Letter to the Editor

Characteristics and management of rheumatoid arthritis in France: Analysis of a representative French national claims database resulting in an estimated prevalence of 0.35%

Rheumatoid arthritis (RA) is a chronic inflammatory disease mostly affecting the joints. Data on the prevalence of RA differ widely, depending on the study and country. Our objectives were to estimate the prevalence of RA in France and the mortality rate, characterise the causes of death, and identify prescribed treatments.

This nationwide cohort study was based on data of the French National Health Data System (SNDS) which covers 99% of the French population. All patients identified with RA based on specific ICD-10 codes (M05 and M06, except M06.1) between 2010 and 2019 were included.

We identified 385,919 RA cases between 2010 and 2019, 318,243 of which were followed in 2019 (65.8 ± 16.8 years, 72% women). The overall crude prevalence rate in 2019 was 0.47%: 0.66% for women and 0.28% for men. The crude annual mortality rate was 3.1%. The overall standardised mortality ratio (SMR) of RA patients relative to the French general population decreased over time, reaching 1.21 in 2019. Cause-specific mortality was increased in RA patients for cardiovascular (SMR 1.40, 95% confidence interval 1.36–1.43), respiratory system (1.80, 1.73–1.87), digestive system (1.73, 1.59–1.88), and urogenital system (1.73, 1.59–1.88) diseases and infections (1.91, 1.76–2.06). We found no excess mortality due to tumours. The prevalence of treatment with conventional synthetic and biological/targeted synthetic disease-modifying antirheumatic drugs for RA in 2019 was 41.9% (n = 133,477) and 18.7% (n = 59,409), respectively.

Our results may provide a better understanding of RA and its care in France.

Rheumatoid arthritis (RA) is considered a major risk factor for fragility fractures. We examined the quality of management of bone fragility in RA patients in a real-life setting.

We performed a longitudinal case-control retrospective study in a 1/97th random sample of French health care claims database from 2014 to 2016 to determine the extent of bone fragility management in patients with RA compared with non-RA matched controls.

Compared to their non-RA controls (n = 4652), RA patients (n = 1008; mean age: 61.1 years; methotrexate: 69.7%; other conventional disease-modifying antirheumatic drugs (cDMARDs): 26.8%; biologic: 26.0%; corticosteroids: 36.9%) had more reimbursements for bone mineral density (BMD) measurements (21.6 vs. 9.2%; OR = 2.7 [2.3; 3.3]; P < 0.01) and for bisphosphonates (7.1 vs. 3.6%, OR = 2.0 [1.5; 2.7]; P < 0.05). In patients exposed to corticosteroids, RA patients underwent more BMD assessments than non-RA controls (28.0 vs. 18.8%; OR = 1.7 [1.3; 2.2]; P < 0.05). RA patients exposed to corticosteroids were more likely to sustain fracture than non-exposed RA patients (5.7 vs. 2.4%, P < 0.01). In addition, only when comparing patients exposed to corticosteroids, was there statistical evidence of an association between RA and an increased fracture rate (6.2 vs. 3.5%, P < 0.05).

Patients with RA exposed to corticosteroids are at high risk of fracture. Patients with RA had more bone fragility management than controls.

Radiolunate arthrodesis is a validated surgical technique in rheumatoid wrist surgery. When the radioscaphoid joint is involved or when there is radiolunate instability, a radioscapholunate arthrodesis must be preferred. The objective was to compare clinical and radiographic outcomes for both types of arthrodesis. Patients were evaluated retrospectively at a minimal follow-up of 12 months after radiolunate arthrodesis (RL-A group) or radioscapholunate arthrodesis (RSL-A group). Mean follow-up was 10.7 years (1–25 years). One hundred and one patients were included in RL-A group and 26 in RSL-A group. At follow-up, pain level was significantly reduced by 3.7 points and by 2.9 points in RL-A and RSL-A groups, respectively. Mobility in flexion/extension was significantly reduced by 25° in both groups. DASH and PRWE scores were 42.9 and 41.4 in RL-A group, 41.8 and 20.6 in RSL-A group, respectively. Larsen stage for the midcarpal joint increased significantly in both groups (+0.8 in RL-A group; +0.9 in RSL-A group), carpal height index decreased (−0.03 in RL-A group (significant); −0.02 in RSL-A group (non-significant)), carpal ulnar translation index increased (+0.038 in RL-A group; +0.037 in RSL-A group), without significant difference between both groups. Nonunion rate was significantly higher in RSL-A group (62%) than in RL-A group (30%). A pain free and functional wrist can be obtained after radiolunate and radioscapholunate arthrodesis. However, arthritis lesions and carpal deformities increased with follow-up similarly with both surgical techniques. Our results have shown that radiolunate arthrodesis remains a reliable surgical procedure for advanced rheumatoid wrist.

L’arthrodèse radio-lunaire est une des techniques de référence dans la chirurgie du poignet rhumatoïde dorsal. En cas d’atteinte de l’interligne radio-scaphoïdien ou d’instabilité scapho-lunaire, il est nécessaire d’élargir l’arthrodèse à l’interligne radio-scaphoïdien. L’objectif était de comparer les résultats cliniques et radiographiques de ces deux arthrodèses. Il s’agissait d’une étude comparative rétrospective. Les patients étaient évalués au recul minimum de 12 mois après arthrodèse partielle radio-lunaire (groupe RL-A) ou radio-scapho-lunaire (groupe RSL-A). Au recul moyen de 10,7 ans (1–25 ans), 101 patients ont été inclus dans le groupe RL-A et 26 dans le groupe RSL-A. La douleur était significativement diminuée de 3,7 points et de 2,9 points respectivement dans les groupes RL-A et RSL-A. L’arc de mobilité en flexion/extension était significativement diminué de 25° dans les deux groupes. Au dernier recul, les scores DASH et PRWE étaient respectivement de 42,9 et 41,4 dans le groupe RL-A, de 41,8 et 20,6 dans le groupe RSL-A. On observait dans chacun des groupes RL-A et RSL-A une augmentation significative du stade de Larsen sur l’interligne médiocarpien (respectivement +0,8 ; +0,9), une diminution de l’indice de hauteur du carpe (respectivement −0,03 (significatif) ; −0,02 (non significatif)), une augmentation significative de l’indice de translation ulnaire du carpe (respectivement +0,038 ; +0,037), sans différence significative entre les deux groupes. Le taux de pseudarthrose était significativement plus élevé dans le groupe RSL-A (62 %) que dans le groupe RL-A (30 %). Les arthrodèses radio-lunaires et radio-scapho-lunaires permettent d’obtenir de façon comparable l’indolence du poignet. La progression des lésions d’arthrite et des déformations du carpe sont similaires pour les deux types d’arthrodèse. L’arthrodèse radio-lunaire reste l’arthrodèse partielle de référence dans la chirurgie du poignet rhumatoïde dorsal.

Des études ont relevé une fréquence moins élevée de la polyarthrite rhumatoïde (PR) dans la population africaine. Il n’existe cependant aucune donnée précise concernant la population d’origine afro-caribéenne. Le projet EPPPRA est une étude épidémiologique prospective visant à définir la prévalence et les caractéristiques cliniques de la PR aux Antilles françaises (Martinique, Guadeloupe, Guyane française).

EPPPRA regroupe l’ensemble des rhumatologues exerçant aux Antilles françaises auxquels il a été proposé d’inclure pendant une période d’un an tous les patients ayant un diagnostic clinique de PR. Nous rapportons ici les résultats obtenus en Martinique.

D’après les résultats de l’EPPPRA, la prévalence globale de la PR standardisée selon l’âge (population mondiale de référence) est estimée à 0,10 % [IC 95 % : 0,09 % à 0,11 %] en Martinique avec une nette prédominance féminine (88,1 %) et 93,1 % des patients auto-déclarés d’origine ethnique afro-caribéenne. L’âge moyen au moment du diagnostic était de 49,6 ± 16,0 ans. Dans la majorité des cas, les sujets remplissaient au moins 4 critères (94,4 %) de la classification 1987 de l’American College of Rheumatology (ACR) et obtenaient un minimum de 6 points (78,2 %) selon la classification 2010 de l’ACR/European League Against Rheumatism (EULAR). Un taux élevé de séropositivité a été retrouvé (84,2 %). Malgré le retentissement fonctionnel observé chez 40,5 % des patients, la maladie était faiblement active chez 71,4 % d’entre eux. Le traitement le plus courant était le Methotrexate (73 %), suivi des biothérapies (24,4 %). De nombreux patients (68,6 %) ont également bénéficié d’une corticothérapie. Les facteurs de risque cardiovasculaire très fréquents contrastaient avec une consommation de tabac particulièrement basse (8,7 %).

Ce travail met en évidence la faible prévalence standardisée de la PR observée dans une population française d’origine afro-caribéenne et en souligne les caractéristiques spécifiques (forte prédominance féminine, taux de séropositivité élevé, faible consommation de tabac). Malgré la facilité d’accès aux soins de santé et aux biothérapies, la PR est d’évolution destructrice au retentissement fonctionnel invalidant dans environ la moitié des cas de cette étude.

To compare different early clinical criteria of non-response determined at three months as predictors of clinical failure at one year in patients with rheumatoid arthritis starting therapy with certolizumab pegol.

Data were derived from a randomised Phase III clinical trial in patients with rheumatoid arthritis who failed to respond to methotrexate monotherapy. Patients included in this post-hoc analysis were treated with certolizumab pegol (400 mg qd reduced to 200 mg qd after one month) and with methotrexate. The study duration was twelve months. Response at three months was determined with the American College of Rheumatology-50, Disease Assessment Score-28 ESR, Health Assessment Questionnaire and the Clinical Disease Activity Index. The performance of these measures at predicting treatment failure at twelve months defined by the American College of Rheumatology-50 criteria was determined, using the positive predictive values as the principal evaluation criterion.

Three hundred and eighty two patients were available for analysis and 225 completed the twelve-month follow-up. At Week 52, 149 (38.1%) patients met the American College of Rheumatology-50 response criterion. Positive predictive values ranged from 81% for a decrease in Health Assessment Questionnaire- Disability index score since baseline > 0.22 to 95% for a decrease in Disease Assessment Score-28 score since baseline ≥ 1.2. Sensitivity was ≤  70% in all cases. Performance of these measures was similar irrespective of the definition of treatment failure at 12 months.

Simple clinical measures of disease activity can predict future treatment failure reliably and are appropriate for implementing treat-to-target treatment strategies in everyday practice.

Studies suggest that rheumatoid arthritis (RA) is less frequent in African populations. However, no recent precise data exists for Afro-Caribbeans. The EPPPRA project is a prospective epidemiological survey to describe prevalence and clinical aspects of RA in the French West Indies (Martinique, Guadeloupe, French Guiana).

EPPPRA involved all rheumatologists from the French West Indies who included all patients with a known clinical diagnosis of RA, during a one-year period. We outline here results for Martinique.

EPPPRA estimated an overall world age-standardized prevalence of RA at 0.10% [95% CI 0.09% to 0.11%] in Martinique, with a high female predominance (88.1%) and 93.1% of self-reported Afro-Caribbeans. Mean age at diagnosis was 49.6 ± 16.0 years. A majority of subjects presented at least 4 criteria points from the 1987 American College of Rheumatology (ACR) classification (94.4%) and at least 6 points (78.2%) from the 2010 ACR/European League Against Rheumatism (EULAR) classification. A high immune seropositivity rate was highlighted (84.2%). Despite functional impact observed in 40.5% of patients, 71.4% presented a low disease activity level. Methotrexate was the most common ongoing treatment (73%), followed by biotherapies (24.4%). Numerous patients (68.6%) received a steroid regimen. Cardiovascular risk factors were very frequent, contrasting with a very low tobacco use (8.7%),

This work outlines low standardized prevalence of RA in a French Afro-Caribbean population with specific characteristics (high female predominance, high immune seropositivity, low tobacco use). Despite easy access to care and biotherapies, approximately half of RA patients still present destructive disease with functional impact.