Predictors of fatigue in rheumatoid arthritis

Arthritis is associated with high nutritional risk among older Canadian adults from the Canadian Longitudinal Study on Aging

This study assessed the association between arthritis, functional impairment, and nutritional risk (NR). Cross-sectional data were from the Canadian Longitudinal Study on Aging, a nationally representative sample of 45-85-year-old community-dwelling Canadians (n = 41,153). The abbreviated Seniors in the Community: Risk Evaluating for Eating and Nutrition II (SCREEN II-AB) Questionnaire determined NR scores (continuous), and high NR (score < 38); the Older American Resources and Services scale measured functional impairment. NR scores and status (low/high) were modelled using multiple linear and logistic regressions, respectively. Analyses adjusted for demographic characteristics, functional impairment, and health (body mass index, self-rated general and mental health). Additional analyses stratified the models by functional impairment. People with arthritis had poorer NR scores (B: - 0.35, CI - 0.48, - 0.22; p < 0.05) and increased risks of high NR (OR 1.11, 95% CI 1.06, 1.17). Among those with functional impairment, the likelihood of high NR was 31% higher in people with arthritis compared to those without arthritis (95% CI 1.12, 1.53). Among those with no functional impairment, the likelihood of high NR was 10% higher in people with arthritis compared to those without (95% CI 1.04, 1.16). These relationships differed based on the type of arthritis. Arthritis is associated with high NR in community-dwelling older adults, both with and without functional impairment. Findings highlight the need for further research on these relationships to inform interventions and improve clinical practices.

Why does malaise/fatigue occur? Underlying mechanisms and potential relevance to treatments in rheumatoid arthritis

INTRODUCTION

Fatigue and malaise are commonly associated with a wide range of medical conditions, including rheumatoid arthritis (RA). Evidence suggests that fatigue and malaise can be overwhelming for patients, yet these symptoms remain inadequately-managed, largely due to an incomplete elucidation of the underlying causes.

AREAS COVERED

In this assessment of the published literature relating to the pathogenesis of fatigue or malaise in chronic conditions, four key mechanistic themes were identified. Each theme (inflammation, hypothalamic-pituitary-adrenal axis, dysautonomia, and monoamines) is discussed, as well as the complex network of interconnections between themes which suggests a key role for inflammatory cytokines in the development and persistence of fatigue.

EXPERT OPINION

Fatigue is multifaceted, poorly defined, and imperfectly comprehended. Moreover, the cause and severity of fatigue may change over time, as a consequence of the natural disease course or pharmacologic treatment. This detailed synthesis of available evidence permits us to identify avenues for current treatment optimization and future research, to improve the management of fatigue and malaise in RA. Within the development pipeline, several new anti-inflammatory therapies are currently under investigation, and we anticipate that the next five years will herald much-needed progress to reduce the debilitating nature of fatigue in patients with RA.

Clinical significance of anti-mutated citrullinated vimentin antibodies in rheumatoid arthritis patients

BACKGROUND

Anti-mutated citrullinated vimentin (MCV) antibodies have recently been recommended as a better arthritis diagnostic marker.

OBJECTIVES

To investigate the association between anti-MCV antibodies and the clinical, functional, and radiographic characteristics of rheumatoid arthritis (RA) patients.

METHODS

This case-control study was conducted on 40 RA patients and 40 healthy subjects. All patients were subjected to an assessment of disease using the 28-joint DAS (DAS28) and Clinical Disease Activity Index (CDAI), function by HAQ-DI, physical activity by International Physical Activity Questionnaire (IPAQ), fatigue by Functional Assessment of Chronic Illness Therapy (FACIT), serological tests as well as anti-MCV Abs measurement. A plain X-ray of both hands and wrists was done.

RESULTS

The anti-MCV Abs level was significantly higher in RA patients than in healthy controls (P< 0.001). The anti-MCV Abs had a significant positive correlation with DAS, CDAI, HAQ, RF, Anti-CCP, and CRP (P= 0.006, 0.013, 0.005, < 0.001, < 0.001and 0.041 respectively) and a significant negative correlation with FACIT (p= 0.007). Positive anti-MCV RA patients had significantly higher erosions, JSN, and a total sharp score.

CONCLUSIONS

Anti-MCV Abs may contribute to poor physical activity and more fatigue in RA patients beyond their established role in disease activity and erosion.

2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases

OBJECTIVES

Fatigue is prevalent in people with inflammatory rheumatic and musculoskeletal diseases (I-RMDs) and recognised as one of the most challenging symptoms to manage. The existence of multiple factors associated with driving and maintaining fatigue, and the evidence about what improves fatigue has led to a multifaceted approach to its management. However, there are no recommendations for fatigue management in people with I-RMDs. This lack of guidance is challenging for those living with fatigue and health professionals delivering clinical care. Therefore, our aim was to develop EULAR recommendations for the management of fatigue in people with I-RMDs.

METHODS

A multidisciplinary taskforce comprising 26 members from 14 European countries was convened, and two systematic reviews were conducted. The taskforce developed the recommendations based on the systematic review of evidence supplemented with taskforce members' experience of fatigue in I-RMDs.

RESULTS

Four overarching principles (OAPs) and four recommendations were developed. OAPs include health professionals' awareness that fatigue encompasses multiple biological, psychological and social factors which should inform clinical care. Fatigue should be monitored and assessed, and people with I-RMDs should be offered management options. Recommendations include offering tailored physical activity and/or tailored psychoeducational interventions and/or, if clinically indicated, immunomodulatory treatment initiation or change. Patient-centred fatigue management should consider the individual's needs and preferences, their clinical disease activity, comorbidities and other psychosocial and contextual factors through shared decision-making.

CONCLUSIONS

These 2023 EULAR recommendations provide consensus and up-to-date guidance on fatigue management in people with I-RMDs.

A cross-sectional study of multidimensional fatigue in biologic-treated rheumatoid arthritis: which variables play a role?

PURPOSE

Despite efficient biological disease-modifying antirheumatic drugs (bDMARDs) Rheumatoid Arthritis (RA) patients still suffer from high fatigue. This study aims to further our knowledge by assessing severity levels of the various fatigue dimensions and their associations with pain, sleep quality, and psychological well-being in bDMARDs treated RA patients.

MATERIAL AND METHODS

The sample consisted of 146 RA patients (84.9% females; mean age 56.6 ± 13.6 years), who completed the MFI-20, SF-36, PSQI, GAD-7 and PHQ-9. Correlation analyses and multiple linear regressions were used to analyse the data.

RESULTS

General fatigue was the highest reported type of fatigue, followed by physical fatigue dimensions. In the final regression model, pain and disability were significantly associated with physical fatigue (p ≤ 0.001, p ≤ 0.05, respectively) and reduced activity (p ≤ 0.01, p ≤ 0.05, respectively). Anxiety was significantly associated with mental fatigue (p ≤ 0.05) and reduced motivation (p ≤ 0.01). Regression analyses showed no significant associations between depression, sleep quality, and fatigue in any of the final models.

CONCLUSIONS

Our findings indicate that effectively addressing fatigue in RA patients requires an individualized approach. This approach should acknowledge the varying degrees of fatigue across different fatigue dimensions (physical or mental), while also taking into account the patient's mental health problems, pain levels, and disability levels.

Potential Mechanism of Fatigue Induction and Its Management by JAK Inhibitors in Inflammatory Rheumatic Diseases

It is well known that fatigue is a highly disabling symptom commonly observed in inflammatory rheumatic diseases (IRDs). Fatigue is strongly associated with a poor quality of life and seems to be an independent predictor of job loss and disability in patients with different rheumatic diseases. Although the pathogenesis of fatigue remains unclear, indirect data suggest the cooperation of the immune system, the central and autonomic nervous system, and the neuroendocrine system in the induction and sustainment of fatigue in chronic diseases. Fatigue does not correspond with disease activity and its mechanism in IRDs. It is suggested that it may change over time and vary between individuals. Abnormal production of pro-inflammatory cytokines such as interleukin-6 (IL-6), interferons (IFNs), granulocyte-macrophage colony-stimulating factor (GM-CSF), TNF, IL-15, IL-17 play a role in both IRDs and subsequent fatigue development. Some of these cytokines such as IL-6, IFNs, GM-CSF, and common gamma-chain cytokines (IL-15, IL-2, and IL-7) activate the Janus Kinases (JAKs) family of intracellular tyrosine kinases. Therapy blocking JAKs (JAK inhibitors - JAKi) has been recently proven to be an effective approach for IRDs treatment, more efficient in pain reduction than anti-TNF. Therefore, the administration of JAKi to IRDs patients experiencing fatigue may find rational implications as a therapeutic modulator not only of disease inflammatory symptoms but also fatigue with its components like pain and neuropsychiatric features as well. In this review, we demonstrate the latest information on the mechanisms of fatigue in rheumatic diseases and the potential effect of JAKi on fatigue reduction.

Fatigue in Inflammatory Joint Diseases

Fatigue is a prevalent symptom in various rheumatic diseases, such as rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. It is characterised as a subjective, enduring feeling of generalised tiredness or exhaustion, impacting the patient's life quality and exacerbating disability. The fatigue nature is multifaceted, encompassing physiological, psychological, and social factors, and although the exact cause of inflammatory joint diseases is not fully understood, several factors are believed to contribute to its development. Despite high prevalence and importance, the symptom is often underestimated in clinical practice. Chronic inflammation, commonly associated with rheumatic diseases, has been proposed as a potential contributor to fatigue development. While current treatments effectively target inflammation and reduce disease activity, fatigue remains a persistent problem. Clinical evaluation of rheumatic diseases primarily relies on objective criteria, whereas fatigue, being a subjective symptom, is solely experienced and reported by the patient. Managing fatigue in inflammatory joint diseases involves a multifaceted approach. Identifying and comprehensively assessing the subjective components of fatigue in individual patients is crucial for effectively managing this symptom in everyday clinical practice.

Recurring Fatigue After Biologic Administration: Patient-Reported Data from the Dutch Biologic Monitor

BACKGROUND

Fatigue is a common problem in immune-mediated inflammatory disease (IMID) patients, significantly impacting their quality of life.

OBJECTIVES

In this study, we describe the pattern and characteristics of fatigue as a patient-reported adverse drug reaction (ADR) of biologics, and compared patient and treatment characteristics with patients reporting other ADRs or no ADRs.

METHODS

In this cohort event monitoring study, the description and characteristics of fatigue reported as a possible ADR in the Dutch Biologic Monitor were assessed and analysed for commonly recurring themes or patterns. Baseline and treatment characteristics of patients with fatigue and patients reporting other ADRs or no ADRs were compared.

RESULTS

Of 1382 participating patients, 108 patients (8%) reported fatigue as an ADR of a biologic. Almost half of these patients (50 patients, 46%) described episodes of fatigue during or shortly after biologic injection, which often recurred following subsequent injections. Patients with fatigue were significantly younger than patients with other ADRs or patients without ADRs (median age for patients with fatigue, 52 years; median age for patients with other ADRs, 56 years; and median age for patients without ADRs, 58 years); significantly more often smoked (25% vs. 16% and 15%); used infliximab (22% vs. 9% and 13%), rituximab (9% vs. 3% and 1%) or vedolizumab (6% vs. 2% and 1%); and significantly more often had Crohn's disease (28% vs. 13% and 13%) and other comorbidities (31% vs. 20% and 15%). Patients with fatigue significantly less frequently used etanercept (12% vs. 29% and 34%) or had rheumatoid arthritis (30% vs. 45% and 43%).

CONCLUSIONS

IMID patients may experience fatigue as a postdosing effect of biologics.

Relative Impact of Pain and Disease Activity on Improvements in Fatigue: Results From 2 Baricitinib Phase 3 Clinical Trials

BACKGROUND/OBJECTIVE

Fatigue is common in patients with rheumatoid arthritis (RA). We assessed the relative impact of pain and disease activity on improvements in fatigue in 2 phase 3 baricitinib clinical trials.

METHODS

RA-BEAM (NCT01710358) and RA-BEACON (NCT01721044) were randomized, double-blind, placebo-controlled studies in adults with moderate to severe RA. RA-BEAM assessed baricitinib + methotrexate (MTX) and adalimumab + MTX in patients with prior inadequate response/intolerance (IR) to MTX (MTX-IR). RA-BEACON assessed patients with IR to ≥1 biologic disease-modifying antirheumatic drug (bDMARD-IR). Measures included the Functional Assessment of Chronic Illness Therapy-Fatigue scale, Clinical Disease Activity Index (CDAI) for RA, and pain visual analog scale (VAS). Analyses were implemented separately for each study.

RESULTS

Significant improvements were seen in disease activity and pain, which were greater with baricitinib versus adalimumab. A statistically significant improvement was seen in fatigue with both active treatments versus placebo. Moderate correlations were observed between improvements in disease activity and fatigue and between improvements in pain and fatigue in both MTX-IR and bDMARD-IR patients. Reductions in pain (≥50%) and remission or low disease activity (CDAI ≤10) had significant associations with fatigue improvement at week 24. In mediation analysis, improvements in fatigue attributable to CDAI and pain VAS in MTX-IR patients were 31% and 52%, respectively, for baricitinib, and 30% and 47%, respectively, for adalimumab. In bDMARD-IR patients, improvement in fatigue was attributed 48% to CDAI and 48% to pain VAS.

CONCLUSIONS

In both MTX-IR and bDMARD-IR patients, a large proportion of improvements in fatigue across treatment arms were accounted for by improvements in pain and disease activity.

Examining the variability of multiple daily symptoms over time among individuals with multiple long-term conditions (MLTC-M/multimorbidity): An exploratory analysis of a longitudinal smartwatch feasibility study

Introduction

People living with multiple long-term conditions (MLTC-M) (multimorbidity) experience a range of inter-related symptoms. These symptoms can be tracked longitudinally using consumer technology, such as smartphones and wearable devices, and then summarised to provide useful clinical insight.

Aim

We aimed to perform an exploratory analysis to summarise the extent and trajectory of multiple symptom ratings tracked via a smartwatch, and to investigate the relationship between these symptom ratings and demographic factors in people living with MLTC-M in a feasibility study.

Methods

'Watch Your Steps' was a prospective observational feasibility study, administering multiple questions per day over a 90 day period. Adults with more than one clinician-diagnosed long-term condition rated seven core symptoms each day, plus up to eight additional symptoms personalised to their LTCs per day. Symptom ratings were summarised over the study period at the individual and group level. Symptom ratings were also plotted to describe day-to-day symptom trajectories for individuals.

Results

Fifty two participants submitted symptom ratings. Half were male and the majority had LTCs affecting three or more disease areas (N = 33, 64%). The symptom rated as most problematic was fatigue. Patients with increased comorbidity or female sex seemed to be associated with worse experiences of fatigue. Fatigue ratings were strongly correlated with pain and level of dysfunction.

Conclusion

In this study we have shown that it is possible to collect and descriptively analyse self reported symptom data in people living with MLTC-M, collected multiple times per day on a smartwatch, to gain insights that might support future clinical care and research.

Identifying trajectories of fatigue in patients with primary mitochondrial disease due to the m.3243A > G variant

Severe fatigue is a common complaint in patients with primary mitochondrial disease. However, less is known about the course of fatigue over time. This longitudinal observational cohort study of patients with the mitochondrial DNA 3243 A>G variant explored trajectories of fatigue over 2 years, and characteristics of patients within these fatigue trajectories. Fifty-three adult patients treated at the Radboud University Medical Center Nijmegen were included. The majority of the patients reported consistent, severe fatigue (41%), followed by patients with a mixed pattern of severe and mild fatigue (36%). Then, 23% of patients reported stable mild fatigue levels. Patients with a stable high fatigue trajectory were characterized by higher disease manifestations scores, more clinically relevant mental health symptoms, and lower psychosocial functioning and quality of life compared to patients reporting stable low fatigue levels. Fatigue at baseline and disease manifestation scores predicted fatigue severity at the 2-year assessment (57% explained variance). This study demonstrates that severe fatigue is a common and stable complaint in the majority of patients. Clinicians should be aware of severe fatigue in patients with moderate to severe disease manifestation scores on the Newcastle Mitochondrial Disease Scale, the high prevalence of clinically relevant mental health symptoms and overall impact on quality of life in these patients. Screening of fatigue and psychosocial variables will guide suitable individualized treatment to improve the quality of life.

Work Ability and Quality of Life in Patients with Rheumatoid Arthritis

BACKGROUND

Reduced work participation has social implications (sickness absence, economic impact) and consequences for the individual patient (impoverishment, depression, limited social interaction). As patients with rheumatoid arthritis (RA) are more likely to experience job loss and/or at-work productivity loss and are at higher risk of sickness absence and, ultimately, permanent work productivity, consideration should be given to the association between work productivity or partial work capacity and quality of life (QoL). The aim of the study was to assess the relationship between QoL and the risk of work disability, as well as to estimate the risk of a future event and identify factors affecting the risk of work disability in RA inpatients.

MATERIAL AND METHODS

This cross-sectional study included 142 inpatients (65 male) aged 47 (38-58) years, who met the established criteria for a diagnosis of RA and treatment with biologic drugs. Only standardized tools were used to examine the patients: WHOQOL-BREF, MFIS and AS-WIS.

RESULTS

An analysis of the QoL scores on the WHOQOL-BREF demonstrated that the patients' QoL was lowest in the physical health domain and highest in the social relationships domain. The median WHOQOL-BREF total score in the group studied was 62.8, which indicates a moderate QoL. The median total score for the risk of work disability (AS-WIS) was 10.1, which indicates that the level of risk of work disability in the patients was higher than the average level reported in the literature. A multivariate analysis showed that the following were significant independent determinants of a higher risk of work disability: low QoL in the WHOQOL-BREF physical health (β = 0.961; p = 0.029) and psychological health (β = 1.752; p = 0.002) domains, being in a relationship (β = 0.043; p = 0.005) and the use of opioids for pain (β = 3.054; p = 0.012).

CONCLUSIONS

RA patients presented with moderate QoL, moderate fatigue (MFIS) and high risk of disability (AS-WIS). There is an association between a high risk of work disability and lower QoL, especially in the physical and psychological health domains. The lower the QoL in those domains, the higher the risk of work disability. The identification of factors increasing the risk of work disability will help in planning tailored interventions to improve at-work productivity loss and thus prevent work disability.

Proteomic analyses do not reveal subclinical inflammation in fatigued patients with clinically quiescent inflammatory bowel disease

Fatigue is a common and clinically challenging symptom in patients with inflammatory bowel diseases (IBD), occurring in ~ 50% of patients with quiescent disease. In this study, we aimed to investigate whether fatigue in patients with clinically quiescent IBD is reflected by circulating inflammatory proteins, which might reflect ongoing subclinical inflammation. Ninety-two (92) different inflammation-related proteins were measured in plasma of 350 patients with clinically quiescent IBD. Quiescent IBD was defined as clinical (Harvey-Bradshaw Index < 5 or Simple Clinical Colitis Activity Index < 2.5) and biochemical remission (C-reactive protein < 5 mg/L and absence of anemia) at time of fatigue assessment. Leukemia inhibitory factor receptor (LIF-R) concentrations were inversely associated with severe fatigue, also after adjustment for confounding factors (nominal P < 0.05). Although solely LIF-R showed weak ability to discriminate between mild and severe fatigue (area under the curve [AUC] = 0.61, 95%CI: 0.53–0.69, P < 0.05), a combined set of the top seven (7) fatigue-associated proteins (all P < 0.10) was observed to have reasonable discriminative performance (AUC = 0.82 [95%CI: 0.74–0.91], P < 0.01). Fatigue in patients with IBD is not clearly reflected by distinct protein signatures, suggesting there is no subclinical inflammation defined by the studied inflammatory proteins. Future studies are warranted to investigate other proteomic markers that may reflect fatigue in clinically quiescent IBD.

Remote sampling of biomarkers of inflammation with linked patient generated health data in patients with rheumatic and musculoskeletal diseases: an Ecological Momentary Assessment feasibility study

Background

People with rheumatic diseases experience troublesome fluctuations in fatigue. Debated causes include pain, mood and inflammation. To determine the relationships between these potential causes, serial assessments are required but are methodologically challenging. This mobile health (mHealth) study explored the viability of using a smartphone app to collect patient-reported symptoms with contemporaneous Dried Blood Spot Sampling (DBSS) for inflammation.

Methods

Over 30 days, thirty-eight participants (12 RA, 13 OA, and 13 FM) used uMotif, a smartphone app, to report fatigue, pain and mood, on 5-point ordinal scales, twice daily. Daily DBSS, from which C-reactive Protein (CRP) values were extracted, were completed on days 1–7, 14 and 30. Participant engagement was determined based on frequency of data entry and ability to calculate within- and between-day symptom changes. DBSS feasibility and engagement was determined based on the proportion of samples returned and usable for extraction, and the number of days between which between-day changes in CRP which could be calculated (days 1–7).

Results

Fatigue was reported at least once on 1085/1140 days (95.2%). Approximately 65% of within- and between-day fatigue changes could be calculated. Rates were similar for pain and mood. A total of 287/342 (83.9%) DBSS, were returned, and all samples were viable for CRP extraction. Fatigue, pain and mood varied considerably, but clinically meaningful (≥ 5 mg/L) CRP changes were uncommon.

Conclusions

Embedding DBSS in mHealth studies will enable researchers to obtain serial symptom assessments with matched biological samples. This provides exciting opportunities to address hitherto unanswerable questions, such as elucidating the mechanisms of fatigue fluctuations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05723-w.

Prevalence and factors associated with fatigue in patients with ulcerative colitis in China: a cross-sectional study

Background

Fatigue is one of the most common symptoms reported by patients with ulcerative colitis (UC), while it has not been fully recognized and taken seriously in clinical practice. We aimed to investigate the prevalence of fatigue in patients with UC and identify the factors associated with fatigue and its severity in China.

Methods

A cross-sectional study was conducted in Affiliated Hospital of Nanjing University of Chinese Medicine from May 2020 to February 2021. Demographic and clinical characteristics were collected. Fatigue was evaluated with the Fatigue Severity Scale and the Multidimensional Fatigue Inventory. The Hospital Anxiety and Depression Scale, the Pittsburgh Sleep Index Scale and the Malnutrition Universal Screening Tool were respectively used to evaluate the anxiety, depression, sleep disturbance and nutritional risk of patients with UC.

Results

A total of 220 UC patients were enrolled in this study. The prevalence of fatigue in patients was 61.8%, of which in patients with disease activity was 68.2%, and in patients in remission was 40.0%. Univariate analysis indicated that the Montreal classification, disease activity, anemia, anxiety, depression, sleep disturbance and high nutritional risk were the factors associated with fatigue in Patients with UC. Multivariate logistic regression analysis showed that the Montreal classification (E3: E1, OR = 2.665, 95% CI = 1.134–6.216), disease activity (OR = 2.157, 95% CI = 1.055–4.410) and anxiety (OR = 2.867, 95% CI = 1.154–7.126) were related to an increased risk of fatigue. Disease activity (RC = 0.240, 95% CI = 0.193–0.674) and anxiety (RC = 0.181, 95% CI = 0.000–0.151) were associated with severity of fatigue.

Conclusions

This study demonstrated that the prevalence of fatigue among UC patients in China. The Montreal classification, disease activity and anxiety are associated with an increased risk of fatigue.

The Lived Experiences of Iranian Patients with Rheumatoid Arthritis: A Qualitative Research

BACKGROUND

Rheumatoid Arthritis (RA) is a chronic inflammatory disease that affects various systems of the body. The present study was conducted with the aim to explain the lived experiences of Iranian patients with RA.

MATERIALS AND METHODS

According to the research question, the phenomenological research approach was used. The participants were selected through purposive sampling, and sampling was continued until data saturation was achieved. The data was collected by conducting unstructured interviews and using an audio recorder. To interpret the data, an interpretive/hermeneutic approach was implemented using Van Manen's method. In addition, Lincoln and Guba's criteria were used to evaluate data robustness.

RESULTS

A total of 24 participants participated in the study. Overall, 145 basic concept codes were extracted which were classified into the four main themes of self-management with the participation of the family, spiritual resilience in the face of existing problems, the tendency to hide the disease, and the fear of an uncertain future.

CONCLUSIONS

It is recommended that care providers use the findings of this study to develop care plans in the various aspects of the physical, mental, social, and spiritual needs of patients with RA based on their concerns and deep experiences. It is also suggested that other qualitative research approach methodologies such as grounded theory for explaining the process of patient care and providing an appropriate model, or action research for solving the problems of hospitalized patients through suitable care at home be implemented.

Pathway Phenotypes Underpinning Depression, Anxiety, and Chronic Fatigue Symptoms Due to Acute Rheumatoid Arthritis: A Precision Nomothetic Psychiatry Analysis

Rheumatoid arthritis (RA) is a chronic inflammatory and autoimmune disorder which affects the joints in the wrists, fingers, and knees. RA is often associated with depressive and anxiety symptoms as well as chronic fatigue syndrome (CFS)-like symptoms. This paper examines the association between depressive symptoms (measured with the Beck Depression Inventory, BDI), anxiety (Hamilton Anxiety Rating Scale, HAMA), CFS-like (Fibro-fatigue Scale) symptoms and immune–inflammatory, autoimmune, and endogenous opioid system (EOS) markers, and lactosylcer-amide (CD17) in RA. The serum biomarkers were assayed in 118 RA and 50 healthy controls. Results were analyzed using the new precision nomothetic psychiatry approach. We found significant correlations between the BDI, FF, and HAMA scores and severity of RA, as assessed with the DAS28-4, clinical and disease activity indices, the number of tender and swollen joints, and patient and evaluator global assessment scores. Partial least squares analysis showed that 69.7% of the variance in this common core underpinning psychopathology and RA symptoms was explained by immune–inflammatory pathways, rheumatoid factor, anti-citrullinated protein antibodies, CD17, and mu-opioid receptor levels. We constructed a new endophenotype class comprising patients with very high immune–inflammatory markers, CD17, RA, affective and CF-like symptoms, and tobacco use disorder. We extracted a reliable and replicable latent vector (pathway phenotype) from immune data, psychopathology, and RA-severity scales. Depression, anxiety, and CFS-like symptoms due to RA are manifestations of the phenome of RA and are mediated by the effects of the same immune–inflammatory, autoimmune, and other pathways that underpin the pathophysiology of RA.

A New Tool for Rapid Assessment of Acute Exercise-Induced Fatigue

Background

There are limited sensitive evaluation methods to distinguish people's symptoms of peripheral fatigue and central fatigue simultaneously. The purpose of this study is to identify and evaluate them after acute exercise with a simple and practical scale.

Methods

The initial scale was built through a literature review, experts and athlete population survey, and a small sample pre-survey. Randomly selected 1,506 students were evaluated with the initial scale after exercise. Subjective fatigue self-assessments (SFSA) were completed at the same time.

Results

The Acute Exercise-Induced Fatigue Scale (AEIFS) was determined after performing a factor analysis. In the exploratory factor analysis, the cumulative variance contribution rate was 65.464%. The factor loadings of the total 8 questions were 0.661-0.816. In the confirmatory factor analysis, χ2/df = 2.529, GFI = 0.985, AGFI = 0.967, NFI = 0.982, IFI = 0.989, CFI = 0.989, and RMSEA = 0.048. The Cronbach's alpha coefficient for the scale was 0.872, and it was 0.833 for peripheral fatigue and 0.818 for central fatigue. The intra-class correlation coefficient for the scale was 0.536, and the intra-class correlation coefficients for peripheral fatigue and central fatigue were 0.421 and 0.548, respectively. The correlation coefficient between the total score of the AEIFS and the SFSA score was 0.592 (p < 0.01).

Conclusion

Our results demonstrate that the AEIFS can distinguish peripheral fatigue and central fatigue and can also reflect their correlation. This scale can be a useful evaluation tool not only for measuring fatigue after acute exercise but also for guiding reasonable exercise, choosing objective testing indicators, and preventing sports injuries resulting from acute exercise-induced fatigue.

Fatigue Is Not Associated With Objective Assessments of Inflammation During Tocilizumab Treatment of Patients With Rheumatoid Arthritis

Objective

In patients with rheumatoid arthritis (RA), the relation between fatigue and disease activity is not established, and our objective was to explore in post hoc analyses the associations between fatigue and subjective as well as objective assessments of inflammation during follow‐up of patients with RA initiating biologic treatment.

Methods

In a Nordic multicenter study, patients with RA starting tocilizumab were examined for fatigue (Functional Assessment of Chronic Illness Therapy–Fatigue sum score) as well as patient‐reported outcome measures (PROMs) (patient's global disease activity, joint pain, and Health Assessment Questionnaire Disability Index), clinical examinations (examiner's global disease activity, 28 tender/swollen joint counts), laboratory variables (erythrocyte sedimentation rate, C‐reactive protein), and ultrasound assessments (semiquantitative scoring [0‐3]) of gray scale and Doppler of 36 joints and 4 tendons) at baseline and 4, 12, and 24 weeks. The associations were explored by using nonparametric tests, including the Wilcoxon rank test, the Mann–Whitney U test, Spearman correlations, and a linear regression and linear mixed model.

Results

One hundred ten patients were included (83% female, mean [SD] age 55.6 [12.1] years, mean [SD] RA duration 8.7 [9.5] years, 81% anti–cyclic citrullinated peptide positive). Fatigue, PROMs, and clinical, laboratory, and ultrasound variables all decreased significantly during follow‐up, already at 4 weeks (P < 0.001). Fatigue was both cross‐sectionally and longitudinally associated with PROMs, whereas there were no or low associations with clinical, laboratory, or ultrasound assessments of inflammation. Baseline fatigue was predictive of PROMs at 12 and 24 weeks (P < 0.05 and P < 0.001, respectively) but not of any objective assessments.

Conclusion

Fatigue was primarily associated with subjective assessments of disease activity. Thus, the present study supports fatigue to reflect other aspects of RA disease activity than inflammation.

Fatigue in inflammatory rheumatic diseases: current knowledge and areas for future research

Fatigue is a complex phenomenon and an important health concern for many people with chronic inflammatory rheumatic diseases, such as rheumatoid arthritis, psoriatic arthritis, primary Sjögren syndrome and systemic lupus erythematosus. Although some clinical trials have shown the benefits of cognitive behavioural therapy in fatigue management, the effect of this approach is relatively modest, and no curative treatment has been identified. The pathogenesis of fatigue remains unclear. Despite many challenges and limitations, a growing body of research points to roles for the immune system, the central and autonomic nervous systems and the neuroendocrine system in the induction and maintenance of fatigue in chronic diseases. New insights indicate that sleep, genetic susceptibility, metabolic disturbances and other biological and physiological mechanisms contribute to fatigue. Furthermore, understanding of the relationships between psychosocial factors and fatigue is increasing. However, the interrelationships between these diverse mechanisms and fatigue remain poorly defined. In this Review, we outline various biological, physiological and psychosocial determinants of fatigue in inflammatory rheumatic diseases, and propose mechanistic and conceptual models of fatigue to summarize current understanding, stimulate debate and develop further research ideas.

Systemic effects of IL-6 blockade in rheumatoid arthritis beyond the joints

Interleukin (IL)-6 is produced locally in response to an inflammatory stimulus, and is able to induce systemic manifestations at distance from the site of inflammation. Its unique signaling mechanism, including classical and trans-signaling pathways, leads to a major expansion in the number of cell types responding to IL-6. This pleiotropic cytokine is a key factor in the pathogenesis of rheumatoid arthritis (RA) and is involved in many extra-articular manifestations that accompany the disease. Thus, IL-6 blockade is associated with various biological effects beyond the joints. In this review, the systemic effects of IL-6 in RA comorbidities and the consequences of its blockade will be discussed, including anemia of chronic disease, cardiovascular risks, bone and muscle functions, and neuro-psychological manifestations.

The effect of progressive muscle relaxation on sleep quality and fatigue in patients with rheumatoid arthritis: A randomized controlled trial

AIMS

The aim of this study was to investigate the effects of progressive muscle relaxation on sleep quality and fatigue in patients with rheumatoid arthritis.

METHODS

This randomized controlled study was conducted with 72 patients with rheumatoid arthritis who applied to the rheumatology outpatient clinic of a university hospital between January and May 2018. The data were collected using the Patient Information Form, Pittsburgh Sleep Quality Index and Fatigue Severity Scale. After the patients in the intervention group completed the forms, patients were given training with regard to the application of progressive muscle relaxation which they subsequently performed, and the Pittsburgh Sleep Quality Index and Fatigue Severity Scale forms were repeated after 6 weeks.

RESULTS

After performing progressive muscle relaxation for 6 weeks, the total score of the Pittsburgh Sleep Quality Index and the fatigue score decreased among patients in the intervention group; no change was observed among the patients in the control group. A statistical difference was found between the two groups in terms of the Pittsburgh Sleep Quality Index's and Fatigue Severity Scale's mean scores.

CONCLUSION

Progressive muscle relaxation can be recommended to enhanced sleep quality and reduce fatigue in patients with rheumatoid arthritis.

PLD1 knockdown reduces metastasis and inflammation of fibroblast-like synoviocytes in rheumatoid arthritis by modulating NF-κB and Wnt/β-catenin pathways

Considered as an autoimmune disease, rheumatoid arthritis (RA) is an chronic inflammatory disorder that causes inflammation of the joints. This study is performed with the aim to clarify the expression of phospholipase D1 (PLD1) in RA and its specific regulation role of RA as well as the underlying mechanisms. In this study, synovial tissue samples were collected from RA patients, and RA-fibroblast-like synoviocytes (FLSs) were subsequently isolated. The expression levels of PLD1 and pathway-related proteins were detected by quantitative reverse transcription polymerase chain reaction (qRT-PCR), western blotting or immunohistochemistry (IHC). Upon shPLD1 treatment, cell viability, proliferation, migration, invasion, and the level of inflammation-related factors were measured by Cell Counting Kit-8 (CCK-8), Edu, wound healing, Transwell and enzyme-linked immunosorbent assay (ELISA). Furthermore, C-reactive protein (CRP), rheumatoid factor (RF), arthritis score and synovial tissue lesions were assessed by collecting the blood or tissues from collagen induced arthritis (CIA) model rats. Our results showed that PLD1 level was increased in RA synovial tissues. Cell viability, proliferation, migration, invasion, and the level of inflammatory factors were reduced upon PLD1 knockdown in RA-FLSs. Moreover, p-IκBα/IκBα, β-catenin, p-IKKβ/IKKβ and TCF-4 were inhibited under PLD1 knockdown treatment. PLD1 knockdown alleviated the collagen-induced addition of arthritis score, CRP and RF, as well as the filling of inflammatory cells and proliferation of synovium in CIA model rat. To sum up, knockdown of PLD1 could reduce RA-FLSs metastasis as well as inflammatory response by modulating the activity of NF-κB and Wnt/β-catenin pathways.

Fatigue in Systemic Lupus Erythematosus and Rheumatoid Arthritis: A Comparison of Mechanisms, Measures and Management

Fatigue is a common constitutional feature of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). While the two diseases share a common mechanism of autoimmunity, they differ in their clinical manifestations and treatment. Fatigue is one of the most commonly reported symptoms in both groups, associated with pain, depression and anxiety, and affecting function, work and quality of life. Fatigue is not easy to assess or conceptualise. It can be linked to disease activity, although it is not always, and is challenging to treat. Several measures have been trialled in RA and SLE; however, none have been adopted into mainstream practice. Despite being a common symptom, fatigue remains poorly managed in both RA and SLE—more so in the latter, where there have been relatively fewer studies. Additionally, comorbidities contribute to fatigue, further complicating its management. Pain, depression and anxiety also need to be addressed, not as separate entities, but together with fatigue in a holistic manner. Here, we describe the similarities and differences between fatigue in patients with RA and SLE, discuss concepts and practices applicable to both conditions and identify areas for further research. Through this review, we aim to highlight the importance of the holistic management of fatigue in SLE.

Fatigue in patients with early rheumatoid arthritis undergoing treat-to-target therapy: predictors and response to treatment

Objectives

Fatigue is a frequent symptom in rheumatoid arthritis (RA) and has high impact on quality of life. We explored associations between disease activity and fatigue in patients with early RA during the initial 24 months of modern treat-to-target therapy and predictors of fatigue after 24 months of follow-up.

Methods

Data were obtained from the treat-to-target, tight control Aiming for Remission in Rheumatoid Arthritis: a Randomised Trial Examining the Benefit of Ultrasound in a Clinical Tight Control Regime (ARCTIC) trial. Fatigue was measured on a visual analogue scale (VAS) from 0 to 100 mm and defined as clinically relevant if VAS was ≥20 mm. Baseline predictors of fatigue at 24 months were analysed by multivariable logistic regression.

Results

205 patients with fatigue data at baseline and 24 months were included. Median (25th, 75th percentiles) symptom duration was 5.4 months (2.8, 10.4), fatigue VAS 37.0 mm (13.0, 62.0) and mean Disease Activity Score (DAS) 3.4 (SD 1.1) at baseline. Prevalence of fatigue declined from 69% at baseline to 38% at 24 months. Fewer swollen joints (OR 0.92, 95% CI 0.87 to 0.98, p=0.006), lower power Doppler ultrasound score (OR 0.95, 95% CI 0.90 to 0.99, p=0.027) and higher patient global assessment (PGA) (OR 1.03, 95% CI 1.01 to 1.04, p<0.001) increased the risk of clinically relevant fatigue at 24 months. Not achieving remission at 6 months was associated with a higher risk of reporting fatigue at 24 months.

Conclusions

Fatigue in patients with early RA was prevalent at disease onset, with a rapid and sustained reduction during treatment. Low objective disease activity and high PGA at baseline were predictors of clinically relevant fatigue at 24 months.

Central Aspects of Pain in Rheumatoid Arthritis (CAP-RA): protocol for a prospective observational study

BACKGROUND

Pain and fatigue are persistent problems in people with rheumatoid arthritis. Central sensitisation (CS) may contribute to pain and fatigue, even when treatment has controlled inflammatory disease. This study aims to validate a self-report 8-item questionnaire, the Central Aspects of Pain in Rheumatoid Arthritis (CAP-RA) questionnaire, developed to measure central pain mechanisms in RA, and to predict patient outcomes and response to treatment. A secondary objective is to explore mechanisms linking CS, pain and fatigue in people with RA.

METHODS/DESIGN

This is a prospective observational cohort study recruiting 250 adults with active RA in secondary care. The CAP-RA questionnaire, demographic data, medical history, and patient reported outcome measures (PROMs) of traits associated with central sensitization will be collected using validated questionnaires. Quantitative sensory testing modalities of pressure pain detection thresholds, temporal summation and conditioned pain modulation will be indices of central sensitization, and blood markers, swollen joints and ultrasound scans will be indices of inflammation. Primary data collection will be at baseline and 12 weeks. The test-retest reliability of CAP-RA questionnaire will be determined 1 week after the baseline visit. Pain and fatigue data will be collected weekly via text messages for 12 weeks. CAP-RA psychometric properties, and predictive validity for outcomes at 3 months will be evaluated.

DISCUSSION

This study will validate a simple self-report questionnaire against psychophysical indices of central sensitization and patient reported outcome measures of traits associated with CS in a population of individuals with active RA. The application of this instrument in the clinical environment could provide a mechanism-based stratification tool to facilitate the provision of targeted therapy to individuals with pain and fatigue in RA, alongside treatments that target joint inflammation.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04515589 . Date of registration 17 August 2020.

Influence of successful psychopharmacotherapy of anxiety-depressive spectrum disorders on the severity of chronic fatigue in patients with rheumatoid arthritis

Aim. To assess the influence of psychopharmacotherapy (PPT) of anxiety and depressive disorders on fatigue severity in patients with rheumatoid arthritis (RA). Materials and methods. 128 RA-patients were included. Severity of fatigue was measured with fatigue severity scale (FSS), clinically important fatigue was diagnosed in patients with FSS4. Anxiety and depressive disorders (ADD) were diagnosed by a licensed psychiatrist in 123 (96.1%) of RA-patients in accordance with ICD-10 in semi-structured interview. Severity of depression and anxiety was evaluated with MontgomeryAsberg Depression Rating Scale (MADRS) and Hamilton Anxiety Rating Scale (HAM-A). RA-patients with ADD were divided into the following treatment groups: 1 сDMARDs (n=39), 2 сDMARDs+PPT (sertraline or mianserine), n=43, 3 сDMARDs+bDMARDs (n=32), 4 сDMARDs+bDMARDs+PPT (sertraline or mianserine), n=9. Biologics treatment duration varied from 1 to 5 years, antidepressants from 6 to 96 weeks. 83 (67.5%) RA patients were assessed at five-years follow-up. Multinominal logistic regression analysis was conducted to determine factors associated with clinically important fatigue. Results. Multinominal logistic regression analysis showed clinically important fatigue at baseline to be positively associated (OR 13.57; 95% CI 3.04460.486; p=0.01) and remission of ADD negatively associated (OR 0.162; 95% CI 0.0320.809; p=0.027), with clinically important fatigue at 5 years follow-up (R2=0.385, p0.0001). Conclusion. Due to significant relationship between mental health status, antidepressants treatment and clinically important fatigue in RA-patients, all patients reporting clinically important fatigue should be recommended mental health counselling by a licensed psychiatrist.

The characteristics and its contributing factors of refractory rheumatoid arthritis, view of the rheumatologists of China: results of a nationwide cross-sectional survey

OBJECTIVE

To explore the characteristics of refractory RA and its contributory factors based on the understanding of the rheumatologists of China.

METHODS

A national cross-sectional survey was performed in 32 provinces across China, and 1381 rheumatologists were recruited. Information about the sociodemographic background, refractory RA characteristics, and contributory factors was collected using a pre-made questionnaire including fourteen single-choice and four multiple-choice questions, respectively. Each of the single-choice and multiple-choice question had several items.

RESULTS

In response to the single-choice questions regarding the definition of refractory RA, 52.28% responded that "the 28 joint disease activity score-erythrocyte sedimentation rate (DAS28-ESR) > 5.1 with presence of signs suggestive of inflammatory disease" is characteristic of refractory RA, whereas 50.18% opined that "If target was not achieved with 2 conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) combined with 1 biological or 1 targeted synthetic DMARD (b/tsDMARD), over a total of 3~6 months" should be considered refractory RA. In addition, 39.32% rheumatologists were in favor of inability to taper glucocorticoids (GCs) ≤ 10mg prednisone or equivalent daily. Additional features considered characteristics of refractory RA were extra-articular manifestations (84.94%), interfering comorbidities (76.32%), and radiographic progression (71.83%). Among the contributory factors, 92.03% considered infection, and interstitial lung disease was chosen by 90.95%, vasculitis by 82.26%, osteoporosis by 70.67%, and fibromyalgia syndrome by 70.38%.

CONCLUSIONS

Our survey has demonstrated a variety of concepts of refractory RA among the rheumatologists of China. Disease activity assessment, treatment options, interfering comorbidities, and radiological progression all were associated with the characteristics of refractory RA. Key Points • This study demonstrated the definition, characteristics, and contributing factors of refractory RA from the rheumatologists' views in China. • The clarification of the insights and concepts on refractory RA will help to make comprehensive guidelines to treat this disease, further improving prognosis and reducing the societal burdens of RA.

Fatigue assessment by FACIT-F scale in Pakistani cohort with Rheumatoid Arthritis (FAF-RA) study

Objective:

To fine out fatigue frequency and severity by FACIT-F scale in Pakistani cohort with rheumatoid arthritis.

Methods:

This study was conducted at department of Medicine division of rheumatology CPMC Lahore. After the approval of IRB, 192 patients of RA were recruited. Written, informed consent was taken, demographic details were noted, patients filled the URDU version of FACIT-F (fatigue severity scale). 5-ml of blood was taken for fasting blood sugar, viral markers and ESR by a trained phlebotomist. Each individual’s disease activity was assessed by DAS-28 and FACIT-F score was calculated.

Results:

The Mean age (39.9±10.5) years, (71.9%) were females. Fatigue frequency was 62% (n=126), age, education, hypertension, DAS-28, exercise levels and HCV gives significant association with fatigue score. Linear regression analysis, results showed one unit increase in DAS-28 will gives 2.71 unit increases in fatigue scores(P <0.05).

Conclusions:

We have very high frequency of fatigue in RA, increases with disease activity & associated conditions.

Factors associated with fatigue in hip and/or knee osteoarthritis: a systematic review and best evidence synthesis

Objective

The aim was systematically to identify and evaluate factors related to fatigue in individuals with hip and/or knee OA.

Methods

A systematic literature search was conducted using AMED, CINAHL, MEDLINE, ProQuest and Web of Science Core Collections databases. Inclusion criteria comprised cross-sectional, case–control or longitudinal studies on patients with a diagnosis of hip and/or knee OA that included self-reported fatigue measures. Study quality was assessed using the National Heart, Lung and Blood Institute quality appraisal tool, and factors were synthesized within a bio-behavioural framework. Study designs and quality were combined to determine current evidence levels using best evidence synthesis grading. The full review protocol is available from PROSPERO (PROSPERO 2019: CRD42019138571).

Results

Twenty-four studies were included, of which 19 were high, 4 moderate and 1 low quality. There was strong evidence of an association between poor self-reported physical function and high depressive symptoms with higher fatigue. Moderate evidence of an association was found between severe pain, high numbers of co-morbidities and low physical activity levels with higher fatigue. There was moderate or limited evidence of no association between most sociodemographic factors and radiographic OA severity with fatigue.

Conclusion

Targets for fatigue management might include improving physical function, reducing depressive symptoms, pain and co-morbidities, and increasing physical activity levels. There is a need for more rigorous longitudinal studies to understand the causal effect of fatigue determinants within the hip and knee OA populations.

Exploring the Prevalence and Factors Associated With Fatigue in Axial Spondyloarthritis in an Asian Cohort in Singapore

Aim: To evaluate the prevalence of fatigue and the factors associated with fatigue among patients with axial spondyloarthritis (axSpA) within an Asian population.

Method: We used the baseline data from a clinic registry in a tertiary referral center. All patients fulfilled the 2009 Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axSpA. Severe fatigue was defined as Bath Ankylosing Spondylitis Disease Activity Index-fatigue (BASDAI-fatigue) ≥5/10 and vitality domain of Short Form-36 Health Survey (SF-36 VT) ≤10th percentile of the general population.

Results: We included 262 consecutive patients with axSpA (79% men, 82.4% Chinese). The mean (standard deviation, SD) age and duration of disease were 41.7 (13.7) and 10.1 (8.3) years, respectively. 145 (55.3%) and 52 (31.1%) patients reported severe fatigue by the BASDAI-fatigue and SF-36 VT criteria, respectively. Patients with severe fatigue had worse scores across all disease activity assessments and disease impact measures compared to those without severe fatigue. Using principal component analyses, disease activity and impact were associated with BASDAI-fatigue, while disease activity and impact, and disease chronicity were associated with SF-36 VT. In the univariable analyses, all disease activity assessments and disease impact measures correlated with both BASDAI-fatigue and SF-36 VT. In the multivariable analyses, BASDAI-axial pain, BASFI, BAS-G, and ethnicity were associated with BASDAI-fatigue, while ASQoL and BASDAI-morning stiffness were associated with SF-36 VT.

Conclusion: Fatigue is prevalent amongst patients with axSpA in Asia and is associated with disease activity, disease impact as well as patient related factors.

Understanding Refractory Rheumatoid Arthritis: Implications for a Therapeutic Approach

Refractory rheumatoid arthritis (RA) has emerged as an area of unmet need in a landscape of generally well-controlled disease. Whilst most patients are adequately treated on methotrexate and other first-line disease-modifying anti-rheumatic drugs (DMARDs), a proportion requires biologic (b) and targeted synthetic (ts) DMARDs, with a further subsection failing multiple agents. Recent observational studies have adopted working definitions of refractory RA based on number of failed DMARDs, with prevalence estimates of 6-21% depending on threshold and study population. Risk factors include treatment delay, baseline disease activity and function, female gender, smoking, obesity and lower socioeconomic status. Practical and conceptual challenges in defining refractory RA arise from limitations of disease activity scores used to assess response, with attendant misclassification risk of co-existent non-inflammatory pathology, and failure to capture additional outcomes, such as fatigue, that have variable treatment response. Time is an important factor in defining refractory disease; registry studies show that growing treatment options have resulted in rapid b/tsDMARD cycling and earlier refractory status, and refractory RA is itself a dynamic concept, evolving with each new therapeutic class. Whilst the biology underpinning refractory RA remains largely unknown, a general overview of biomarker studies and clinical trials old and new offers insights into prediction of response and treatment failure. Whilst the future holds promise, current data are insufficient to personalise or meaningfully sequence b/tsDMARDs. Therefore, avoidance of a refractory course is best achieved by following proven management paradigms (e.g. early diagnosis and treat-to-target), addressing modifiable risk factors, and considering enrolment in novel trials.

Measuring fatigue: a meta-review

There is a lack of validated tools to measure fatigue in patients with inflammatory skin, neuropsychiatric, and medical disorders. The use of nonvalidated tools may compromise the quality of data. The purpose of this meta-review was to evaluate existing fatigue scales commonly used to assess fatigue in other inflammatory conditions and to identify if there are scales that have been validated in dermatologic conditions. The PubMed/MEDLINE and SCOPUS databases were systematically searched from inception through March 10, 2020, in accordance with the PRISMA statement. Validated tools were identified and assessed according to their main measurement properties. The literature search identified 403 references, and eight studies were eligible and assessed in this review. The unidimensional fatigue scales included were the Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F), Brief Fatigue Inventory, Fatigue Severity Scale, Numerical Rating Scale - Fatigue, and Visual Analog Scale - Fatigue. The multidimensional fatigue scales found were the Checklist Individual Strength, Chalder Fatigue Scale, Multidimensional Assessment of Fatigue, Multidimensional Fatigue Inventory Scale, and Piper Fatigue Scale. To measure fatigue, a brief scale with the ability to detect change is needed as there is a growing interest in evaluating this dimension of treatment response. In addition, a good content validity is also needed. From this systematic review, none of the selected scales have had content validation, even though the FACIT was validated in patients with psoriatic arthritis. Validation studies in specific disorders are urgently warranted.

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

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 2009/1254

Key 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.