Factors Associated With Initiation of Biologics in Patients With Axial Spondyloarthritis in an Urban Asian City: A PRESPOND Study

Association of anxiety, depression and resilience with overall health and functioning in axial spondyloarthritis (axSpA): a cross-sectional study

OBJECTIVES

To evaluate the association between anxiety, depression and resilience with overall health and functioning in axial spondyloarthritis (axSpA).

DESIGN

Cross-sectional evaluation of baseline data from a prospective cohort study, with recruitment from January 2018 to March 2021.

SETTING

Outpatient clinic in a tertiary hospital in Singapore.

PARTICIPANTS

Patients aged 21 years and above who were diagnosed with axSpA.

OUTCOME MEASURES

The Hospital Anxiety and Depression Scale (HADS) was used for assessing anxiety and depression, 10-item Connor Davidson Resilience Scale (CD-RISC-10) for resilience, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for disease activity, Bath Ankylosing Spondylitis Functional Index (BASFI) for functional limitation and Assessment of SpondyloArthritis International Society Health Index (ASAS HI) for overall health and functioning. Univariable and multivariable linear regression analyses were performed to assess the association between anxiety, depression and resilience with health and functioning.

RESULTS

We included 296 patients in this study. The median (IQR) score for HADS-Anxiety was 5.0 (2.0-8.0), with 13.5% and 13.9% having borderline abnormal and abnormal anxiety, respectively. The median (IQR) score for HADS-Depression was 3.0 (1.0-7.0), with 12.8% and 8.4% having borderline abnormal and abnormal depression, respectively. The median (IQR) CD-RISC-10 score was 29.0 (23.0-32.0) while the median (IQR) ASAS HI score was 4.0 (2.0-7.0). Apart from BASDAI, BASFI and disease duration, anxiety and depression were associated with overall health and functioning (β: 0.12, 95% CI 0.03, 0.20; β: 0.20, 95% CI 0.09, 0.31) in the multivariable linear regression. Level of resilience was not associated with health and functioning.

CONCLUSION

Anxiety and depression, but not resilience, were associated with poorer health and functioning. Clinicians could consider routinely screening for anxiety and depression in their patients, especially in patients with more severe symptoms.

Physical activity in patients with axial spondyloarthritis in a multi-ethnic south-east Asian country

Background

Patients with axial spondyloarthritis (axSpA) may experience spinal stiffness and pain, leading to reduced physical function and quality of life. Despite the benefits of physical activity (PA) and exercise, previous studies have demonstrated lower levels of PA among patients with axSpA. This study aims to examine the patterns of PA among patients with axSpA compared to the general population in a multi-ethnic Asian country.

Methods

This was a cross-sectional study conducted between May 2016 and Jan 2017. Consecutive patients with axSpA were recruited at an outpatient rheumatology clinic at Singapore General Hospital, the largest tertiary hospital in Singapore. Controls were based on a previous cross-sectional study. PA was assessed using the Global Physical Activity Questionnaire (GPAQ).

Results

Seventy-four patients with axSpA were recruited and compared with 2679 controls. Lower proportion of patients with axSpA met the WHO recommendations for PA (axSpA = 77.0%, controls = 89.7%, p <  0.001). More patients with axSpA had high level of sedentary activity compared to controls (axSpA = 56.8%, controls = 36.1%, p <  0.001). Levels of PA did not differ between patients with inactive versus active axSpA disease (p = 0.91).

Conclusions

Proportion of patients with axSpA meeting the WHO recommendations for PA differed significantly from the general population, and level of PA did not differ between patients with active and inactive axSpA disease. Higher levels of sedentary activity were seen in patient with axSpA compared to the general population, highlighting the need for interventions to promote PA among patients with axSpA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-021-00211-5.

Prevalence and impact of comorbidities in axial spondyloarthritis: systematic review and meta-analysis

OBJECTIVES

Comorbidities are common in people with axial spondyloarthritis (axSpA). In this systematic review and meta-analysis, we aimed to: (i) describe the prevalence of commonly reported comorbidities, (ii) compare comorbidities between axSpA and control populations, and (iii) examine the impact of comorbidity burden on axSpA outcomes.

METHODS

We systematically searched Medline, PubMed, Scopus and Web of Science using a predefined protocol in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We excluded studies of only one comorbid condition or a few closely related diseases within one organ system. Where possible, meta-analysis was performed using random-effects models.

RESULTS

A total of 40 studies were included for analysis. 36 studies reported prevalence of comorbidities, amounting to a combined sample size of 119 427 patients. The number of comorbidities studied ranged from 3 to 43. The most prevalent individual comorbidities were hypertension (pooled prevalence 23%), hyperlipidaemia (17%) and obesity (14%). Eleven studies consistently showed higher prevalence of comorbidities in axSpA than controls, particularly large differences were seen for depression [pooled odds ratio (OR) 1.80] and heart failure (OR 1.84). Comorbidities (total number of and individual conditions) were also associated with axSpA disease activity, functional impairment, quality of life, work productivity and mortality.

CONCLUSIONS

Comorbidities are common in axSpA, particularly cardiovascular diseases and risk factors. Most comorbidities were more prevalent in axSpA patients than in control populations. Overall comorbidity burden, and many individual conditions, were associated with axSpA outcomes including worse disease severity, work productivity and mortality.

Risk of malignancies in patients with spondyloarthritis treated with biologics compared with those treated with non-biologics: a systematic review and meta-analysis

Background:

The aim of our study was to synthesize evidence on the occurrence of malignancy in spondyloarthritis (SpA), from randomized controlled trials (RCTs) comparing biologics with non-biologics and biologics to each other.

Methods:

We systematically searched Medline, Cochrane Library, EMBASE, Scopus and ClinicalTrials.gov from inception until 31 October 2018. RCTs with ⩾24-week follow-up were included. We extracted data using standardized forms and assessed the risk of bias using the Cochrane Risk of Bias Tool. We performed pair-wise meta-analyses and network meta-analyses to compare the risk of malignancy for each biologics class and SpA type. We reported the Peto odds ratio (OR) of any malignancy along with 95% confidence intervals (95% CI). Bayesian posterior probabilities comparing risk of malignancy of each biologic class with non-biologics were computed as supplementary measures.

Results:

Fifty-four trials were included; most (44/54) had follow-up <1 year. Among 14,245 patients, 63 developed a malignancy. While most Peto ORs were >1, they had wide 95% CI and p >0.05. The overall Peto OR comparing biologics with non-biologics was 1.42 (95% CI 0.80–2.53). Only interleukin-17 inhibitors in peripheral SpA had p <0.05 (Peto OR 2.77, 95% CI 1.07–7.13); the posterior probability that the risk was higher than non-biologics was 98%. Stratified analyses revealed no consistent trend by prior exposure to biologics, duration of follow-up, study quality, study-arm crossover, analytical approaches and type of malignancy.

Conclusions:

Our findings indicate no overall elevated risk of malignancy with biologics in SpA. As our meta-analyses are unable to conclude on the long-term risk, long-term pharmacovigilance of biologics in SpA may still be warranted.

The direct and indirect costs of axial spondyloarthritis (axSpA) in Singapore

OBJECTIVE

To estimate the economic annual direct and indirect costs of axial spondyloarthritis (axSpA) in Singapore, and to identify factors associated with these costs.

METHODS

A retrospective, cross-sectional, Institutional Review Board-approved study was conducted. A questionnaire was administered to the patients between 2013 and 2016 from the Singapore General Hospital (SGH) spondyloarthritis registry. Direct medical costs and indirect costs were estimated using the SGH database and the human capital approach respectively. Multivariate analyses using generalized linear model with gamma distribution and a log-linked function was conducted to identify factors associated with these total, direct and indirect costs. All costs were adjusted to 2017 using the Singapore Consumer Price Index and converted to 2017 US dollars (USD) by purchasing power parity.

RESULTS

A total of 135 consecutive patients were included in the study, with a mean age of 40.4 ± 13.2 years. The overall annual total economic cost to society was around USD 74 790 820, with annual direct cost being the main component of total cost (90.8%). Annual direct cost was around USD 67 931 457, while annual indirect cost was around USD 6 855 951. Presence of extra-spinal symptoms (ever) was associated with an increase in total and direct costs. Higher education level and Patient Global Assessment were associated with an increase in indirect costs. Lack of employment was associated with a decrease in indirect costs.

CONCLUSION

The disease burden of axSpA in Singapore is not trivial given that the disease is relatively common. This highlights the need for measures to accommodate patients with axSpA economically in Singapore.

Are extra-spinal symptoms associated with quality of life in patients with axial spondyloarthritis? A 1-year follow-up study

To assess the extent to which a history of extra-spinal symptoms (including peripheral arthritis, heel enthesitis, or dactylitis) (HPED) is associated with quality of life (QoL) in patients with axial spondyloarthritis (axSpA) at baseline and 1-year follow-up. We analyzed data from 138 patients with axSpA from a tertiary referral center in Singapore, seen between 2011 and 2015. Demographic, clinical variables, and patient-reported outcomes [Ankylosing Spondylitis Quality of Life (ASQoL) and SF-36] at baseline and 1-year follow-up were collected. We used linear mixed models to assess the association of HPED with QoL at baseline and 1 year post-baseline. Among 138 patients (mean age 39.3 years, 74.6% males, 87.6% Chinese, disease duration 7.4 years), at baseline, HPED was associated with poorer QoL for 3 of 8 SF-36 domains [role physical (RP) scores β - 8.38, p < 0.05; social functioning (SF) scores β - 6.74, p < 0.05; role emotional (RE) scores β - 9.37, p < 0.01] and SF-36 Physical Component Summary (PCS) (β - 4.52, p < 0.01) scores, but not ASQoL scores. At 1 year post-baseline, HPED was associated with poorer ASQoL (β 1.61, p < 0.05) scores, SF-36 PCS (β - 5.61, p < 0.01) scores, and three out of eight SF-36 domains (physical functioning (PF) β - 9.60, p < 0.01; RP β - 12.17, p < 0.01; RE β - 7.87, p < 0.05) scores. HPED was associated with QoL in patients with axSpA. After 1-year, patients with HPED have poorer QoL especially for physical health domains than patients without HPED.