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Motyl G, Krupka WM, Maślińska M. The problem of residual pain in the assessment of rheumatoid arthritis activity. Reumatologia 2024; 62:176-186. [PMID: 39055728 PMCID: PMC11267660 DOI: 10.5114/reum/189779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/07/2024] [Indexed: 07/27/2024] Open
Abstract
Residual pain is a major unmet medical need observed in patients suffering from rheumatoid arthritis (RA), which decreases their quality of life, even after achieving remission or low disease activity. The article has two aims: 1) to present mechanisms involved in the pathophysiology of residual pain, both inflammatory and non-inflammatory, i.e. neuropathic and nociplastic pain, as well as secondary pain syndromes, i.e. osteoarthritis and fibromyalgia, which can contribute to residual pain; 2) to show the limitations of current disease activity measures recommended by European Alliance of Associations for Rheumatology (EULAR) and American College of Rheumatology (ACR), which raise the need for a separate assessment of pain, and examples of methods that could be used by medical professionals to assess the pain and make a differential diagnosis. In conclusion, establishing a valid method to assess pain is essential to identify the pathomechanism of residual pain and to create treatments tailored specifically to individual RA patients.
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Affiliation(s)
- Gabriela Motyl
- Medical University of Warsaw, Poland
- Rheumatology Student Research Group at the National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Wiktoria Maria Krupka
- Medical University of Warsaw, Poland
- Rheumatology Student Research Group at the National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Maria Maślińska
- Early Arthritis Clinic, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
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2
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Choy E, Bykerk V, Lee YC, van Hoogstraten H, Ford K, Praestgaard A, Perrot S, Pope J, Sebba A. Disproportionate articular pain is a frequent phenomenon in rheumatoid arthritis and responds to treatment with sarilumab. Rheumatology (Oxford) 2023; 62:2386-2393. [PMID: 36413080 PMCID: PMC10321097 DOI: 10.1093/rheumatology/keac659] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/10/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES In some patients with RA, joint pain is more severe than expected based on the amount of joint swelling [referred to as disproportionate articular pain (DP)]. We assessed DP prevalence and the effects of sarilumab, an IL-6 inhibitor, on DP. METHODS Data from RA patients treated with placebo or 200 mg sarilumab in the phase 3 randomized controlled trials (RCTs) MOBILITY and TARGET, adalimumab 40 mg or sarilumab 200 mg in the phase 3 RCT MONARCH and sarilumab 200 mg in open-label extensions (OLEs) were used. DP was defined as an excess tender 28-joint count (TJC28) over swollen 28-joint count (SJC28) of ≥7 (TJC28 - SJC28 ≥ 7). Treatment response and disease activity were determined for patients with and without DP. RESULTS Of 1531 sarilumab 200 mg patients from RCTs, 353 (23%) had baseline DP. On average, patients with DP had higher 28-joint DAS using CRP (DAS28-CRP) and pain scores than patients without DP, whereas CRP levels were similar. After 12 and 24 weeks, patients with baseline DP treated with sarilumab were more likely to be DP-free than those treated with placebo or adalimumab. In RCTs, more sarilumab-treated patients achieved low disease activity vs comparators, regardless of baseline DP status. In OLEs, patients were more likely to lose rather than gain DP status. CONCLUSION About one-quarter of patients with RA experienced DP, which responded well to sarilumab. These data support the concept that other mechanisms (potentially mediated via IL-6) in addition to inflammation may contribute to DP in RA. TRIAL REGISTRATIONS NCT01061736, NCT02332590, NCT01709578, NCT01146652.
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Affiliation(s)
- Ernest Choy
- Correspondence to: Ernest Choy, School of Medicine, UHW Main Building, Heath Park, Cardiff CF14 4XN, UK. E-mail:
| | - Vivian Bykerk
- Inflammatory Arthritis Centre, Hospital for Special Surgery, New York, NY, USA
| | - Yvonne C Lee
- Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Kerri Ford
- Medical Affairs Immunology and Inflammation-Rheumatology, Rare Inflammatory Disorders, Sanofi, Bridgewater, NJ, USA
| | | | - Serge Perrot
- Pain Center, Cochin Hospital, Paris University, Paris, France
| | - Janet Pope
- Division of Rheumatology, Schulich School of Medicine, University of Western Ontario, St. Joseph’s Health Care, London, ON, Canada
| | - Anthony Sebba
- Department of Rheumatology, University of South Florida, Tampa, FL, USA
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3
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Gorzewski AM, Heisler AC, Neogi T, Muhammad LN, Song J, Dunlop D, Bingham CO, Bolster MB, Clauw DJ, Marder W, Lee YC. Predicting Disease Activity in Rheumatoid Arthritis With the Fibromyalgia Survey Questionnaire: Does the Severity of Fibromyalgia Symptoms Matter? J Rheumatol 2023; 50:684-689. [PMID: 36521924 PMCID: PMC10159881 DOI: 10.3899/jrheum.220507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine if the degree of baseline fibromyalgia (FM) symptoms in patients with rheumatoid arthritis (RA), as indicated by the Fibromyalgia Survey Questionnaire (FSQ) score, predicts RA disease activity after initiation or change of a disease-modifying antirheumatic drug (DMARD). METHODS One hundred ninety-two participants with active RA were followed for 12 weeks after initiation or change of DMARD therapy. Participants completed the FSQ at the initial visit. The Disease Activity Score in 28 joints using C-reactive protein (DAS28-CRP) was measured at baseline and follow-up to assess RA disease activity. We evaluated the association between baseline FSQ score and follow-up DAS28-CRP. As a secondary analysis, we examined the relationship between the 2 components of the FSQ, the Widespread Pain Index (WPI) and Symptom Severity Scale (SSS), with follow-up DAS28-CRP. Multiple linear regression analyses were performed, adjusting for clinical and demographic variables. RESULTS In multiple linear regression models, FSQ score was independently associated with elevated DAS28-CRP scores 12 weeks after DMARD initiation (B = 0.04, P = 0.01). In secondary analyses, the WPI was significantly associated with increased follow-up DAS28-CRP scores (B = 0.08, P = 0.001), whereas the SSS was not (B = -0.03, P = 0.43). CONCLUSION Higher levels of FM symptoms weakly predicted worse disease activity after treatment. The primary factor that informed the FSQ's prediction of disease activity was the spatial extent of pain, as measured by the WPI.
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Affiliation(s)
| | - Andrew C Heisler
- A.C. Heisler, MD, MSci, Rheumatology, Department of Medicine, Western Michigan University, Kalamazoo, Michigan
| | - Tuhina Neogi
- T. Neogi, MD, PhD, Department of Rheumatology, Boston University School of Medicine, Boston, Massachusetts
| | - Lutfiyya N Muhammad
- L.N. Muhammad, PhD, J. Song, MS, Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Jing Song
- L.N. Muhammad, PhD, J. Song, MS, Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Dorothy Dunlop
- D. Dunlop, PhD, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Clifton O Bingham
- C.O. Bingham III, MD, Johns Hopkins Arthritis Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marcy B Bolster
- M.B. Bolster, MD, Division of Rheumatology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel J Clauw
- D.J. Clauw, MD, Rheumatology, Department of Medicine and Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, Michigan
| | - Wendy Marder
- W. Marder, MD, Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Yvonne C Lee
- Y.C. Lee, MD, MMSc, Rheumatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA.
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Durmaz Y, Ilhanli I. Rheumatoid arthritis activity scores in patients with and without fibromyalgia syndrome. Ann Saudi Med 2021; 41:246-252. [PMID: 34420399 PMCID: PMC8380282 DOI: 10.5144/0256-4947.2021.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Fibromyalgia syndrome (FM) is a systemic disease of unknown etiology, which can cause widespread musculoskeletal pain. In patients with rheumatoid arthritis (RA), FM can cause an additional symptom burden, which can affect some variables on the RA disease activity score 28 (DAS28), a tool that evaluates 28 joints in RA patients. OBJECTIVE Compare the results of four different versions of the DAS28 and the parameters used to determine disease activity scores in RA patients with and without FM, and determine whether there are treatment differences between RA patients with and without FM. DESIGN Retrospective, cross-sectional. SETTING Tertiary hospital. PATIENTS AND METHODS We identified patients diagnosed with RA between 1 September 2016 and 1 February 2020 and identified patients with and without FM. MAIN OUTCOME MEASURES Differences between variables in the DAS28 calculations (tender joint count [TJC], patient global assessment [PGA], and others), between patients with and without FM, and differences between patients with and without FM who were using or not using biological agents. SAMPLE SIZE 381, including 322 females (84.5%). RESULTS The frequency of FM in RA patients was 25.7% (89 females, 24.6%). In RA patients with FM, the TJC and PGA median values were significantly higher than in patients without FM (P<.05). The use of corticosteroids and biological therapy in patients with FM was more frequent than in patients without FM (P<.05). Compared to patients without FM, patients with FM switched treatment more often because of non-response to treatment (P=.01) Median values of the DAS28 scores (calculated by four different versions of the instrument) in RA patients with FM were higher than in patients without FM (P<.05). CONCLUSION The presence of FM in RA patients may affect the subjective variables in different versions of DAS28 scores, causing the disease activity to score higher on the instrument, erroneously indicating worse disease than is actually present. LIMITATIONS A single center, retrospective study. CONFLICTS OF INTEREST None.
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Affiliation(s)
- Yunus Durmaz
- From the Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Karabuk Training and Research Hospital, Karabuk, Turkey
| | - Ilker Ilhanli
- From the Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Espinoza G, Maldonado G, Narvaez J, Guerrero R, Citera G, Rios C. Beyond Rheumatoid Arthritis Evaluation: What are We Missing? Open Access Rheumatol 2021; 13:45-55. [PMID: 33790666 PMCID: PMC8007602 DOI: 10.2147/oarrr.s298393] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/05/2021] [Indexed: 12/30/2022] Open
Abstract
Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune systemic disease that preferentially affects small and large joints with a progressive course and can become deforming and disabling. In recent years, much progress has been made in the evaluation of inflammation and disease activity, however, there are other factors that have a high impact on the quality of life of these patients, such as depression, anxiety, fatigue, sleep disorders, suicidal behavior, fibromyalgia, sexual activity, sarcopenia, frailty, cachexia and obesity that are not always evaluated by rheumatologists. This review shows that the evaluation and timely detection of these aspects in patients with RA could interfere with the prognosis and improve their quality of life.
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Affiliation(s)
- Gianna Espinoza
- Rheumatology Department - Universidad Espiritu Santo, Samborondon, Ecuador
| | - Genessis Maldonado
- Internal Medicine Department - Loyola MacNeal Hospital, Berwyn, United States of America
| | - Jemina Narvaez
- Rheumatology Department - Universidad Espiritu Santo, Samborondon, Ecuador
| | - Roberto Guerrero
- Rheumatology Department - Universidad Espiritu Santo, Samborondon, Ecuador
| | - Gustavo Citera
- Rheumatology Department – Instituto Nacional de Rehabilitación Psicofísica, Buenos Aires, Argentina
| | - Carlos Rios
- Rheumatology Department - Universidad Espiritu Santo, Samborondon, Ecuador
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Gullick NJ, Ibrahim F, Scott IC, Vincent A, Cope AP, Garrood T, Panayi GS, Scott DL, Kirkham BW. Real world long-term impact of intensive treatment on disease activity, disability and health-related quality of life in rheumatoid arthritis. BMC Rheumatol 2019; 3:6. [PMID: 30886994 PMCID: PMC6390620 DOI: 10.1186/s41927-019-0054-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 01/25/2019] [Indexed: 12/25/2022] Open
Abstract
Background The emphasis on treating rheumatoid arthritis (RA) intensively reduces disease activity but its impact in routine care is uncertain. We evaluated temporal changes in disease activities and outcomes in a 10-year prospective observational cohort study of patients in routine care at one unit. Methods The Guy’s and St Thomas’ RA cohort was established in 2005. It involved most RA patients managed in this hospital. Clinical diagnoses of RA were made by rheumatologists. Patients were seen regularly in routine care. Each visit included measurement of disease activity scores for 28 joints (DAS28), health assessment questionnaire scores (HAQ) and EuroQol scores. Patients received intensive treatments targeting DAS28 remission. Results In 1693 RA patients mean DAS28 scores fell from 2005 to 15 by 11% from 4.08 (95% CI: 3.91, 4.25) in 2005 to 3.64 (3.34, 3.78); these falls were highly significant (p < 0.001). DAS28 components: swollen joint counts fell by 32% and ESR by 24%; in contrast tender joint counts and patient global assessments showed minimal or no reductions. The reduction in DAS28 scores was predominantly between 2005 and 2010, with no falls from 2011 onwards. Associated with falls in mean DAS28s, patients achieving remission increased (18% in 2005; 27% in 2015) and the number with active disease (DAS28 > 5.1) decreased (25% in 2005; 16% in 2015). In 752 patients seen at least annually for 3 years, persisting remission (68 patients) and intermittent remission (376 patients) were associated with less disability and better health related quality of life. Over time biologic use increased, but they were used infrequently in patients in persistent remission. Conclusions Over 10 years an intensive management strategy in a routine practice setting increased combination DMARD and biologic use: disease activity levels declined; this association is in keeping with a causal relationship. Patients who achieved remission, even transiently, had better functional outcomes than patients never achieving remission. Electronic supplementary material The online version of this article (10.1186/s41927-019-0054-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicola J Gullick
- 1Department of Rheumatology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Fowzia Ibrahim
- 2Department of Rheumatology, 3rd Floor, Weston Education Centre, King's College London, Cutcombe Road, London, UK
| | - Ian C Scott
- 3Research Institute for Primary Care & Health Sciences, Primary Care Sciences, Keele University, Keele, Staffordshire UK.,4Department of Rheumatology, Haywood Hospital, High Lane, Burslem, Staffordshire UK.,6Academic Department of Rheumatology, Centre for Molecular and Cellular Biology of Inflammation, 1st Floor, New Hunt's House, Guy's Campus, King's College London, Great Maze Pond, London, UK
| | - Alexandra Vincent
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
| | - Andrew P Cope
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK.,6Academic Department of Rheumatology, Centre for Molecular and Cellular Biology of Inflammation, 1st Floor, New Hunt's House, Guy's Campus, King's College London, Great Maze Pond, London, UK
| | - Toby Garrood
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
| | - Gabriel S Panayi
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
| | - David L Scott
- 2Department of Rheumatology, 3rd Floor, Weston Education Centre, King's College London, Cutcombe Road, London, UK
| | - Bruce W Kirkham
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
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Lee YC, Bingham CO, Edwards RR, Marder W, Phillips K, Bolster MB, Clauw DJ, Moreland LW, Lu B, Wohlfahrt A, Zhang Z, Neogi T. Association Between Pain Sensitization and Disease Activity in Patients With Rheumatoid Arthritis: A Cross-Sectional Study. Arthritis Care Res (Hoboken) 2019; 70:197-204. [PMID: 28437846 DOI: 10.1002/acr.23266] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 04/18/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Pain sensitization may contribute to pain severity in rheumatoid arthritis (RA), impacting disease activity assessment. We examined whether pain processing mechanisms were associated with disease activity among RA patients with active disease. METHODS The study included 139 subjects enrolled in the Central Pain in Rheumatoid Arthritis cohort. Subjects underwent quantitative sensory testing (QST), including assessment of pressure pain thresholds (PPTs) at multiple sites, conditioned pain modulation, and temporal summation. RA disease activity was assessed using the Clinical Disease Activity Index (CDAI) and its components. We examined cross-sectional associations between QST measures and disease activity using linear regression. RESULTS Low PPTs (high pain sensitization) at all sites were associated with high CDAI scores (P ≤ 0.03) and tender joint counts (P ≤ 0.002). Associations between PPTs and patient global assessments were also seen at most sites. High temporal summation at the forearm (also reflecting high pain sensitization) was significantly associated with high CDAI scores (P = 0.02), patient global assessment scores (P = 0.0006), evaluator global assessment scores (P = 0.01), and tender joint counts (P = 0.02). Conversely, conditioned pain modulation (a measure of descending inhibitory pain pathways) was associated only with tender joint count (P = 0.03). CONCLUSION High pain sensitization is associated with elevations in disease activity measures. Longitudinal studies are underway to elucidate the cause-effect relationships between pain sensitization and inflammatory disease activity in RA.
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Affiliation(s)
- Yvonne C Lee
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - Wendy Marder
- University of Michigan Medical School, Ann Arbor
| | | | | | | | | | - Bing Lu
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Zhi Zhang
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Tuhina Neogi
- Boston University School of Medicine, Boston, Massachusetts
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Is a Fundamental Change in the Interpretation of Rheumatoid Arthritis Disease Activity Necessary? J Clin Rheumatol 2018; 25:272-277. [PMID: 30570492 DOI: 10.1097/rhu.0000000000000937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Disease Activity Score (DAS) composite models are moderately precise and robust measures of disease severity when they are used in rheumatoid arthritis (RA) cohorts. They are less so when used for individual patients. This is because subjective components, patient global assessment of well-being and tender joint count, modified by factors other than RA biological disease activity, often obfuscate interpretation of disease activity. Comorbidities, especially distress, can disproportionately inflate these components. Fibromyalgia, essentially synonymous with distress, pain augmentation, and depression, is a common comorbidity. Its presence and severity can be determined by the Polysymptomatic Distress Scale (PSD). The differential effects of distress and fibromyalgia syndrome on the DAS can be demonstrated by manipulating information already there: the arithmetic differences or ratios of the tender joint count and swollen joint count and comparison of the modified disease activity score with 28 joints to the disease activity score with 28 joints-patient (DAS28-derived indices that measure the contribution of the relatively objective or relatively subjective components, respectively). The potentially more objective multibiomarker disease activity might also be used to test the severity of biological RA disease activity. These tools may be used to elucidate disproportionate values for subjective DAS model components, which then should facilitate identification of the underlying process factors, including depression, for potential treatment.
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Bilberg A, Bremell T, Bjersing J, Mannerkorpi K. High prevalence of widespread pain in women with early rheumatoid arthritis. Scand J Rheumatol 2018; 47:447-454. [PMID: 29973088 DOI: 10.1080/03009742.2018.1447683] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES The aim of the study was to determine the prevalence of widespread pain (WP) in women with early rheumatoid arthritis (RA) and to compare physical function, activity limitations, health-related quality of life, mental distress, and disease activity between women with WP and non-widespread pain (NWP). METHOD This cross-sectional study included 102 women with early RA. Participants were provided with self-reported questionnaires quantifying activity limitations, physical activity, pain intensity, health-related quality of life, and fatigue. Hand-grip force, muscle function test of the lower extremities, erythrocyte sedimentation rate, and number of tender and swollen joints were assessed. RESULTS One-third (35.9%) of the women fulfilled the American College of Rheumatology criteria for WP 20 months after disease onset. Women with RA + WP had significantly higher 28-joint Disease Activity Score (DAS28) (p = 0.004), number of tender joints (p = 0.001), pain intensity (p < 0.001), fatigue (p < 0.001), Health Assessment Questionnaire score (p < 0.001), and Hospital Anxiety and Depression Scale - Depression (p = 0.001). Furthermore, women with RA + WP showed significantly worse global health (p < 0.001) and physical health (36-item Short Form Health Survey - Physical Component Summary) (p < 0.001). The hand-grip force was found to be significantly reduced (p = 0.001), as was the muscle function of the lower extremities (p < 0.001), for women with RA + WP compared to women with RA + NWP. After adjustment for inflammatory joint disease, the significant differences between the groups remained. CONCLUSION A significant group of women with early RA experience WP with a high DAS28 and increased pain intensity level. These women display severe muscle function deficiency in clinical examinations, and report general activity limitations and low psychological and physical health, despite an absence of or low objective signs of inflammation.
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Affiliation(s)
- A Bilberg
- a Institute of Neuroscience and Physiology, Section of Health and Rehabilitation, Physiotherapy, Sahlgrenska Academy , University of Gothenburg , Gothenburg , Sweden
| | - T Bremell
- b Institute of Medicine, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy , University of Gothenburg , Gothenburg , Sweden
| | - J Bjersing
- b Institute of Medicine, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy , University of Gothenburg , Gothenburg , Sweden
| | - K Mannerkorpi
- a Institute of Neuroscience and Physiology, Section of Health and Rehabilitation, Physiotherapy, Sahlgrenska Academy , University of Gothenburg , Gothenburg , Sweden
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The subjective components of the Disease Activity Score 28-joints (DAS28) in rheumatoid arthritis patients and coexisting fibromyalgia. Rheumatol Int 2018; 38:1911-1918. [PMID: 29955927 DOI: 10.1007/s00296-018-4096-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 06/26/2018] [Indexed: 12/31/2022]
Abstract
To determine the contribution of fibromyalgia (FM) to the subjective components of the Disease Activity Score 28-joints (DAS28) in patients with rheumatoid arthritis (RA), and to analyse the discriminatory performance of the derived DAS28 patient-reported components (DAS28-P) to identify patients with fibromyalgic RA. Consecutive RA patients underwent clinical and clinimetric assessment. The DAS28-P index was derived from the components of the DAS28 scores by rearranging the DAS28-ESR formula. Patients were distinguished by the presence of FM. Student parametric t tests or Mann-Whitney non-parametric U tests were used to determine any between-group differences. Receiver operating characteristic (ROC) curve analysis was used to test the ability of the DAS28-P index to distinguish patients with RA and those with fibromyalgic RA. The study involved 292 RA patients (80.5% females, mean age 63 years) with a mean disease duration of 11.6 ± 8.5 years. Forty-three patients (14.7%) had concomitant FM, and significantly higher tender joint count (p < 0.001), pain numerical rating scale, global health status (p = 0.007), and DAS28 scores (p = 0.006) than those without FM. The DAS28-P values were also significantly higher in the patients with FM (0.68 ± 0.09 vs 0.58 ± 0.06; p < 0.001). The discriminatory power of the DAS28-P was very good (area under the ROC of 0.858, optimal cut-off value of 0.631). The presence of FM strongly influences the DAS28 results. The assessment of patient-reported components to the DAS28 through the DAS28-P can be a useful way to identify patients with fibromyalgic RA.
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11
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High burden of adverse events is associated with reduced remission rates in early rheumatoid arthritis. Clin Rheumatol 2017; 37:1689-1694. [DOI: 10.1007/s10067-017-3958-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/09/2017] [Accepted: 12/14/2017] [Indexed: 12/01/2022]
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12
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Provan SA, Olstad DS, Solberg EE, Smedslund G, Dagfinrud H. Evidence of reduced parasympathetic autonomic regulation in inflammatory joint disease: A meta-analyses study. Semin Arthritis Rheum 2017; 48:134-140. [PMID: 29291895 DOI: 10.1016/j.semarthrit.2017.11.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Rheumatoid arthritis (RA) and spondyloarthritis (SpA) are inflammatory joint disorders (IJD) with increased risk of cardiovascular disease (CVD). Autonomic dysfunction (AD) is a risk factor for CVD, and parasympathetic AD is linked to key features of IJD such as inflammation, physical inactivity and pain. Heart-rate variability (HRV) is a marker of cardiac AD. The study objective was to compare parasympathetic cardiac AD, measured by HRV, between patients with IJD and healthy controls, using meta-analysis methodology, and to examine the impact of inflammation, physical inactivity and pain on HRV in IJD. METHODS Medline, Embase and Amed were searched. Inclusion criteria were adult case-control studies published in English or a Scandinavian language, presenting HRV data in IJD. Two measures of HRV and 3 from the Ewing protocol were selected: square root of mean squared difference of successive R-R intervals (RMSSD), high frequency (HF), Ewing protocol; standing (E-S), breathing (E-B) and Valsalva (E-V). Patients with RA, SpA and healthy controls were compared separately using random-effects meta-analyses of standardized mean differences (SMD). RESULTS In all, 35 papers were eligible for inclusion. For RMSSD the pooled SMD (95% CI) RA vs. controls was -0.90 (-1.35 to -0.44), for SpA vs. controls; -0.34 (-0.73 to 0.06). For HF pooled SMD RA vs. controls was -0.78 (-0.99 to -0.57), for SpA vs. controls; -0.04 (-0.22 to 0.13). All Ewing parameters were significantly lower in cases, except for E-V which was comparable between cases and controls in patients with RA. CONCLUSION Patients with IJD have cardiac parasympathetic AD which is related to inflammation.
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Affiliation(s)
- Sella A Provan
- Department of Rheumatology, Diakonhjemmet Hospital, PB 23 Vindern, 0319 Oslo, Norway.
| | - Daniela Schäfer Olstad
- Department of Rheumatology, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Erik E Solberg
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Geir Smedslund
- Department of Rheumatology, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Hanne Dagfinrud
- Department of Rheumatology, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
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Curtis JR, Herrem C, Ndlovu 'MN, O'Brien C, Yazici Y. A somatization comorbidity phenotype impacts response to therapy in rheumatoid arthritis: post-hoc results from the certolizumab pegol phase 4 PREDICT trial. Arthritis Res Ther 2017; 19:215. [PMID: 28962590 PMCID: PMC5622491 DOI: 10.1186/s13075-017-1412-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/29/2017] [Indexed: 01/09/2023] Open
Abstract
Background Comorbidities may contribute to disease activity and treatment response in rheumatoid arthritis (RA) patients. We defined a somatization comorbidity phenotype (SCP) and examined its influence on response to certolizumab pegol (CZP) using data from the PREDICT trial. Methods Patients in PREDICT were randomized to the patient-reported Routine Assessment of Patient Index Data 3 (RAPID3) or physician-based Clinical Disease Activity Index (CDAI) for treatment response assessment. Post-hoc analyses identified patients with the SCP, which included diagnosis of depression, fibromyalgia/myalgias, and/or use of medications indicated for treatment of depression, anxiety, or neuropathic pain. The effect of the SCP on RAPID3 or CDAI response at week 12 and low disease activity (LDA; Disease Activity Score in 28 joints based on erythrocyte sedimentation rate ≤ 3.2) at week 52, in week-12 responders, was analyzed using non-parametric analysis of covariance (ANCOVA). Results At baseline, 43% (313/733) of patients met the SCP classification. Patients with the SCP were 9% more likely to withdraw from the trial. American College of Rheumatology 20% (ACR20), ACR50, and ACR70 responses were 5–14% lower among those with the SCP, and 11% more patients reported adverse events (AEs). Patients without SCP in the CDAI arm were twice as likely to achieve LDA at week 52 compared with those with SCP (32% versus 16%). No differentiation by SCP was observed in the RAPID3 arm (pooled result 21.5%). Conclusions We operationalized a potentially important somatization comorbidity phenotype in a trial setting that was associated with a substantially lower likelihood of treatment response and a higher frequency of AEs. Including large numbers of patients with this phenotype in RA trials may reduce the measured clinical effectiveness of a new molecule. Trial registration ClinicalTrials.gov, NCT01255761. Registered on 6 December 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1412-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, FOT 802, 510 20th Street South, Birmingham, AL, 35294, USA.
| | | | | | - Cathy O'Brien
- UCB Pharma, Allée de la Recherche 60, 1070, Brussels, Belgium
| | - Yusuf Yazici
- NYU Hospital for Joint Diseases, New York University School of Medicine, 301 East 17th Street, New York, NY, 10003, USA
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Salaffi F, Gerardi MC, Atzeni F, Batticciotto A, Talotta R, Draghessi A, Di Carlo M, Sarzi-Puttini P. The influence of fibromyalgia on achieving remission in patients with long-standing rheumatoid arthritis. Rheumatol Int 2017; 37:2035-2042. [PMID: 28875224 DOI: 10.1007/s00296-017-3792-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 08/09/2017] [Indexed: 12/19/2022]
Abstract
To investigate the influence of fibromyalgia (FM) on achieving remission defined on the basis of the Simplified Disease Activity Index (SDAI) remission criteria in patients with long-standing rheumatoid arthritis (RA). This observational longitudinal cohort consisted of long-standing RA patients being treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biological DMARDs (bDMARDs). After 6 months of follow-up, the patients fulfilling or not fulfilling the remission criteria were identified and compared with each other in terms of the presence of FM, neuropathic pain, and other comorbidities. At the end of the 6-month observation period, 24 of the 117 patients (20.4%) met the SDAI remission criteria. Logistic regression analysis showed that the modified Rheumatic Disease Comorbidity Index (mRDCI) (p = 0.0001), the FM presence (p = 0.0001), and the 36-item short-form health survey Mental Component Summary (SF-36 MCS) Score (p = 0.0088) were the strongest predictors of not being in SDAI remission. None of the patients with concomitant FM (17.1%) achieved SDAI remission. In comparison with the non-FM patients, the patients with RA and FM patients had worse scores on the SF-36 MCS (p = 0.011), on the sleep Visual Analogue Scale (VAS) (p = 0.018), on the self-counts of tender joints (p = 0.039), and on the PainDetect Questionnaire (PDQ) (p = 0.001). To avoid over treatment, an assessment of FM should be considered in RA patients who do not fulfil the remission criteria.
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Affiliation(s)
- Fausto Salaffi
- Rheumatology Department, Università Politecnica delle Marche, c/o Ospedale "Carlo Urbani", Via Aldo Moro 25, 60035, Jesi, AN, Italy.
| | - Maria Chiara Gerardi
- Rheumatology Unit, ASST Fatebenefratelli-L. Sacco University Hospital, Milan, Italy
| | - Fabiola Atzeni
- Rheumatology Unit, ASST Fatebenefratelli-L. Sacco University Hospital, Milan, Italy
| | - Alberto Batticciotto
- Rheumatology Unit, ASST Fatebenefratelli-L. Sacco University Hospital, Milan, Italy
| | - Rossella Talotta
- Rheumatology Unit, ASST Fatebenefratelli-L. Sacco University Hospital, Milan, Italy
| | - Antonella Draghessi
- Rheumatology Department, Università Politecnica delle Marche, c/o Ospedale "Carlo Urbani", Via Aldo Moro 25, 60035, Jesi, AN, Italy
| | - Marco Di Carlo
- Rheumatology Department, Università Politecnica delle Marche, c/o Ospedale "Carlo Urbani", Via Aldo Moro 25, 60035, Jesi, AN, Italy
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15
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Cohen H. Controversies and challenges in fibromyalgia: a review and a proposal. Ther Adv Musculoskelet Dis 2017; 9:115-127. [PMID: 28458723 DOI: 10.1177/1759720x17699199] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 02/04/2017] [Indexed: 12/13/2022] Open
Abstract
Fibromyalgia (FM) is the most commonly encountered chronic widespread pain (CWP) condition in rheumatology. In comparison to inflammatory arthritis (IA), it can seem ill defined with no clear understanding of the pathology and therefore no specific targeted treatment. This inevitably raises controversies and challenges. However, this is an outdated view perpetuated by poor teaching of pain at undergraduate and postgraduate levels, and the perennial problem of advances in relevant cross-speciality knowledge penetrating speciality silos. Research has provided a better understanding of the aetiopathology and FM is now regarded as a centralized pain state. Effective treatment is possible utilizing a multidisciplinary approach combining nonpharmacologic and pharmacologic treatments rooted in a biopsychosocial model. This article will provide a review of the mechanisms, diagnosis and treatment of FM, focus on some ongoing contentious issues and propose a change to the diagnostic terminology.
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Affiliation(s)
- Helen Cohen
- Royal National Orthopaedic Hospital, Stanmore, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
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16
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Bugatti S, Bogliolo L, Vitolo B, Manzo A, Montecucco C, Caporali R. Anti-citrullinated protein antibodies and high levels of rheumatoid factor are associated with systemic bone loss in patients with early untreated rheumatoid arthritis. Arthritis Res Ther 2016; 18:226. [PMID: 27716332 PMCID: PMC5052789 DOI: 10.1186/s13075-016-1116-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/13/2016] [Indexed: 01/19/2023] Open
Abstract
Background Autoantibodies such as anti-citrullinated protein antibodies (ACPA) are major risk factors for articular bone destruction from the earliest phases of rheumatoid arthritis (RA). The aim of the current study was to determine whether RA-associated autoantibodies also impact on systemic bone loss in patients with early disease. Methods Systemic bone mineral density (BMD) was measured in the lumbar spine and the hip in 155 consecutive treatment-naïve patients with early RA (median symptom duration 13 weeks). Demographic and disease-specific parameters, including clinical disease activity, ultrasonographic (US) examination of the hands and wrists, radiographic scoring of joint damage, ACPA and rheumatoid factor (RF) levels were recorded from all patients. Reduced BMD was defined as Z score ≤ -1 SD and analysed in relation to disease-related characteristics and autoantibody subgroups. Results Reduced BMD was found in 25.5 % of the patients in the spine and 19.4 % in the hip. Symptom duration, clinical and US disease activity, functional disability and radiographic damage did not significantly impact on spine and hip BMD loss in regression analyses adjusted for possible confounders (age, gender, menopausal status, current smoking, body mass index). In contrast, ACPA positivity (at any level) negatively affected the spine Z-score (adjusted OR (95 % CI) 2.76 (1.19 to 6.42)); the hip Z score was affected by high titres only (adjusted OR (95 % CI) 2.96 (1.15 to 7.66)). The association of ACPA with reduced BMD in the spine was confirmed even at low levels of RF (adjusted OR (95 % CI) 2.65 (1.01 to 7.24)), but was further increased by concomitant high RF (adjusted OR (95 % CI) 3.38 (1.11 to 10.34)). In contrast, Z scores in the hip were significantly reduced only in association with high ACPA and RF (adjusted OR (95 % CI) 4.96 (1.48 to 16.64)). Conclusions Systemic BMD in patients with early RA is reduced in relation with ACPA positivity and high RF levels. This finding supports the notion that RA-associated autoimmunity may have a direct causative role in bone remodeling.
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Affiliation(s)
- Serena Bugatti
- Rheumatology and Translational Immunology Research Laboratories (LaRIT) and Early Arthritis Clinic, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation/University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy
| | - Laura Bogliolo
- Rheumatology and Translational Immunology Research Laboratories (LaRIT) and Early Arthritis Clinic, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation/University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy
| | - Barbara Vitolo
- Rheumatology and Translational Immunology Research Laboratories (LaRIT) and Early Arthritis Clinic, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation/University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy
| | - Antonio Manzo
- Rheumatology and Translational Immunology Research Laboratories (LaRIT) and Early Arthritis Clinic, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation/University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy
| | - Carlomaurizio Montecucco
- Rheumatology and Translational Immunology Research Laboratories (LaRIT) and Early Arthritis Clinic, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation/University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy.
| | - Roberto Caporali
- Rheumatology and Translational Immunology Research Laboratories (LaRIT) and Early Arthritis Clinic, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation/University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy
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