Sleep in ankylosing spondylitis and non-radiographic axial spondyloarthritis: associations with disease activity, gender and mood

Reduced sleep quality is highly prevalent and associated with physical function and cardiorespiratory fitness in patients with axial spondyloarthritis: a cross-sectional study

OBJECTIVES

To assess sleep quality, and its associations with physical function, cardiorespiratory fitness, and spinal mobility, in axial spondyloarthritis (axSpA) patients.

METHOD

Baseline data from the Exercise for Spondyloarthritis trial were used. Assessments included [Pittsburgh Sleep Quality Index (PSQI), 0-21, 21 = worst], performance-based physical function [Ankylosing Spondylitis Performance Index (ASPI), seconds, higher = worse], patient-reported physical function [Bath Ankylosing Spondylitis Functional Index (BASFI), 0-10, 10 = worst], cardiorespiratory fitness [peak oxygen uptake (V O2peak), mL/kg/min, lower = worse], and spinal mobility [Bath Ankylosing Spondylitis Metrology Index (BASMI), 0-10, 10 = worst]. Associations were examined in separate models using multiple linear regression.

RESULTS

Ninety-nine patients with axSpA were included, 53% female, mean age 46 years, and 72% with high disease activity (ASDAS-C-reactive protein ≥ 2.1), of whom 84 (85%) had reduced sleep quality. Sleep disturbance was most frequently reported (65%), followed by poor subjective sleep quality (53%), daytime dysfunction (41%), and increased sleep latency (41%). Positive associations were observed between PSQI and ASPI [β = 0.10, 95% confidence interval (CI) 0.01, 0.19] and PSQI and BASFI (β = 0.85, 95% CI 0.51, 1.20), and there was an inverse association between PSQI and V O2peak (β = -0.14, 95% CI -0.27, -0.01), adjusted for age and sex. There was no association between PSQI and BASMI.

CONCLUSION

Reduced sleep quality was common in axSpA patients with moderate to high disease activity. Better sleep quality was associated with better physical function and higher cardiorespiratory fitness. There was no association between sleep quality and spinal mobility.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02356874.

Pain and Inflammation as Mediators of Tofacitinib Treatment Effect on Fatigue in Patients with Ankylosing Spondylitis: A Mediation Analysis

INTRODUCTION

Tofacitinib is an oral Janus kinase inhibitor for treatment of ankylosing spondylitis (AS). Using mediation modelling, we describe interrelationships between fatigue, pain, morning stiffness, C-reactive protein (CRP) and tofacitinib treatment in patients with AS.

METHODS

Data from phase 2 (NCT01786668)/phase 3 (NCT03502616) studies of patients receiving tofacitinib 5 mg twice daily (BID) or placebo were used. Initial models included treatment as the independent binary variable (tofacitinib 5 mg BID versus placebo); fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F; model A] or Bath AS Disease Activity Index [BASDAI] Q1 [model B]) as the dependent variable; and pain (total back pain/nocturnal spinal pain [model A] or pain measured by BASDAI Q2/3 [model B]), morning stiffness (BASDAI Q5/6) and CRP as mediator variables.

RESULTS

Pooled data from 370/371 patients were included in models A/B. Initial models demonstrated that tofacitinib treatment affects fatigue mainly indirectly via pain and morning stiffness. As a result, initial models were respecified to exclude direct treatment effect and the indirect effect via CRP. For respecified model A, 44.0% of the indirect effect of tofacitinib treatment on fatigue was mediated via back pain/morning stiffness, 40.0% via morning stiffness alone and 16.0% via back pain alone (all P < 0.05). For respecified model B, 80.8% of the indirect effect of tofacitinib treatment on fatigue was mediated via pain/morning stiffness and 19.2% via pain alone (both P < 0.05).

CONCLUSIONS

In tofacitinib-treated patients with AS, improvements in fatigue were collectively mediated through combined treatment effects on morning stiffness and pain.

Prevalence of sleep disturbance in patients with ankylosing spondylitis: a systematic review and meta-analysis

BACKGROUND

Ankylosing Spondylitis (AS) patients face several challenges due to the nature of the disease and its physical and psychological complications. Sleep disorders are among the most important concerns. Sleep disorders can aggravate the signs and symptoms of the disease and ultimately reduce the quality of patients' lives. This study uses a systematic review and meta-analysis to pool the reported prevalence of sleep disorders among AS patients.

METHODS

To find related studies, the WoS, PubMed, ScienceDirect, Scopus, Embase, and Google Scholar databases were systematically searched without a lower time limit. Heterogeneity among the identified studies was checked using the I2 index, and the Begg and Mazumdar correlation test examined the existence of published bias. Comprehensive Meta-Analysis (v.2) software was adopted to analyze the data.

RESULTS

In the review of 18 studies with a sample size of 5,840, the overall pooled prevalence of sleep disorders among AS patients based on the random effects method was found to be 53% (95% CI: 44.9-61). The highest and lowest prevalence was in Egypt at 90% and Australia at 19.2%, respectively. Our meta-regression results show that with the increase in 'sample size' and 'year of publication', the overall prevalence of sleep disorders in patients with AS decreases (p < 0.05).

CONCLUSION

The results of the present study indicate a high and significant prevalence of sleep disorders among AS patients. Thus, health policymakers and healthcare providers must focus on timely diagnosis and effective educational and therapeutic interventions for the prevention and proper treatment of sleep disorders in this population of patients.

Sleep behaviour differs in women and men with psoriatic arthritis and axial spondyloarthritis with impact on quality of life and depressive symptoms

OBJECTIVES

Axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) may have a profound impact on sleep and health-related quality of life. The aim of this study was to assess sleep quality and quality of life and determine associated factors in patients treated with spondyloarthritides (SpA).

METHODS

Cross-sectional questionnaire-based assessment of sleep behaviour, quality of life, functional impairment and depression (Regensburg Insomnia Scale, WHO Quality of Life questionnaire, Funktionsfragebogen Hannover questionnaire, Beck Depression Inventory II, Patient health questionnaire 9) and retrospective medical chart analysis of a monocentric cohort of 330 patients with SpA (n=168 PsA and n=162 axSpA).

RESULTS

46.6% of patients with SpA demonstrated abnormal sleep behaviour. Linear regression models showed HLA-B27 positivity, Bath Ankylosing Spondylitis Disease Activity Index, depressive symptoms, functional capacity and disease duration to be predictive of insomnia symptoms in axSpA, respectively, depressive symptoms, female sex and Disease Activity Score 28 in patients with PsA. Patients with unrestful sleep had a significantly reduced health-related quality of life (p<0.001) as well as significantly more depressive symptoms (p<0.001). Satisfaction with health was rated significantly lower (p<0.001), indicating poor sleep as a burden on general well-being.In particular, female patients had a significantly worse sleep quality with a prolonged sleep latency (p=0.009), increased sleep disturbances (p=0.014) and unrestful sleep (p<0.001) as well as a reduced physical and mental health-related quality of life (p=0.015, p<0.001) and more depressive symptoms (p=0.015).

CONCLUSION

Despite treatment, many patients with SpA demonstrate abnormal sleep behaviour with symptoms of insomnia and a reduced quality of life with significant differences between male and female patients. An interdisciplinary and holistic approach may be needed to address unmet needs.

The relationship between central sensitization and disease activity, quality of life, and sleep quality among patients with axial spondyloarthritis

BACKGROUND

Central sensitization (CS) has been held responsible in previous studies for persistent pain and persistently high disease activity in axial spondyloarthritis (axSpA). Sleep disturbance is also regarded as an important problem for patients with axSpA.

AIMS

This study determines the CS levels of patients with axSpA compared to healthy controls (HC) and investigates its relationship with disease activity, quality of life (QoL), and sleep quality.

METHODS

Eighty-two patients with axSpA (group 1: mean age 38.83 ± 10.11 (76.8%male)) and 40 healthy volunteers (group2: mean age 38.58 ± 7.48 (77.5%male)) were included in this cross-sectional observational study. Evaluation parameters were visual analog scale (VAS), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), Short Form-36 (SF-36), Central Sensitization Inventory (CSI), and Pittsburgh Sleep Quality Index (PSQI). Also, participants were divided into subgroups as CSI < 40 and CSI ≥ 40. Groups were compared to themselves. A correlation between the patients' CSI scores and other evaluation parameters was examined.

RESULTS

CS rates were 45.1% and 7.5% for axSpA and HC, respectively (p < 0,001). The frequency of severe forms of CS was higher in patients with axSpA than in the healthy controls (p < 0.05). AxSpA patients with CS exhibited significantly higher pain, MASES, BASDAI, ASDAS-CRP, and PSQI scores than axSpA patients without CS (p < 0.05). A close relationship between CS severity and the female gender, pain, disease activity, sleep quality, and QoL was found among axSpA patients.

CONCLUSIONS

Clinical CS is common among axSpA patients. CS adversely affects disease activity, pain, sleep quality, and QoL of axSpA patients. CS should be considered when planning axSpA treatment.

Australian Consensus Statements for the Assessment and Management of Non-radiographic Axial Spondyloarthritis

Background

The understanding of non-radiographic axial spondyloarthritis (nr-axSpA) has accelerated over the last decade, producing a number of practice-changing developments. Diagnosis is challenging. No diagnostic criteria exist, no single finding is diagnostic, and other causes of back pain may act as confounders.

Aim

To update and expand the 2014 consensus statement on the investigation and management of non‐radiographic axial spondyloarthritis (nr-axSpA).

Methods

We created search questions based on our previous statements and four new topics then searched the MEDLINE and Cochrane databases. We assessed relevant publications by full-text review and rated their level of evidence using the GRADE system. We compiled a GRADE evidence summary then produced and voted on consensus statements.

Results

We identified 5145 relevant publications, full-text reviewed 504, and included 176 in the evidence summary. We developed and voted on 22 consensus statements. All had high agreement. Diagnosis of nr-axSpA should be made by experienced clinicians, considering clinical features of spondyloarthritis, blood tests, and imaging. History and examination should also assess alternative causes of back pain and related conditions including non-specific back pain and fibromyalgia. Initial investigations should include CRP, HLA-B27, and AP pelvic radiography. Further imaging by T1 and STIR MRI of the sacroiliac joints is useful if radiography does not show definite changes. MRI provides moderate-to-high sensitivity and high specificity for nr-axSpA. Acute signs of sacroiliitis on MRI are not specific and have been observed in the absence of spondyloarthritis. Initial management should involve NSAIDs and a regular exercise program, while TNF and IL-17 inhibitors can be used for high disease activity unresponsive to these interventions. Goals of treatment include improving the frequent impairment of social and occupational function that occurs in nr-axSpA.

Conclusions

We provide 22 evidence-based consensus statements to provide practical guidance in the assessment and management of nr-axSpA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00416-7.

Association of sleep disturbance with calcitonin, disease severity and health index among patients with ankylosing spondylitis

To investigate the association of sleep disturbance with calcium regulatory hormones, disease severity and health index among the patients with ankylosing spondylitis (AS).There were 104 AS patients enrolled in the cross-sectional study, and their sleep quality was recorded. Serum levels of calcium, parathyroid hormone, vitamin D3 and calcitonin were measured. We evaluated patient's disease activity, functional ability, patient's global assessment, physical mobility, radiographic damage and health index. Blood ESR and CRP levels were tested.Sleep quality was positively correlated with serum calcitonin levels (r = 0.260, P = .008). Bad sleep and advanced radiographic damage were found among the AS patients with detectable serum calcitonin levels (P < .05). Sleep quality was significantly correlated with disease duration, CRP, BASDAI, ASDAS-ESR, ASDAS-CRP, BASFI, BAS-G, BASMI and ASAS-HI among the AS patients (all P < .05). Female gender, longer disease duration, higher ASDAS-CRP and serum calcitonin levels (OR [95% CI] = 3.210 [1.012-10.181], P = .048) were independent factors associated with bad sleep. Inflammation, disease activity, functional ability, patient's global assessment and cervical rotation were useful in predicting bad sleep among the AS patients, and ASDAS-CRP was the best predictor (AUC = 0.772, P < .001).Serum calcitonin levels was elevated in the AS patients with bad sleep, and may participate in the pathophysiology of sleep disturbance. Bad sleep was associated with female gender, longer disease duration, higher inflammation, disease activity, functional impairment, mobility restriction, poor patient's global assessment and health index in AS. ASDAS-CRP was best in predicting bad sleep.

Bath Ankylosing Spondylitis Disease Activity Index is Associated With the Quality of Sleep in Ankylosing Spondylitis Patients

Objective

High disease activity of ankylosing spondylitis (AS) is associated with poor sleep quality The purpose of this study was to identify which of the representative tools for evaluating the disease activity of AS best reflect the quality of sleep

Methods

A total of 107 AS patients were enrolled in the study and the sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) Age, sex, concomitant medication, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) level, Beck Depression Inventory second edition (BDI-II), Bath ankylosing spondylitis disease activity index (BASDAI), ankylosing spondylitis disease activity score (ASDAS)-ESR, ASDAS-CRP, pain visual analog scale, Insomnia Severity Index (ISI), and Epworth Sleepiness Scale (ESS) were analyzed as covariates

Results

Overall, 65% (70/107) of subjects reported poor sleep quality (PSQI>5) There was a positive correlation between the sleep quality and disease activity as measured by the BASDAI, ASDAS-ESR, and ASDAS-CRP In addition, the BASDAI demonstrated good correlations with ISI, ESS, and BDI-II, respectively However, only BASDAI showed reliable correlation with PSQI among the disease activity parameters of AS (adjusted odd ratio 5.36, p=0.023)

Conclusion

BASDAI is the most reliable parameter of disease activity associated with the sleep quality in patients with AS

Nonpharmacologic Pain Management in Inflammatory Arthritis

This article provides an overview of nonpharmacologic options for the treatment of pain in patients with inflammatory arthritis, such as peripheral spondyloarthritis, psoriatic arthritis, ankylosing spondylitis, and rheumatoid arthritis. The experience of pain in chronic disease is a complex process influenced by multiple domains of health. The discussion focuses on the establishment of a framework for pain control that engages with factors that influence the experience of pain and explores the evidence base that supports specific modalities of nonpharmacologic pain control, such as mindfulness, cognitive behavioral therapy, exercise, massage, splinting, and heat therapy. Rheumatoid and spondyloarthritides are considered separately.