Upadacitinib for the treatment of adults with active non-radiographic axial spondyloarthritis (nr-axSpA)

INTRODUCTION

Non-radiographic axial spondyloarthritis (nr-axSpA) is a chronic inflammatory condition with axial and peripheral musculoskeletal involvement, fulfilling criteria of axSpA in the absence of advanced radiographic sacroiliitis. While appropriate treatment is required for chronic pain and disability resulting from disease progression, the limited availability of treatment options becomes evident. Upadacitinib, an oral selective Janus kinase 1 inhibitor, was approved in Europe, the United States, and other countries for management of nr-axSpA with inadequate response to existing therapies.

AREA COVERED

This review summarizes essential drug profiles, efficacy, and safety of upadacitinib for nr-axSpA in conjunction with data pertaining to radiographic axSpA.

EXPERT OPINION

In a phase 3 trial, upadacitinib exhibited efficacy for patients with nr-axSpA, irrespective of prior exposures to biological disease-modifying antirheumatic drugs (bDMARDs). The safety profiles of upadacitinib in nr-axSpA mirrored those in other indications, underscoring its potential as a promising treatment option for nr-axSpA. Concurrently, physicians should be aware of the absence of real-world data, longitudinal efficacy and safety, direct comparative studies between upadacitinib and bDMARDs in nr-axSpA, and evidence for precision medicine to identify patients who may optimally benefit from upadacitinib over bDMARDs. Future research is imperative to facilitate the effective utilization of upadacitinib in daily clinical practice.

Achievement of higher thresholds of clinical responses and lower levels of disease activity is associated with improvements in workplace and household productivity in patients with axial spondyloarthritis

Background

Patients with active axial spondyloarthritis (axSpA) exhibit more absences and lower levels of productivity in the workplace and household than the general population, which can improve upon treatment.

Objectives

The objective of this study is to determine the long-term impact of achieving different levels of clinical response or disease activity on workplace and household productivity in patients with axSpA.

Design

RAPID-axSpA (NCT01087762) was a 204-week phase III trial evaluating the safety and efficacy of certolizumab pegol (CZP) in adult patients with active axSpA.

Methods

The impact of axSpA on workplace and household productivity was evaluated using the validated arthritis-specific Work Productivity Survey. Outcomes included the percentage of patients achieving Assessment of SpondyloArthritis International Society (ASAS) response and Ankylosing Spondylitis Disease Activity Score (ASDAS) thresholds. This post hoc study used a generalised estimating equations model to determine the association between the threshold of clinical response achieved and patient productivity.

Results

Of 218 CZP-randomised patients, 65.1% completed week 204. At baseline, 72.0% were employed outside the home. Of the patients who were unemployed, 42.6% were unable to work due to arthritis. Achievement of higher treatment response thresholds, such as clinical remission, was associated with fewer days affected by workplace absenteeism (ASAS-partial remission: 4.0 days, ASAS40: 8.6 days, ASAS20 but not reaching ASAS40 response: 29.4 days, ASAS20 non-response: 69.2 days; ASDAS-inactive disease: 5.0 days, ASDAS-low disease activity: 15.6 days, ASDAS-high disease activity: 32.7 days, ASDAS-very high disease activity: 93.4 days). Similar associations were found for workplace presenteeism, and household absenteeism and presenteeism.

Conclusions

Over 4 years, achievement of higher clinical response thresholds and lower levels of disease activity was associated with fewer cumulative days affected by absenteeism or presenteeism, with clinical remission associated with the greatest improvements in productivity. This highlights the importance of targeting these thresholds to limit the burden of axSpA on society and on patients' daily lives.

Exploring the emotional impact of axial Spondyloarthritis: a systematic review and thematic synthesis of qualitative studies and a review of social media

BACKGROUND

The psychological burden in people with inflammatory arthritis is substantial, yet little is known about the disease-related affect experienced by individuals with axial Spondyloarthritis (axial SpA). The aim of this study was to conduct a qualitative evidence synthesis and a review of social media to explore the emotional impact of living with axial SpA.

METHODS

We searched nine databases for studies reporting qualitative data about participants' emotional experience of living with axial SpA. In addition, we searched social media platforms for posts from people with axial SpA based in the UK that offered insights into emotional responses to living with the condition. We employed a thematic approach to synthesise the data.

RESULTS

We included 27 studies (1314 participants; 72% men) in our qualitative evidence synthesis and developed seven descriptive themes from the data: 1) delayed diagnosis: a barrier to emotional wellbeing; 2) disruptive symptoms: a source of mood swings; 3) work disability: a loss of self-esteem; 4) obstacles in interpersonal relationships: a trigger of distress; 5) taking up exercise: personal pride or unwelcomed reminders; 6) anti-TNF therapy: hope reignited despite concerns and 7) a journey of acceptance: worry mixed with hope. Posts extracted from social media fora (537; 48% from women) for the most part supported the seven themes. One additional theme-COVID-19, uncertainty and anxiety during the pandemic, was developed, reflecting common emotions expressed during the UK's first wave of the coronavirus pandemic.

CONCLUSION

This study highlights a preponderance of negative affect experienced by people living with axial SpA, conditioned through existing and anticipated symptoms, failed expectations, and lost sense of self. Given the bidirectional relationships between negative emotions and inflammation, negative emotions and perceptions of pain, and the influence of affect in self-care behaviours, this finding has important implications for treatment and management of people with axial SpA.

Evaluating remission and low disease activity from the perspective of the patient with axial spondyloarthritis: The cross-sectional ConREspAx study

OBJECTIVES

To evaluate the properties of a single question to determine patient perception of remission and disease activity; to compare this with existing definitions for remission and low disease activity (LDA).

METHODS

Single-center, cross-sectional study in a tertiary care hospital. Patients with axSpA (fulfilling ASAS criteria) were consecutively included. Both the patient's perception of remission and LDA and that of the physician were evaluated with a single question. Agreement between the patients' perception and other current definitions was tested using the prevalence-adjusted and bias-adjusted kappa (PABAK). The sensitivity (S) and specificity (Sp) of current definitions of disease states were tested against the patient's perception as the gold standard.

RESULTS

The study population included 105 axSpA patients (63.8% males; 67.6% with radiographic sacroiliitis). Patients considered themselves to be in remission in 21% of cases and in LDA in 51.4%; physicians considered patients to be in remission in 45.7% of cases and in LDA in 35.2%. The poorest agreement was recorded for the patient's and the physician's perception of remission. The best agreement for patients' perception of remission was for a BASDAI < 2 and normal C-reactive protein values. This definition was also the most sensitive (S=72.7%) and specific (Sp=83.1%) when the patient's perception was taken as the gold standard.

CONCLUSION

In a real-life setting, the evaluation of remission by the patient through a single question was the hardest criterion to achieve, although it did prove to be a feasible, valid, and specific way to assess remission.

The Quality of Life in Muslim Patients With Ankylosing Spondylitis in Türkiye

INTRODUCTION

Successful approaches to managing physical and psychosocial impacts on quality of life (QoL) of people with ankylosing spondylitis (AS) are grounded in their sociocultural and religious perspectives. The purpose of this study was to assess the QoL of Muslim patients with AS in Türkiye.

METHODOLOGY

This descriptive, cross-sectional study was conducted in 101 patients. The data were collected using a Demographic Form and the Ankylosing Spondylitis Quality of Life Index.

RESULTS

It was determined that the QoL of those who use medication regularly and whose physical activity, psychological state, social and sexual life are affected is statistically significantly worse (p < .05).

DISCUSSION

Results can provide better understanding of the QoL of Muslim patients and physical, social, and psychological influences of AS on QoL in this population. These results may have substantial impact on designing interventions to improve the QoL of Muslim patients with AS and the factors affecting it.

Age-stratified trends in the progression of spinal radiographic damage in patients with ankylosing spondylitis: a longitudinal study

Objective:

The objective of this study was to investigate spinal radiographic progression in specific age ranges of ankylosing spondylitis (AS) patients.

Methods:

Longitudinal data for 1125 AS patients at a single hospital from 2000 to 2018 were retrospectively reviewed. Radiographic intervals were obtained from patients with consecutive spinal radiographs. The radiographic progression rate was defined as the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) change per year within each interval. Using generalized estimating equations (GEEs), estimated marginal means were calculated for the mSASSS progression rate across age groups after adjusting for potential confounders.

Results:

We obtained 4016 radiographic intervals and stratified them into five groups based on patient age at the interval start: <20 (n = 122); 20–29 (n = 1124); 30–39 (n = 1690); 40–49 (n = 794); and ⩾50 years (n = 286). The mean (SD) mSASSS progression rate for all the intervals was 0.8 (1.9). The GEE-estimated mean mSASSS progression rate increased with age, peaking in the 30–39 age group with a value of 1.15 [95% confidence interval (CI) 1.03, 1.27], and decreased slightly thereafter. In the presence of risk factors, rapid progression occurred at earlier ages: the GEE-estimated mean mSASSS progression rate in those with elevated C-reactive protein levels and preexisting syndesmophytes was 2.82 (95% CI 1.93, 3.71) in the 20–29 age group.

Conclusion:

Spinal structural damage in AS seems to progress most rapidly when patients are age 30–39 years. An awareness of the trends in radiographic progression with advancing age could improve understanding of the natural course of AS.

Nonpharmacologic Pain Management in Inflammatory Arthritis

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

Gender differences in patient journey to diagnosis and disease outcomes: results from the European Map of Axial Spondyloarthritis (EMAS)

Introduction/objectives

To evaluate the journey to diagnosis, disease characteristics and burden of disease in male and female patients with axial spondyloarthritis (axSpA) across Europe.

Method

Data from 2846 unselected patients participating in the European Map of Axial Spondyloarthritis (EMAS) study through an online survey (2017–2018) across 13 countries were analysed. Sociodemographic characteristics, lifestyle, diagnosis, disease characteristics and patient-reported outcomes (PROs) [disease activity –BASDAI (0–10), spinal stiffness (3–12), functional limitations (0–54) and psychological distress (GHQ-12)] were compared between males and females using chi-square (for categorical variables) and student t (for continuous variables) tests.

Results

In total, 1100 (38.7%) males and 1746 (61.3%) females participated in the EMAS. Compared with males, females reported considerable longer diagnostic delay (6.1 ± 7.4 vs 8.2 ± 8.9 years; p < 0.001), higher number of visits to physiotherapists (34.5% vs 49.5%; p < 0.001) and to osteopaths (13.3% vs 24.4%; p < 0.001) before being diagnosed and lower frequency of HLA-B27 carriership (80.2% vs 66.7%; p < 0.001). In addition, females reported higher degree of disease activity in all BASDAI aspects and greater psychological distress through GHQ-12 (4.4 ± 4.2 vs 5.3 ± 4.1; p < 0.001), as well as a greater use of alternative therapies.

Conclusion

The patient journey to diagnosis of axSpA is much longer and arduous in females, which may be related to physician bias and lower frequency of HLA-B27 carriership. Regarding PROs, females experience higher disease activity and poorer psychological health compared with males. These results reflect specific unmet needs in females with axSpA needing particular attention.

Key Points • Healthcare professionals’ perception of axSpA as a predominantly male disease may introduce some bias during the diagnosis and management of the disease. However, evidence about male-female differences in axSpA is scarce. • EMAS results highlight how female axSpA patients report longer diagnostic delay and higher burden of the disease in a large sample of 2846 participants of 13 European countries. • Results reflect unmet needs of European female patients. Healthcare professionals should pay close attention in order to accurately diagnose and efficiently manage axSpA cases while further research should be developed on the cause of reported gender differences.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10067-020-05558-7.

Cost of Illness, Quality of Life, and Work Outcomes in Active Ankylosing Spondylitis Patients Treated With Adalimumab in China

Objectives: To access the cost of illness, quality of life and work limitation in active ankylosing spondylitis (AS) patients using adalimumab in China.

Methods: A prospective study was performed in 91 patients with active AS in China. Adult patients (aged ≥ 18 years) fulfilled the 1984 New York modified criteria of AS with the Bath Ankylosing Spondylitis Disease Activity Index ≥ 4 were enrolled. All participants received adalimumab (40 mg per 2 weeks) therapy and completed questionnaires about disease characteristics, quality of life and cost. Only patients with pay-work completed the Work Limitation Questionnaire and Work productivity and activity impairment questionnaire in AS. Factors associated with work outcomes were evaluated.

Results: A total of 91 patients with mean age of 30 years old (87.8% males) and mean disease duration of 10 years received adalimumab treatment for 24 weeks. The annual estimated cost of each patient was $37581.41 while the direct cost accounted for 84.6%. Seventy-eight percent of patients have a paid job with average work productivity loss of 0.28 measured by work limitation questionnaire, absenteeism and presenteeism were 10.22 and 43.86%, respectively, with a mean work productivity loss of 47.92% measured by Work productivity and activity impairment questionnaire in AS. Patients experienced significantly greater improvements after adalimumab treatment in presenteeism, absenteeism, work productivity, and quality of life.

Conclusions: The cost of AS patients with adalimumab therapy was high in China. Disease activity, physical function, quality of life, and work outcomes improved significantly after therapy.

Ankylosing spondylitis and undifferentiated spondyloarthritis: The relationship between living with these diseases and psychological well-being

BACKGROUND AND PURPOSE

This study explored the psychological impact of living with chronic pain as a result of ankylosing spondylitis or undifferentiated spondyloarthritis. The aim was to investigate individual's current pain experience and their current psychological state.

METHODS

A total of 161 individuals who had a clinical diagnosis of ankylosing spondylitis or undifferentiated spondyloarthritis participated in an online survey. This survey measured daily/weekly pain, quality of life and psychological wellbeing.

RESULTS

Results indicated that participants reported feeling high levels of pain consistently that impaired their daily functioning more than 50% of the time. Furthermore, on average participants reported experiencing extremely severe levels of psychological distress, that significantly correlated with their experience with pain.

CONCLUSIONS

This research is significant as it highlights a need to address the psychological well-being of individuals who are diagnosed with chronic rheumatic disease in conjunction with the support they receive for their physical well-being. Furthermore, health professionals need to be mindful of the degree of debilitation associated with these diseases.

A prospective study of novel disease activity indices for ankylosing spondylitis

There is an ongoing quest for robust disease activity measures in Ankylosing spondylitis (AS). Thus, we prospectively validated two new disease activity indices, Simplified AS Disease Activity Score (SASDAS) and modified Juvenile Spondyloarthritis Disease Activity Score (JSpADA). Patients with AS were assessed for BASDAI, ASDAS and other outcome measures at baseline and 3 months. Comparisons were drawn between those with juvenile onset, early disease and peripheral involvement, with the rest. Fisher's r to Z transformation was used to compare correlations. Receiver-operating characteristic (ROC) curves were used to calculate cutoffs for inactive, low, high and very high disease activity. Of the 107 patients (mean age-29 years) of 6-years long disease, 38.3% had a juvenile onset. SASDAS and modified JSpADA exhibited excellent correlation with BASDAI and ASDAS (all p < 0.001) and were higher in active vs. inactive disease. Treatment responders had a greater fall in SASDAS and modified JSpADA as compared to non-responders. The novel scores were higher in those with peripheral disease. Only SASDAS could discriminate early from late disease. Based on the previously proposed cutoffs, optimal scores for inactive, moderate, high and very high disease activity were deduced. SASDAS-CRP showed better internal consistency than SASDAS-ESR and correlated better with ASDAS-CRP in late disease (Z = 3.04; p = 002) and those with adult onset disease (Z = 2.18; p = 0.03). SASDAS and Modified JSpADA perform as well as standard complex scores and have potential for simpler daily use. From our analyses, SASDAS with CRP performs better than SASDAS-ESR, pending further validation.

Factors associated with depressive symptoms in patients with ankylosing spondylitis in Northern Taiwan

Patients with ankylosing spondylitis (AS) experience impaired physical function and reduced quality of life, which puts this group at high risk for depression. Identifying factors associated with depressive symptoms could improve outcomes for this at-risk group. However, few studies have examined the relationship between demographic and clinical variables and depressive symptoms in patients with AS. This cross-sectional correlation study recruited patients with AS by convenience sampling from the division of immunology and rheumatology of a medical center in Northern Taiwan. Participants (N = 120) included 91 males and 29 females, age ≥ 20 years. Data were collected from chart reviews, and structural questionnaires, which included demographic information regarding employment status, history of falls, impact of AS on work; clinical information relative to AS was obtained from structural questionnaires: the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and functional index (BASFI), Numerical Rating Scale (NRS), Body Image Scale (BIS), and Beck Depression Inventory-II (BDI-II). Multiple regression analysis identified predictors of depression. The mean BDI-II score was 9.50 ± 8.30; 25% had scores indicating mild to severe depressive symptoms. Mean score on the BIS was 68.17 ± 16.14; 14.2% had fallen within the previous year; and 57.5% reported AS affected their work. Variables associated with depressive symptoms were work affected by AS (β = 0.14, p = .049), occurrence of a fall within the previous year (β = 0.14, p = .032), higher scores on the BASDAI (β = 0.21, p = .032), and lower body image (β = −0.38, p < .001). Clinical professionals should regularly assess patients with AS for depressive symptoms. Health care planning should provide instruction in fall prevention and control of disease activity, and strategies to improve body image, which could improve patients’ self-management capabilities and body image as well as mitigate depressive symptoms.

(Un)Spoken realities of living with axial spondyloarthritis: a qualitative study focused on couple experiences

OBJECTIVE

Axial spondyloarthritis is a long-term rheumatic condition. The symptoms, including pain, can impact on the daily life routines and psychological well-being of individuals that are diagnosed with axial spondyloarthritis (axSpA). Partners are often a main source of support for individuals who manage a long-term condition and they can also be affected by the illness experience, often themselves reporting elevated levels of emotional distress. Few qualitative studies have explored the impact of axSpA on partner relationships. This study addresses the social context of axSpA by investigating the experiences for both individuals with axSpA and their partners.

DESIGN

Semistructured individual telephone interviews analysed using thematic analysis at a dyadic partner level.

SETTING

Participants were recruited from the social media pages of a UK-based axSpA-specific charity.

PARTICIPANTS

Nine heterosexual partner dyads (23-65 years), who were currently cohabiting, comprising nine individuals diagnosed with axSpA (n=6 females) and nine partners (n=3 females).

RESULTS

Three themes 'Perceived relational closeness', 'Playing third wheel to axSpA' and 'Tensions surrounding a carer-type role' were identified. The findings illustrate how living with axSpA can influence closeness between partners and dominate daily decisions, particularly surrounding leisure activities. Partners commonly adopted a carer-type role, despite many individuals with axSpA expressing desire for a greater sense of autonomy.

CONCLUSIONS

This study provides an important insight into the lived experiences of both individuals with axSpA and their partners. Findings highlight the social context of managing a long-term condition and suggest the need for including partners within consultations, and the need for support provision for partners.

The European Map of Axial Spondyloarthritis: Capturing the Patient Perspective-an Analysis of 2846 Patients Across 13 Countries

PURPOSE OF REVIEW

Scientific research in axial spondyloarthritis (axSpA) has grown significantly. Nevertheless, the patient perspective remains insufficiently explored. Using a cross-sectional survey, the European Map of Axial Spondyloarthritis (EMAS) describes how patients living with self-reported axSpA experience their disease physically, psychologically, and socially.

RECENT FINDINGS

2846 patients participated: mean age 43.9 ± 12.3 years, 61.3% female, mean disease duration was 17.2 ± 12.4 years, and 71.3% were HLA-B27 positive. Mean diagnostic delay was 7.4 ± 8.4 years. Mean BASDAI score was 5.5 ± 2.0 and 75.7% reported moderate/severe spinal stiffness throughout the day. Daily life was substantially impaired: 74.1% reported difficulties finding a job due to the disease, and 61.5% reported psychological distress. EMAS results showed long diagnostic delay and substantial physical and psychological burden, indicating important unmet needs for patients. Furthermore, axSpA restricted patients' ability to participate in their daily routine and lead a productive work life. Understanding the patient's perspective can improve both health outcomes and shared decision-making between patient and rheumatologist.

Evaluation of coping with chronic rheumatic disease, in the context of socio-demographic factors and disease duration, based on the example of patients with ankylosing spondylitis

Objectives

Ankylosing spondylitis (AS) impairs patients' functioning, reducing their quality of life. The author of salutogenesis, Antonovsky, claims that maintaining an inner balance in a chronic disease is possible through a high sense of coherence. The aim of the current study was to identify socio-demographic factors and disease duration related to the feeling of coherence of patients with AS, acceptance of disease and risk of depression.

Material and methods

The study was conducted on 82 patients with diagnosed AS. The research method was a diagnostic survey using the Life Orientation Questionnaire (SOC-29), Beck Depression Inventory (BDI) and Acceptance of Illness Scale (AIS).

Results

In the study, the majority of the patients were male (89%), aged 42 (±11.3). The average duration of AS is 13 (±7.8) years. It was reported that with age, illness acceptance got worse (r_p = -0.567, p < 0.0001), and the risk of depressive disorders increased (r_p = 0.648, p < 0.0001). The longer the patient suffered from AS, the weaker was their illness acceptance (r_p = -0.446, p < 0.0001) and sense of coherence (r_p = -0.448, p < 0.001) whereas the risk of depressive disorder increased (r_p = 0.479, p < 0.0001). A high linear correlation between illness acceptance and sense of coherence (r_p = 0.638, p < 0.0001) and a very high negative correlation between overall sense of coherence and risk of depression (r_p = -0.857, p < 0.0001) were observed.

Conclusions

Patients with low sense of coherence demonstrated poorer adaptation to the illness and a greater risk of depressive disorders. Factors lowering the sense of coherence and illness acceptance and increasing risk of depression in the studied patients with AS were progressing illness, older age and lower education level.

Optimizing outcomes for ankylosing spondylitis and axial spondyloarthritis patients: a holistic approach to care

Axial SpA (axSpA) can affect diverse elements of an individual's life. The areas affected can be much more wide-ranging than the historical medical model of SpA, causing increased disease activity (pain and stiffness) and disability (reduced range of movement and physical function). A more holistic view of the individual results in the realization that many other areas of life can be adversely affected by axSpA, from the ability to work effectively and function socially, to effects on quality of life and the onset of worsening fatigue or mood disturbance. A good understanding of these areas outside the medical model allows for an improved understanding of the overall life impact of axSpA. This highlights the importance of understanding how to measure these elements of life using patient-reported outcome measures that can truly reflect an individual's experience of axSpA. These measures can then provide a better insight into the risks and benefits of interventions and medications used to treat axSpA.

Fear Assessment in Inflammatory Rheumatic diseases (FAIR) questionnaire: a cross-cultural adaptation and validation to the Turkish language

In chronic inflammatory rheumatic diseases (CIRD), it is important to understand patients' fears towards their disease in order to improve patient-physician dialog, to raise the quality of care offered, and to optimize treatment adherence. In this study, we aimed to translate the Fear Assessment in Inflammatory Rheumatic diseases (FAIR) questionnaire into Turkish and evaluate its psychometric properties in patients with CIRD. One hundred fifteen patients filled the provided socio-demographic information form, FAIR-Tr questionnaire, Hospital Anxiety and Depression Scale (HADS), and Beck's Hopelessness Scale (BHS). For the analysis of short-term reliability, 50 patients re-filled the FAIR-Tr questionnaire 1 week later. Internal consistency was evaluated with Cronbach's α coefficient and test-retest reliability was evaluated with intraclass correlation coefficients (ICC). Construct validity analysis was investigated based on the correlation with HADS and BHS. All patients found FAIR-Tr easily understandable and acceptable. FAIR-Tr internal consistency (Cronbach's α = 0.93) and test-retest reliability (ICC = 0.91) were excellent. Psychometric validation was proved upon observing high correlation with HADS (Anxiety, r = 0.77; Depression, r = 0.70) and moderate correlation with BHS (r = 0.65). FAIR-Tr is a questionnaire that has excellent internal consistency and test-retest reliability. The successful correlation with HADS and BHS supported its psychometric validity in terms of evaluating the fear in CIRD cases. We think that FAIR-Tr is a specific scale that can help to evaluate the disease- and treatment-related fears of the Turkish patients with CIRD and may be useful in both routine practice and clinical studies.

Patient Burden of Axial Spondyloarthritis

Axial spondyloarthritis (AxSpA) is an inflammatory spondyloarthritis (SpA) that has significant impact on a patient's life. Symptoms, including fatigue, sleep problems, depression, and sexual dysfunction, can profoundly impact health-related quality of life (HRQoL) and limit work, leisure, and daily activities. Available therapies effectively manage pain and inflammation in early-stage disease, but patients often continue to experience impaired HRQoL. Thus, there remains a need for new therapies with novel mechanisms that can stop disease progression, potentially reverse damage caused by AxSpA and improve HRQoL in patients with AxSpA. Newer biologic agents, such as those targeting the interleukin 17-interleukin 23 axis, have promising efficacy and may improve HRQoL for patients with AxSpA. The AxSpA has many negative effects on HRQoL. By targeting disease pathways responsible for the development of AxSpA, approved and emerging therapies potentially reduce disease activity and improve the functional status of patients with AxSpA. This narrative review reflects on the findings of studies evaluating HRQoL of individuals with AxSpA and the role of newer therapies.

Development and psychometric validation of a patient-reported outcome measure to assess fears in rheumatoid arthritis and axial spondyloarthritis: the Fear Assessment in Inflammatory Rheumatic diseases (FAIR) questionnaire

Objectives

To develop and validate an outcome measure for assessing fears in patients with rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA).

Methods

Fears were identified in a qualitative study, and reformulated as assertions with which participants could rate their agreement (on a 0–10 numeric rating scale). A cross-sectional validation study was performed including patients diagnosed with RA or axSpA. Redundant items (correlation >0.65) were excluded. Internal consistency (Cronbach’s α) and factorial structure (principal component analysis) were assessed. Patients were classified into fear levels (cluster analysis). Associations between patient variables and fear levels were evaluated using multiple logistic regression.

Results

672 patients were included in the validation study (432 RA, 240 axSpA); most had moderate disease activity and were prescribed biologics. The final questionnaire included 10 questions with high internal consistency (α: 0.89) and a single dimension. Mean scores (±SD) were 51.2 (±25.4) in RA and 60.5 (±22.9) in axSpA. Groups of patients with high (17.2%), moderate (41.1%) and low (41.7%) fear scores were identified. High fear scores were associated with high Arthritis Helplessness Index scores (OR 6.85, 95% CI (3.95 to 11.87)); high Hospital Anxiety and Depression Scale anxiety (OR 5.80, 95% CI (1.19 to 4.22)) and depression (OR 2.37, 95% CI (1.29 to 4.37)) scores; low education level (OR 3.48, 95% CI (1.37 to 8.83)); and high perceived disease activity (OR 2.36, 95% CI (1.10 to 5.04)).

Conclusions

Overall, 17.2% of patients had high fear scores, although disease was often well controlled. High fear scores were associated with psychological distress. This questionnaire could be useful both in routine practice and clinical trials.

Educational needs in patients with spondyloarthritis in Sweden - a mixed-methods study

BACKGROUND

There is a demand for a flexible and individually tailored patient education to meet patients' specific needs and priorities, but this area has seldom been studied in patients with spondyloarthritis (SpA), a family of inflammatory rheumatic diseases. The aim of the present study was to identify needs and priorities in patient education in patients with SpA. A second aim was to investigate patients' experiences and preferences of receiving patient education.

METHODS

Data collection included a questionnaire survey with the Educational Needs Assessment Tool (ENAT) and interviews, using a mixed-methods design. Patients were identified through a specialist clinic register. Descriptive data are presented as mean with standard deviation, or frequencies. Chi-square test and independent-samples t-test were used for group comparisons. A manifest qualitative conventional content analysis was conducted to explore patients' experiences and needs in patient education, based on two focus groups (n = 6) and five individual interviews.

RESULTS

Almost half (43%) of the 183 SpA patients had educational needs, particularly regarding aspects of self-help, feelings, and the disease process. More educational needs were reported by women and in patients with higher disease activity, while duration of disease did not affect the needs. The qualitative analysis highlighted the importance of obtaining a guiding, reliable, and easily available patient education for management of SpA. Individual contacts with healthcare professionals were of importance, but newer media were also requested.

CONCLUSION

There are considerable educational needs in patients with SpA, and education concerning self-help, feelings, and the diseases process were raised as important issues. Healthcare professionals need to consider the importance of presenting varied formats of education based on the experiences and preferences of patients with SpA.

A systematic review of quality-of-life domains and items relevant to patients with spondyloarthritis

OBJECTIVES

To summarize, from the literature, quality-of-life (QoL) domains and items relevant to patients with spondyloarthritis (SpA), and to determine if commonly used SpA patient-reported outcome (PRO) instruments include the identified domains.

METHODS

We used PRISMA statement for systematic review and searched Medline^® , Embase^®, and PsycInfo^® using relevant keywords. In addition, hand searches of references of the included articles were conducted. All articles were reviewed for inclusion by 2 independent reviewers. QoL domains and items relevant to patients with axial or peripheral SpA were extracted and presented using the adapted World Health Organization Quality-of-Life (WHOQOL) domain framework. SpA PROs were assessed to determine if they included the domains identified.

RESULTS

We retrieved 14,343 articles, of which 34 articles fulfilled inclusion criteria for review. Twenty-five articles were conducted in the European population. Domains such as negative feelings and activities of daily living were found to be present in 28 and 27 articles, respectively. SpA impacted QoL in all domains of the adapted WHOQOL framework. Domains that differed between types of SpA were financial resources, general levels of independence and medication side effects. Embarrassment, self-image, and premature ageing were items that differed by geographical setting. PROs to capture domains for peripheral SpA were similar for axial SpA.

CONCLUSIONS

We found that a wide range of domains and items of QoL were relevant to patients with SpA with minimal differences between patients with axial and peripheral SpA. Clinicians may consider using peripheral SpA PROs to measure QoL of patients with axial SpA.

Evaluation and Management of the Patient With Suspected Inflammatory Spine Disease

Axial spondyloarthritis (AxSpA) is a chronic inflammatory rheumatic disease characterized by inflammatory back pain (IBP) that manifests in childhood, late adolescence, or early adulthood. Ankylosing spondylitis (AS) and nonradiographic AxSpA represent 2 ends of the AxSpA spectrum. Diagnosis can be challenging because patients develop IBP that may not be associated with radiographic changes in the sacroiliac joints. Patients early in the course of disease are estimated to have at least the same level of disease activity and pain as patients with established disease; thus, they could benefit substantially from earlier diagnosis. Although the recent use of magnetic resonance imaging and its inclusion in diagnostic criteria has enhanced the identification of early AxSpA, improvement in early diagnosis has not been consistently reported across all studies. Limited knowledge of the continuum of AxSpA disease manifestations and lack of recognition of IBP in primary practice may contribute to this. Implementing a referral strategy that identifies patients with IBP for additional testing and assessment may lead to better recognition of early signs and symptoms of AxSpA, thereby offering the potential for improved patient outcomes. This review presents an overview of the epidemiology, clinical characteristics, and burdens of AxSpA, followed by a case presentation outlining approaches to the evaluation and management of a patient with suspected inflammatory spine disease.

Relationship between optimism and quality of life in patients with two chronic rheumatic diseases: axial spondyloarthritis and chronic low back pain: a cross sectional study of 288 patients

BACKGROUND

Axial Spondyloarthritis (AxSpA) and chronic low back pain are rheumatic diseases that impact patients' health-related quality of life (HRQoL). In other chronic conditions, HRQoL was positively associated with dispositional optimism, a personality trait. The objective was to explore the relationship between optimism and HRQoL in these two diseases.

METHOD

A cross-sectional study was performed in 2 tertiary care hospitals and 2 private practices in France. Patients had definite AxSpA or chronic low back pain according to the rheumatologist. A generic HRQoL questionnaire (Short Form, SF-12) with physical and mental composite scores (PCS and MCS respectively) and an optimism questionnaire (the Life Orientation Test-revised, LOT-R) were collected. Analyses included non-parametric correlations and multiple regression analyses to study the effect of optimism on PCS and MCS.

RESULTS

In all, 288 (199 AxSpA and 89 low back pain) patients were included: mean age, 47.3 ± 11.9 years, 48.6 % were males. Pain levels (0-10) were 4.5 ± 2.4 and 4.3 ± 2.4 in AxSpA and LOW BACK PAIN patients, respectively. HRQoL was similarly altered in both diseases, for both physical and mental composite scores (mean PCS: 43.7 ± 8.2 vs. 41.9 ± 7.1; mean

MCS

45.9 ± 7.8 vs. 46.7 ± 8.1 for AxSpA and low back pain respectively). Optimism was moderate and similar in both populations. Optimism was positively correlated to MCS in both diseases (rho = 0.54 and 0.58, respectively, both p <0.01) and these relations persisted in multivariate analyses (beta = 1.03 and 1.40, both p <0.0001).

CONCLUSIONS

Optimism was similar in these 2 chronic diseases and was an explanatory factor of the mental component of HRQoL, but not physical HRQoL. Physical HRQoL may reflect more the disease process than character traits.

The impact of ankylosing spondylitis/axial spondyloarthritis on work productivity

Ankylosing spondylitis (AS) is a chronic inflammatory condition that has a significant impact on the quality of life and work productivity. New classification criteria have enabled earlier diagnosis of this condition. However, work productivity is an important issue that is still often overlooked during clinical assessments and consultations. This article focusses on the relationship between axial spondyloarthritis (axial SpA) and work productivity. It summarises the impact of this condition on work productivity, and it highlights the tools available to assess this. It also highlights the increasing role and potential of employers, health professionals and new treatments for enhancing work productivity for people with this condition.

Men's experiences of living with ankylosing spondylitis: a qualitative study

BACKGROUND

The majority of patients with ankylosing spondylitis (AS) are male, although potential gender differences have not been investigated in relation to disease management. Moreover, men's perceptions of experiencing AS have not been reported in the literature.

AIMS

This study sought to develop an understanding of how men experience AS and the challenges related to living with AS as a chronic disease.

METHODS

A purposive sample of 13 men diagnosed with AS, with a median age of 44 years (range 32-58) was recruited from a rheumatology outpatient clinic. The median duration of disease was 12 years (range 0.3-28 years), and the median time from the first symptom to final diagnosis was seven years (range 2-20 years). Semi-structured interviews were conducted using an interview guide, and the interviews were analysed using content analysis inspired by Graneheim qualitative methodology.

RESULTS

The analysis revealed four categories: (1) 'Approaching a diagnosis'; (2) 'Ill in a social context'; (3) 'Challenged as a man'; and (4) 'The importance of remaining physically well'. Based on these categories, the overall category of 'An invisible companion for life' emerged, which captures the experience of living with an invisible, life-long disease.

CONCLUSIONS

These findings demonstrate that AS impacts men's perceptions of themselves as men, relationships as a partner and father, social lives, and masculine identity. Physical activity was highlighted as an important part of being a man, and not being able to exercise challenged the men's masculine identity.

Perceived Stigma Among People With Chronic Health Conditions

Objectives:

This study addresses whether age, functional limitation and other stressor exposure, and psychosocial coping resources influence variation in perceived stigma and the form this influence takes (i.e., independent and/or interdependent).

Methods:

Using data from two waves of a large community study of adults (age 20–93) with chronic health conditions ( n = 417), a residual change regression analysis considers direct and moderating factors influencing perceived stigma over a 3-year period.

Results:

Age, functional limitation, the experience of discrimination, and self-esteem independently account for variation in perceived stigma. Moderation tests reveal that age is associated with a greater increase in stigma in the context of greater functional limitation and increases in limitation. Functional limitation and stressor exposure are also associated with declines in stigma in the context of greater mastery and self-esteem.

Discussion:

Multiple processes bear on perceived stigma among people with chronic health conditions. Implications for stigma and stress research are discussed.

The impact of stigma in healthcare on people living with chronic illnesses

Approximately half of adults are living with a chronic illness, many of whom may feel stigmatized by their chronic illness in different contexts. We explored the impact of internalized, experienced, and anticipated stigma within healthcare settings on the quality of life of 184 participants living with chronic illnesses (e.g. diabetes, inflammatory bowel disease, asthma). Results of a path analysis demonstrate that participants who internalized stigma and experienced stigma from healthcare workers anticipated greater stigma from healthcare workers. Participants who anticipated greater stigma from healthcare workers, in turn, accessed healthcare less and experienced a decreased quality of life.