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VBCR - August 2016, Vol 5, No 4 - In the Literature

In This Article




Growing Burden of Arthritis in the United States

Healthcare professionals should be on high alert for the growing burden of arthritis in the United States. By 2040, 1 in 4 adults will have physician-diagnosed arthritis, and 1 in 9 will have arthritis-attributable activity limitations. The predictions of the incidence of arthritis and accompanying activity limitations were subjects of a special article published recently in Arthritis & Rheumatology.

The aging of baby boomers “will likely have serious effects on Social Security Disability Income and Medicare programs,” according to the authors.

“Using effective health promotion and chronic disease management programs aimed at reducing the risk of onset and progression of chronic disease such as arthritis could save Medicare between $650 million and $1.43 trillion over 10 years,” they added.

One important approach to mitigate these predictions is encouraging physical activity in adults with arthritis. Many studies have shown that walking has a protective effect against functional limitation in adults with knee osteoarthritis, for example. “These…are easy and inexpensive strategies for increasing physical activity, which in turn may reduce functional limitation,” the study authors explained.

Using the National Health Interview Survey, they updated the age- and sex-specific projections for arthritis prevalence and arthritis-attributable activity limitations in adults aged ≥18 years through the year 2040. They quantified self-reported arthritis as an answer of “yes” to the question of whether they had received a diagnosis from a healthcare professional of arthritis or other related diseases. Arthritis-attributable activity limitation was defined as an answer of “yes” to related questions about activity limitations.

From 2010 to 2012, 52.5 million US adults—or approximately 22% of all adults—had physician-diagnosed arthritis, and 22.7 million (9.8%) had arthritis-attributable activity limitations. These numbers have already surpassed the prevalence previously projected for 2020, the authors noted.

In addition, by 2040, the percentage of physician-diagnosed arthritis is projected to increase by 49% to 78.4 million—25.9% of all adults—and the number of adults with arthritis-attributable activity limitations is expected to increase by 52% to 34.6 million (11.4% of all adults). In 2040, women will continue to account for the majority of arthritis cases (58.5%; 45.8 million).

Between 2015 and 2040, the number of adults with physician-diagnosed arthritis will increase by 37% among men, and 34% among women. The number of people with arthritis-attributable activity limitations will increase by 40% and 36% in men and women, respectively. For both sexes, the largest increase in prevalence of physician-diagnosed arthritis and arthritis-attributable activity limitations will occur in adults aged ≥65 years. However, adults of working age—18 to 64 years—will still comprise the majority of affected adults through 2040.

Although this study has several limitations, including omitting the effect of the obesity epidemic, it is based on a large population-based database. The projections are useful for planning for future clinical and public health needs, assessing healthcare uses, anticipating workforce demands, and informing health policy.

Hootman JM, Helmick CG, Barbour KE, et al. Arthritis Rheumatol. 2016;68:1582-1587.

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Patients with Lupus at Risk for End-Stage Renal Disease

Although estimates have varied in the past 4 decades, patients with lupus nephritis remain at increased risk for end-stage renal disease (ESRD), according to a large meta-analysis published in Arthritis & Rheumatology. These findings suggest that current treatments for lupus nephritis may be inadequate or not initiated promptly, or that adherence may be poor.

The study was based on 187 articles published between 1971 and 2015 that included a total of 18,309 patients with lupus nephritis and ESRD from developed and developing countries.

“Although there is a clinical impression that the risks in lupus nephritis have decreased over the past 40 years, few studies have examined changes in these risks,” the authors explained. “Our analysis documents for the first time show clear improvement in ESRD risk between the 1970s and mid-1990s in developed countries, with absolute decreases of 10% in 10- and 15-year risks.”

Improvements in the 5-year risk were also observed, but to a lesser extent, they added. Furthermore, the data indicated a slight increased risk for ESRD in the late 2000s, despite extensive use of immunosuppressive medications throughout that time period.

Lupus nephritis affects >50% of patients with systemic lupus erythematosus, and is the most common serious complication of the disease. ESRD, which develops in 10% to 30% of patients with lupus nephritis, is the most important and costly sequela, increasing the risk of death by 26 times at an annual cost per patient ranging from $43,000 to $107,000, according to estimates measured in 2006.

The authors sought to characterize contemporary estimates of risk for ESRD, assess changes over time to provide prognostic information, and evaluate whether treatment advances have had an impact on long-term outcomes. Therapeutic advances for treatment of lupus include the ability to subtype patients, and availability of more aggressive immunotherapeutic combination regimens. The effect of these advances is unclear, and has not been tested in clinical trials.

The meta-analysis was based on a literature search of cohort studies and clinical trials of patients with lupus nephritis and ESRD included in PubMed, Embase, and the Cochrane database of systematic reviews. The probability of developing ESRD at 5, 10, and 15 years of living with lupus nephritis was collected.

The 5-year risk for ESRD decreased from 16% between 1970 and 1979 to 11% in the mid-1990s, after reaching a plateau. The risk for ESRD at 10 and 15 years showed steeper declines in the 1970s and 1980s, and reached a plateau between 1992 and 1997, increasing markedly in the late 2000s. A decrease in risk after 1980 was observed in correlation with the increased use of cyclophosphamide at that time. Developing countries, as may be expected, had a higher 15-year risk for ESRD than developed countries.

The highest risk of ESRD was found in patients with class 4 lupus nephritis, with a 15-year risk of 44% in the 2000s; 78% of patients with lupus nephritis did not develop ESRD, possibly because of milder disease or effective treatments, the authors pointed out.

“However, for the 22% of patients overall and for the 44% of those with class 4 lupus nephritis who do develop ESRD within 15 years, the risk is greatest within the first 5 years,” they wrote.

Determining whether early ESRD reflects failures of treatment, delayed treatment initiation, or poor adherence will lead the way to strategies aimed at reducing these risks. A coauthor of this study stated that progress in decreasing the risk for renal failure in patients with lupus nephritis, particularly those with proliferative disease, appears to have stalled. It is important to determine whether this is because the limits of effectiveness of currently available therapies have been reached, or because many patients do not have timely access to treatment.

Tektonidou MG, Dasgupta A, Ward MM. Arthritis Rheumatol. 2016;68:1432-1441.

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