Frailty common in rheumatoid arthritis, predicts mortality, hospitalization
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Frailty is common in patients with early and established rheumatoid arthritis, is potentially responsive to early treatment, and predicts all-cause mortality and hospitalization, according to data published in RMD Open.
“No study has assessed whether frailty in RA predicts clinical outcomes independently of disease activity, nor whether frailty, like disease activity, improves following treatment for RA,” Peter Hanlon, MD, of the University of Glasgow Institute of Health and Wellbeing, in Scotland, and colleagues wrote. “These questions are of clinical importance as they have implications for the optimal approach to the management of frailty in RA.”
To investigate frailty’s association with disease activity and mortality in patients with RA, Hanlon and colleagues conducted a review of patients with RA identified from the Scottish Early Rheumatoid Arthritis (SERA) cohort, as well as the UK Biobank cohort. Patients from the SERA dataset were included if they fulfilled the 2010 American College of Rheumatology classification criteria for RA at baseline, while patients from the UK Biobank group were included if they had a previous diagnostic code for RA in their primary care or inpatient hospital records.
Hanlon and colleagues used frailty indexes to quantify how frail the included patients were during the time of data collection. They used an established frailty index for patients in the UK Biobank cohort and created a new index for the SERA participants based on 42 health deficits. According to the researchers, many of the deficits and systems employed come from previously established procedures. The researchers examined the correlation between frailty and all-cause mortality as well as unscheduled hospital visits. The study included 899 patients from the SERA cohort and 3,605 patients from the UK Biobank group.
The mean frailty index was 0.16 in the SERA group and 0.19 in the UK Biobank group. In both groups, moderate or severe frailty was associated with a higher risk for mortality (HR vs. robust = 4.14; 95% CI, 1.49-1151 for SERA; HR = 1.68; 95% CI, 1.26-2.13 for UK Biobank) and unscheduled hospitalization (IRR = 2.27; 95% CI, 1.45-3.57 for SERA; IRR = 2.74; 95% CI, 2.29-3.29 for UK Biobank), according to the researchers. Mild frailty was also correlated with an increased risk of mortality or hospitalization in the UK Biobank group.
“Our findings indicate that frailty may be a useful measure to identify people at greater risk of mortality, hospitalization, and with greater functional limitation,” Hanlon and colleagues wrote. “However, given the close relationship between disease activity and frailty over time, care should be taken in applying a ‘label’ of frailty to people living with RA.
“Frailty is a common and prognostically significant factor in RA, however measured,” they added. “Active RA is likely to drive at least some of the identification of frailty, however, in early RA frailty may be partially reversible through treatment. Frailty identification may be valuable in RA; however it should be done with caution and only where identification of reversible factors, broad assessment of health needs and follow-up with reassessment are part of the clinical management.”
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
Frailty in our rheumatoid arthritis patients is a concern, as these individuals pose significant challenges. In view of our oath to “first do no harm,” these patients sometimes are on the precipice, and any change in their situation will lead to disaster.
Two cases come to mind. One was an elderly gentleman who presented with untreated RA and was also found to have severe iron-deficiency anemia. In the workup, I referred him to a gastroenterologist. At colonoscopy, he had a massive heart attack and died. Nowadays, he would most likely be considered too old for colonoscopy and would receive intravenous iron.
The second case was an elderly woman with RA who had previously been treated by me with methotrexate with good results but had stopped due to an intervening illness. On restarting methotrexate at 15 mg per week when she returned, she developed severe mucositis, which led to dehydration and hospital admission for intravenous fluids. It seems with these frail patients, if you just touch them, they go over the edge.
In this Scottish study, the definition of frailty was made using the codes for many chronic diseases common to the aging patient. These include chronic heart, lung, liver and kidney disease, as well as diabetes, cancer, strokes, anxiety, depression, Parkinson’s and glaucoma. Frailty was also be defined by HAQ kind of questions regarding functionality. This study found that frailty was common with early and established RA, and was associated with hospitalization and mortality. They also saw that this was reversible with treatment. RA patients with frailty are a challenge that we face, and it is an area worthy of study.
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