Gender difference in ASAS HI among patients with ankylosing spondylitis

Clinical performance of the ASAS health index in chinese patients with ankylosing spondylitis and its influencing factors

OBJECTIVE

The aim of this study was to investigate the status of health-related quality of life in Chinese patients with ankylosing spondylitis (AS) and to analyze factors associated with the Assessment of SpondyloArthritis international Society Health Index (ASAS-HI) in AS and its relationship with disease activity and psychological status.

METHODS

A cross-sectional study of 484 patients with AS attending 10 hospitals in China from March 2021 to September 2023 was recruited. The ASAS-HI assessed general health and functional status; the Depression Anxiety Stress Scales (DASS-21) assessed psychological disorders such as anxiety, depression, and stress; and the Functional Assessment of Chronic illness Therapy-Fatigue Scale (FACIT-F) assessed patients' fatigue symptoms; the Ankylosing Spondylitis Disease Activity Score-C-Reactive Protein (ASDAS-CRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), and Bath Ankylosing Spondylitis Measurement Index (BASMI) were used to assess patients' disease activity and functional impairment. The correlation between ASAS-HI and the ASDAS, poor psychological status, and fatigue symptoms was observed. Univariate and multivariate logistic regression analyses were used to explore the relevant influencing factors of ASAS-HI.

RESULTS

A total of 484 patients were included in this study of whom 162 were in poor health, 139 in moderate health, and 183 in good health. On univariate analysis, disease activity is an important factor affecting ASAS-HI. People with extremely high disease activity (ASDAS ≥ 3.5) had a 12 times elevated risk of having poor health status (OR = 12.53; P < 0.001). Other significant covariates included age ≥ 36 (OR = 1.58; P = 0.015), BMI ≥ 24 kg/m2 (OR = 2.93; P = 0.013), smoke (OR = 1.96; P = 0.002), BASFI (OR = 1.49; P < 0.001), BASMI (OR = 1.22; P < 0.001), fatigue (OR = 6.28; P < 0.001), and bad psychological conditions such as depression (OR = 10.86; P < 0.001), anxiety (OR = 3.88; P < 0.001), and stress (OR = 4.65; P < 0.001). The use of bMARDs is inversely associated with the appearance of adverse health status (OR = 0.54; P = 0.012). There was no significant relationship between HLA-B27 and sex. Multivariable logistic regression showed that higher disease activity (ASDAS ≥ 3.5) (OR = 5.14; P = 0.005), higher scores of BASMI (OR = 1.10; P = 0.009), self-reported depression (OR = 3.68; P = 0.007), and fatigue (OR = 2.76; P < 0.001) were factors associated with adverse health status.

CONCLUSION

The health status of AS patients is related to age, BMI, smoking, disease activity, poor psychological status, and fatigue and is influenced by a combination of multiple factors such as emotional state, economic level, pain, and dysfunction. Therefore, clinicians should pay attention to the early assessment of ASAS-HI in order to improve the prognosis of the disease. Key Points •Ankylosing spondylitis (AS) is a chronic inflammatory autoimmune disease with a long course and heavy disease burden, which greatly affects patients' quality of life. Therefore, this study aims to evaluate the health status of ankylosing spondylitis in the Chinese population and its influencing factors. •This is a multi-center cross-sectional study in China, which can better reflect the overall situation of the Chinese population.

Determinants of health-related quality of life and global functioning and health in axSpA, pSpA and PsA: results from the ASAS-PerSpA study

OBJECTIVES

We aimed to identify determinants of health-related quality of life (HRQoL) and global functioning and health (GH) in axial SpA (axSpA), peripheral SpA (pSpA) and (PsA).

METHODS

The ASAS-perSpA study data were analysed. Models for the three patient groups were run separately to explore factors associated with HRQoL and GH, assessed by EQ-5D and ASAS-HI, respectively.

RESULTS

The analyses included 4185 patients: 2719 with axSpA, 433 with pSpA, and 1033 with PsA.In axSpA, disease activity (β = -0.061), physical function (β = -0.041), female sex (β = -0.019) and fibromyalgia (FM) (β = -0.068) were associated with worse HRQoL; age (β = 0.001) and university education (β = 0.014) were associated with better HRQoL. In pSpA, disease activity (β = -0.04) and physical function (β = -0.054) were associated with worse HRQoL. In PsA, disease activity (β = -0.045), physical function (β = -0.053), axial disease (β = -0.041) and female sex (β = -0.028) were associated with worse HRQoL. In axSpA, disease activity (β = 0.889), physical function (β = 0.887), peripheral disease (β = 0.564), female sex (β = 0.812) and FM (β = 1.639) were associated with worse GH; age (β = -0.013) and university education (β = -0.274) were associated with better GH. In pSpA, physical function (β = 1.142) and female sex (β = 1.060) were associated with worse GH; university education (β = -0.611) was associated with better GH. In PsA, disease activity (β = 0.703), physical function (β = 1.025), axial involvement (β = 0.659), female sex (β = 0.924) and FM (β = 1.387) were associated with worse GH; age (β = -0.024) and university education (β = -0.856) were associated with better GH.

CONCLUSION

Disease activity and physical function are major HRQoL and GH determinants across SpA types, and clinical characteristics and sociodemographic factors play an important role, highlighting the importance of a holistic approach for individual patients.

Comparison of the ASAS Health Index in patients classified as radiographic axial spondyloarthritis (axSpA) or non-radiographic axSpA in the ASAS Health Index international validation study

OBJECTIVES

To determine if there were differences in the Assessment of SpondyloArthritis international Society Health Index (ASAS HI) scores between patients classified as radiographic axial spondyloarthritis (r-axSpA) and non-radiographic axSpA (nr-axSpA), and to identify factors associated with higher ASAS HI scores in both disease phenotypes.

METHODS

This study was an ancillary analysis of the ASAS HI international validation project performed in 23 countries. Patients were included if they were ≥18 years of age and diagnosed with axSpA. Univariable and multivariable analysis were performed to determine if ASAS HI scores differed between the axSpA phenotypes, and to identify other variables associated with ASAS HI scores. We also tested for potential interactions between the axSpA phenotype and significant variables identified through the multivariable regression.

RESULTS

A total of 976 patients were included, with 703 having r-axSpA and 273 nr-axSpA. Patients with r-axSpA reported higher (worse) ASAS HI scores compared with those with nr-axSpA (6.8 (4.4) vs 6.0 (4.0), p=0.02), but the axSpA phenotype was not associated with ASAS HI scores in the multivariable regression (β: -0.19, 95% CI: -0.56 to 0.19). Female gender, having worse physical function (Bath Ankylosing Spondylitis Functional Index), disease activity (Ankylosing Spondylitis Disease Activity Score) and anxiety and depressive symptoms (Hospital Anxiety and Depression Scale) were associated with higher ASAS HI scores. No interactions were found to be significant.

CONCLUSION

Overall health and functioning are similarly affected in patients with r-axSpA and nr-axSpA. Female patients, having worse physical function, disease activity, anxiety and depressive symptoms were independently associated with higher ASAS HI scores.

Exploring physical function and physical activity in axial spondyloarthritis: Beyond clinical remission or low disease activity

OBJECTIVES

To investigate the crucial roles of physical function (PF) and physical activity (PA) in axial spondyloarthritis (axSpA) patients, as well as their correlation with disease activity (DA), and to explore the influence of general characteristics among them.

METHODS

We enrolled axSpA patients from Xijing Hospital, spanning March 2022 to August 2022. Spearman rank correlation coefficients were used to assess correlations between PA (measured by the Global Physical Activity Questionnaire [GPAQ]), PF (measured by the Assessment of Spondyloarthritis international Society Health Index [ASAS-HI], the Short Form 36-Item Health Survey [SF-36], and the Bath Ankylosing Spondylitis Functional Index [BASFI]), DA, and their influencing factors. A Mann-Whitney U-test and Kruskal-Wallis H-test were used to compare variables between different patients grouped by sex, human leukocyte antigen B27 (HLA-B27), hip involvement, and intensity of PA and DA.

RESULTS

Three hundred fifty-five axSpA patients were included. We observed a moderate to strong correlation between DA and PF in axSpA patients. PA was weakly correlated with DA or PF. DA varied significantly at different PA levels, and patients with low PA levels had poorer PF. Active patients had worse PF, less transport-related PA, and a higher rate of hip involvement with a worse Harris Hip Score (HHS).

CONCLUSIONS

We identified a close relationship between DA, PF, and PA in axSpA patients. Further, gender, HLA-B27, and hip involvement affected the clinical manifestation of axSpA patients. These findings demonstrate that clinical remission of axSpA patients requires a comprehensive assessment rather than a single remission of DA.

Influence of Sex on Early Axial Spondyloarthritis: A Six-Year Longitudinal Analysis From a Large National Cohort

OBJECTIVE

The objective was to determine sex differences in disease outcomes in recent axial spondyloarthritis (SpA) over time.

METHODS

We analyzed the first 6 years of follow-up of the prospective French multicenter DESIR cohort. Patients analyzed had <3 years of disease, were naive to disease-modifying antirheumatic drugs, and fulfilled the Assessment of SpondyloArthritis international Society classification criteria for axial SpA. Disease activity (Ankylosing Spondylitis Disease Activity Score [ASDAS] using the C-reactive protein [CRP] level), patient global assessment (PtGA), CRP level, and radiographic sacroiliitis were compared between men and women (self-reported sex) by linear and logistic mixed-effects models. Models were created for trajectories of disease activity over 6 years in men and women, using k-means.

RESULTS

Of 494 patients analyzed (mean ± SD age 31.9 ± 7.5 years, symptoms duration 20.7 ± 11.7 months), 50.4% were men. Over 6 years of follow-up, both men and women showed clear improvements in ASDAS-CRP, PtGA, and CRP level. Women had higher ASDAS-CRP and PtGA over time compared to men (both P < 0.0001) with overall similar CRP levels (P = 0.089), whereas structural damage increased more in men (P < 0.0001). One-third of both men (33%) and women (34%) belonged to persistent high/very high disease activity trajectories, but ASDAS-CRP was globally higher in women in these trajectories.

CONCLUSION

In early axial SpA, clinical outcomes (disease activity and symptoms) were worse in women than men over 6 years of follow-up, whereas CRP was similar and structural damage was more frequent in men. Although similarly distributed, disease activity scores were higher in women in high/very high disease activity trajectories. Sex appears to be an important contextual factor in axial SpA.

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.

The effects of supervision on the outcomes of exercise training in patients with ankylosing spondylitis: A single-blind randomized controlled trial

AIM

Exercise training is crucial for managing ankylosing spondylitis. We evaluated the effects of exercise with different levels of supervision on clinical outcomes in patients with ankylosing spondylitis.

METHODS

We performed a single-blind randomized controlled trial in a university outpatient clinic. Overall, 45 (31 men) patients with ankylosing spondylitis were randomly allocated to 3 groups. The mean (SD) for age and disease duration were 39.3 (9.3) and 8.4 (7.8) years. The primary outcome was chest expansion in cm, and the secondary outcomes were the index scores of 5 standard questionnaires. For each participant, adalimumab 40 mg/0.8 mL/2 wk was injected and a 3-session exercise program per week for 1 month was prescribed. Controls received a pamphlet on the exercise program. Another group received the pamphlet and underwent a 2-hour training session. The supervised group received the pamphlet, and the 2-hour training, and completed the program by attending each exercise session in the clinic.

RESULTS

Within-group analysis showed significant improvement in chest expansion (P = 0.016) and all subjective or objective questionnaire scores (all P < 0.001) for the full-supervised group. Between-group analysis implied best outcomes for chest expansion (P = 0.046), Ankylosing Spondylitis Disease Activity Score (P < 0.001), Bath Disease Activity (P = 0.010), and Metrology (P = 0.002) Indices for ankylosing spondylitis. The group with 2-hour training experienced an improvement in some indices, and the control group did not show significant changes in the outcomes.

CONCLUSION

We recommend the prescription of a supervised training program instead of in-home exercises for patients with ankylosing spondylitis.

The electronic medical record management systems may improve monitoring and control of disease activity in patients with ankylosing spondylitis

To investigate the impact of an electronic medical record management system (EMRMS) on disease activity and the frequency of outpatient visits among patients with ankylosing spondylitis (AS). We identified 652 patients with AS who were followed up for at least 1 year before and after the first Ankylosing Spondylitis Disease Activity Score (ASDAS) assessment and compared the number of outpatient visits and average visit time within 1 year before and after the initial ASDAS assessment. Finally, we analyzed 201 patients with AS who had complete data and received ≥ 3 continuous ASDAS assessments at an interval of 3 months, and we compared the results of the second and third ASDAS assessments with those of the first. The number of annual outpatient visits increased after ASDAS assessment (4.0 (4.0, 7.0) vs. 4.0 (4.0, 8.0), p < 0.001), particularly among those with a high initial disease activity. The average visit time was reduced within 1 year after ASDAS assessment (6.4 (8.5, 11.2) vs. 6.3 (8.3, 10.8) min, p = 0.073), especially among patients whose with an inactive disease activity was < 1.3 (ASDAS C-reactive protein (CRP) 6.7 (8.8, 11.1) vs. 6.1 (8.0, 10.3) min, p = 0.033; ASDAS erythrocyte sedimentation rate (ESR) 6.4 (8.7, 11.1) vs. 6.1 (8.1, 10.0) min, p = 0.027). Among patients who received at least three ASDAS assessments, the third ASDAS-CRP tended to be lower than the first (1.5 (0.9, 2.1) vs. 1.4 (0.8, 1.9), p = 0.058). The use of an EMRMS increased the frequency of ambulatory visits among AS patients with high and very high disease activity and reduced the visit time among those with an inactive disease. Continual ASDAS assessments may help control the disease activity of patients with AS.

The Impact of Whole-Body Cryotherapy on Endothelium Parameters in Patients with Ankylosing Spondylitis

BACKGROUND

The aim of the study was to assess the effect of whole-body cryotherapy (WBC) with subsequent exercise training (WBC group) or exercise-only training (ET group) on endothelium inflammation parameters in patients with ankylosing spondylitis (AS).

METHODS

The WBC procedure lasted 3 min, and exercise training consisted of one 60 min session a day, which was the same in each group. The ET group was compared to the WBC group. Endothelium (high-sensitivity C-reactive protein (hsCRP), soluble P-Selectin, soluble vascular cell adhesion molecule-1 (sVCAM-1), neopterin), and oxidative stress (lipid hydroperoxide (LHP), protein sulfhydryl (PSH), lipofuscin, paraoxonase-1(PON-1), and albumin) parameters were estimated 1 day before and 1 day after the completion of the study.

RESULTS

A significant decrease in hsCRP, sP-Selectin, sVCAM-1, and neopterin concentrations was observed in the WBC group after the treatment. After the treatment, in both groups, LHP and lipofuscin levels and PON-1 activity decreased significantly. The observed drop in these parameters was higher in the WBC group compared to the ET group. Albumin concentration increased in the WBC group after treatment.

CONCLUSION

Procedures of WBC have a beneficial effect on endothelium parameters in AS patients; therefore, this method can be applied in the treatment of this group of patients.

Investigation of changes in ankylosing spondylitis disease activity through 2021 COVID-19 wave in Taiwan by using electronic medical record management system

We aim to investigate the alteration in disease activity of ankylosing spondylitis (AS) individuals before, during, and after the COVID-19 wave in Taiwan by using electronic medical-record management system (EMRMS). We identified 126 AS individuals from the single center, and gathered data of the three disease activities (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI], Ankylosing Spondylitis Disease Activity Score with erythrocyte sedimentation rate [ASDAS-ESR], and Ankylosing Spondylitis Disease Activity Score with C-Reactive Protein [ASDAS-CRP]) by using EMRMS before (7 February to 1 May, 2021), during (2 May to 24 July, 2021), and after the COVID-19 wave (25 July to 16 October, 2021). We compared the disease activity measures of the three phases through a paired t test. Among the 126 individuals, CRP was significantly higher during the COVID-19 wave (0.2 (0.1, 0.5) mg/dl, p = 0.001) than before the wave (0.2 (0.1, 0.4) mg/dl), ESR (8.0 (4.0, 15.0) mm/h, p = 0.003) and ASDAS-ESR (1.4 (1.0, 1.9), p = 0.032) were significantly higher after the wave than during the wave (6.0 (3.0, 12.0) mm/h and 1.2 (0.9, 1.8) mm/h) e. ESR, CRP, ASDAS-ESR and ASDAS-CRP were all significant higher after COVID-19 wave than before. The disease activities of AS individuals in Taiwan worsened after 2021 COVID-19 wave in Taiwan.

The identification of association between ultrasonographic enthesitis and the ASAS Health Index in patients with axial spondyloarthritis

This study aimed to evaluate association between the entheseal abnormalities in ultrasound and the Assessment of Spondyloarthritis International Society Health Index (ASAS HI) in patients with axial spondyloarthritis (axSpA). Seventy-four patients with axSpA were enrolled in this study. Ultrasonographic evaluation of entheses was performed by a blinded rheumatologist with the Madrid Sonographic Enthesitis Index (MASEI). The MASEI total score and the MASEI sub-scores (e.g., structural damage and activity scores) were calculated. The ASAS HI and the other SpA tools (e.g., Bath Ankylosing Spondylitis Disease Index, the Ankylosing Spondylitis Disease Activity Score) were used to evaluate patients' health and disease activity. Correlation and multivariate linear regression analyses were performed to assess the relationship between the MASEI and the ASAS HI. The mean score of the ASAS HI was 7.7 ± 4.6. The MASEI total score was calculated as 8.4 ± 6.8, while the mean MASEI-activity was 4.7 ± 3.6 and the mean MASEI-structural damage was 3.8 ± 4.5. There was no correlation between ASAS HI and MASEI total scores (r = 0.11, p = 0.34). However, the ASAS HI had a positive correlation with the MASEI-activity (r = 0.49, p < 0.001) and had a low negative correlation with the MASEI-structural damage (r = - 0.29, p < 0.05). In the linear regression model, the MASEI-activity and MASEI-structural damage were significantly related to the ASAS HI (β = 0.72 and - 0.58, respectively; R² = 0.53 p < 0.001). This study reported that the ASAS HI score was more negatively affected by active entheseal lesions rather than structural lesions. We suggest adding the entheses evaluation with ultrasonography to other tools for monitoring the health status of patients with axSpA.

Disease activity indexes might not capture the same disease aspects in males and females with ankylosing spondylitis: A real-world nationwide analysis

Background

To evaluate gender differences in disease activity and health status (HS) in patients with radiographic axial spondyloarthritis (r-axSpA)/ankylosing spondylitis (AS).

Methods

Ancillary analysis of the MIDAS study, an observational, non-interventional, cross-sectional and retrospective multicenter nationwide study to assess disease activity and its relationship with HS in clinical practice. Adult patients with AS diagnosis, fulfilling ASAS and modified New York criteria, treated for ≥3 months upon study inclusion according to clinical practice were included. The primary outcome was "disease control" assessed by the percentage of patients in remission and low disease activity (BASDAI and ASDAS-CRP scores). HS was evaluated using the ASAS health index (ASAS-HI). Patients' responses and characteristics were analyzed by gender.

Results

We analyzed 313 patients with AS, 237 (75.7%) males and 76 (24.3%) females. A total of 202 (64.5%) patients had adequate disease control (BASDAI < 4); 69.2% of males [mean (SD) BASDAI 2.9 (2.1)] and 50.0% of females [mean (SD) BASDAI 3.8 (2.4); p = 0.01]. According to ASDAS-CRP, 57.5% of patients were adequately controlled (ASDAS-ID +ASDAS-LDA); 138 (58.2%) males and 42 (55.3%) females. The mean (SD) ASDAS-CRP was 1.9 (1.1); being 1.9 (1.0) in males and 2.0 (1.1) in females. Overall, the impact of AS on HS was low to moderate [mean (SD) ASAS-HI 5.8 (4.4)]; being 5.5 (4.4) for males and 6.8 (4.2) for females (p = 0.02).

Conclusion

This study showed a higher proportion of females with AS and active disease using the BASDAI definition. When using the ASDAS-CRP definition these differences by gender were less pronounced. The impact of disease activity on HS appears to be higher in females than males.

The BASDAI Cut-Off for Disease Activity Corresponding to the ASDAS Scores in a Taiwanese Cohort of Ankylosing Spondylitis

Objectives

The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) has been widely utilized to evaluate disease activity in patients with ankylosing spondylitis (AS) by an arbitrary cut-off of ≥4 to indicate high disease activity and initiate biological therapy. The Ankylosing Spondylitis Disease Activity Score (ASDAS) is a new composite index to assess AS disease activity states that have been defined and validated. ASDAS ≥2.1 was selected as a criterion to start biological therapy. The purpose of this study was to estimate the corresponding BASDAI and ASDAS cut-off in a Taiwanese AS cohort.

Methods

From November 2016 to October 2018, we assessed the ASDAS and the BASDAI regularly and recorded demographic data for 489 AS patients in Taichung Veterans General hospital (TCVGH) using an electronic patient-reported data system linked to electronic medical records. We used receiver operating characteristic curves with Youden's J statistic to determine the BASDAI values that correspond to ASDAS disease activity cut-offs (i.e., 1.3, 2.1, and 3.5).

Results

In our population, the best trade-off BASDAI values corresponding to ASDAS -C-reactive protein (CRP) 1.3, 2.1, and 3.5 were 2.1, 3.1, and 3.7, respectively. The optimal BASDAI values corresponding to ASDAS-erythrocyte sedimentation rates 1.3, 2.1, and 3.5 were 2.0, 2.6, and 4.8, respectively.

Conclusion

We propose a revised BASDAI cut-off based on our data, as BASDAI scores are commonly used globally. A more reasonable, lower BASDAI cut-off to initiate or change biological therapy will bring us closer to better decisions to treat AS patients.

Sex-Based Medicine Meets Psoriatic Arthritis: Lessons Learned and to Learn

Humorally associated autoimmune diseases generally show a female predominance whereas ankylosing spondylitis, a disease that overlaps with psoriatic arthritis (PsA), shows a male predominance. The present review ascertains the current knowledge of sex-specific differences related to psoriatic arthritis (PsA), a chronic, inflammatory condition associated with psoriasis. Sex differences may have important implications for clinical research in PsA and in terms of epidemiology (incidence, prevalence, lifetime risk, survival, and mortality), clinical, radiological, and laboratory features, and response to treatment. While nationwide surveys and large-scale databases and registries show no sex-specific differences, varying male/female ratios have been reported, ranging from 0.42 to 2.75 (comparable with those reported for psoriasis vulgaris: ranging from 0.28 to 2.38). This may reflect subtle, complex, nonlinear interactions between the biological make-up of the individual (genetic and epigenetic differences), hormonal components including menopausal status, environmental exposures including skeletal physical stressing, and psychological variables. There exists methodological heterogeneity and paucity of data concerning sex-specific differences, in terms of the specific population studied, study design, and the diagnostic criteria utilized. Harmonizing and reconciling these discrepancies would be of crucial importance in achieving the ambitious goals of personalized/individualized medicine and further standardized meta-data and Big Data could help disentangle and elucidate the precise mechanisms of underlying potential PsA sex-specific differences.

Poor health and functioning in patients with axial spondyloarthritis during the COVID-19 pandemic and lockdown: REUMAVID study (phase 1)

Aim:

To evaluate the overall health and functioning in patients with axial spondyloarthritis (axSpA) and related factors affecting these during the COVID-19 pandemic and lockdown measures.

Methods:

Data from 587 axSpA patients participating in the first phase (April–July 2020) of the REUMAVID study who completed the ASAS Health Index (ASAS-HI) were analysed. REUMAVID is a cross-sectional study that collects data through an online survey to assess the impact of the COVID-19 pandemic on patients with rheumatic and musculoskeletal diseases across seven European countries. Poor health was defined as ASAS-HI ⩾ 12. The World Health Organization Five well-being index, self-perceived health status and change in health status during COVID-19 pandemic were evaluated as secondary outcomes. Logistic regression models were used to identify the factors associated with poor health.

Results:

According to the ASAS-HI, 147 (25.0%) patients reported poor health. Pain and moving around were the main affected categories. In addition, 14.0% reported their self-perceived health status as ‘bad’ or ‘very bad’ and 46.8% as worse than before the pandemic. In the multivariate analysis, smoking (OR = 1.98), diabetes (OR = 4.89) and taking painkillers (OR = 2.82) or corticosteroids use (OR = 2.20) were significantly associated with poor health, while engaging in physical activity (OR = 0.54) and being actively employed (OR = 0.48) were inversely associated with this.

Conclusions:

During the first wave of the COVID-19 pandemic, one in four axSpA patients reported poor health and functioning, while the self-perceived health status of almost half of these patients worsened. Nonsmoking, physical activity and being employed were associated with better outcomes.

Effectiveness of Physiotherapy in Patients with Ankylosing Spondylitis: A Systematic Review and Meta-Analysis

This study aimed to evaluate the safety and effectiveness of non-pharmacological interventions supervised by a physiotherapist in patients with Ankylosing Spondylitis, PROSPERO Protocol number CRD42020209453. Five databases (PubMed, PEDro, Scopus, Web of Science Core, and EMBASE) and reference lists with relevant articles were searched. Randomised controlled trials (RCTs) on the effectiveness of non-pharmacological interventions supervised by a physiotherapist were compared with usual care or home-based exercise programmes. Two investigators independently screened eligible studies. A total of 12 RCTs satisfied eligible criteria. The risk of bias ranged between medium and high. The meta-analysis results indicated that between supervised physiotherapy and usual care, the former was significantly associated with improvement in disease activity (standardised mean difference = -0.37, 95% CI, -0.64; -0.11; p < 0.001, I² = 71.25%, n = 629), and functional capacity (standardised mean difference = -0.36, 95% CI, -0.61; -0.12, p < 0.05; n = 629). No statistically significant differences emerged when interventions were compared with home-based exercise programmes. Supervised physiotherapy is more effective than usual care in improving disease activity, functional capacity, and pain in patients with ankylosing spondylitis. No significant improvements emerged when supervised physiotherapy and home-based exercise programmes were compared. Further investigation and RCTs with larger samples are needed.

Individual and country-level socioeconomic factors and health outcomes in spondyloarthritis: analysis of the ASAS perSpA study

OBJECTIVES

To investigate the association between individual and country-level socioeconomic (SE) factors and health outcomes across spondyloarthritis (SpA) phenotypes.

METHODS

Patients with axial SpA, peripheral SpA or psoriatic arthritis (PsA) from the ASAS-perSpA study (23 countries) were included. The effect of individual (age, gender, education and marital status) and country-level (e.g. Gross Domestic Product [GDP]) SE factors on health outcomes (ASDAS ≥ 2.1, ASDAS, BASFI, fatigue and ASAS-HI) was assessed in mixed-effects models, adjusted for potential confounders. Interactions between SE factors and disease phenotype were tested. A mediation analysis was conducted to explore whether the impact of country-level SE factors on ASDAS was mediated through b/tsDMARD uptake.

RESULTS

In total 4185 patients (61% males, mean age 45) were included (65% axSpA, 25% PsA, 10% pSpA). Female gender (β = 0.14 (95%CI 0.06-0.23)) lower educational level (0.35 (0.25-0.45)) and single marital status (0.09 (0.01-0.17)) were associated with higher ASDAS. Living in lower GDP countries was also associated with higher ASDAS (0.39 (0.16-0.63)) and 7% of this association was mediated by b/tsDMARD uptake. Higher BASFI was similarly associated with female gender, lower education and living alone, without effect of country-level SE factors. Female gender and lower educational level were associated with worse ASAS-HI, while more fatigue was associated with female gender and higher country-level SE factors (lower GDP, -0.46 (-0.89 to -0.04)). No differences across disease phenotype were found.

CONCLUSIONS

Our study shows country-driven variations in health outcomes in SpA, independently influenced by individual and country-level SE factors and without differences across disease phenotypes.

Reviewing Disease Activity Indices in Spondyloarthritis From the Sex Perspective: A Systematic Review and Metaanalysis

OBJECTIVE

To determine whether the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Ankylosing Spondylitis Disease Activity Score (ASDAS) exhibited differences between women and men.

METHODS

We systematically searched MEDLINE, Embase, Web of Science, and other sources in English or Spanish from January 1, 1995, to July 31, 2020, to assess the differences according to sex in BASDAI and ASDAS. We performed a comparative analysis by sex using t test and mean difference by sex metaanalyses for BASDAI and ASDAS, as well as a random-effects model using the inverse-variance method.

RESULTS

Forty-one studies included BASDAI (6785 women, 12,929 men) and 16 of them included ASDAS (2046 women, 4403 men). Disease activity detected using BASDAI was significantly higher in women than in men (mean 4.9 vs 4.2, P = 0.02), whereas ASDAS did not detect differences between sexes (mean 2.8 women vs 2.8 men). In the metaanalyses, BASDAI detected significant differences between women and men (mean difference = 0.55 [95% CI 0.46-0.65], P < 0.00001), but ASDAS did not identify significant mean difference between sexes (0.04, 95% CI -0.05 to 0.12], P = 0.38).

CONCLUSION

The 2 most widely used indices of disease activity in spondyloarthritis (SpA) discriminate differently according to sex by their different evaluations of peripheral disease. The different components and weights in BASDAI and ASDAS influence their values. BASDAI may be affected by fatigue, and in predominantly peripheral manifestations such as enthesitis, ASDAS may not be sensitive enough to detect activity. This may represent a sex bias unfavorable to women, because peripheral SpA is more common in women than in men.

Clinical performance of ASAS Health Index in patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis: real-world evidence from Multicenter Nationwide Registry

The Assessment of SpondyloArthritis international Society Health Index (ASAS HI) is used as a new instrument in measuring the function, disability and health of patients with spondyloarthritis (SpA). However, the real-world evidence of ASAS HI is very limited. In the present study, our objective is to evaluate the psychometric properties and performance of ASAS HI in the real-world setting as well as comparing ASAS HI with the current instruments to assess the construct validity and determine the cut-off points in patients with both ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA). A total of 991 patients with axSpA who fulfilled either the ASAS classification criteria for axial SpA (axSpA) or the Modified New York Criteria (mNY) for AS were recruited from the Biologic and targeted Synthetic antirheumatic drugs Registry (BioStaR) SpA. The construct validity of ASAS HI against the Bath Ankylosing Spondylitis Disease Activities Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score-C-Reactive Protein (ASDAS-CRP) the Bath Ankylosing Spondylitis Functional index (BASFI) was performed. Using the receiver operating characteristic (ROC) curves analysis, the cut-off points were calculated. Of all the recruited patients, 851 (85.9%) were AS and 140 (14.1%) were nr-axSpA. The difference in the mean ASAS HI scores of the patients with AS and the ones with nr-axSpA were not statistically significant (6.12 ± 4.29 and 6.42 ± 4.86, respectively). The mean ASAS HI score was significantly higher in females and small city residents. The ASAS HI had a strong construct validity against ASDAS-CRP, BASDAI and BASFI. A cut-off point of ≤ 4 was determined to discriminate good and moderate, as well as ≥ 12 to discriminate moderate and poor health status. In conclusion, ASAS HI is a reliable instrument to evaluate health and functioning for both patients with AS and nr-axSpA in clinical practice.