1
|
Carmona L, Aurrecoechea E, García de Yébenes MJ. Tailoring Rheumatoid Arthritis Treatment through a Sex and Gender Lens. J Clin Med 2023; 13:55. [PMID: 38202062 PMCID: PMC10779667 DOI: 10.3390/jcm13010055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
Rheumatoid arthritis (RA) occurs more frequently in women than in men, and the studies that have addressed clinical and prognostic differences between the sexes are scarce and have contradictory results and methodological problems. The present work aims to evaluate sex- and gender-related differences in the clinical expression and prognosis of RA as well as on the impact on psychosocial variables, coping behavior, and healthcare use and access. By identifying between sex differences and gender-related outcomes in RA, it may be possible to design tailored therapeutic strategies that consider the differences and unmet needs. Being that sex, together with age, is the most relevant biomarker and health determinant, a so-called personalized medicine approach to RA must include clear guidance on what to do in case of differences.
Collapse
Affiliation(s)
- Loreto Carmona
- Instituto de Salud Musculoesquelética, 28045 Madrid, Spain
| | - Elena Aurrecoechea
- Rheumatology Department, Hospital Sierrallana, Instituto de Investigación Valdecilla (IDIVAL), 39300 Torrelavega, Spain
| | | |
Collapse
|
2
|
Jiang N, Li Q, Li H, Fang Y, Wu L, Duan X, Xu J, Zhao C, Jiang Z, Wang Y, Wang Q, Leng X, Li M, Tian X, Zeng X. Chinese registry of rheumatoid arthritis (CREDIT) V: sex impacts rheumatoid arthritis in Chinese patients. Chin Med J (Engl) 2022; 135:2210-2217. [PMID: 36103962 PMCID: PMC9771299 DOI: 10.1097/cm9.0000000000002110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The impact of sex on the clinical manifestations of rheumatoid arthritis (RA) were diversely reported in the literature. The Chinese Registry of rhEumatoiD arthrITis provides a platform for the investigation of this issue in Chinese patients. METHODS Demographic and clinical parameters were collected from all enrolled patients with RA and from patients with early RA (disease duration ≤6 months). The differences in data regarding disease activity, comorbidities, and medications for RA were compared between men and women. The proportions of patients who achieved remission and low disease activity were compared at enrollment and during 3-, 6-, and 12-month follow-up visits. RESULTS A total of 11,564 patients were enrolled, 83.6% of whom were female. In all the enrolled patients and patients with early RA, C-reactive protein (CRP, 12.0 vs . 6.7 mg/L), pain visual analogue scale (4.8 vs . 4.5), patient's and physician's global assessment (4.9 vs . 4.5 and 4.9 vs . 4.5), 28-joint disease activity score using DAS28-CRP (4.3 vs . 4.0) simplified disease activity index (21.9 vs . 19.9), and clinical disease activity index (19.3 vs . 18.0) were significantly higher in men than in women. Additionally, the swollen joint count/tender joint count and DAS28 using erythrocyte sedimentation rate were higher in male patients than in female patients with early RA. More female patients with early RA reached the treatment target at baseline than male patients (23.4% vs . 18.2%, assessed by CDAI). At 3 months, 6 months, and 12 months, the proportion of remission and treatment target achievement was similar in both sexes. Coronary artery disease (CAD) and stroke were more frequent in men than in women. CONCLUSIONS In Chinese patients with RA, men were found to have more active disease, as well as more cases of CAD and stroke. Therefore, sex should be carefully considered during the personalization of RA treatment.
Collapse
Affiliation(s)
- Nan Jiang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Qin Li
- Department of Rheumatology, the First People's Hospital of Yunnan Province, Kunming, Yunnan 650032, China
| | - Hongbin Li
- Department of Rheumatology, the Affiliated Hospital of Inner Mongolia Medical College, Hohhot, Inner Mongolia 010050, China
| | - Yongfei Fang
- Department of Rheumatology, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Lijun Wu
- Department of Rheumatology and Immunology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang 830001, China
| | - Xinwang Duan
- Department of Rheumatology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Jian Xu
- Department of Rheumatology and Immunology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650032, China
| | - Cheng Zhao
- Department of Rheumatology, The First Affiliated Hospital of Guangxi Medical University, Manning, Guangxi 530021, China
| | - Zhenyu Jiang
- Department of Rheumatology, The First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Yanhong Wang
- Department of Epidemiology and Bio-Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing 100005, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Xiaomei Leng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology; State Key Laboratory of Complex Severe and Rare Diseases; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| |
Collapse
|
3
|
Abramkin AA, Lisitsyna TA, Veltishchev DY, Seravina OF, Kovalevskaya OB, Glukhova SI, Nasonov EL. Successful psychopharmacotherapy of anxiety and depressive disorders improve functional limitations in patients with rheumatoid arthritis. TERAPEVT ARKH 2022; 94:616-621. [PMID: 36286959 DOI: 10.26442/00403660.2022.05.201514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/22/2022]
Abstract
Aim. To compare changes in functional limitations in patients with rheumatoid arthritis (RA) and comorbid anxiety and depressive disorders (ADD) treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) alone or in combination with biologic DMARDs (bDMARDs) and/or psychopharmacotherapy (PPT), and to determine predictors of HAQ treatment response.
Materials and methods. 128 RA-patients were enrolled, 86% were women with a mean age of 47.411.3 (MSD) years and a median of RA duration 96 [48; 228] months. Disease activity was assessed using DAS28, functional limitations using Health Assessment Questionnaire (HAQ). The Minimal Clinical Important Difference in HAQ was considered to be 0.22. ADD were diagnosed by a licensed psychiatrist in 123 (96.1%) of RA-pts in accordance with ICD-10 in semi-structured interview. Severity of depression and anxiety was evaluated with MontgomeryAsberg Depression Rating Scale and Hamilton Anxiety Rating Scale. RA-pts with ADD were divided into the following treatment groups: 1 сsDMARDs (n=39), 2 сsDMARDs + PPT (sertraline or mianserine; n=43), 3 сsDMARDs + bDMARDs (n=32), 4 сsDMARDs + bDMARDs + PPT (sertraline or mianserine; n=9); 83 (67.5%) patients were assessed at 5-years follow-up. Multivariable logistic regression was performed to determine predictors of HAQ treatment response.
Results. Only remission of anxiety and depressive symptoms at 5-yrs endpoint (OR 6.6, 95% CI 1.7824.43, p=0.005), higher baseline HAQ (OR 2.61, 95% CI 1.126.11, p=0.027) and lower baseline BMI (OR 0.9, 95% CI 0.850.96, p=0.001) were independently associated with HAQ treatment response at 5-years follow-up.
Conclusion. While ADD do affect functional limitations in patients with RA, PPT tends to attenuate the negative impact of ADD on RA outcomes, and RA patients with functional limitations should therefore be screened for depression and long-term PPT should be recommended.
Collapse
|
4
|
The point of no return? Functional disability transitions in patients with and without rheumatoid arthritis: A population-based cohort study. Semin Arthritis Rheum 2022; 52:151941. [PMID: 35000788 PMCID: PMC8810705 DOI: 10.1016/j.semarthrit.2021.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 11/03/2021] [Accepted: 12/07/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess transition probability between different levels of functional disability (FD) and time spent with FD in patients with versus without rheumatoid arthritis (RA) after RA incidence/index date. METHODS This retrospective population-based cohort study included Olmsted County, Minnesota residents (1987 ACR criteria met in 1999-2013) and comparators without RA from the same area with similar age, sex and RA incidence/index date. Activities of Daily Living (ADL) were obtained by self-report questionnaires annually since 1999. FD was defined as having difficulty with ≥1 ADL. Multistate modeling was used to estimate the probability of transitioning between FD states. RESULTS Five hundred fifty-eight patients with RA and 457 comparators completed ≥2 questionnaires and were included. Patients with RA had increased risk of transitioning from no FD to FD: Hazard Ratio (HR) 2.4; 95%CI:1.9-3.0. Each additional FD at RA onset reduced the probability of returning to no FD by 14%. However, the probability of having ≥1 FD was stable between RA incidence and 10-year follow-up. In the first 15 years of disease, patients with RA spent on average 10.1 years without FD and 3.4 years with ≥1 FD versus 11.6 years and 2.0 years (p<0.001) in comparators. CONCLUSION Patients with RA remain functionally disadvantaged compared to individuals without RA. The likelihood of returning to no FD in RA decreases with each additional preexisting FD. However, the probability of FD does not increase within 10 years of RA onset, potentially reflective of the benefits of disease-modifying treatments in RA.
Collapse
|
5
|
Flórez-Suárez JB, Mendez-Patarroyo P, Coral-Alvarado P, Quintana-López G. Association of Obesity With Lower Rates of Remission in a Colombian Cohort of Patients With Rheumatoid Arthritis. J Clin Rheumatol 2021; 27:S161-S167. [PMID: 33065629 DOI: 10.1097/rhu.0000000000001598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Modifiable risk factors associated with the severity of rheumatoid arthritis have been studied, including the body mass index (BMI). The aim was to compare the evolution of disease activity during 24 months of follow-up in different initial BMI groups of patients with rheumatoid arthritis. METHOD Patients were classified based on their initial BMI (normal weight, overweight, and obese). Data were collected during 24 months of follow-up. At 24 months, they were reclassified based on their BMI. The proportion of patients in each BMI category was calculated. The mean differences between the initial and final DAS-28 (Disease Activity Score 28) were calculated using the Kruskal-Wallis test. Results were stratified based on sex and age. Survival analysis and Mantel-Cox test for the achievement of sustained remission during follow-up were calculated. RESULTS A total of 269 patients were included. Most patients were at the normal weight category (n = 111). Normal weight group had the highest initial score (DAS-28, 4.01). Women present higher variability in BMI and greater disease activity compared with men. Based on age group, patients between the ages 31 and 50 years are more stable in their BMI, whereas those older than 50 years had lower BMI with time. Sustained remission was achieved by 58% of patients from the normal weight group, by 57% of patients from the overweight group, and by 42% of patients from the obese group. Survival curves of the initial normal and obese groups were significantly different (p = 0.0209). CONCLUSIONS Patients with initial obesity were less likely to achieve remission compared with patients with initial overweight or normal weight. Sex and age affects disease activity and BMI variation.
Collapse
Affiliation(s)
- Jorge Bruce Flórez-Suárez
- From the REUMAVANCE Group, Rheumatology Section, Department of Internal Medicine, Fundación Santa Fe de Bogotá University Hospital
| | | | | | | |
Collapse
|
6
|
Scott DL, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.
Objectives
To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.
Design
Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.
Setting
Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).
Participants
Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.
Interventions
Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.
Main outcome measures
Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.
Results
Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.
Limitations
The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.
Conclusion
The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.
Future work
Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.
Trial registration
Current Controlled Trials ISRCTN70160382.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Jackie Sturt
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Frances MK Williams
- Twin Research and Genetic Epidemiology, School of Life Course Sciences, King’s College London, St Thomas’ Hospital, London, UK
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| |
Collapse
|
7
|
Pope JE. Management of Fatigue in Rheumatoid Arthritis. RMD Open 2021; 6:rmdopen-2019-001084. [PMID: 32385141 PMCID: PMC7299512 DOI: 10.1136/rmdopen-2019-001084] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 04/04/2020] [Accepted: 04/09/2020] [Indexed: 12/31/2022] Open
Abstract
Fatigue in rheumatoid arthritis is highly prevalent. It is correlated only weakly with disease activity but more so with pain, mood, personality features, poor sleep, obesity and comorbidities. Fatigue can be measured by many standardised questionnaires and more easily with a Visual Analogue Scale or numeric rating scale. Most patients with RA have some fatigue, and at least one in six have severe fatigue. Chronic pain and depressed mood are also common in RA patients with significant fatigue. It affects function and quality of life and is worse on average in women. Evidence-based treatment for fatigue includes treatment of underlying disease activity (with on average modest improvement of fatigue), exercise programmes and supervised self-management programmes with cognitive-behavioural therapy, mindfulness and reinforcement (such as reminders). The specific programmes for exercise and behavioural interventions are not standardised. Some medications cause fatigue such as methotrexate. More research is needed to understand fatigue and how to treat this common complex symptom in RA that can be the worst symptom for some patients.
Collapse
Affiliation(s)
- Janet E Pope
- Medicine, Division Rheumatology, Western University, Ontario, Canada
| |
Collapse
|
8
|
Carpenter L, Nikiphorou E, Kiely PDW, Walsh DA, Young A, Norton S. Secular changes in the progression of clinical markers and patient-reported outcomes in early rheumatoid arthritis. Rheumatology (Oxford) 2021; 59:2381-2391. [PMID: 31899521 PMCID: PMC7449804 DOI: 10.1093/rheumatology/kez635] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/22/2019] [Indexed: 11/21/2022] Open
Abstract
Objectives To examine secular trends in the progression of clinical and patient-reported outcomes in early RA. Methods A total of 2701 patients recruited to the Early Rheumatoid Arthritis Study or Early Rheumatoid Arthritis Network with year of diagnosis from 1986 to 2011. The 5-year progression rates for patients diagnosed at different points in time were modelled using mixed-effects regression; 1990, 2002 and 2010, were compared. Clinical markers of disease included the 28-joint count DAS and the ESR. Patient-reported markers included the HAQ, visual analogue scale of pain and global health, and the Short-Form 36. Results Statistically significant improvements in both 28-joint count DAS and ESR were seen over the 5 years in patients diagnosed with RA compared with those diagnosed earlier. By 5 years, 59% of patients with diagnosis in 2010 were estimated to reach low disease activity compared with 48% with diagnosis in 2002 and 32% with diagnosis in 1990. Whilst HAQ demonstrated statistically significant improvements, these improvements were small, with similar proportions of patients achieving HAQ scores of ≤1.0 by 5 years with a diagnosis in 1990 compared with 2010. Levels of the visual analogue scale and the Mental Component Scores of the Short-Form 36 indicated similar, statistically non-significant levels over the 5 years, irrespective of year diagnosed. Conclusion This study demonstrates improvements in inflammatory markers over time in early RA, in line with improved treatment strategies. These have not translated into similar improvements in patient-reported outcomes relating to either physical or mental health.
Collapse
Affiliation(s)
| | | | - Patrick D W Kiely
- Department of Rheumatology, St George's University Hospital NHS Foundation TrustLondon, UK.,Institute of Medical and Biomedical Education, St George's University of London, LondonUK
| | - David A Walsh
- Arthritis UK Pain Centre, University of Nottingham, Nottingham, UK
| | - Adam Young
- Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Sam Norton
- Health Psychology Section, King's College LondonUK.,Centre for Rheumatic Diseases, King's College LondonUK
| |
Collapse
|
9
|
Fatigue is cross-sectionally not associated with objective assessments of inflammation, but changes in fatigue are associated with changes of disease activity assessments during biologic treatment of patients with established rheumatoid arthritis. Clin Rheumatol 2020; 40:1739-1749. [PMID: 33040226 PMCID: PMC8102439 DOI: 10.1007/s10067-020-05402-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 09/08/2020] [Accepted: 09/12/2020] [Indexed: 01/03/2023]
Abstract
Objective The associations between fatigue and disease activity in patients with rheumatoid arthritis (RA) have not been defined. The present objectives were to explore in RA patients the cross-sectional and longitudinal relation of fatigue with subjective as well as objective assessments of disease activity. Methods RA patients were consecutively included when initiating biologic disease-modifying anti-rheumatic drugs (DMARDs) and assessed at baseline, 1, 2, 3, 6, and 12 months with investigation of fatigue, patient-reported outcome measures (PROMs; joint pain and patient’s global disease activity, MHAQ, pain catastrophizing, Mental Health score), clinical examinations (examiner’s global disease activity, 28 tender and swollen joint counts), and laboratory variables (ESR, CRP, calprotectin). Ultrasound examinations (semi-quantitative scoring (0–3)) with grey scale and power Doppler were performed of 36 joints and 4 tendons. Statistics included one-way analysis of variance, Pearson’s correlations, and multiple linear and logistic regression analysis. Results A total of 208 RA patients (mean (SD) age 53.2 (13.2) years, disease duration 9.8 (8.5) years) were included. Fatigue levels diminished during follow-up (mean (SD) baseline/12 months; 4.8 (2.8)/3.0 (2.5) (p < 0.001)). Substantial correlations were cross-sectionally found between fatigue and PROMs (median (IQR) r=0.61 (0.52-0.71)) but not with the objective inflammatory assessments. During follow-up, baseline fatigue was associated with PROMs (p < 0.001) but not with objective inflammatory assessments. However, change of fatigue was associated with change in all variables. Higher baseline fatigue levels were associated with lower clinical composite score remission rates. Conclusion Fatigue was cross-sectionally associated to subjective but not to objective disease assessments. However, change of fatigue during treatment was associated to all assessments of disease activity. Trial registration number Anzctr.org.au identifier ACTRN12610000284066, Norwegian Regional Committee for Medical and Health Research Ethics South East reference number 2009/1254Key Points • In this longitudinal study of patients with established RA, fatigue was associated with patient reported outcome measures at each visit, but not with objective assessments of inflammation including calprotectin and comprehensive ultrasound examinations. • Changes in fatigue during biological treatment were associated with changes in patient reported outcome measures, clinical, laboratory and ultrasound assessments. • Baseline fatigue was associated with all patient reported outcome measures, but not objective assessments of inflammation at all the prospective visits. • Higher baseline fatigue levels were associated with lower remission rates as assessed by clinical composite scores. |
Collapse
|
10
|
Geenen R, Dures E. A biopsychosocial network model of fatigue in rheumatoid arthritis: a systematic review. Rheumatology (Oxford) 2020; 58:v10-v21. [PMID: 31682275 PMCID: PMC6827269 DOI: 10.1093/rheumatology/kez403] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 08/09/2019] [Indexed: 11/13/2022] Open
Abstract
Fatigue in RA is prevalent, intrusive and disabling. We propose a network model of fatigue encompassing multiple and mutually interacting biological, psychological and social factors. Guided by this model, we reviewed the literature to offer a comprehensive overview of factors that have been associated with fatigue in RA. Six categories of variables were found: physical functioning, psychological functioning, medical status, comorbidities and symptoms, biographical variables and miscellaneous variables. We then systematically reviewed associations between fatigue and factors commonly addressed by rheumatology health professionals. Correlations of fatigue with physical disability, poor mental well-being, pain, sleep disturbance and depression and anxiety were ∼0.50. Mostly these correlations remained significant in multivariate analyses, suggesting partly independent influences on fatigue and differences between individuals. These findings indicate the importance of research into individual-specific networks of biopsychosocial factors that maintain fatigue and tailored interventions that target the influencing factors most relevant to that person.
Collapse
Affiliation(s)
- Rinie Geenen
- Department of Psychology, Utrecht University, Utrecht, The Netherlands
| | - Emma Dures
- Department of Nursing and Midwifery, University of the West of England, Bristol, UK.,Academic Rheumatology, the Bristol Royal Infirmary, Bristol, UK
| |
Collapse
|
11
|
Baker JF, England BR, Mikuls TR, Sayles H, Cannon GW, Sauer BC, George MD, Caplan L, Michaud K. Obesity, Weight Loss, and Progression of Disability in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2019; 70:1740-1747. [PMID: 29707921 DOI: 10.1002/acr.23579] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/10/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Cross-sectional studies have demonstrated that obese patients with rheumatoid arthritis (RA) often report greater disability. The longitudinal effects of obesity, however, are not well-characterized. We evaluated associations between obesity, weight loss, and worsening of disability in patients of 2 large registry studies, which included patients who were followed for longer periods of time. METHODS This study included patients with RA from the National Data Bank for Rheumatic Diseases (FORWARD) (n = 23,323) and the Veterans Affairs RA (VARA) registry study (n = 1,697). Results of the Health Assessment Questionnaire (HAQ) or Multidimensional HAQ (MD-HAQ) were recorded through follow-up. Significant worsening of disability was defined as an increase of >0.2 in HAQ or MD-HAQ scores. The Cox proportional hazards model was used to evaluate the risk of worsening of disability from baseline and to adjust for demographics, baseline disability, comorbidity, disease duration, and other disease features. RESULTS At enrollment, disability scores were higher among severely obese patients compared to those who were overweight both in FORWARD (β = 0.17 [95% confidence interval (95% CI) 0.14, 0.20]; P < 0.001) and in the VARA registry (β = 0.17 [95% CI 0.074, 0.27]; P = 0.001). In multivariable models, patients who were severely obese at enrollment had a greater risk of progressive disability compared to overweight patients in FORWARD (HR 1.25 [95% CI 1.18, 1.33] P < 0.001) and in the VARA registry (HR 1.33 [95% CI 1.07, 1.66]; P = 0.01). Weight loss following enrollment was also associated with a greater risk in both cohorts. In the VARA registry, associations were independent of other clinical factors, including time-varying C-reactive protein and swollen joint count. CONCLUSION Severe obesity is associated with a more rapid progression of disability in RA. Weight loss is also associated with worsening disability, possibly due to it being an indication of chronic illness and the development of age-related or disease-related frailty.
Collapse
Affiliation(s)
- Joshua F Baker
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, and University of Pennsylvania, Philadelphia
| | - Bryant R England
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | - Ted R Mikuls
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska, University of Nebraska Medical Center, Omaha
| | | | - Grant W Cannon
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, and University of Utah, Salt Lake City
| | - Brian C Sauer
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, and University of Utah, Salt Lake City
| | | | | | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and the National Data Bank for Rheumatic Diseases, Wichita, Kansas
| |
Collapse
|
12
|
Twigg S, Nikiphorou E, Nam JL, Hunt L, Mankia K, Pentony PE, Freeston JE, Tan AL, Emery P. Comorbidities in Anti-Cyclic Citrullinated Peptide Positive At-Risk Individuals Do Not Differ from Those Patients with Early Inflammatory Arthritis. Front Med (Lausanne) 2018. [PMID: 29516000 PMCID: PMC5825886 DOI: 10.3389/fmed.2018.00035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Objectives To compare comorbidities in a cohort of cyclic citrullinated peptide (CCP) antibody positive patients without or prior to onset of inflammatory arthritis (IA) to those in patients with early IA. Methods Baseline data from two established cohorts were used. The first recruited people at risk of IA: CCP antibody positive cases without IA (CCP Cohort, n = 296). The second cohort [the Inflammatory Arthritis CONtinuum study (IACON)] recruited patients with early IA (n = 725). Proportions of patients with given comorbidities were compared between cohorts and then logistic regression was used to determine odds ratios (OR) for the CCP cohort having specific comorbidities, compared to IACON patients. Analyses adjusted for gender, age, smoking status, and body mass index. Results Patients from the CCP cohort were younger (mean age 50, compared to 53 years). The proportion of patients with at least one comorbidity was higher in the IACON than the CCP cohort: (40% compared to 24%, respectively). Results of logistic regression analyses suggested the odds of hypertension, taking a lipid-lowering agent, ischemic heart disease, cerebrovascular disease, lung disease, and diabetes were not increased in either cohort. However, patients in the CCP cohort were more likely to be taking an antidepressant (OR = 1.62, 95% CI 1.03, 2.56, p = 0.037). Conclusion There was no significant difference in comorbidities among people with CCP antibodies but without IA, compared to those of patients with established IA.
Collapse
Affiliation(s)
- Sarah Twigg
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom.,Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Elena Nikiphorou
- Academic Rheumatology Department, King's College London, London, United Kingdom
| | - Jackie L Nam
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Laura Hunt
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Kulveer Mankia
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Peta Elizabeth Pentony
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Jane E Freeston
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Ai Lyn Tan
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Paul Emery
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| |
Collapse
|