Disease activity and disease-related factors are drivers of patient global assessment in rheumatoid arthritis: a real-life cross-sectional study

Despite that the Patient Global Assessment (PGA) is widely used for measuring Rheumatoid Arthritis (RA) disease activity to define the remission state of the disease, the primary contributors influencing patients' ratings are still debated. This study aims to determine which clinical, sociodemographic and lifestyle-related contextual factors might be key drivers of PGA in RA. This single-center cross-sectional study recruited 393 consecutive adult RA patients. Median age 60 years, females 306 (77.9%). Data related to disease activity were assessed by using Simplified Disease Activity Index (SDAI), severity by Health Assessment Questionnaire (HAQ), and impact by RA Impact of Disease (RAID). Sociodemographic/lifestyle features were collected. Disease remission was calculated using Boolean-based criteria 1.0 and 2.0. Quantile regression models were used for univariate and multivariate analysis. The remission rate progressively increased from 15% by using SDAI with a Boolean 1.0-based definition to 43.5% using a Boolean 2.0-based remission. Among factors related to disease activity, the use of low-dose corticosteroids, the RAID items pain and sleep difficulties were predictive for worse PGA scores (p = 0.01). Among factors related to disease severity HAQ score and RAID total were independent factors associated with higher median PGA (p = 0.02 and p < 0.001). RAID's physical well-being was related to PGA scores (p = 0.01). An increasing trend in PGA was observed in longstanding diseases (> 15 years). Our results confirmed that there is no unambiguous interpretation of the PGA score. It is a measure related to some disease activity parameters, but it is also influenced by contextual factors related to disease severity and impact. These data highlighted that PGA should have a broad interpretation, thus supporting the proposal of a dual targets (biological and impact) approach to obtain a more accurate estimate of disease activity.

Clinical and Biological Factors Are Associated with Treatment-Resistant Depression

Background: Treatment-resistant depression (TRD) is a debilitating condition associated with unmet clinical needs. Few studies have explored clinical characteristics and serum biomarkers associated with TRD. Aims: We investigated whether there were differences in clinical and biochemical variables between patients affected by TRD than those without. Methods: We recruited 343 patients (165 males and 178 females) consecutively hospitalized for MDD to the inpatient clinics affiliated to the Fondazione IRCCS Policlinico, Milan, Italy (n = 234), and ASST Monza, Italy (n = 109). Data were obtained through a screening of the clinical charts and blood analyses conducted during the hospitalization. Results: TRD versus non-TRD patients resulted to be older (p = 0.001), to have a longer duration of illness (p < 0.001), to be more currently treated with a psychiatric poly-therapy (p < 0.001), to have currently more severe depressive symptoms as showed by the Hamilton Depression Rating Scale (HAM-D) scores (p = 0.016), to have lower bilirubin plasma levels (p < 0.001). In addition, more lifetime suicide attempts (p = 0.035), more antidepressant treatments before the current episode (p < 0.001), and a lower neutrophil to lymphocyte ratio at borderline statistically significant level (p = 0.060) were all associated with the TRD group. Conclusion: We identified candidate biomarkers associated with TRD such as bilirubin plasma levels and NLR, to be confirmed by further studies. Moreover, TRD seems to be associated with unfavorable clinical factors such as a predisposition to suicidal behaviors. Future research should replicate these results to provide robust data in support of the identification of new targets of treatment and implementation of prevention strategies for TRD.

COVID-19 related poor mental health and sleep disorders in rheumatic patients: a citizen science project

BACKGROUND

Patients with chronic rheumatic diseases (RDs) are more vulnerable and the containment measures related to the COVID-19 pandemic might have severe psychological consequences. We investigated the presence of and risk factors associated with poor mental health, sleep disorders among RDs during the pandemic.

METHODS

This cross-sectional Italian citizen science project evaluated the psychological impact of the COVID-19 pandemic in patients with RDs. Between May and September 2020, eleven RD patients' associations sent the survey by using their mailing list and the related webpage and social network. 507 RD patients completed an ad-hoc anonymous online survey including the Perceived Stress Scale (PSS) and Impact Event Scale-Revised (IES-R).

RESULTS

The mean scores on the PSS-10 and the IES-R were 18.1 and 29.7, respectively. Higher PSS scores were associated with younger age (p <  0.01), female gender (p <  0.01), overweight/obesity (p = 0.01), psychiatric pharmacotherapy (p <  0.01), and anxiety for loss of income (p <  0.01). Higher IES-R scores were associated with female gender (p <  0.01), intestinal diseases (p = 0.03), anxiety (p <  0.01), and health concern (p <  0.01). Among 375 patients with inflammatory arthritis, 246 (65.6%) had trouble staying asleep, 238 (63.5%) falling asleep, and 112 (29.9%) had dreams about the pandemic. Older age (OR = 1.038, CI 1.002-1.076), psychiatric pharmacotherapy (OR = 25.819, CI 11.465-58.143), and COVID infection (OR = 2.783, CI 1.215-6.372) were predictive of insomnia during the pandemic.

CONCLUSIONS

A considerable COVID-19 related psychosocial burden has been detected in RDs. Different factors were predictive of poor mental health and sleep disorders in these patients. Focused supportive strategies should be implemented to improve the psychological well-being of fragile patients during pandemics.

POS1161 A CITIZEN SCIENCE APPROACH TO CAPTURE POOR MENTAL HEALTH RELATED TO COVID-19 IN RHEUMATIC PATIENTS AFTER CONFINEMENT DURING PANDEMIC IN ITALY

Background:

A considerable psychosocial burden is one of the relevant consequences of the COVID-19 pandemic. In particular, quarantine measures have been related to negative psychological effects, including symptoms of post-traumatic stress disorder, stress, anxiety, and depression (1). This rise in mental health disorders might be even worse among people more vulnerable to psychological stress such as patients suffering from chronic rheumatic diseases (RDs).

Objectives:

The present Italian nationwide survey engages patients with rheumatic conditions through eleven associations of RD patients. It is conducted to establish the COVID-19 related self-reported poor mental health symptoms and to identify potential factors associated with these concerns among RDs who experienced the COVID-19 quarantine in Italy.

Methods:

We collected data from May to September 2020 from RD patients living in Italy during the COVID-19 quarantine by an ad-hoc online survey. By using their mailing list and the related webpage and social network, eleven patients’ associations sent a call to RD patients asking them to complete an anonymous online survey which included the Perceived Stress Scale (PSS), and the Impact Event Scale-Revised (IES-R). χ2 tests were performed to detect statistically significant differences in both rating scale scores between groups defined by qualitative variables. Correlation analyses were realized with quantitative variables and rating scale scores. Variables significant in univariate analyses were then inserted in multivariate regression models.

Results:

In total, 507 RD patients completed to the survey. 375 (73.9%) patients had inflammatory arthritis (243 rheumatoid arthritis, 76 psoriatic arthritis, 49 ankylosing spondylitis, and 7 Still’s disease), and 96 (18.9%) with connective tissue diseases or systemic vasculitis. 31 (6.1%) patients had primary fibromyalgia and 5 osteoarthritis or crystal arthropathies. Self-reported major sources of anxiety are reported in the Figure 1 below.

The mean (SD) scores of the PSS-10 and the IES-R were 18.1 ± 8.1 and 29.7 ± 17.5, respectively. With regard to the IES-R subscale scores, the total sample did not show a prominence of one of the three main domains (intrusion, avoidance and hyperarousal). Higher PSS scores were significantly associated with younger age (p<0.01), female gender (p<0.01), living outside Lombardy (p=0.03), presence of overweight/obesity (p=0.01), ongoing psychopharmacotherapy (p<0.01), and anxiety for loss of incomes (p<0.01). Female gender (p<0.01) and living outside Lombardy (p=0.02) were associated also with higher IES-R scores, together with the presence of intestinal diseases (p=0.03), anxiety disorders (p<0.01), and worries about health (p<0.01).

Conclusion:

This nationwide study revealed a high impact of self-reported distress, anxiety, and perceived stress among rheumatic patients after confinement during COVID-19 pandemic in Italy. Different factors were found to be predictive of poor mental health such as having female gender, younger age, living outside Lombardy, having overweight/obesity, or intestinal diseases, having a history of psychiatric symptoms (e.g. anxiety). Moreover, the lockdown experience worsened psychiatric symptoms and increased the assumption of psychopharmacotherapy in this vulnerable population. Prevention strategies focused on specific variables should be implemented to ameliorate psychological well-being of fragile patients during pandemics.

References:

[1]Brooks SK, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395:912-20

Acknowledgements:

We wish to thank the Lombard Association of Rheumatic Diseases (ALOMAR) for its invaluable contribution to the planning and dissemination the survey, all the Italian associations among which the National Association of People with Rheumatic and Rare Diseases (APMARR) and National Association of People with Rheumatic Diseases (ANMAR) that disseminated the survey through social media. The authors are grateful to all patients for contributing to this project.

Disclosure of Interests:

Francesca Ingegnoli: None declared, Massimiliano Buoli: None declared, Cristina Posio: None declared, Raffaele Di Taranto: None declared, Alessandro Lo Muscio: None declared, Enrico Cumbo: None declared, Silvia Ostuzzi: None declared, Roberto Caporali Speakers bureau: Abbvie, Amgen, BMS, Celltrion, Galapagos, Gilead, Lilly, Pfizer, Roche, UCB, Sanofi, Fresenius Kabi, Samsung bioepis, MSD, Consultant of: Galapagos, Gilead, Lilly,Janssen, MSD.

AB0661 EFFECT OF COVID-19 PANDEMIC ON SLEEP DISORDERS IN PATIENTS WITH INFLAMMATORY ARTHRITIS

Background:

A decrease in physical activity, exposure to daylight and a decline in psychological wellbeing due to COVID19 pandemic have led to increased incidence of sleep disorders such as difficulties falling asleep, sleep disruption, insomnia, nightmares and daytime sleepiness (1). Patients with inflammatory arthritis are more vulnerable to pain, depression, anxiety and sleep disorders. These complaints are linked in a cyclical pattern that may negatively affect daily-life activities (2-4). To our knowledge, the impact of pandemic on sleep disturbances in patients with inflammatory arthritis has not been evaluated yet.

Objectives:

The aim of this study is to establish the COVID-19 related impact on sleep disturbances among patients with inflammatory arthritis who experienced the COVID-19 quarantine in Italy.

Methods:

Data about chronic inflammatory arthritis (rheumatoid arthritis [RA], psoriatic arthritis [PsA] and ankylosing spondylitis [AS]) were retrieved from a large nationwide online survey involving patients affected by different rheumatic diseases. From May to September 2020, eleven patients’ associations sent a call to rheumatic patients asking them to complete an anonymous online survey with specific questions also about sleep disturbances and pre- and post-lockdown self-reported use of psychopharmacotherapy. Data were analysed by a binary logistic regression model having the presence of sleep disturbances during COVID 19 pandemic as dependent variable.

Results:

375 of 507 (74%) of patients had inflammatory arthritis: 249 RA, 77 PsA and 49 AS. 291 (77.6%) were females with a median (IQR) age of 54 (44-63) years. There was an increase in the use of psychiatric compounds after quarantine period (59 [15,7%] vs 65 [17,3%]), especially for sleep medications (23 [6,1%] vs 28 [7,5%]) and anxiolytics (15 [4%] vs 18 [4,8%]). 246 (65.6%) of patients had trouble staying asleep, 238 (63.5%) had trouble falling asleep, and 112 (29.9%) had dreams about pandemic (Figure 1 below).

The binary logistic regression suggests that older age (OR= 1.038, p = .040), assumption of medication for psychiatric symptoms before COVID-19 (OR = 25.819, CI 11.465-58.143) and presence of COVID infection (OR = 2.783, CI 1.215-6.372) were predictive of insomnia during pandemic.

Conclusion:

These results confirm that sleep disturbances have been a relevant concern in patients with inflammatory arthritis after COVID-19 national lockdown. Changes in daily life related to confinement have influenced psychological distress leading to a significant impact on sleep difficulties such as inability to fall early asleep or to maintain adequate sleep. Furthermore, older patients who had coronavirus infection and were previously treated for psychiatric disorders were at higher risk developing sleep disorders.

References:

[1]Voulgaris A, et al. Sleep Med. 2020;73:170-176.

[2]Wolfe F, et al. J Rheumatol. 2006;33:1942-51

[3]Irwin MR, et al. Sleep. 2012;35:537-4

[4]Zielinski MR, et al. Front Immunol. 2019;10:1827.

Acknowledgements:

We wish to thank the Lombard Association of Rheumatic Diseases (ALOMAR) for its invaluable contribution to the planning and dissemination the survey, all the Italian associations among which the National Association of People with Rheumatic and Rare Diseases (APMARR) and National Association of People with Rheumatic Diseases (ANMAR) that disseminated the survey through social media. The authors are grateful to all patients for contributing to this project.

Disclosure of Interests:

Francesca Ingegnoli: None declared., Massimiliano Buoli: None declared., Cristina Posio: None declared., Raffaele Di Taranto: None declared., Roberto Caporali Speakers bureau: Abbvie, Amgen, BMS, Celltrion, Galapagos, Gilead, Lilly, Pfizer, Roche, UCB, Sanofi, Fresenius Kabi, Samsung bioepis, MSD, Consultant of: Galapagos, Gilead, Lilly,Janssen, MSD.

POS1176 THE IMPACT OF COVID-19 QUARANTINE ON MENTAL HEALTH OF PATIENTS WITH FIBROMYALGIA

Background:

Detrimental psychological effects, including symptoms of post-traumatic stress disorder (PTSD), stress, anxiety, and depression have been related to COVID-19 quarantine measures (1). These aspects may be particularly relevant in stress-related disorders such as fibromyalgia (FM) in which previous evidence demonstrated a causal effect of psychological stressors on chronic non-inflammatory pain of FM (2). Recent studies highlighted a significant worsening of FM symptoms after COVID-19 related lockdown period (3-4), but the levels of perceived stress and distress have not been evaluated yet.

Objectives:

The aim of this study is to establish the COVID-19 related perceived stress and distress among patients with FM who experienced the COVID-19 quarantine in Italy. Data were retrieved from a larger nationwide online survey involving patients affected by different rheumatic diseases (RD).

Methods:

We collected data from May to September 2020 from RD patients living in Italy during the COVID-19 quarantine by an ad-hoc online survey. Eleven associations of RD patients sent a call by using their mailing list, webpages and social network. They asked to complete an anonymous online survey which included the Perceived Stress Scale (PSS), and the Impact Event Scale-Revised (IES-R). Descriptive statistics were used to summarize results.

Results:

79 of 507 (15.6%) of RD patients who completed the survey declared to have been diagnosed FM. 77 (97.5%) were females, with a mean (± SD) age of 51.0 ± 12.4 yrs. In FM patients, the mean (SD) PSS score was 23.8 ± 8.1. In particular, 8 (10.1%) reported low, 38 (48.1%) moderate and 33 (41.8%) high PSS scores. Moreover, IES-R mean (SD) score was 38.5 ± 17.2. Among FM patients, 51 (64.6%) reported scores greater than 33, indicating the probable presence of a PTSD. With regard to the IES-R subscale scores, the total sample did not show a prominence of one of the three main domains: intrusion (13.9 ± 7.3), avoidance (11.9 ± 6.1) and hyperarousal (12.6 ± 5.9). In these FM patients, self-reported major sources of anxiety were related to personal and relatives’ health (59.5%), followed by social withdrawal (21.5%) and employment loss/financial difficulties (11.4%). There was a slight increase of self-reported use of antidepressants (15 [18.9%] vs 16 [20.2%]) and anxiolytics drugs (4 [5.1%] vs 5 [6.3%]) after lockdown period.

Conclusion:

These results confirm that psychosocial stress and distress were highly pervasive in FM after COVID-19 national lockdown. It is known that stressed status may exacerbate and/or precipitate later development of FM symptoms. These data support the substantial worsening of somatic burden of FM after lockdown period reported in previous studies (3-4). Coping strategies should be implemented to ameliorate psychological well-being of these patients in this stressful era.

References:

[1]Brooks SK, et al. Lancet. 2020;395:912-20.

[2]Hung CH, et al. Ann Rheum Dis 2020;79:1644-1656.

[3]Batres-Marroquín AB, et al. J Clin Rheumatol. 2020 Epub ahead of print.

[4]Cavalli G, et al. Rheumatology 2021;60:465-467.

Acknowledgements:

We wish to thank the Lombard Association of Rheumatic Diseases (ALOMAR) for its invaluable contribution to the planning and dissemination the survey, all the Italian associations among which the National Association of People with Rheumatic and Rare Diseases (APMARR) and National Association of People with Rheumatic Diseases (ANMAR) that disseminated the survey through social media. The authors are grateful to all patients for contributing to this project.

Disclosure of Interests:

Francesca Ingegnoli: None declared, Massimiliano Buoli: None declared, Cristina Posio: None declared, Raffaele Di Taranto: None declared, Roberto Caporali Speakers bureau: Abbvie, Amgen, BMS, Celltrion, Galapagos, Gilead, Lilly, Pfizer, Roche, UCB, Sanofi, Fresenius Kabi, Samsung bioepis, MSD, Consultant of: Galapagos, Gilead, Lilly,Janssen, MSD.