REVISTA
BRASILEIRA
DE
REUMATOLOGIA
www . r e u m a t o l o g i a . c o m . b r
Original
article
Demographic
and
clinical
features
of
patients
with
rheumatoid
arthritis
in
Piauí,
Brazil
–
evaluation
of
98
patients
夽
Maria
do
Socorro
Teixeira
Moreira
Almeida
a,∗,
João
Vicente
Moreira
Almeida
a,
Manoel
Barros
Bertolo
baUniversidadeFederaldoPiauí,Teresina,PI,Brazil
bUniversidadeEstadualdeCampinas,Campinas,SP,Brazil
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t
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e
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o
Articlehistory:
Received22August2013 Accepted10February2014 Availableonline20August2014
Keywords:
Rheumatoidarthritis Epidemiology NortheasternBrazil
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Introduction:Brazilianepidemiologicalstudiesonrheumatoidarthritisarescarce,mainlyin thenortheast;thusmanydatacurrentlyavailableoriginatefromtheinternationalliterature. Objectives:Todescribedemographic,clinicalandserologicalcharacteristicsofpatientswith rheumatoidarthritis(RA)followed-upbythesamephysician,instateofPiauí,Brazil. Patientsandmethods:DatawerecollectedbetweenAugust2010andMarch2013,inthree healthservicesofPiauíthatprovidedhealthcareinRheumatology:auniversity-affiliated hospital,apublicoutpatientclinicandaprivateclinic.
Results:The numbers represent mean ± SD or percentage: 47.5±11.03 years-old non-Caucasianwoman,non-smoker(59.2%),loweducationallevel,meandiseasedurationof 7.7years±7.6,andmajorextra-articularmanifestationswererheumatoidnodules(19.4%) andsiccasyndrome(46.9%).
Conclusion:Featuresofrheumatoidarthritisobtainedinthisstudyaresimilartothosefound insomenationalandinternationalstudies,but weobservedhigherfemale preponder-anceandilliteracyrate,inadditiontoamoderatelysevereerosivediseaseonaverage,with frequentsiccaandotherextra-articularmanifestations.
©2014ElsevierEditoraLtda.Allrightsreserved.
DOIoforiginalarticle:http://dx.doi.org/10.1016/j.rbr.2014.02.005.
夽
Departureandinstitutionwherethestudywasoriginated:HospitalGetúlioVargas,GeneralPracticeDepartment,UniversidadeFederal doPiauí.
∗ Correspondingauthor.
E-mailaddresses:esteios@uol.com.br,smoreira@ufpi.edu.br(M.d.S.T.M.Almeida). http://dx.doi.org/10.1016/j.rbre.2014.02.018
Características
demográficas
e
clínicas
de
pacientes
com
artrite
reumatoide
no
Piauí,
Brasil
–
avaliac¸ão
de
98
pacientes
Palavras-chave: Artritereumatoide Epidemiologia Nordestebrasileiro
r
e
s
u
m
o
Introduc¸ão: Sãoescassososestudosepidemiológicosbrasileirossobreartritereumatoide, sobretudonoNordeste;assim,muitosdadosatualmentedisponíveistêmsuaorigemna literaturainternacional.
Objetivos:Descreverascaracterísticasdemográficas,clínicasesorológicasdepacientescom artritereumatoide(AR)seguidospelomesmomédiconoEstadodoPiauí,Brasil.
Pacientesemétodos:Osdadosforamcoletadosentreagostode2010emarc¸ode2013,emtrês servic¸osdesaúdedoPiauícomatendimentoemreumatologia:umhospitaluniversitário, umaclínicaambulatorialpúblicaeumaclínicaprivada.
Resultados: Os números representam média ± DP ou percentual: 98 pacientes com 47.5±11.03anosdeidade;não-brancos;predominânciademulheres;nãofumantes(59.2%); baixo nível educacional; durac¸ão média da doenc¸a de 7.7±7.6 anos; e as principais manifestac¸õesextra-articularesforamnódulosreumatoides(19.4%)esíndromesicca(46.9%). Conclusão:Ascaracterísticasdaartritereumatoideobtidasnesteestudosãosimilares àque-lasencontradasem algunsestudosnacionaise internacionais,mas observamosmaior preponderânciademulheres,umníveldeanalfabetismomaiore,namédia,umadoenc¸a erosivamoderadamentegravecompresenc¸afrequentedesiccaedeoutrasmanifestac¸ões extra-articulares.
©2014ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
Rheumatoidarthritis(RA)isachronicinflammatorydisease manifestingitselfinvariousextra-articularsignsand progres-sivearticulardamage.1Clinicalonsetofthisdiseasemaybe variable;it generally begins withsymmetrical involvement ofthe small joints,pain, morning stiffness, and limitation of movement for more than 1 hour. Although the meta-carpophalangeal(MCP)joints,theproximalinterphalangeal (PIP)joints,thewrists,themetatarsophalangeal(MTP)joints andthekneejointsarethemostfrequentlyinvolvedjoints, RAmayalsoinvolveotherones.
Rheumatoid arthritis affects approximately 0.5%-1% of thepopulation,and,althoughnotdirectlylife-threatening,it causesareductioninthepatient’squalityoflifeandsevere economicdamagestosociety.2Itismoreprevalentinwomen (female/man ratio of2:1),and its incidence increases with age.3
Theincidence,severity,andoutcomeofthediseaseshow variabilitybetween differentethnical-origin groups.4–6 This variability is related to the socioeconomic level and the levelofdevelopmentofcountries,aswellasgeneticand/or environmentalfactors.Inunderdevelopedcountries,patients with RA are known to have a severe clinical course and a poor prognosis due to limited access to the physician, specialist, and/or drugs. Studies on RA demonstrated that differentgeneticand/orenvironmentalfactorscouldimpact thediseaseindifferentethnicalgroups.Thesestudies sug-gest that RA patients, having different ethnic origin, may exhibitdifferentmanifestationsandoutcomes,whichenables developmentof differenttargeted treatmentmodalities. In our country,there is limiteddata about incidence, clinical course, extra-articular symptoms, and outcomes of RA,7,8
and there are few studies in Northeastern Brazil and no studyinPiauí.Tomeetthisnecessity,thepresentstudywas designedtodescribethedemographic,clinical,andserological characteristics ofpatientswith RAfollowed-up bya physi-cian.
Material
and
methods
Ninety-eightpatients(87women,11men)withRAdiagnosed according to the ACR classification criteria ACR,9 between August 2010 and March 2013, were included in the study. The sample was chosen forconvenience. Diagnosis, treat-mentandmonitoringofallpatientswereperformedbythe same physicianin a university-affiliated hospital, a public outpatientclinicandaprivateclinic.Clinicalhistoryand phys-icalexaminationofall patients wereevaluated byasingle investigator. Thefollowingparameterswere recorded inall patientsduringthefirstexamination:demographicdata, edu-cationallevel,clinicalfindings,useofDMARDs,presenceof extra-articular symptoms, presenceofconcomitant comor-biddiseases,laboratoryparameters(includingcompleteblood count,rheumatoidfactor[RF])andradiologicalchanges.Lung involvementwasdeterminedbyhigh-resolutionCT(HRCT). Erosivechangesweredetectedonradiographybya rheuma-tologist and a radiologist together, and they used Sharp score.
Table1–Demographicsanddiseasecharacteristicsof the98patientswithrheumatoidarthritisinPiauí,Brazil.
M:F 11:87
Meanage(years) 47.5±11.03
Agegroup(years)
20-29 6(6.12%)
30-39 16(16.32%)
40-49 34(34.69%)
50-59 32(32.66%)
60-83 10(10.21%)
Meandiseaseduration(years) 7.7±7.6
Smoking
Smoking(present) 14(14.3%)
Smoking(past) 25(25.5%)
Non-smoking 58(59.2%)
MedicationforRA
Prednisone 30(30.6%)
Methotrexate 39(39.8%)
Antimalarial 30(30.6%)
Leflunomid 14(14.3%)
Anti-TNF-␣ 03(3.06%)
described asthe presenceofsubcutaneous nodules>5mm on extensor surfaces of extremities. Normal ranges of laboratory parameters were described as follows: ane-mia(hemoglobin<11g/dL), RF (normal <5bynephelometry method).
Informedconsentwasobtained.Thisstudywasapproved bytheCommitteeonEthicsandResearchofUniversidade Fed-eraldoPiauíandhasnotconflictofinterest.
Statistical
analysis
Data were inserted into Excel 2007 (Microsoft) sheets and managed to provide the epidemiological profile through description and simplemathematical calculations,such as percentage and arithmetic mean. Data was presented as mean,SDandrangeforcontinuousvariable,andpercentages fordiscretevariables.
Results
Ofthe 98 patients followed-up bythe rheumatology clinic andenrolledinthestudy,87werefemale,and11weremale. Themeanageofpatientswas47.5years(rangingfrom22to 83years), andmean duration ofthedisease was7.7years. Thirty-one(31.6%)liveinurbanareaand67(68.4%)inrural. Thirty-five(35.7%)patientshadrespiratorysymptoms,14.3% werecurrent smokers,59.2%were non-smokers,and25.5% hadsmokedinpast(Table1).
DataoneducationlevelareshowinTable2.
Sixpatients(6.1%)haddiabetesmellitus.Duringthe3-year follow-up,twopatientsdied(oneduetocerebralhemorrhage, theotherduetoheartattack).
Thirtypatients(30.6%)weretakingoralsteroids;39(39.8%) were taking methotrexate (MTX); 30, hydroxychloroquine (30.6%);14,(14.3%)leflunomid;and3anti-TNF-␣ (3.06%).Drug historywasdifficulttoanalyze,sincethepatientshadtakena
Table2–EducationallevelofpatientsinPiauí,Brazil.
Classification n %
Illiteracy/incompleteelementaryeducation 49 50.0%
Completeelementaryeducation 13 13.3%
Incompletesecondaryeducation 8 8.2%
Completesecondaryeducation 15 15.2%
Completehighereducation 13 13.3%
meanof4±1.3second-linedrugsforRAatthetimeof assess-ment.
Thesiccasymptom(46.9%)wasthemostcommon extra-articular involvement, and all patients fullfilled Sjögren’s syndrome classification criteria, followed by pulmonary involvement(39.8%),vasculitis(5.1%),andtheRaynaud’s phe-nomenon(3.1%).Nineteenpatientshadrheumatoidnodules (19.4%).
Thirty-onepatients(31.6%)weredetectedtohaveanemia, 86.7%ofthepatientshadpositiveRF,and61patients(62.2%) haderosion(Table3).
Sixty-threepatientshadnorespiratorysymptoms.Among thosewithrespiratorysymptoms,cough(n=21%-21.4%)was themostcommon,followedbydyspnea(n=19%-19.4%),and chestpain(n=12%-12.2%)(Table3).FindingsonHRCTwere rheumatoid nodule (12%),fibrosis (32%), pleuritis (5%), and interstitialchanges(1%).
Discussion
EpidemiologicalstudiesonRAaremostlylimitedtodeveloped countries,andtheincidenceofRAindevelopingcountriesis unknown.
The study investigated demographic, clinical, and sero-logical data of Brazilian patients with RA born in Piauí and followed-up by a rheumatologist. It was observed that patients with RA have a similar clinical course and
Table3–Clinicalandserologicalfeaturesofpatients withRAinPiauí,Brazil.
MainFeatures Frequency(%)
Siccasymptoms 46.9
Rheumatoidnodules 19.4
Respiratorysymptoms
Dyspnea 19.4
Chestpain 12.2
Sputumproduction 10.2
Drycough 11.2
HRCT 39.8
Lunginvolvement
Vasculitis 5.1
Raynaudphenomenon 3.1
Anemia 31.6
Erosion 62.2
Rheumatoidfactor 86.7
Table4–ComparisonofthemainfeaturesbetweenpatientswithRAindifferentstudies.
Features Badsha
etal.17 n=100
Al-Salem
etal.16 n=100
Calgüneri
etal.13 n=526
KobakS1 n=165
Present study n=98
Female 87 89 453 125 87
Age(years) 42.2 39.1 48 52.5 47.5
RFpositivity(%) 73 62 68.3 90.3 86.7
Erosions(%) 55.2 42 N 55.8 62.2
Siccas/m(%) 28 14 11.4 40.6 46.9
R.nodules(%) 4 9 18.1 3.6 19.4
Lunginvolvement(%) n 7 4.8 6.6 39.8
RF,rheumatoidfactor;Siccas/m,siccasyndrome/manifestations;R.nodules,rheumatoidnodules.
prognosiscomparedwiththepatientsfromotherethnicorigin (Table4).
Itisnotablethattheratiofemale:maleratioof8:1inthis studywasmuchhigherthanthatreportedinWestern popula-tions,butclosertosomestudiesindevelopingcountries.This femalepreponderancemaybemorerelatedtoaccessclinical ordemographicfactorsorhormones.Table5
Thelevelofeducationofpatientsisconsistentwiththe results found in Piauí population, and with the literature showingthatthediseaseisthemostprevalentoneinpeople withloweducationlevels.
Thepatternofinvolvementobservedinourpatientswas similartoCaucasianandAmericanpatternsreported previ-ously.Theincidenceoferosionwasreportedtobehigherin ourpatientsrelativetoGreekRApatients(29%).10
The most common extra-articular pattern, sicca com-plex(46.9%), wassimilar tothat observedin theGreek RA patients.10 Thestudy carriedout inSãoPaulo hasreported concomitanceofthatsyndromein28%ofthesample.11Itis themostcommonocularmanifestation.SecondarySjögren’s syndrome is diagnosed according to the European criteria modifiedbytheAmerican-EuropeanConsensusGroupfor Sjö-gren’ssyndromein2002.12
Sicca manifestations were observed in ophthalmologic exam.
InTurkey,Calgünerietal. evaluatedextra-articular find-ingsof526RApatientsfollowed-upbyasinglecenter.13The mostcommonextra-articularfindings,includingrheumatoid nodules(18.1%)andsiccasymptoms(11.4%),weresimilarto
thoseobservedinsomeMediterraneancountries.Inanother trialconductedinTurkey,14inthat562patientswithRAwere evaluaed, eyeinvolvement (8%)and subcutaneousnodules (7.5%) were reported as the most common extra-articular findings,andtherateofcomorbiddiseaseswasreportedas 35.8%.
PositiveRFratesdetectedinourpatientsweresimilarto the resultsreported in the literature. Positive RF rates are 65%,62%,and60%inEnglish,MalaysianandKuwaitipatients, respectively.15,16
The institution has resources for determining anti-CCP, aswell asthe numberofswollenjointsand DAS-28,anda measure ofsynthesisdeficiency cannotbe includedin the study.
Interestingly, the incidenceof rheumatoid nodules was only19.4%inourpatients,whichisquitedifferentfromthe ratereportedintheliterature(30%).Calagünerietal.reported asimilarincidenceofrheumatoidnodulesdemonstratedin Turkish patients(18.1%).13 Ourvaluesdonotcoincidewith thatreportedinthestudycarriedoutinSãoPaulo(29%).11
Type 2 diabetes mellitus was described in 6.1% of the patients, avalue similar to that ofthe general population (7.6%;range,5%-10%).18
Pulmonarymanifestationswere39.8%,andthatfrequency was greater than that reportedin other studies (10%-20%). A study carried out in São Paulo has reported a 15% fre-quency. Pulmonary manifestations are believed to appear withinthefirstfiveyearsafterthediagnosisofRA.Although pulmonaryinfectionsand/orpulmonarytoxicityduetodrugs
Table5–ComparisonofthemainfeaturesbetweenpatientswithRAindifferentstudiesinBrazil.
Features Davidetal.7
n=38
Louzada Junioretal.11
n=1381
Motaetal.21 n=65
Vazetal.22 n=19
Presentstudy n=98
Female 32 1184 56 15 87
Age(years) 46 50 47.5
RFpositivity(%) 68.4 71 68 86.7
Erosions(%) 18.4 62.2
Siccas/m(%) 28 13.8 46.9
R.nodules(%) 13.2 29 15.4 21 19.4
arefrequentcomplications,pulmonarydiseasedirectly asso-ciated with RA is morecommon. Although cardiovascular diseases are responsible for most deaths related to RA, pulmonarycomplicationsarecommonanddirectly respon-sible for 10%-20% of the deaths directly attributed to RA.19
AllpatientshavereceivedatleastoneoftheDMARDs.The first choice oftherapy was methotrexate(39.8%) and anti-malarial(30.6%). However, only14.3% ofour patients have receivedleflunomide,becausethegeneralhealthinsurance systeminourcountryrestrictsusageofthedrug.Onlythree patients (3.06%)having persistent active disease refractory toconventional DMARDtreatmenthavereceived
anti-TNF-␣ therapy. Thisrate is40%, and 54% for USA and France,
respectively.20
Lessthan40%ofpatientsarereceivingmethotrexate.The inadequatetreatmentcouldhaveinfluencedtheoutcomeof thedisease.
AvarietyofclinicalpresentationsofRAobservedin dif-ferent populations and reported in the literature may be associated withgenetic and environmental factors.In our country,thereisaproblematic situationresulting fromthe small number of rheumatology centers available. Usually, patientspresenttoclinicsatalatestageofthedisease.The socioeconomiclevel,noncompliancewithtreatment,andthe failuretoattendthecontrolvisitsarethefactorsthathavean impactonmorbidityandmortality.
RAis a heterogeneous disease.It may exhibitdifferent clinicalpresentationindifferentpopulations.Sinceourtrial includesdatafromRApatientsfollowed-upbyasingle cen-ter,it cannot berepresentative ofthe wholepopulation of Piauí.To demonstratethe roleofgeneticand environmen-talfactors,multicenterstudies withalarge patientsample that includesthe immune systemand the HLA typing are required.
Conclusion
Wecanconcludethat,incomparisonwithpatientsfrom West-erncountriesandotherBrazilianstudies,ourRApatientswere characterizedbyasimilarageatonset,butahigherfemale preponderance,ahigherilliteracyrate,and,onaverage,a mod-eratelysevereerosivediseasewithfrequentsiccaandother extra-articularmanifestations.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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