C.L. Overman

The prospective association between psychological distress and disease activity in rheumatoid arthritis: a multilevel regression analysis

Background Cross-sectional associations suggest a mutual impact of disease activity and psychological distress in rheumatoid arthritis (RA), but a prospective association has not been established. Objective To examine concurrent and prospective associations between psychological distress and disease activity. Methods Patients with RA (N=545, disease duration ≤1 year, age 18–83 years, 69% female, 64% rheumatoid factor (RF) positive) were monitored for 5 years. The Thompson joint score and erythrocyte sedimentation rate were assessed every 6 months. Depressed mood and anxiety were measured every 12 months. Multilevel regression analysis was used. RF positivity, age and female sex were included as covariates. Results Concurrent levels of psychological distress and disease activity were positively associated (p≤0.04). Prospectively, depressed mood was associated with disease activity levels 6 months later (p≤0.04). The Thompson joint score was associated with psychological distress levels 6 months later (p≤0.03) and also with an increase in depressed mood over the subsequent 6 months (p=0.02). No other significant prospective associations were found (p≥0.07). Conclusions Psychological distress and disease activity are positively associated when measured at the same time as well as when measured 6 months apart. While some support was found for the idea that a higher level of disease activity is a risk factor for an increase in psychological distress, the results do not support the notion that psychological distress is a risk factor for future exacerbation of disease activity.

Change of psychological distress and physical disability in patients with rheumatoid arthritis over the last two decades.

During the past decades, a more cautious approach with respect to prescribing medication and physical exercise progressed toward evidence‐based guidelines regarding the management of rheumatoid arthritis (RA). Currently, physical activity and other means to improve well‐being and functioning are encouraged, and the disease is targeted earlier with more intensive and aggressive pharmacologic treatment. The current study examined whether psychological distress and physical disability in patients with RA reduced over the last 2 decades and whether this is explained by a reduction of disease activity.

Fatigue in patients with systemic lupus erythematosus : the role of dehydroepiandrosterone sulphate

Fatigue is a major problem in systemic lupus erythematosus (SLE), but the physiological substrate of this fatigue is largely unclear. To examine if low levels of dehydroepiandrosterone (DHEA) and its sulphate DHEAS play a role in SLE fatigue, we compared: 1) DHEAS levels and fatigue between 60 female patients with SLE with low disease activity (31 using, 29 not using prednisone) and 60 age-matched healthy women, and 2) fatigue between patients with SLE with low and normal DHEAS levels. Serum DHEAS levels were determined with an Advantage Chemiluminescense System. The Multidimensional Fatigue Inventory (MFI) was used to assess fatigue. Patients were more fatigued (p ≤ 0.001) than healthy women and more often had below-normal DHEAS levels (p < 0.001). Patients using prednisone with low and normal DHEAS levels reported a similar level of fatigue (p ≥ 0.39). Patients with low DHEAS levels not using prednisone reported less fatigue than those with normal DHEAS levels (p ≤ 0.03). Thus, our results indicate that low DHEAS levels in SLE are not – or even inversely – related to fatigue. After our previous finding that DHEA administration does not reduce fatigue, this result further indicates that low serum DHEA(S) levels alone do not offer an explanation for SLE fatigue.

Contribution of the Subjective Components of the Disease Activity Score to the Response to Biologic Treatment in Rheumatoid Arthritis

A significant proportion of patients with rheumatoid arthritis do not respond adequately to biologic treatment. We hypothesized that lack of response to (biologic) disease‐modifying antirheumatic drugs (DMARDs) is high in patients in whom the subjective, patient‐reported component of the Disease Activity Score 28 (DAS28) is high at baseline. The primary aim of our present study was to investigate the contribution of the more subjective versus the objective components of the DAS28 to response to biologic agents in RA patients, as well as the changes in this contribution over time. The secondary aim was to examine whether the value of this subjective contribution at baseline affects the response to treatment.

EULAR recommendations for the health professional’s approach to pain management in inflammatory arthritis and osteoarthritis

Pain is the predominant symptom for people with inflammatory arthritis (IA) and osteoarthritis (OA) mandating the development of evidence-based recommendations for the health professional’s approach to pain management. A multidisciplinary task force including professionals and patient representatives conducted a systematic literature review of systematic reviews to evaluate evidence regarding effects on pain of multiple treatment modalities. Overarching principles and recommendations regarding assessment and pain treatment were specified on the basis of reviewed evidence and expert opinion. From 2914 review studies initially identified, 186 met inclusion criteria. The task force emphasised the importance for the health professional to adopt a patient-centred framework within a biopsychosocial perspective, to have sufficient knowledge of IA and OA pathogenesis, and to be able to differentiate localised and generalised pain. Treatment is guided by scientific evidence and the assessment of patient needs, preferences and priorities; pain characteristics; previous and ongoing pain treatments; inflammation and joint damage; and psychological and other pain-related factors. Pain treatment options typically include education complemented by physical activity and exercise, orthotics, psychological and social interventions, sleep hygiene education, weight management, pharmacological and joint-specific treatment options, or interdisciplinary pain management. Effects on pain were most uniformly positive for physical activity and exercise interventions, and for psychological interventions. Effects on pain for educational interventions, orthotics, weight management and multidisciplinary treatment were shown for particular disease groups. Underpinned by available systematic reviews and meta-analyses, these recommendations enable health professionals to provide knowledgeable pain-management support for people with IA and OA.

SP0121 The Benefits of Prompt Pain Management in Inflammatory Arthritis and Osteoarthritis. A Systematic Literature Review

Objective To identify the scientific evidence associated with the benefits of the health professionals (HPs) approach to pain management for people with inflammatory arthritis (IA) and osteoarthritis (OA), serving as a basis for the the first “recommendations” and “points to consider” that enable HPs to provide prompt and knowledgeable support for pain in people with IA or OA. Methods A systematic literature search was undertaken. Cochrane, Embase, PsycINFo, PubMed, Scopus, and Web of Science were searched for records of systematic reviews, meta-analyses, (practice) guidelines and recommendation articles containing results of studies evaluating management strategies for IA and OA and their effect on pain. Quality of the body of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Of 1569 papers, 184 papers were included. Papers reviewed effects of interventions on pain for OA (141 papers), RA (42 papers), and axial spondyloarthropathies (7 papers); for psoriatic arthritis no relevant papers were found. Interventions covered by this overview of reviews were: exercise interventions (87 papers), non-exercise physiotherapy interventions such as acupuncture, transcutaneous electrical nerve stimulation, electromagnetic fields, laser, diathermy, thermotherapy, and balneotherapy (77 papers), orthotics and assistive devices (41 papers), education (21 papers), weight reduction (14 papers), and psychological interventions (10 papers). Conclusion During the conference the effects on pain and quality of the evidence will be presented per disease by type of intervention. A necessary research agenda is proposed. For IA, but also some types of OA, well-designed randomized controlled trials assessing the effect of non-pharmacological interventions on pain, are still needed. Evidence for prompt types of pain management is even more necessary. Disclosure of Interest None declared

FRI0024 Contribution of the Individual Components of the Disease Activity Score (DAS28) to the Total DAS28 Score among Responders and Non-Responders to Biological Therapy for Rheumatoid Arthritis

Background The commonly used Disease Activity Score based on 28 joints (DAS28) is a composite index composed of two somewhat subjective components (tender joint count and visual analogue scale general well-being) and two more objective components (swollen joint count and erythrocyte sedimentation rate). However, not all individual components of DAS28 might respond similarly to treatment. Furthermore dominance of subjective over objective components in DAS28 at start of therapy might predict less effect of therapy. This subjective contribution relative to the total DAS28 was quantified through the “contribution score” (the subjective part of the DAS28 formula divided by the total DAS28 formula). Objectives First, to investigate if the contribution score of the study population changes over time between starting a first biological (baseline) and after three months of biological use, and to establish if this change is seen and similar in the non-, moderate- and good response to treatment groups. Second, to investigate if the subjective contribution at baseline is predictive of response to treatment at three months. Methods Patients included in this study were selected from two databases of the Utrecht Arthritis Cohort study group. In the CAMERA-II trial early RA patients had been included, comparing the addition of 10mg/day of prednisone or prednisone-placebo to a two-year MTX-based tight –controlled strategy, including a final step of adding a biological. In the more recent Utrecht observational Biological cohort study, any patient with RA who started a biological could be entered. A total of 51 of the CAMERA-II trial database patients and 121 of the Biological cohort study database, all starting a biological treatment, were included. To address the first objective, ANOVAs and paired t tests were performed. To address the second objective, an ordinal logistic regression analysis was performed (correcting for age, DAS28 at the start of the biological therapy, number of prior DMARDs used, cohort, gender, RF-status and smoking), with as criterion variable EULAR response (3 levels: non-, moderate- and good response) and as predictor variable the contribution score. Results Overall, a significant decrease in contribution score was observed (p<0.001), showing -in contrast to our hypothesis- a therapy effect more pronounced in the subjective parts of the DAS28 compared to the therapy effect in the objective components. When looking into the separate response groups, this significant change was observed only in the good responders (p<0.001). The contribution score at baseline was not predictive of the different levels of response to treatment at three months (contribution score at baseline x100: proportional OR=1.001, p=0.8). Conclusions The treatment effect of this first administered biological is largest in the subjective components of DAS28, yet these subjective components of DAS28 at start of therapy do not predict treatment response levels at three months. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4125

Severe fatigue is highly prevalent in ALL rheumatic diseases : an international study

Background Fatigue is a common, disabling, and difficult to manage problem in rheumatic diseases. Prevalence estimates of fatigue within various rheumatic disease groups vary considerably. Data on the relative prevalence of severe fatigue across multiple rheumatic diseases using a similar instrument is missing. Objectives The aim of this study was to provide an overview of the prevalence of severe fatigue across a broad range of rheumatic diseases and to examine its relationship with clinical and demographic variables. Methods Online questionnaires were filled out by an international sample of 6120 patients (88% female, mean age 47) encompassing 30 different rheumatic diseases. Fatigue was measured with the RAND(SF)-36 Vitality scale. A score of ≤35 was taken as representing severe fatigue. This cut-off score is similar to the 10th percentile of the general population; it was found to have 90% sensitivity (90% of people with chronic fatigue syndrome according to established classification criteria was correctly identified as having chronic fatigue syndrome using this cut-off score) and 81% specificity (81% of the people not having chronic fatigue syndrome according to established classification criteria was correctly identified as not having chronic fatigue syndrome using this cut-off score). Results Severe fatigue was present in 41% to 57% of the patients with a single inflammatory rheumatic disease such as rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, Sjögrens syndrome, psoriatic arthritis, and scleroderma. The percentage of patients with severe fatigue was 59% in patients with multiple rheumatic diseases without fibromyalgia. Severe fatigue was least prevalent in patients with osteoarthritis (35%) and most prevalent in patients with (comorbid) fibromyalgia (around 80%). In logistic regression analysis, severe fatigue was predicted by having (comorbid) fibromyalgia, having multiple rheumatic diseases without fibromyalgia, younger age, lower education, and linguistic background. Of Dutch, English, French, German, Portuguese and Spanish speaking patients, severe fatigue was most prevalent in French speaking patients and least prevalent in Dutch speaking patients. Conclusions Severe fatigue is very common in all rheumatic diseases. Our study indicates that about one out of every two patients with a rheumatic disease is severely fatigued. As severe fatigue can have devastating effects for the patient, the near environment, and society at large, unraveling the underlying mechanisms of fatigue and developing optimal treatment strategies should be top priorities in rheumatological research and practice. Acknowledgements Thanks to Isabel Lόpez-Chicheri García (Murcia, Spain), Ricarda Mewes & Winfried Rief (Marburg, Germany), Karoline Vangronsveld & Geert Crombez (Ghent, Belgium), Andreas AJ Wismeijer, Henriët van Middendorp & Johannes WJ Bijlsma (Tilburg & Utrecht, the Netherlands), and Mark A Lumley (Detroit, USA) for help in data collection. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.2399