Assessment of fatigue in rheumatoid arthritis (by Functional Assessment of Chronic Illness Therapy-Fatigue score) and its relation to disease activity and anemia

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.

Development and validation of an ama instrument for assessing the disease activity on the basis of constitutional features in Amavata (Rheumatoid Arthritis)

BACKGROUND

Rheumatoid Arthritis (RA), having a striking clinical resemblance to amavata in traditional Indian medicine (Ayurveda) presents an opportunity to look at disease from two different healthcare perspectives. This differential information may potentially supplement one system with the knowledge of the other for optimal application. This study is the first of its kind, where Ayurvedic concepts of amavata have been adopted to enhance the knowledge about RA where optimal care is still beyond the common reach.

OBJECTIVE

The study was conducted to develop and validate a novel ama score based upon constitutional features of ama as depicted in ayurvedic literature as a disease activity indicator in RA.

MATERIAL AND METHODS

The study was conducted in two parts comprising development and textual validation of the ama assessment instrument (AAI) followed by its clinical testing. AAI comprising ten items, was developed where each item was provided with a range of scores to offer the assessment close to the patient's observations. The score obtained through AAI was clinically and statistically tested on 79 RA/amavata patients randomly selected for validity and reliability. The score obtained through AAI was tested for its correlation with the DAS-28 score and ESR.

RESULTS

Ama Assessment Instrument could find a slight correlation with acute phase reactant ESR (r-value between ESR and AMA at baseline is 0.287, and at 1st, 2nd, and 3rd follow-up is 0.276, 0.276 and 0.160 respectively) and DAS-28 (The r value between DAS and AMA at baseline is 0.231, and at 1st, 2nd and 3rd follow up is 0.218, 0.201 and 0.247 respectively). It however emerged as an independent disease status marker since it could mark the changes in the study population on a time scale more precisely as compared to DAS -28 or ESR. When the ama values at different follow-ups were compared, a significant difference was observed consistent with disease activity marker catching constitutional and GI related domain of the patients. When reducing values of ama score were compared to overall improvements as reported by the patients, a similar trend was observed showing that a change in ama score is reflective of a change in disease status and the impact of the disease on the patient.

CONCLUSION

This study provided a quantitative measure for the abstract concept of ama which could be used to mark the disease activity in amavata or RA. The change in ama based scores can be used to assess disease status and the intervention related benefits. The observations prompt for the possible inclusion of AAI in RA composite score to make it more dynamic in terms of disease activity identification in RA.

A non-invasive machine learning mechanism for early disease recognition on Twitter: The case of anemia

Social media sites, such as Twitter, provide the means for users to share their stories, feelings, and health conditions during the disease course. Anemia, the most common type of blood disorder, is recognized as a major public health problem all over the world. Yet very few studies have explored the potential of recognizing anemia from online posts. This study proposed a novel mechanism for recognizing anemia based on the associations between disease symptoms and patients' emotions posted on the Twitter platform. We used k-means and Latent Dirichlet Allocation (LDA) algorithms to group similar tweets and to identify hidden disease topics. Both disease emotions and symptoms were mapped using the Apriori algorithm. The proposed approach was evaluated using a number of classifiers. A higher prediction accuracy of 98.96 % was achieved using Sequential Minimal Optimization (SMO). The results revealed that fear and sadness emotions are dominant among anemic patients. The proposed mechanism is the first of its kind to diagnose anemia using textual information posted on social media sites. It can advance the development of intelligent health monitoring systems and clinical decision-support systems.

The Assessment of Fatigue in Rheumatoid Arthritis Patients and Its Impact on Their Quality of Life

Introduction: Rheumatoid arthritis (RA) is a common autoimmune illness that manifests mostly as chronic, symmetric, and progressive polyarthritis with a global frequency of 0.3−1.0%. RA is a disease that affects people all over the world. In India, the prevalence is estimated to be 0.7%, with around 10 million persons suffering from RA. Most people with rheumatoid arthritis experience fatigue on most days, with over 70% experiencing symptoms similar to chronic fatigue syndrome. Patients rate fatigue as a top priority and believe this unmanageable symptom is ignored by clinicians; a systematic review shows the biological agents for RA inflammation have only a small effect on fatigue. Fatigue predicts and reduces the quality of life, and it is as difficult to cope with as pain. Physicians have traditionally concentrated on the inflammatory aspects of the illness (e.g., synovitis), whereas RA patients have prioritized pain, exhaustion, sleep difficulties, and other quality-of-life issues. Aims and Objectives: The basic aim of the study was to access the incidence of fatigue in rheumatoid arthritis and evaluate its impact on the quality of life in these patients using the MAF scale (multidimensional assessment of fatigue) after prior permission for the first time in an Asian population. Results: A total of 140 subjects and 100 controls were included in the study. Age was closely matched between the study subjects and controls. Among study subjects with the disease, 94 (67%) had a disease duration ≤ 5 years, 26 (19%) had a disease duration between 6−10 years, 10 (7%) had a duration of 11−15 years and 10 (7%) had >10 years disease duration. Among the sample, 31 (25%) study subjects had a DAS score ≤ 4.0, 63 (50%) study subjects had a DAS score (disease activity score) between 4.01 and 6.0, and in the remaining 31 (25%) study subjects, the DAS score was >6.0. The mean DAS score among study subjects was 4.96, and the study subjects had a mean activity of daily living (ADL) score of 11.64; controls had a mean score of 2.42 with a statistically significant p-value. The global fatigue index was higher in study subjects, with a mean of 33.16 in contrast with a mean of 14.41 in the controls with a significant p-value. Conclusion: Our study fatigue was a persistent problem, despite treatment. The median level of fatigue experienced by study subjects with RA was high. Therefore, as persistent fatigue is associated with functional loss, fatigue in RA remains an ‘unmet need’ and continues to be ignored by clinicians.

Factors influencing the Sharp score of 1057 patients with rheumatoid arthritis and anemia: a retrospective study

Objective

This study examined the relationship of the Sharp score with demographic factors and clinical immune-inflammatory markers in patients with anemia in rheumatoid arthritis (RA).

Methods

The clinical data of 1057 patients with RA and anemia and 1006 patients with RA without anemia were retrospectively analyzed. Spearman’s correlation coefficient analysis, association rule analysis, and logistic regression were used to study the relationships between the Sharp score and influencing factors in patients with RA and anemia.

Results

The incidence of anemia was 51.24% (1057/2063), and mild anemia accounted for 81.93% (866/1057) of cases. Spearman’s correlation coefficient and association rule analyses revealed that the Sharp score of patients with RA and anemia was correlated with immune-inflammatory response and anemia. Logistic regression analysis illustrated that advanced age (>60 years), female, low serum iron levels, C-reactive protein positivity, and immunoglobulin A positivity were risk factors for a high Sharp score (>28.25) in patients with RA and anemia.

Conclusion

The Sharp score is closely related to clinical disease activity and anemia, and it should be considered in the treatment strategy of patients with RA and anemia.

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.

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.

Relationship between disease activity level and physical activity in rheumatoid arthritis using a triaxial accelerometer and self-reported questionnaire

Objective

This study evaluated the relationship between rheumatoid arthritis (RA) disease activity level and physical activity (PA) by using an accelerometer and self-reported questionnaire.

Results

The cross-sectional study was part of a cohort study designed to determine disease activity is associated with PA in RA patients. We classified patients with a Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR) of less than and higher than 3.2 into the low-disease-activity (LDA) group and moderate/high-disease-activity (MHDA) group, respectively. We measured the wear time, time of vigorous-intensity PA, moderate-intensity PA, light-intensity PA, and sedentary behavior per day using a triaxial accelerometer. 34 patients were included in the study. The accelerometer-measured moderate-to-vigorous PA (MVPA) was 17.2 min/day and 10.6 min/day in the LDA group and MHDA group (p < 0.05), respectively. There was no significant association between RA disease activity level and accelerometer-measured PA with adjustment for age and Functional Assessment of Chronic Illness Therapy-Fatigue score. There was no correlation between accelerometer-measured MVPA and self-reported MVPA in the MHDA group, but these factors were correlated in the LDA group (rs = 0.57, p < 0.05). In conclusion, no significant association was noted between RA disease activity level and accelerometer-measured PA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05666-w.

Skeletal muscle redox signaling in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by synovitis and the presence of serum autoantibodies. In addition, skeletal muscle weakness is a common comorbidity that contributes to inability to work and reduced quality of life. Loss in muscle mass cannot alone account for the muscle weakness induced by RA, but instead intramuscular dysfunction appears as a critical factor underlying the decreased force generating capacity for patients afflicted by arthritis. Oxidative stress and associated oxidative post-translational modifications have been shown to contribute to RA-induced muscle weakness in animal models of arthritis and patients with RA. However, it is still unclear how and which sources of reactive oxygen and nitrogen species (ROS/RNS) that are involved in the oxidative stress that drives the progression toward decreased muscle function in RA. Nevertheless, mitochondria, NADPH oxidases (NOX), nitric oxide synthases (NOS) and phospholipases (PLA) have all been associated with increased ROS/RNS production in RA-induced muscle weakness. In this review, we aim to cover potential ROS sources and underlying mechanisms of oxidative stress and loss of force production in RA. We also addressed the use of antioxidants and exercise as potential tools to counteract oxidative stress and skeletal muscle weakness.

Prevalence and severity of fatigue in psoriasis and psoriatic arthritis

Introduction

Fatigue is an important and underrated symptom of many chronic diseases.

Aim

The evaluation of incidence and severity of fatigue as well as the influence of selected factors on fatigue in patients with psoriasis and psoriatic arthritis (PsA).

Material and methods

The study included 60 patients with PsA, 58 patients with psoriasis and 61 persons in the control group aged 35-70 years. Assessment of fatigue was conducted using a fatigue subscale from the FACIT-F questionnaire. Severity of skin lesions and arthritis was determined with PASI and DAS28, respectively, as well as the number of painful and swollen joints, severity of pain and inflammatory markers.

Results

Severe fatigue occurred in 17%, 28%, and 1.6% of patients with psoriasis, PsA and the control group, respectively. Severity of fatigue was significantly higher in patients with PsA as compared to patients with psoriasis (p < 0.0001). In patients with psoriasis and PsA, it decreased along with the duration of psoriasis (r = 0.291, p < 0.05 vs. r = 0.382, p < 0.05, respectively). No significant correlation was found between the duration of PsA and fatigue. After using the linear regression model, severity of fatigue in psoriasis was correlated with the age of patients and the duration of psoriasis, while in PsA, with the duration of psoriasis, PASI, DAS28, CRP and the number of painful joints.

Conclusions

The results of this study may indicate the need for routine fatigue examination among people with psoriasis and psoriatic arthritis.

The Social Context of Sedentary Behaviors and Their Relationships With Health in Later Life

This study examined sedentary behaviors among older adults and explored associations with social context and health measures using cross-sectional data from the National Health and Aging Trends Study (N = 1,687). Multivariate models were estimated to explore associations of time in six sedentary behaviors (i.e., television watching, sitting and talking, hobbies, computer use, driving, and resting) with sociodemographic characteristics and level of social engagement and with health status. Results indicated substantial variability in sedentary behaviors, with television watching being the most frequent and resting the least frequent activities. Sedentary behaviors varied by sociodemographic characteristics, including age, race/ethnicity, and education, as well as by level of social engagement. Television watching and resting, but not other behaviors, were associated with poorer health. These findings help to unpack the role of social context in sedentary behaviors and could inform public health interventions aimed at reducing time spent in behaviors that are adversely associated with health.

Severity of fatigue in people with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis - Results of a cross-sectional study

BACKGROUND

Despite improvements in treatment for rheumatoid arthritis (RA), psoriatic arthritis (PsA) and spondyloarthritis (axSpA), several key unmet needs remain, such as fatigue. The objective of this study was to describe the severity of fatigue, disease characteristics and socioeconomic factors in people with RA, PsA and axSpA.

METHODS

The study was designed as a cross-sectional survey collecting patient characteristics such as disease characteristics, socioeconomic factors and fatigue in people with RA, PsA and axSpA in Denmark. Respondents were consecutively recruited for the study over a six-month period in 2018 via routine visits to outpatient rheumatology clinics. Study nurses collected information on diagnosis, current disease-related treatment and disease activity from medical journals. People were invited to complete a questionnaire related to socioeconomic factors and containing the FACIT-Fatigue subscale. Descriptive statistics were analyzed using SAS.

RESULTS

We invited 633 people to participate, and 488 (77%) completed the questionnaire. Women constituted 62% of respondents, and the mean age was 53.5 years. Respondents had on average been diagnosed between 11 and 15 years ago. Overall, 79% had no changes to their disease-related treatment during the past year, and the average disease activity as indicated by DAS28 for RA and PsA was 2.48 and 2.36, respectively, and BASDAI for axSpA was 28.40. Fatigue was present in all three diagnoses (mean: 34.31). The mean fatigue score varied from respondents answering that they suffered from no or little fatigue (mean: 45.48) to extreme fatigue (mean: 10.11). Analyses demonstrated that the respondents were not considerably different from nonrespondents, and the study population is considered representative compared with Danish RA and axSpA patients in the Danish National Rheumatology Registry, the DANBIO database.

CONCLUSION

We found that the majority of the study population were fatigued (61%). They had low disease activity and few disease-related treatment changes.

Correlation of fatigue with other disease related and psychosocial factors in patients with rheumatoid arthritis treated with tocilizumab: ACT-AXIS study

To assess the hypothesis if tocilizumab (TCZ) is effective on disease activity, and also its effect in fatigue and other clinical and psychological disease-related factors in patients with rheumatoid arthritis (RA) treated with TCZ.A 24-week, multicenter, prospective, observational study in patients with moderate to severe RA receiving TCZ after failure or intolerance to disease-modifying antirheumatic drugs or tumor necrosis factor-alpha was conducted.Of the 122 patients included, 85 were evaluable for effectiveness (85% female, 51.9 ± 12.5 years, disease duration 8.7 ± 7.4 years). Mean change in C-reactive protein level from baseline to week 12 was -11.2 ± 4.0 (P < .001). Mean Disease Activity Index score (DAS28) decreased from 5.5 ± 1.0 at baseline to 2.7 ± 1.3 (P < .001) at week 24. Mean change in Functional Assessment of Chronic Illness Therapy score was -5.4 ± 11.2 points at week 24. Multiple regression analysis showed that the improvement in DAS28, sleep, and depression explained 56% and 47% of fatigue variance at week 12 and 24, respectively.Tocilizumab is effective in reducing disease activity and results in a clinically significant improvement in fatigue, pain, swollen joint count, morning stiffness, sleepiness, depression, and DAS28; the last 3 were specifically identified as factors explaining fatigue variance with the use of TCZ in RA patients.

Call for action: how to improve use of patient-reported outcomes to guide clinical decision making in rheumatoid arthritis

Current guidelines for the management of rheumatoid arthritis (RA) recommend early treatment and a treat-to-target goal of remission or low disease activity. Over the past decade, this approach has been extremely successful in reducing disease activity and joint damage in patients with RA. At the same time, however, overall patient perception of well-being appears to have decreased with respect to outcome measures considered important by patients themselves, such as pain, fatigue, physical function and quality of life. The timely and effective use of patient-reported outcomes (PROs) could encourage physicians to focus more on the impact of RA on patients and how patients are feeling. This in turn would facilitate shared decision making between patients and physicians, ultimately leading to a more patient-centered approach and improved patient care. Indeed, PROs provide information about individual patients that complements information provided by physical assessment and composite scores, and can also be used to guide patient care, such as determining whether a clinic visit is needed or whether treatment modifications are necessary. This is particularly important for patients who do not achieve the aspirational target of remission or low disease activity with pharmacological treatment. A number of validated PRO questionnaires are available, but how and which PROs should be incorporated into rheumatology clinical practice as part of the decision-making process is still controversial. Combining PROs with technology, such as computer adaptive tests, electronic PRO systems, web-based platforms and patient dashboards, could further aid PRO integration into daily rheumatology clinical practice.

Fatigue in Rheumatoid Arthritis

PURPOSE OF REVIEW

The purpose of this study was to review the current information on fatigue in rheumatoid arthritis (RA).

RECENT FINDINGS

Severe fatigue is common among individuals with RA and has a significant impact on quality of life (QOL). RA-related factors (e.g., inflammation, pain) are associated with greater fatigue, but other factors, such as obesity, physical inactivity, sleep disturbance, and depression, explain the majority of variation in fatigue. Medications targeting RA have little effect on fatigue. Instead, the most effective interventions seem to address non-RA-specific factors such as physical inactivity or use cognitive behavioral approaches. No recommendations have been made for tools to measure fatigue in RA, leading to potential difficulty comparing studies. Although fatigue has great impact on patients' QOL, effective interventions that are feasible for broad dissemination remain elusive. Additional multi-faceted research is needed to identify modifiable sources of fatigue. Such research would be enhanced by harmonization of fatigue measurement across studies.

Fatigue - an underestimated symptom in psoriatic arthritis

The nature of fatigue is very complex and involves physiological, psychological and social phenomena at the same time, and the mechanisms leading to occurrence and severity of fatigue are still poorly understood. The condition of chronic inflammation associated with psoriatic arthritis can be regarded as a potential factor affecting development of fatigue. Only a few studies so far have focused on the occurrence of fatigue in psoriatic arthritis. The problem of chronic fatigue is underestimated in everyday clinical practice. Identification and analysis of subjective fatigue components in each patient can provide an objective basis for optimal fatigue treatment in daily practice. This review presents a definition of chronic fatigue and describes mechanisms that may be associated with development of fatigue, highlighting the role of chronic inflammation, selected fatigue measurement methods and relations of fatigue occurrence with clinical aspects of psoriatic arthritis.

Measuring fatigue with multiple instruments in a Brazilian cohort of early rheumatoid arthritis patients

OBJECTIVE

To assess the prevalence of fatigue in a Brazilian population with early rheumatoid arthritis using multiple instruments, and the predictors of these instruments by differents independent variables.

METHODS

Cross-sectional study with direct interview and medical records review. Fatigue, dependent variable, was assessed using eight instruments: Profile of Mood States (POMS), Multidimensional Assessment of Fatigue scale (MAF), Fatigue Severity Scale (FSS), Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire (BRAF-MDQ), Numerical Rating Scales (BRAF-NRS), Short-form Survey 36 (SF-36), Functional Assessment of Chronic Illness Therapy Fatigue Scale (FACIT-F) and Visual Analogic Scale for Fatigue (VASf).

INDEPENDENT VARIABLES

sociodemographic, clinical and serological, were measured using medical records and direct interview. Disability and disease activity were assessed using the Health Assessment Questionnaire (HAQ) and disease activity assessed using the Disease Activity Score 28 joints (DAS28). The scores of scales demonstrated the level of fatigue and multiple linear regression method used in statistical analysis to demonstrate prediction models.

RESULTS

A total of 80 patients was assessed, and 57 reported clinically relevant fatigue (VASf>2), representing 71.25% prevalence point (51 women [89.5%], mean age 48.35±15 years, and mean disease duration of 4.92±3.8 years). Eight predictive models showed statistical significance, one for each fatigue instrument. The highest coefficient of determination (R²) was 56% for SF-36 and the lowest (R²=21%) for FSS. The HAQ was the only independent variable to predict fatigue on all instruments.

CONCLUSION

Clinically relevant fatigue is a highly prevalent symptom and is mostly predicted by disability and age in the population assessed.

Improvements in Fatigue in 1536 Patients with Rheumatoid Arthritis and Correlation with Other Treatment Outcomes: A Post Hoc Analysis of Three Randomized Controlled Trials of Abatacept

INTRODUCTION

A post hoc analysis of three randomized controlled trials of abatacept in rheumatoid arthritis (RA) was conducted to explore the effect of abatacept on fatigue in RA and its correlation with other outcomes.

METHODS

In this analysis of AGREE (early RA) and AIM and ATTAIN (established RA), changes in baseline fatigue (0-100 mm scale), pain, sleep (AIM and ATTAIN only) and Disease Activity Score (DAS) 28 (C-reactive protein; CRP) were calculated at days 29, 85, and 169. Agreement between improvements ≥minimum clinically important differences (MCID) in fatigue and other outcomes were evaluated using agreement statistics (kappa) in each study and at each time point.

RESULTS

Of 1536 patients (mean disease duration: 6.2 months [AGREE], 8.5 years [AIM], 12.2 years [ATTAIN]), mean (SE) decreases in fatigue from baseline to day 169 with abatacept were 28.9 (1.7), 25.3 (1.2), and 21.9 (1.6) in AGREE, AIM, and ATTAIN, respectively, with corresponding decreases of 16.0, 13.7, and 13.4 at day 29. Most patients (67.8%; 624/920) reported improvements ≥MCID in fatigue with abatacept at day 169; 79.2% (671/847) and 57.8% (388/671) reported improvements ≥MCID in pain and sleep, respectively; 18.9% (158/836) were in DAS28 (CRP) remission. Agreement between improvement in fatigue and other outcomes was low (kappa range 0.30-0.51 [pain], 0.14-0.26 [sleep], and 0.02-0.12 [DAS28 (CRP) remission]).

CONCLUSIONS

Abatacept resulted in rapid improvements in fatigue and pain in patients with RA. However, low agreement between improvements in these outcomes indicates that fatigue and other outcomes including pain and sleep may represent different domains of response.

FUNDING

Bristol-Myers Squibb.

Quality of Working Life of cancer survivors: associations with health- and work-related variables

PURPOSE

This study aimed to (1) describe the Quality of Working Life (QWL) of cancer survivors and (2) explore associations between the QWL of cancer survivors and health- and work-related variables.

METHODS

Employed and self-employed cancer survivors were recruited through hospitals and patient organizations. They completed the Quality of Working Life Questionnaire for Cancer Survivors (QWLQ-CS) and health- and work-related variables in this cross-sectional study. The QWL scores of cancer survivors were described, and associations between QWL and health- and work-related variables were assessed.

RESULTS

The QWLQ-CS was completed by 302 cancer survivors (28% male) with a mean age of 52 ± 8 years. They were diagnosed between 0 and 10 years ago with various types of cancer, such as breast cancers, gastrointestinal cancers, urological cancers, and haematological cancers. The QWL mean score of cancer survivors was 75 ± 12 (0-100). Cancer survivors had statistically significant lower QWL scores when they had been treated with chemotherapy or when they reported co-morbidity (p ≤ 0.05). Cancer survivors without managerial positions, with low incomes or physically demanding work, and who worked a proportion of their contract hours had statistically significantly lower QWL scores (p ≤ 0.05).

CONCLUSIONS

This study described the QWL of cancer survivors and associations between QWL and health- and work-related variables. Based on these variables, it is possible to indicate groups of cancer survivors who need more attention and support regarding QWL and work continuation.

Analysis of haematological changes in tofacitinib-treated patients with rheumatoid arthritis across phase 3 and long-term extension studies

OBJECTIVES

Tofacitinib is an oral Janus kinase inhibitor for the treatment of RA. The aim of this analysis was to characterize changes in haematological parameters following tofacitinib treatment, and to compare changes in haemoglobin with markers of disease activity, fatigue and vitality.

METHODS

Changes in neutrophil counts, lymphocyte counts and haemoglobin levels were analysed in patients with RA from six phase 3 randomized controlled trials (n = 4271) of tofacitinib 5 or 10 mg bd, placebo or active comparators of up to 24 months' duration, and two long-term extension (LTE) studies (n = 4858) of tofacitinib of up to 84 months' duration. Disease activity markers included CRP and ESR. Fatigue and vitality were assessed using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) and Short Form Health Survey-36 vitality domain scores.

RESULTS

In phase 3 studies, mean neutrophil and lymphocyte counts decreased and mean haemoglobin levels increased in all tofacitinib treatment groups. Haemoglobin levels and neutrophil counts stabilized in the LTE studies, while lymphocyte count decreases stabilized at approximately month 48. Increased haemoglobin was associated with decreased ESR and CRP levels. Clinically meaningful reductions in haemoglobin levels (⩾3 g/dl from baseline or haemoglobin ⩽7 g/dl) occurred in <1.0% of patients in all treatment groups. FACIT-F and Short Form Health Survey-36 vitality scores were weakly correlated with haemoglobin levels.

CONCLUSION

Small changes in haematological parameters were seen with tofacitinib treatment, which stabilized over time in the LTE studies. Changes in haemoglobin levels, although associated with changes in ESR and CRP, were not associated with fatigue or vitality.

Fatigue in chronic inflammation - a link to pain pathways

Fatigue is a frequent symptom in several inflammatory diseases, particularly in rheumatic diseases. Elements of disease activity and cognitive and behavior aspects have been reported as causes of fatigue in patients with rheumatoid arthritis. Fatigue could be associated with activity of inflammatory rheumatism. Indeed, biologic agents targeting inflammatory cytokines are effective in fatigue. Fatigue is also associated with pain and depressive symptoms. Different pathways could be involved in fatigue and interact: the immune system with increased levels of pro-inflammatory cytokines (interleukin-1 and -6 and tumor necrosis factor alpha), dysregulation of the hypothalamic-pituitary-adrenal axis and neurological phenomena involving the central and autonomic nervous systems. A pro-inflammatory process could be involved in pain and behavioral symptoms. Inflammation could be a common link between fatigue, pain, and depression.

Fatigue in rheumatic diseases

Fatigue is a common and important problem in many diseases including rheumatologic illnesses, and it has a negative impact on health-related quality of life. Fatigue is described as having an impact on multiple aspects of a patient's life. There is a need for knowledge about causes of and treatments for fatigue to ensure that patient outcomes are improved. There are several effective treatment strategies available for fatigue including pharmacological and non-pharmacological therapies. We aim to provide an overview of fatigue in rheumatologic disorders and some recommendations on its optimal management.

Delayed-release prednisone improves fatigue and health-related quality of life: findings from the CAPRA-2 double-blind randomised study in rheumatoid arthritis

OBJECTIVES

Like morning stiffness, fatigue is a common, debilitating symptom of rheumatoid arthritis (RA). Delayed-release (DR) prednisone is designed for evening administration (approximately 22:00) and releases 4 h later to coincide with the rise of nocturnal inflammatory cytokines associated with development of morning stiffness. The impact of DR prednisone on fatigue and other related patient-reported outcomes was analysed with data obtained from the Circadian Administration of Prednisone in Rheumatoid Arthritis (CAPRA) 2 study.

METHODS

Patients with symptomatic RA (n=350) despite treatment with a disease-modifying antirheumatic drug (DMARD) were randomised 2:1 to receive additional therapy with DR prednisone 5 mg or placebo once daily for 12 weeks. Fatigue was assessed using validated instruments: the fatigue scale of the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) and the vitality domain of the Short Form-36 (SF-36). General quality of life was assessed using the general score and individual domains of Functional Assessment of Cancer Therapy-General (FACT-G) and SF-36.

RESULTS

The change from baseline to week 12 in FACIT-F score was statistically significantly different with DR prednisone/DMARD (3.8) versus placebo/DMARD (1.6; difference 2.2, p=0.0032). Improvement in FACIT-F score correlated positively with clinical response. Compared with placebo/DMARD, DR prednisone/DMARD showed a significantly greater improvement in SF-36 vitality score (5.6, p=0.001), physical component of SF-36 (2.3, p=0.0003) and general score with FACT-G (2.6, p=0.0233).

CONCLUSIONS

DR prednisone in addition to a DMARD significantly improves fatigue and other aspects of health-related quality of life in patients with symptomatic RA compared with DMARD treatment alone.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT00650078.