Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement
Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.
Lower Extremity Ulcers in Rheumatoid Arthritis.
DeMaria2, David M., Attinger1, Christopher E., Shanmugam2, Victoria K.
Lower extremity ulcers are a known complication of rheumatoid arthritis (RA). They are associated with longstanding uncontrolled RA. However, their prevalence has not been assessed since the advent of more effective biologic and non-biologic disease modifying anti-rheumatic therapies (DMARDs). The purpose of this study was to establish the prevalence of lower extremity ulcers in a modern day consecutive cohort of RA patients, and to report the features associated with ulcer development.
Consecutive patients evaluated in the Georgetown University Hospital Division of Rheumatology between June 2007 and June 2010 and fulfilling the ACR criteria for rheumatoid arthritis were identified using an ICD-9 diagnosis code search of the electronic medical record (Centricity, GE). Charts were reviewed for the presence of lower extremity ulcers during the study period. Demographic characteristics, rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) positivity, presence of comorbidities including venous and arterial disease, presence of other vasculitic manifestations of RA such as neuropathy and nodulosis, complement levels, inflammatory markers, biopsy findings and prothrombotic screen were noted.
In the three years of this study 366 RA patients were evaluated, and 16 had active leg ulcers, giving a prevalence of 4.37%. Patients with ulcers were predominantly female (81.25%) and 56.25% were African American. All patients had erosive disease, and 62.5 % were RF or CCP positive. Ulcers were bilateral in 43.75%. The mean age at first ulcer was 64.81 ±3.533 years. In 3 patients RA had previously been undiagnosed. In the remaining 13 patients the mean duration of RA at the time of ulcer development was 25.92 ± 4.944 years. In 37.5% of patients, the joint disease was in remission at the time of ulcer development. However at the initial visit mean ESR was elevated at 56.63 ± 7.591mm/hr, mean CRP was 5.928 ± 1.561 mg/dL and DAS-28 score was 3.836 ± 0.5460 suggesting ongoing inflammation. All patients had normal complement levels and negative SSA and B antibodies. Biopsy specimens were available in 12 cases. Only 3 had clear evidence of vasculitis, the biopsy was inconclusive in 5, 3 patients had gangrene and one had cholesterol emboli. Size of the initial ulcer ranged from 0.01 to 800 cm2. None of the patients in this study had significant titers of antiphospholipid antibodies, and the frequency of genetic prothrombotic states was similar to that reported in the general population. The mean duration of follow-up was 22.6 months but only 31.25% of ulcers were healed at the last follow-up visit. Due to the small sample size we were unable to show a significant association between ulcer healing and use of biologic or non-biologic DMARDs.
Even in the era of biologic and non-biologic DMARD therapy, the prevalence of lower extremity ulcers in RA is 4.37%. We found healing rates of only 31.25% in 22.6 months of follow-up. Larger studies are warranted to evaluate the role of small vessel vasculitis in chronic wounds and to investigate the role of aggressive immune suppression even when the joint disease is in remission.
To cite this abstract, please use the following information:
DeMaria, David M., Attinger, Christopher E., Shanmugam, Victoria K.; Lower Extremity Ulcers in Rheumatoid Arthritis. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :1045