Rheumatoid arthritis (RA) is a chronic, progressive, autoimmune, inflammatory disease that affects more than 2 million Americans. It is a condition that is associated with increased mortality (rate of death) as a result of malignancy (lymphoma), cardiovascular events (heart attack and stroke), and significant disability.

The purpose of this article is to discuss the state of the art as it relates to disability.

It is clear that persistent disease activity leads to joint damage which leads to disability. While a patient has active disease- disease that is not well controlled- they will experience some degree of functional impairment. With the onset of permanent joint damage though, disability becomes a significant issue.

How severe is the risk of disability from RA? A number of epidemiologic studies have demonstrated that roughly 20 per cent of patients with RA are disabled within one year, between 32 and 50 per cent of patients by 10 years, and up to 90 per cent after 30 years.

The most sobering statistic is the extent of potential disability in the first year. Disability of this magnitude has an enormous physical, social, psychological, and economic impact.

Basic research has demonstrated that tumor necrosis factor (TNF) is a major contributor to the joint damage that results from RA. TNF stimulates cells called osteoclasts to chew away" at cartilage and bone. This chewing away process ultimately causes irreversible joint damage.

While current therapies such as the combination of methotrexate with TNF-inhibitors (Examples include Enbrel, Humira, and Remicade) are very effective for controlling early RA, there has been scant proof of their ultimate impact on work outcomes.

Recent studies though have demonstrated that early intervention with methotrexate and TNF-inhibitors is effective in reducing work disability. The best current study (presented at the European League Against Rheumatism meeting in 2007), is the PROWD study evaluating the effects of a combination of methotrexate with adalimumab (Humira). The study showed that patients treated with the combination of methotrexate and adalimumab fared better as far as job loss and work time lost compared with patients taking methotrexate alone.

All studies evaluating the newer therapies seem to agree on one issue: Because of the consequences that result from irreversible joint damage, only early aggressive intervention prevents irreversible disability.

Therefore, prevention of disability and restoration of function should be an important goal of therapy. Both persistent disease activity and joint damage contribute to disability. The use of a combination of methotrexate and TNF inhibition early reduces inflammation and controls joint damage. It is this control of joint damage that helps preserve physical function and reduce work disability.