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A subgroup of patients with rheumatoid arthritis (RA) experienced high levels of pain, fatigue, and psychosocial distress three years after diagnosis.

That's according to an observational study in that included 1,055 people with RA with three years of follow-up data. Patients were divided into three clusters: cluster 1 (466 patients with good health status), cluster 2 (398 patients in an intermediate group), and cluster 3 (147 patients with high levels of pain and fatigue together with poor health-related quality of life).

Compared with cluster 1, cluster 3 was associated with higher baseline pain (RR 3.71 [95% CI 2.14-6.41]), global health (RR 6.60 [95% CI 3.53-12.33]), and Stanford Health Assessment Questionnaire scores (RR 4.40 [95% CI 2.46-7.87]). An inverse association occurred for baseline swollen joint count (RR 0.51 [95% CI 0.34-0.85]).

The study was led by a team of Swedish researchers. The following study excerpts have been edited for length and clarity.

What was the impetus for this study?

The authors write that with new and effective antirheumatic treatments now available, inflammatory remission has become an increasingly feasible goal for patients with RA. Features other than inflammatory disease have thus become increasingly important -- features such as persistent pain, fatigue, and quality of life, among other "unmet needs."

The study attempted to identify subgroups of patients according to their health status three years after diagnosis of RA and to assess risk factors associated with each group.

What did the study discover about these three clusters of patients?

Those in cluster 3 had high levels of pain, fatigue, and clearly impaired health-related quality of life 3 years after diagnosis. By comparison, health status among patients in cluster 1 was comparable to that of the general population. Cluster 2 was an intermediate group.

Furthermore, cluster 3 patients already displayed these features at diagnosis despite having low or average inflammatory parameters. The authors note this suggests that factors that influence the long-term course of the disease were already present at diagnosis.

What are the clinical implications of these findings?

Early identification of patients who are at risk -- and timely adoption of appropriate interventions -- should be priorities in managing the unmet needs of patients with RA.

The study found that patients in cluster 3 had higher BMI, higher levels of pain, and higher HAQ and patient global assessment scores at the time of diagnosis. Researchers found no association between cluster 3 and smoking status, nor educational level.

Implications for practice

• A significant percentage of people with RA had high levels of pain, fatigue, and psychosocial distress three years after diagnosis.
• These features were present at diagnosis but without a corresponding increase in inflammatory parameters.
• Early identification and interventions with RA patients at risk of having unmet clinical needs should be a future priority in managing people with RA.

Read the study here and expert commentary on the clinical implications here.