Page 146 - THE EVOLUTION OF EARLY ARTHRITIS AND CARDIOVASCULAR RISK Samina A. Turk
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CHAPTER 7
A difference was not found in the improvement of DAS44 score, SJC or TJC between patients who did and did not agree with the physician on being in remission. But, where physicians focus on disease activity (inflammation), patients also incorporate other domains(7;10;11). Patients who did not agree with their physician on being in remission did show less improvement on components of the RAID about sleep, pain and emotional well-being. A non-significant difference in fatigue was found between patients who did and did not perceive themselves in remission. This is in contrast with other studies, in which fatigue was an important explanation of patients perception of disease activity (7,34). However, in these studies fatigue covered fatigue and sleep problems, which was separated in our study. This might explain the difference as instead of the disease itself, the side effects of medication, especially glucocorticoids, can also explain a part of the sleep difficulties and fatigue symptoms. In this study, all patients received the same dose of glucocorticoids, however some patients may experience more side effects than others. Patients who did not agree also showed more improvement in ESR after 12 weeks. These patients showed a trend of a higher ESR at baseline, but no significant difference was found after 12 weeks of anti-rheumatic treatment. We hypothesized that patients who did not perceive themselves in remission, had more low grade inflammation during the 12 weeks, which might be associated with more fatigue and sleep difficulties(34;35). At baseline their mean ESR was higher, but they improved more in ESR to reach the same ESR levels at week 12 as patients who were in self-perceived remission. However, this was not seen for CRP-levels. The comparison between the RAID score and the discordance of physician- and patient-perceived remission has not yet been performed before, as far as we know, which is a strength of this study. Our study has some limitations. First, there is no widely accepted cut-off point for discordance and therefore we used the same cut-off as the ACR/EULAR Boolean- based definition of remission(23) were a VAS≤10 mm was accepted to define physician- perceived remission. We also performed a sensitivity analysis with a cut-off VAS≤20mm, which showed similar results. However, similar results were found in a study performed in 800 RA patients, where a median VAS physician of 15 mm was found in patients who were in physician-perceived remission(9). Second, the number of patients included in this study was small, which influences the possibility to find significant relationships in the data. However, this was of minimal influence as similar results in previous articles were found(5-9). Finally, we did not take adverse effects as well as other concomitant diseases into account that could influence the self-assessment of RA activity. However, the measurements of RA disease activity that are used in general care, do not consider this aspect either(10). Nonetheless, for future perspectives questions on adverse effects, comorbidity and mental state might be useful. Future studies are needed to confirm our findings and to determine the optimal set of patient-reported outcomes. And eventually to compare the current treat-to-target treatment strategy with patient- reported outcome guided treatment.
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