The extra-articular impacts of rheumatoid arthritis: moving towards holistic care

Although treat-to-target has revolutionised the outcomes of patients with rheumatoid arthritis (RA) there is emerging evidence that attaining the target of remission is insufficient to normalise patients' quality of life, and ameliorate the extra-articular impacts of RA. RA has a broad range of effects on patient's lives, with four key "extra-articular" impacts being pain, depression and anxiety, fatigue and rheumatoid cachexia. All of these are seen frequently; for example, studies have reported that 1 in 4 patients with RA have high-levels of fatigue. Commonly used drug treatments (including simple analgesics, non-steroidal anti-inflammatory drugs and anti-depressants) have, at most, only modest benefits and often cause adverse events. Psychological strategies and dynamic and aerobic exercise all reduce issues like pain and fatigue, although their effects are also only modest. The aetiologies of these extra-articular impacts are multifactorial, but share overlapping components. Consequently, patients are likely to benefit from management strategies that extend beyond the assessment and treatment of synovitis, and incorporate more broad-based, or "holistic", assessments of the extra-articular impacts of RA and their management, including non-pharmacological approaches. Innovative digital technologies (including tablet and smartphone "apps" that directly interface with hospital systems) are increasingly available that can directly capture patient-reported outcomes during and between clinic visits, and include them within electronic patient records. These are likely to play an important future role in delivering such approaches.