2.7 + /- 6.8 ) ( P < or = 0.001 for each comparison ) . In addition , there were statistically significant changes in the components of the TSS . At week 24 , ACR20 responses were achieved by 63 % and 61 % of patients in the adalimumab 40 mg every other week and 20 mg weekly groups , respectively , versus 30 % of patients in the placebo group ( P < or = 0.001 for each comparison ) . At week 52 , ACR20 responses were achieved by 59 % and 55 % of patients taking adalimumab 40 mg every other week and 20 mg weekly , respectively , versus 24 % of patients taking placebo ( P < or = 0.001 for each comparison ) . At week 52 , physical function as measured by the HAQ demonstrated statistically significant improvement with adalimumab 40 mg every other week and 20 mg weekly compared with placebo ( mean change in HAQ score -0.59 and -0.61 , respectively , versus -0.25 ; P < or = 0.001 for each comparison ) . A total of 467 patients ( 75.4 % ) completed 52 weeks of treatment . Adalimumab was generally well tolerated . Discontinuations occurred in 22.0 % of adalimumab-treated patients and in 30.0 % of placebo-treated patients . The rate of adverse events ( both serious and nonserious ) was comparable in the adalimumab and placebo groups , although the proportion of patients reporting serious infections was higher in patients receiving adalimumab ( 3.8 % ) than in those receiving placebo ( 0.5 % ) ( P < or = 0.02 ) , and was highest in the patients receiving 40 mg every other week . CONCLUSION In this 52-week trial , adalimumab was more effective than placebo at inhibiting the progression of structural joint damage , reducing the signs and symptoms , and improving physical function in patients with active RA who had demonstrated an incomplete response to MTX Objectives : The degree to which treatment with tumour necrosis factor ( TNF ) antagonists may be associated with increased risks for serious infections is unclear . An observational cohort study was performed using prospect ively collected data from the Swedish Biologics Register ( ARTIS ) and other national Swedish registers . Methods : First , in the ARTIS , all 4167 rheumatoid arthritis ( RA ) patients starting TNF antagonist treatment between 1999 and 2003 were identified . Secondly , in the Swedish Inpatient Register , all individuals hospitalised for any reason and who also carried a diagnosis of RA , between 1964 and 2003 ( n = 44 946 of whom 2692 also occurred in ARTIS ) , were identified . Thirdly , in the Swedish Inpatient Register , all hospitalisations listing an infection between 1999 and 2003 were identified . By cross-referencing these three data sets , RRs for hospitalisation with infection associated with TNF antagonist treatment were calculated within the cohort of 44 946 RA patients , using Cox regression taking sex , age , geography , co-morbidity and use of inpatient care into account . Results : Among the 4167 patients treated with TNF antagonists  , 367 hospitalisations with infections occurred during 7776 person-years . Within the cohort of 44 496 RA patients , the RR for infection associated with  TNF antagonists  was 1.43 ( 95 % CI 1.18 to 1.73 ) during the first year of treatment , 1.15 ( 95 % CI 0.88 to 1.51 ) during the second year of treatment , and 0.82 ( 95 % CI 0.62 to 1.08 ) for subjects remaining on their first TNF antagonist treatment after 2 years . Conclusion : Treatment with TNF antagonists may be associated with a small to moderate increase in risk of hospitalisation with infection , which disappears with increasing treatment duration BACKGROUND Severity of rheumatoid arthritis and progression of radiographic joint damage have decreased over the last decades . AIM To examine whether this trend is attributable to an underlying trend towards milder disease or to improved treatment . METHODS The study used an inception cohort of patients with early rheumatoid arthritis seen at the Wichita Arthritis Center , Wichita , Kansas , USA , since 1973 and monitored prospect ively since their first clinic visit through clinical , radiographic , laboratory , demographic and self-reported data . The radiographic disease progression in patients with disease onset in the 1970s , 1980s and 1990s was compared using a multivariate regression model for longitudinal data . The analysis was adjusted for differences in baseline predictors , type of disease-modifying antirheumatic drugs ( DMARDs ) and steroid use . RESULTS 418 patients with rheumatoid arthritis with radiographic follow-up were included . Patients in earlier decades used fewer DMARDs , had longer disease duration s and higher tender joint counts at their first visit . Other important predictors of disease progression did not differ significantly between decades of disease onset . The unadjusted rates of radiographic progression differed between decades ( analysis of variance , p = 0.01 ) , with a significant trend towards less radiographic progression in more recent times ( trend , p<0.001 ) . However , after adjusting for DMARD use , steroid use and baseline predictors , differences between decades vanished ( analysis of variance , p = 0.40 ) and the trend towards less radiographic progression disappeared ( trend , p = 0.45 ) . CONCLUSION These results suggest that the observed trend towards milder disease in rheumatoid arthritis is attributable to more effective antirheumatic treatment and not to a secular trend
Anti-tumour necrosis factor ( TNF ) therapies have revolutionized the management of rheumatoid arthritis ( RA ) .
A high proportion of RA patients are now established users of anti-TNF agents .
Unfortunately , many RA patients with longst and ing disease still require elective orthopaedic procedures .
Published studies on the influence of TNF antagonist on infection rates in RA patients undergoing surgery are conflicting .