Vasculitis associated with rheumatoid arthritis: a case-control study

Abstract

Objective: The aim of this study was to determine the clinical correlates and predictors of rheumatoid vasculitis (RV).

Methods: A retrospective cohort of patients with RV evaluated at a tertiary referral centre between 1 January 2000 and 1 January 2010 was identified. RV cases were compared in a 1:2 ratio to controls (RA without vasculitis) to identify risk factors for developing RV.

Results: Eighty-six RV cases (58% women, 88% white) were identified. Histopathological confirmation was available for 58% of patients. Cutaneous vasculitis was the most common presentation, followed by vasculitic neuropathy. The median age at presentation was 63 years and the median duration of RA was 10.8 years. One third were current smokers. The majority were seropositive and had elevated inflammatory markers. Treatment was with a range of immunomodulating agents. At 6 months, 38% of patients achieved complete remission, 52% had partial improvement and 10% noted no clinical improvement. Thirty-six per cent relapsed by 5 years and 26% died. After adjusting for age and disease duration, current smoking at RA diagnosis [odds ratio (OR) 1.98], coexistent peripheral vascular disease (OR 3.98), cerebrovascular disease (OR 6.48), severe RA (OR 2.02) (characterized by radiographic erosions, nodulosis on clinical examination or requirement of joint surgery) and the use of biologics (OR 2.80) were found to increase the odds for developing RV; the use of HCQ (OR 0.54, CI 0.31, 0.94) and low-dose aspirin (OR 0.42, CI 0.21, 0.85) was associated with decreased odds for developing RV.

Conclusion: This largest single-centre series of patients with RV suggests that even in recent years, RV remains a serious complication of RA and is associated with significant mortality.

Keywords: biologics; rheumatoid arthritis; rheumatoid vasculitis; systemic vasculitis.

Fig. 1

Forest plot depicting risk factors for rheumatoid vasculitis in RA patients seen at the Mayo Clinic (Rochester, MN, USA) between 2000 and 2010 Values plotted are odds ratios and 95% CIs. (Other DMARDs in this forest plot indicate oral DMARDs besides HCQ and MTX.)

Fig. 2

Kaplan–Meier plots depicting survival rate (upper panel) and relapse rate (lower panel) in 86 patients with rheumatoid vasculitis The solid line in each plot shows the estimated rate over time, with hashed lines showing where patients are censored; dotted lines are 95% CIs. The numbers beneath each plot show the number of patients still under observation at the corresponding time points.