Correlations between fatigue and disease duration, disease activity, and pain in patients with rheumatoid arthritis: a systematic review

Tight control in patients with rheumatoid arthritis treated with targeted therapies across the COVID-19 pandemic era

OBJECTIVES

To analyze the impact of different patterns of healthcare delivery on remission of rheumatoid arthritis (RA) patients treated with targeted therapies during the first wave (2020) and second/third waves (2021) of the pandemic compared to the pre-pandemic period (2019).

METHODS

In this observational real-life study, data from RA patients treated with biologic or targeted synthetic drugs were extracted from a longitudinal registry. Clinical Disease Activity Index (CDAI) was analyzed in the same period from the 22nd of February to the 18th of May for three consecutive years. These three periods were characterized by different patterns of healthcare delivery: (1) before the pandemic (2019) only in-person visits, (2) during the first wave (2020) both in-person visits and telehealth, and (3) during the second/third waves (2021) only in-person visits. A generalized linear model with the binomial error was fitted to evaluate the difference in the proportion of patients in CDAI remission. Quantile regression was used to compare the median of CDAI in difficult-to-treat (D2T) patients.

RESULTS

In the three periods, we included 407, 450, and 540 RA patients respectively. The percentages of patients in CDAI remission were similar in the three periods (prevalence ratio 1.07, p value 0.423 between 2020 and 2019, and 1.01, p-value 0.934 between 2021 and 2019). The CDAI remission rate was 40.55% (N = 163), 43.18% (N = 155) and 40.82% (N = 220) in 2019, 2020 and 2021, respectively. Among our cohort of D2T patients, CDAI remission was similar across the three periods (N = 30, 22.22%; N = 27, 23.68%; and N = 34, 21.52% respectively).

CONCLUSION

Although the pandemic has imposed changes in our healthcare delivery, these different strategies seem to be effective in ensuring satisfactory management of RA treated with targeted therapies. The approaches modulated in the context of the different periods have been a feasible compensation for ensuring disease control even in D2T patients.

Sociodemographic and clinical variables associated with negative illness perception in patients newly diagnosed with rheumatoid arthritis, axial spondyloarthritis, or psoriatic arthritis-a survey based cross-sectional study

When newly diagnosed with inflammatory arthritis (IA), acquiring self-management skills is beneficial, to enhance quality of life. The personal beliefs and mental representations patients hold about their illness, known as illness perception, significantly influence the development of these skills. Recognizing characteristics that affect illness perception is key to identifying patients requiring additional support for the development of self-management skills. This study aimed at identifying the sociodemographic and clinical characteristics associated with a negative illness perception. This cross-sectional study was based on survey data from patients diagnosed for ≤ 2 years. The Brief Illness Perception Questionnaire (B-IPQ) was used to measure illness perception. After psychometric testing, we divided the B-IPQ into two domains: (1) a control domain and (2) a consequence domain. We performed logistic regression analyses with multiple imputations. A total of 1,360 patients (61% females) were included. Among them, 64%, 20%, and 16% were diagnosed with rheumatoid arthritis, psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), respectively. Younger patients with lower socioeconomic status, a diagnosis of PsA or axSpA, high disease activity (OR 3.026, CI 2.208;4.147), severe physical disability (OR 4.147. CI 2.883;6.007), severe pain (OR 3.034, CI 1.991;4.622), and severe fatigue (OR 2.612, CI 1.942;3.513) were significantly more likely to report having a negative illness perception. Younger patients with a higher symptom burden, increased disease activity, lower socioeconomic status, and a diagnosis of PsA or axSpA may require additional attention and support in rheumatology clinical practice to aid in the development of their self-management skills.

Baseline predictors of fatigue and persistent fatigue in rheumatoid arthritis: A longitudinal observational study

OBJECTIVES

To determine factors associated with fatigue in patients with rheumatoid arthritis (RA), and to identify baseline predictors of persistent fatigue at 12 months of follow-up.

METHODS

We enroled patients with RA fulfiling the 2010 American College of Rheumatology/European League Against Rheumatism criteria. Fatigue was assessed using the Arabic version of the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). Using univariate and multivariate analyses, we examined baseline variables associated with fatigue and persistent fatigue (if the FACIT-F score was less than 40 at baseline and 12 months of follow-up).

RESULTS

We included 100 RA patients of whom 83% reported fatigue. At baseline, the FACIT-F score was significantly associated with older age (p = 0.007), pain (p < 0.001), global patient assessment (GPA) (p < 0.001), tender joint count (TJC) (p < 0.001), swollen joint count (p = 0.003), erythrocyte sedimentation rate (ESR) (p < 0.001), disease activity score (DAS28 ESR) (p < 0.001), and health assessment questionnaire (HAQ) (p < 0.001). At 12 months of follow-up, the percentage of patients who reported persistent fatigue was 60%. The FACIT-F score was significantly associated with age (p = 0.015), symptom duration (p = 0.002), pain (p < 0.001), GPA (p < 0.001), TJC (p < 0.001), C-Reactive Protein (p = 0.007), ESR (p = 0.009), DAS28 ESR (p < 0.001), and HAQ (p < 0.001). Pain was an independent baseline predictor of persistent fatigue (OR = 0.969 (95% CI [0.951-0.988]), p = 0.002).

CONCLUSIONS

Fatigue is a frequent symptom in RA. Pain, GPA, disease activity and disability were associated with fatigue and persistent fatigue. Baseline pain was the only independent predictor of persistent fatigue.

Fatigue in Inflammatory Joint Diseases

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

Associations between cardiovascular risk factors, disease activity and cardiorespiratory fitness in patients with inflammatory joint disease: a cross-sectional analysis

BACKGROUND

Inflammatory joint diseases (IJD) are accompanied by an increased risk of cardiovascular disease (CVD). Cardiorespiratory fitness (CRF) is a modifiable CVD risk factor and low levels of CRF associate with an elevated CVD risk. This study aimed to investigate the associations between CVD risk factors, disease activity and CRF in patients with IJD and to explore differences between patients with normal versus low levels of CRF.

METHODS

CRF was measured as peak oxygen uptake (VO_2peak) with a cardiopulmonary exercise test. Participants were also evaluated for: Body composition, blood pressure, blood lipids, inflammatory markers and disease activity. Patient-reported use of cigarettes/snuff, medication, disease duration, pain, fatigue, CVD history, habitual physical activity and exercise beliefs and self-efficacy were collected by questionnaire. Cross-sectional associations between CVD risk factors, disease-related factors and CRF were analyzed by multiple linear regression. CRF was categorized to normal CRF (VO_2peak ≥ 80%) or low CRF (VO_2peak < 80%) according to age- and gender-stratified reference data. Differences in demographic, CVD and disease-related factors between patients with normal versus low CRF were explored.

RESULTS

In 60 Norwegian patients with IJD [34 females, age 59 years (IQR: 52-63)], mean VO_2peak was 30.2 (± 6.9) mL/kg/min, corresponding to 83% (± 18) of normative reference values. Age (coefficient: - 0.18 years, p = 0.01) and fat mass (coefficient: - 0.67 %, p < 0.001) were inversely associated with CRF, while physical activity index (coefficient: 0.13 points, p = 0.05) was positively associated with CRF (R² = 0.66). There were no significant associations between CRF, classical CVD risk factors and disease-related variables. Compared to patients with low CRF (n = 30), patients with normal CRF (n = 30) had higher peak oxygen uptake (+ 9.4 mL/kg/min, p < 0.001), high-density lipoprotein cholesterol (+ 0.5 mmol L^-1, p < 0.001), and exercise self-efficacy (+ 6.9, p < 0.01) as well as lower fat mass (- 8.7%, p < 0.001), resting heart rate (- 8.0 beats/min, p < 0.01) and triglycerides (- 0.5 mmol L^-1, p < 0.01).

CONCLUSIONS

In this sample of IJD-patients, age, fatmass and physical activity level were associated with CRF. CRF was lower than reference values and patients with normal CRF presented with a more favorable health profile. There is a continued need for exercise interventions to improve CRF in patients with IJD.

TRIAL REGISTRATION

NCT04922840.

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

BACKGROUND/OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Differences between Maximum Tongue Force in Women Suffering from Chronic and Asymptomatic Temporomandibular Disorders-An Observational Study

Background: Temporomandibular disorders are craniofacial disorders characterized by the presence of chronic pain in masticatory muscles, with higher incidence in the women population. There is little research that has studied tongue force related to temporomandibular disorders, but there are a lot of studies that have demonstrated the impact of tongue force in vital functions, such as chewing, swallowing, phonation, or breathing. According to this, the aim of this study was to compare the maximum force of the tongue between females with chronic temporomandibular disorders and asymptomatic females. We also wanted to establish whether any relationship existed between the pain and fatigue versus the maximum force developed in females with chronic temporomandibular disorders. Material and methods: A cross-sectional study of 67 women between the ages of 18 and 65 years old was performed. The included women were assigned to one of two groups, according to whether they had chronic temporomandibular disorders or not. The procedure was the same for both groups. Outcome measures included the maximum tongue force, intensity of perceived orofacial pain, and intensity of perceived orofacial fatigue. Results: The results showed significant statistical differences for the maximum tongue force measurement between the chronic temporomandibular disorders group and the control group (p < 0.05) for all the movements, except the lip pressure measurement. Furthermore, the analysis revealed significant statistical differences between the intensity of perceived orofacial fatigue between the groups (p < 0.05). Moreover, the data showed no significant correlations between variables. Conclusion: The study found significant differences in maximum tongue force when comparing women with chronic temporomandibular disorders and asymptomatic women (being superior in these). Likewise, we found that the intensity of perceived orofacial fatigue after tongue exercises showed significant differences between groups. However, this study reveals no correlations between the intensity of perceived orofacial pain and fatigue and the maximum tongue force.

The Link between the Demographic and Clinical Factors and Fatigue Symptoms among Rheumatoid Arthritis Patients

Rheumatoid arthritis (RA) is a chronic systemic disease of connective tissue with periods of exacerbation and remission. Fatigue is excessive strain throughout the body that is disproportionate or unrelated to an activity or lifestyle. Fatigue is an integral part of RA in most patients. The study aimed to assess the level of fatigue in RA patients and establish the relationship between fatigue and demographic and clinical factors. The study group consisted of 128 RA patients according to European League Against Rheumatism (EULAR) criteria. The Functional Assessment of Chronic Illness Therapy-Fatigue and -Medical Outcomes Study Short Form 36 (SF-36) vitality scores were used to assess the severity of fatigue symptoms. The analyzed variables were gender, age, disease duration, education, marital status, place of residence, work and residence status, pharmacological treatment, pain, morning stiffness, hemoglobin, C-reactive protein (CRP), rheumatoid factor (RF), compression soreness, Richie Articular Index, and DAS28 disease activity. The examined patients experience chronic fatigue-the mean value on the FACIT-F scale was 24.1 ± 9.1 points and on the SF-36 Vitality score was 14.2 ± 1.8 points. There is a relationship between the level of fatigue and pain, long-lasting morning stiffness, active disease, increased soreness of joints, and low hemoglobin values. When analyzing the symptom of fatigue, each patient should be approached individually, using the existing questionnaires or asking key questions to recognize the situation. The presence of fatigue symptoms should be considered during therapy and patient care by searching for and eliminating additional, intensifying stimuli and increasing its level.

The Relationship between Stress, Inflammation, and Depression

A narrative review about the relationship between stress, inflammation, and depression is made as follows: Chronic stress leads to various stress-related diseases such as depression. Although most human diseases are related to stress exposure, the common pathways between stress and pathophysiological processes of different disorders are still debatable. Chronic inflammation is a crucial component of chronic diseases, including depression. Both experimental and clinical studies have demonstrated that an increase in the levels of pro-inflammatory cytokines and stress hormones, such as glucocorticoids, substantially contributes to the behavioral alterations associated with depression. Evidence suggests that inflammation plays a key role in the pathology of stress-related diseases; however, this link has not yet been completely explored. In this study, we aimed to determine the role of inflammation in stress-induced diseases and whether a common pathway for depression exists. Recent studies support pharmacological and non-pharmacological treatment approaches significantly associated with ameliorating depression-related inflammation. In addition, major depression can be associated with an activated immune system, whereas antidepressants can exert immunomodulatory effects. Moreover, non-pharmacological treatments for major depression (i.e., exercise) may be mediated by anti-inflammatory actions. This narrative review highlights the mechanisms underlying inflammation and provides new insights into the prevention and treatment of stress-related diseases, particularly depression.

Bio-Psychological Predictors of Acute and Protracted Fatigue After Burns: A Longitudinal Study

Objective

Fatigue after burns is often attributed to the hyperinflammatory and hypermetabolic response, while it may be best understood from a bio-psychological perspective, also involving the neuro-endocrine system. This longitudinal multi-center study examined the course of fatigue up to 18 months postburn. The contribution of bio-psychological factors, including burn severity, pain, and acute PTSD symptoms, to the course and persistence of fatigue was studied in a multifactorial model.

Methods

Participants were 247 adult burn survivors. Fatigue symptoms were assessed with the Multidimensional Fatigue Inventory during the acute phase and subsequently at 3, 6, 12, and 18 months postburn, and were compared to population norms. Age, gender, burn severity, acute PTSD symptoms and pain were assessed as potential predictors of fatigue over time in a latent growth model.

Results

At 18 months postburn, 46% of the burn survivors reported fatigue, including 18% with severe fatigue. In the acute phase, higher levels of fatigue were related to multiple surgeries, presence of pain, and higher levels of acute PTSD symptoms. Fatigue gradually decreased over time with minor individual differences in rate of decrease. At 18 months, pain and acute PTSD symptoms remained significant predictors of fatigue levels.

Conclusions

Protracted fatigue after burns was found in almost one out of five burn survivors and was associated with both pain and acute PTSD symptoms. Early detection of PTSD symptoms and early psychological interventions aimed at reducing PTSD symptoms and pain may be warranted to reduce later fatigue symptoms.

Identification and Prediction of Fatigue Trajectories in People With Rheumatoid Arthritis

OBJECTIVE

We aimed to identify groups demonstrating different long-term trajectories of fatigue among people with rheumatoid arthritis and determine baseline predictors for these trajectories.

METHODS

Our study included 2741 people aged 18 to 75 years who were independent in daily living. Data were collected from the Swedish Rheumatology Quality Register and questionnaires at baseline, 14 months, and 26 months. Fatigue was rated on a 100-mm visual analog scale. K-means cluster analysis was used to identify fatigue trajectories. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals for potential predictors of trajectory membership.

RESULTS

The mean age was 60 years, 73% of participants were female, and the mean baseline fatigue level was 39. Three distinct fatigue trajectories were identified, representing mild (mean 15, n = 1024), moderate (mean 41, n = 986), and severe (mean 71, n = 731) fatigue. Consistent patterns indicated that poorer health perception (ORs 1.68-18.40), more pain (ORs 1.38-5.04), anxiety/depression (ORs 0.85-6.19), and activity limitation (ORs 1.43-7.39) were associated with more severe fatigue. Those in the severe fatigue group, compared with those in the mild fatigue group, were more likely to be college educated than university educated (OR 1.56) and less likely to maintain physical activity (OR 0.54). Those in the severe fatigue group, compared with those in both the moderate (OR 0.67) and mild (OR 0.59) fatigue groups, were less likely to have one additional adult in the household.

CONCLUSION

This study identified stable fatigue trajectories, predicted by health perception, pain, anxiety/depression, activity limitation, educational level, maintained physical activity, and household composition. Interventions aimed at reducing these disabilities and supporting physical activity behaviors may help reduce fatigue.

Trajectories of fatigue in actively treated patients with established rheumatoid arthritis starting biologic DMARD therapy

Objectives

To define fatigue trajectories in patients with rheumatoid arthritis (RA) who initiate biological DMARD (bDMARD) treatment, and explore baseline predictors for a trajectory of continued fatigue.

Methods

One-hundred and eighty-four patients with RA initiating bDMARDs were assessed at 0, 1, 2, 3, 6 and 12 months. Swollen and tender joint counts, patient reported outcomes (PROMs), blood samples and ultrasound examinations were collected at each time point. Fatigue was assessed by the fatigue Numeric Rating Scale (0–10) from the Rheumatoid Arthritis Impact of Disease (RAID) questionnaire. Clinically significant fatigue was predefined as fatigue ≥4. Three trajectories of interest were defined according to level of RAID fatigue: no fatigue (≤3 at 5/6 visits), improved fatigue (≥4 at start, but ≤3 at follow-up) and continued fatigue (≥4 at 5/6 visits). Baseline variables were compared between groups by bivariate analyses, and logistic regression models were used to explore baseline predictors of continued vs improved fatigue.

Results

The majority of patients starting bDMARD therapy followed one of three fatigue trajectories, (no fatigue; n=61, improved; n=33 and continued fatigue; n=53). Patients with continued fatigue were more likely to be anti–citrullinated protein antibody and/or rheumatoid factor positive and had higher baseline PROMs compared to the other groups, while there were no differences between the groups for variables of inflammation including. Patient global, tender joint count and anxiety were predictors for the continued fatigue trajectory.

Discussion

A trajectory of continued fatigue was determined by PROMs and not by inflammatory RA disease activity.

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

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

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

Objectives

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

Methods

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

Results

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

Conclusions

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

A Structural Equation Model of Health-Related Quality of Life in Chinese Patients With Rheumatoid Arthritis

Background: The aim of this study was to examine how body image, Disease Activity Score in 28 joints, the feeling of being anxious, depression, fatigue, quality of sleep, and pain influence the quality of life (QoL) in patients with rheumatoid arthritis (RA). Methods: A multicenter cross-sectional survey with convenience sampling was conducted from March 2019 and December 2019, 603 patients with RA from five hospitals were evaluated using the Body Image Disturbance Questionnaire, Disease Activity Score in 28 joints, Hospital Anxiety and Depression Scale, Fatigue Severity Scale, Pittsburgh Sleep Quality Index, Short Form 36 Health Survey, and Global Pain Scale. The relationship between quality of life and other variables was evaluated by using the structural equation model (SEM). Results: A total of 580 patients were recruited. SEM fitted the data very well with a root mean square error of approximation (RMSEA) of 0.072. Comparative fit index of 0.966, and Tucker-Lewis index of 0.936. The symptoms and the normalized factor load of six variables showed that the normalized factor load of pain was 0.99. Conclusions: The QoL model was used to fit an SEM to systematically verify and analyze the population disease data, biological factors, and the direct and indirect effects of the symptom group on the QoL, and the interactions between the symptoms. Therefore, the diagnosis, treatment and rehabilitation of RA is a long-term, dynamic, and complex practical process. Patients' personal symptoms, needs, and experiences also vary greatly. Comprehensive assessment of patients' symptoms, needs, and experiences, as well as the role of social support cannot be ignored, which can help to meet patients' nursing needs, improve their mood and pain-based symptom management, and ultimately improve patients' QoL.

Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme

Background

Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.

Objectives

To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.

Design

Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.

Setting

Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).

Participants

Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.

Interventions

Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.

Main outcome measures

Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.

Results

Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.

Limitations

The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.

Conclusion

The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.

Future work

Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.

Trial registration

Current Controlled Trials ISRCTN70160382.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Current status and influencing factors of fatigue in patients with rheumatoid arthritis: A cross-sectional study in China

AIM

This study aimed to explore the level and influencing factors of fatigue in patients with rheumatoid arthritis.

METHODS

This cross-sectional study was conducted in 243 patients with rheumatoid arthritis from April 2016 to March 2017. The Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaire, Arthritis Self-Efficacy Scale-8, Visual Analogue Scale for pain, physical function subscale of Short Form 36-Item Health Survey, Hospital Anxiety and Depression Scale, Perceived Social Support Scale, Pittsburgh Sleep Quality Index and a self-designed demographic and disease-related information questionnaire were used to collect the data. Stepwise linear multiple regression was used to clarify the impact of statistically significant variables (P < 0.05) in the independent sample t test, one-way ANOVA and correlation analysis on the level of fatigue.

RESULTS

Stepwise linear multiple regression analyses showed that disease activity, self-efficacy, physical function, pain, depression, duration of morning stiffness and anxiety were major factors influencing fatigue in patients with rheumatoid arthritis, which explained 59.5% of the total variance.

CONCLUSION

Our study demonstrated a moderate level of fatigue in Chinese patients with rheumatoid arthritis. In clinical practice, nurses should explore individualized intervention programmes based on related predictors of fatigue to help patients relieve fatigue.

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

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

Management of Fatigue in Rheumatoid Arthritis

Fatigue in rheumatoid arthritis is highly prevalent. It is correlated only weakly with disease activity but more so with pain, mood, personality features, poor sleep, obesity and comorbidities. Fatigue can be measured by many standardised questionnaires and more easily with a Visual Analogue Scale or numeric rating scale. Most patients with RA have some fatigue, and at least one in six have severe fatigue. Chronic pain and depressed mood are also common in RA patients with significant fatigue. It affects function and quality of life and is worse on average in women. Evidence-based treatment for fatigue includes treatment of underlying disease activity (with on average modest improvement of fatigue), exercise programmes and supervised self-management programmes with cognitive-behavioural therapy, mindfulness and reinforcement (such as reminders). The specific programmes for exercise and behavioural interventions are not standardised. Some medications cause fatigue such as methotrexate. More research is needed to understand fatigue and how to treat this common complex symptom in RA that can be the worst symptom for some patients.

C-reactive protein and implications in rheumatoid arthritis and associated comorbidities

C-reactive protein (CRP) is routinely assessed as a marker of systemic inflammation in rheumatoid arthritis (RA). However, it is also an immune regulator that plays an important role in inflammatory pathways associated with RA and promotes atherogenic effects. Comorbidities linked to systemic inflammation are common in RA, and CRP has been associated with the risk for cardiovascular disease, diabetes, metabolic syndrome, pulmonary diseases, and depression. The relationship between systemic inflammation, CRP, and comorbidities in RA is complex, and it is challenging to determine how changing CRP levels may affect the risk or progression of these comorbidities. We review the biological role of CRP in RA and its implications for disease activity and treatment response. We also discuss the impact of treatment on CRP levels and whether reducing systemic inflammation and inhibiting CRP-mediated inflammatory pathways may have an impact on conditions commonly comorbid with RA.

Correlations of fatigue in Danish patients with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis

Objective

To describe fatigue in relation to disease-specific and socioeconomic factors and to test possible correlations between fatigue and work impairment, quality of life, pain, sleep, depression, and physical functioning in people with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA).

Methods

A questionnaire-based cross-sectional survey collecting patient characteristics such as disease characteristics, socioeconomic factors and patient-reported outcomes (PROs) from patients with RA, PsA and axSpA in Denmark. PRO scales included the FACIT-Fatigue sub-scale, Work Productivity and Activity Impairment scale (WPAI), EuroQol (EQ-5D), Medical Outcomes Study Sleep Scale (MOS), Major Depression Inventory (MDI), and Health Assessment Questionnaire (HAQ). Respondents were recruited via routine visits to the outpatient rheumatology clinic; information on diagnosis, treatment and disease activity was collected from medical journals by trained nurses.

Results

487 patients participated in the study. Fatigue was more present in women, experienced patients, and patients who changed medication in the past 12 months, who were unemployed, who had less education, and who had lower household income. There was no statistically significant difference between mean fatigue in the three diagnostic groups (p = 0.08). Fatigue correlated with all included PROs (Pearson correlation coefficients, p<0.0001). Stratifying for diagnosis and adjusting for socioeconomic factors did not change the conclusion.

Conclusion

In a stable, representative group of patients with RA, PsA and axSpA, we found significant correlations between fatigue and work impairment, quality of life, pain, sleep, depression and physical functioning. Fatigue cannot be perceived as a single problem, but rather as a symptom that affects broadly.

Fatigue in inflammatory arthritis

Fatigue is highly prevalent in inflammatory arthritis, and people living with the symptom have described it as overwhelming and a challenge to manage. In this article, we explore the experience, impact and non-pharmacological management of fatigue from a multi-disciplinary perspective. We start by presenting qualitative evidence from people living with fatigue, including the physical, cognitive and emotional nature of the symptom and its impact on daily life. This is followed by discussion of current conceptual models of mechanisms and factors that may cause and maintain fatigue, within and between individuals. We then address the issue of fatigue measurement and modes of assessment, which is an integral aspect of management and evaluating support provision. This leads to a review of the research evidence for non-pharmacological interventions to reduce fatigue severity and impact. Finally, we consider implementation of this evidence in clinical practice and we introduce some key practical tools and techniques.

A biopsychosocial network model of fatigue in rheumatoid arthritis: a systematic review

Fatigue in RA is prevalent, intrusive and disabling. We propose a network model of fatigue encompassing multiple and mutually interacting biological, psychological and social factors. Guided by this model, we reviewed the literature to offer a comprehensive overview of factors that have been associated with fatigue in RA. Six categories of variables were found: physical functioning, psychological functioning, medical status, comorbidities and symptoms, biographical variables and miscellaneous variables. We then systematically reviewed associations between fatigue and factors commonly addressed by rheumatology health professionals. Correlations of fatigue with physical disability, poor mental well-being, pain, sleep disturbance and depression and anxiety were ∼0.50. Mostly these correlations remained significant in multivariate analyses, suggesting partly independent influences on fatigue and differences between individuals. These findings indicate the importance of research into individual-specific networks of biopsychosocial factors that maintain fatigue and tailored interventions that target the influencing factors most relevant to that person.

The Role of Inflammation in Depression and Fatigue

Depression and fatigue are conditions responsible for heavy global societal burden, especially in patients already suffering from chronic diseases. These symptoms have been identified by those affected as some of the most disabling symptoms which affect the quality of life and productivity of the individual. While many factors play a role in the development of depression and fatigue, both have been associated with increased inflammatory activation of the immune system affecting both the periphery and the central nervous system (CNS). This is further supported by the well-described association between diseases that involve immune activation and these symptoms in autoimmune disorders, such as multiple sclerosis and immune system activation in response to infections, like sepsis. Treatments for depression also support this immunopsychiatric link. Antidepressants have been shown to decrease inflammation, while higher levels of baseline inflammation predict lower treatment efficacy for most treatments. Those patients with higher initial immune activation may on the other hand be more responsive to treatments targeting immune pathways, which have been found to be effective in treating depression and fatigue in some cases. These results show strong support for the hypothesis that depression and fatigue are associated with an increased activation of the immune system which may serve as a valid target for treatment. Further studies should focus on the pathways involved in these symptoms and the development of treatments that target those pathways will help us to better understand these conditions and devise more targeted treatments.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Perceived Fatigability and Objective Physical Activity in Mid- to Late-Life

Background

Fatigability, defined as fatigue in relation to a standardized task, predicts functional decline in older adults independent of reported tiredness or energy level. Although the sensation of fatigue, tiredness, and energy level adversely affect physical activity (PA), the association between fatigability and objectively measured PA is unknown.

Methods

Participants in the Baltimore Longitudinal Study of Aging (n = 557, 50% women, aged 50-97 years) were instructed to wear an Actiheart accelerometer for 7 consecutive days in the free-living environment. Perceived fatigability was assessed using the Borg rating of perceived exertion (RPE) after 5 minutes of treadmill walking at 1.5 mph (0.67 m/s) and categorized as low (6-7 RPE), intermediate (8-9 RPE), and high (10+ RPE) fatigability. Time-of-day PA differences between fatigability groups were assessed using mixed-effects modeling.

Results

Total daily PA was 1.3% lower for every unit increment in perceived fatigability after adjusting for demographic, behavioral, and medical factors (p = .01). In time-of-day analyses, the high fatigability group was less active compared to the low fatigability group throughout the day (8:00 am to 8:00 pm) and the intermediate fatigability group in the morning (8:00 am to 12:00 pm). Patterns of PA within the high fatigability group differed from both the intermediate and low groups in the morning but mirrored the intermediate group in the afternoon and evening.

Discussion

These results suggest that RPE is a bio-marker of fatigability associated with progressively lower PA with aging. Whether the effects of fatigability occurring at the end of the day reflect waning energy levels or a voluntary choice that could be modified remains to be evaluated.

Patient-reported fatigue in patients with rheumatoid arthritis who commence biologic therapy: a longitudinal study

Aims and objectives

To examine changes in patient-reported fatigue, over a twelve month period, in rheumatoid arthritis patients who commence biologic treatment, and to identify possible predictors for such changes.

Background

Fatigue is a burdensome symptom for patients with rheumatoid arthritis. Despite biologics being effective in reducing disease activity, patients still report fatigue.

Design

A longitudinal observational study.

Methods

A total of 48 patients were enrolled in the study. Fatigue was measured by the Fatigue Severity Scale. Independent samples T-tests were used to test gender differences, and paired samples T-tests were used to measure differences between repeated measures. Bivariate and multiple regression analyses were used to examine potential predictors for changes in fatigue, such as age, sex, Disease Activity Score 28, pain and physical and emotional well-being.

Results

Forty-seven patients completed the study. From baseline to 12-month follow-up, fatigue decreased significantly in both women and men. Analyses of predictors were performed step-wise, and the final model included sex and physical well-being. The results from this final step showed that female sex was the only significant predictor for changes in fatigue.

Conclusion

Patients commencing biologic therapy reported a significant reduction in fatigue. Female sex was a significant predictor of changes in fatigue.

Relevance to clinical practice

Despite improvements in pharmacological treatment, patients with rheumatoid arthritis still report fatigue. This is a multifaceted health problem encompassing personal and emotional factors in addition to the clinical factors directly connected to the disease.

The extra-articular impacts of rheumatoid arthritis: moving towards holistic care

Although treat-to-target has revolutionised the outcomes of patients with rheumatoid arthritis (RA) there is emerging evidence that attaining the target of remission is insufficient to normalise patients’ quality of life, and ameliorate the extra-articular impacts of RA. RA has a broad range of effects on patient’s lives, with four key “extra-articular” impacts being pain, depression and anxiety, fatigue and rheumatoid cachexia. All of these are seen frequently; for example, studies have reported that 1 in 4 patients with RA have high-levels of fatigue. Commonly used drug treatments (including simple analgesics, non-steroidal anti-inflammatory drugs and anti-depressants) have, at most, only modest benefits and often cause adverse events. Psychological strategies and dynamic and aerobic exercise all reduce issues like pain and fatigue, although their effects are also only modest. The aetiologies of these extra-articular impacts are multifactorial, but share overlapping components. Consequently, patients are likely to benefit from management strategies that extend beyond the assessment and treatment of synovitis, and incorporate more broad-based, or “holistic”, assessments of the extra-articular impacts of RA and their management, including non-pharmacological approaches. Innovative digital technologies (including tablet and smartphone “apps” that directly interface with hospital systems) are increasingly available that can directly capture patient-reported outcomes during and between clinic visits, and include them within electronic patient records. These are likely to play an important future role in delivering such approaches.

Fatigue in Rheumatoid Arthritis Patients: Association With Sleep Quality, Mood Status, and Disease Activity

OBJECTIVES

Rheumatoid arthritis (RA) is a chronic inflammatory disease, characterized by polyarthritis and systemic manifestations. RA-fatigue is a significant problem and adds on disease burden. Sleep disturbance, depression, and disease activity are suggested contributing factors to RA-fatigue; however, their combined role did not examine before among Egyptian RA patients. The objective of the study was to investigate the presence of fatigue, sleep and mood disturbances in RA patients. Also, to evaluate the possible association of poor sleep, depression, and disease activity with RA-fatigue.

METHODS

This cross-sectional study included 115 RA patients diagnosed according to the 2010 ACR-EULAR criteria and 46 age and sex matched controls. Fatigue using the Multidimensional Assessment of Fatigue-Global Fatigue Index, sleep using the Pittsburgh Sleep Quality Index and mood status using Beck Depression Inventory were assessed for all participants. RA disease activity was evaluated using disease activity score-28 joints.

RESULTS

RA patients had higher mean fatigue, sleep disturbance, and depression scores (27.2±8.9, 6.4±3.6, and 12.8±7.3; respectively) than controls (22.7±7, 4.8±3, 7.8±5.9; respectively) (P<.05). Poor sleep, depression and higher disease activity were significantly correlated with fatigue (r=0.4, r=0.65, r=0.55; respectively) (P<.001). The three variables may explain up to 49.1% of the variation in fatigue on multiple regression analysis.

CONCLUSION

Fatigue, poor sleep, and depression are more common in Egyptian patients with RA. A remarkably higher fatigue was associated with poor sleep, depression, and high disease activity, thus monitoring these silent comorbidities in clinical practice is required.

Association of weight loss with improved disease activity in patients with rheumatoid arthritis: A retrospective analysis using electronic medical record data

Objective

To evaluate the association between weight loss and rheumatoid arthritis (RA) disease activity.

Methods

We conducted a retrospective cohort study of RA patients seen at routine clinic visits at an academic medical center, 2012-2015. We included patients who had ≥2 clinical disease activity index (CDAI) measures. We identified visits during follow-up where the maximum and minimum weights occurred and defined weight change and CDAI change as the differences of these measures at these visits. We defined disease activity improvement as CDAI decrease of ≥5 and clinically relevant weight loss as ≥5 kg. We performed logistic regression analyses to establish the association between improved disease activity and weight loss and baseline BMI category (≥25 kg/m² or <25 kg/m²). We built linear regression models to investigate the association between continuous weight loss and CDAI change among patients who were overweight/obese at baseline and who lost weight during follow-up.

Results

We analyzed data from 174 RA patients with a median follow-up of 1.9 years (IQR 1.3-2.4); 117 (67%) were overweight/obese at baseline, and 53 (31%) lost ≥5 kg during follow-up. Patients who were overweight/obese and lost ≥5 kg had three-fold increased odds of disease activity improvement compared to those who did not (OR 3.03, 95%CI 1.18-7.83). Among those who were overweight/obese at baseline, each kilogram weight loss was associated with CDAI improvement of 1.15 (95%CI 0.42-1.88). Our study was limited by using clinical data from a single center without fixed intervals for assessments.

Conclusion

Clinically relevant weight loss (≥5 kg) was associated with improved RA disease activity in the routine clinical setting. Further studies are needed for replication and to evaluate the effect of prospective weight loss interventions on RA disease activity.

Fatigue in Rheumatoid Arthritis

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Causes and consequences of fatigue in rheumatoid arthritis

PURPOSE OF REVIEW

To review current information on the causes, treatments, and consequences of fatigue in rheumatoid arthritis.

RECENT FINDINGS

Disease activity (inflammation, pain, joint symptoms) is associated with greater fatigue. However, disease activity per se accounts for only a small portion of fatigue, and rheumatoid arthritis medications that reduce disease activity have small effects on fatigue. Instead, factors outside the direct effects of rheumatoid arthritis, such as obesity, physical inactivity, sleep disturbance, and depression, explain the majority of variation in fatigue. Some of these factors may be indirect effects of disease (e.g. pain can lead to sleep disturbance). Rheumatoid arthritis has significant effects on the quality of life of individuals with rheumatoid arthritis. The most effective approaches to reducing rheumatoid arthritis fatigue appear to be behavioral, such as increasing physical activity, or cognitive, such as cognitive behavioral interventions.

SUMMARY

Fatigue in rheumatoid arthritis appears to be largely because of factors outside the direct effects of the disease, such as behavioral and psychological factors. In spite of the tremendous impact of fatigue on patient health and quality of life, effective treatments remain elusive, but existing data show that behavioral and cognitive approaches may be most effective.

Fatigue and sleep quality in rheumatoid arthritis patients during hospital admission

Objectives

Rheumatoid arthritis (RA) is a systemic disease of connective tissue characterised by chronic course with periods of exacerbation and remission. Even in the early stages of the disease patients report the occurrence of fatigue and sleep disorders. Reduced sleep quality and chronic fatigue are common among patients with rheumatoid arthritis. The aim of the research was to evaluate the severity of fatigue and sleep quality assessment among patients hospitalised with rheumatoid arthritis and to determine the relation between the level of symptoms of fatigue and sleep quality and variables such as: age, gender, disease duration, marital status, applied pharmacological treatment, and pain intensity.

Materials and methods

The study involved 38 patients (12 men and 26 women) hospitalised in the Rheumatologic Ward of the Orthopaedics and Rehabilitation Hospital of the University of Medical Sciences. The average age of the entire group was 56.26 years. Fatigue was evaluated with use of Polish version of Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), while in order to evaluate sleep quality within the examined group of patients the Pittsburgh Sleep Quality Index (PSQI) was used.

Results

Patients with rheumatoid arthritis in the analysed group have lower sleep quality, and within subjects with such a diagnosis the fatigue is present. The relation was found between fatigue and such variables as: age, illness duration, marital status, applied pharmacological treatment, and severity of pain. Sleep quality within patients with RA is correlated by such variables as: age, gender, applied pharmaceutical treatment, and severity of pain. It was identified that patients with lower sleep quality experience increased levels of fatigue.

Conclusions

There is a need to clarify which factors determine the level of fatigue and sleep quality in patients suffering from RA in future population-based research and to indicate to doctors, nurses, psychologists, and physiotherapists the significance and importance of the problem, which requires specialised and holistic care.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

FUNDING

Bristol-Myers Squibb.