In rheumatoid arthritis, country of residence has an important influence on fatigue: results from the multinational COMORA study

Hifinger, Monika; Putrik, Polina; Ramiro, Sofía; Keszei, András; Hmamouchi, Ihsane; Dougados, Maxime; Gossec, Laure; Boonen, Annelies

doi:10.1093/rheumatology/kev395

Cited by 26 publications

(18 citation statements)

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“…The conclusions of this study need to be considered in the light of potential limitations. First, our population was recruited in a single center in Portugal, which may limit generalizability, as PGA and other PROs have been shown to vary across countries . The similarity of our findings with other studies is, however, rather reassuring in this respect.…”

Section: Discussionsupporting

confidence: 56%

Suppressing Inflammation in Rheumatoid Arthritis: Does Patient Global Assessment Blur the Target? A Practice‐Based Call for a Paradigm Change

Ferreira

Duarte

Ndosi

et al. 2018

Arthritis Care & Research

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107

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Objective In current management paradigms of rheumatoid arthritis (RA), patient global assessment (PGA) is crucial to decide whether a patient has attained remission (target) or needs reinforced therapy. We investigated whether the clinical and psychological determinants of PGA are appropriate to support this important role. Methods This was a cross‐sectional, single‐center study including consecutive ambulatory RA patients. Data collection comprised swollen 28‐joint count (SJC28), tender 28‐joint count (TJC28), C‐reactive protein (CRP) level, PGA, pain, fatigue, function, anxiety, depression, happiness, personality traits, and comorbidities. Remission was categorized using American College of Rheumatology/European League Against Rheumatism Boolean‐based criteria: remission, near‐remission (only PGA >1), and nonremission. A binary definition without PGA (3v‐remission) was also studied. Univariable and multivariable analyses were used to identify explanatory variables of PGA in each remission state. Results A total of 309 patients were included (remission 9.4%, near‐remission 37.2%, and nonremission 53.4%). Patients in near‐remission were indistinguishable from remission regarding disease activity, but described a disease impact similar to those in nonremission. In multivariable analyses, PGA in near‐remission was explained (R2adjusted = 0.50) by fatigue, pain, anxiety, and function. Fatigue and pain had no relationship with disease activity measures. Conclusion In RA, a consensually acceptable level of disease activity (SJC28, TJC28, and CRP level ≤1) does not equate to low disease impact: a large proportion of these patients are considered in nonremission solely due to PGA. PGA mainly reflects fatigue, pain, function, and psychological domains, which are inadequate to define the target for immunosuppressive therapy. This consideration suggests that clinical practice should be guided by 2 separate remission targets: inflammation (3v‐remission) and disease impact.

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Section: Discussionsupporting

confidence: 56%

Suppressing Inflammation in Rheumatoid Arthritis: Does Patient Global Assessment Blur the Target? A Practice‐Based Call for a Paradigm Change

Ferreira

Duarte

Ndosi

et al. 2018

Arthritis Care & Research

Self Cite

107

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“…These findings mimic those in rheumatoid arthritis: even in countries with highly developed social welfare such as Norway, lower education and old age (> 57 years) are associated with later prescription of a first biologic at the same levels of disease activity, whereas lower education and residence in countries with lower gross domestic product (GDP) are associated with higher disease activity, and part of this relationship is mediated by lower uptake of biologics . Conversely, fatigue and patient global assessment (highly ‘subjective’ patient‐reported outcomes) have been found either not to be significantly associated with GDP or even to be higher in patients from wealthier countries, which might be explained by differences in social roles and patient expectations …”

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confidence: 69%

“…3,4 Conversely, fatigue and patient global assessment (highly 'subjective' patientreported outcomes) have been found either not to be significantly associated with GDP 5 or even to be higher in patients from wealthier countries, which might be explained by differences in social roles and patient expectations. 6,7 In a National Psoriasis Foundation survey, severe psoriasis (> 10% body surface area involvement) was found to be associated with self-reported low income after adjusting for age, age at onset, sex, race and drug treatment. 8 Data from Medicare in the U.S.A. indicate that younger age, lower income level and lack of insurance, 9 as well as lack of low-income subsidy in Medicare patients, 10 are associated with a much lower chance of receiving biologics.…”

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confidence: 99%

Psoriasis: inequality or individualized care?

Puig

Putrik

2017

Br J Dermatol

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“…Explaining the discrepancy observed between countries regarding the correlation between PtGA and parameters of disease activity is beyond the scope of this article. A multitude of factors, including patient education on PROs and patient expectations, are probably involved ().…”

Section: Discussionmentioning

confidence: 99%

Impact of Patient's Global Assessment on Achieving Remission in Patients With Rheumatoid Arthritis: A Multinational Study Using the METEOR Database

Ferreira

Carvalho

Ndosi

et al. 2019

Arthritis Care & Research

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Objective There is an ongoing debate about excluding patient's global assessment (PtGA) from composite and Boolean‐based definitions of rheumatoid arthritis (RA) remission. This study aimed at determining the influence of PtGA on RA disease states, exploring differences across countries, and understanding the association between PtGA, measures of disease impact (symptoms), and markers of disease activity (inflammation). Methods Cross‐sectional data from the Measurement of Efficacy of Treatment in the Era of Outcome in Rheumatology international database were used. We calculated the proportion of patients failing American College of Rheumatology/European League Against Rheumatism Boolean‐based remission (4‐variable remission) solely due to PtGA (PtGA‐near‐remission) in the overall sample and in the most representative countries (i.e., those with >3,000 patients in the database). Multivariable linear regression models were used to identify the main determinants of PtGA, grouped in predominantly inflammatory impact factors (28 tender joint counts, 28 swollen joint counts, and C‐reactive protein level) and disease impact factors (pain and function). Results This study included 27,768 patients. Excluding PtGA from the Boolean‐based definition (3‐variable remission) increased the remission rate from 5.8% to 15.8%. The rate of PtGA‐near‐remission varied considerably between countries, from 1.7% in India to 17.9% in Portugal. One‐third of the patients in PtGA‐near‐remission group scored PtGA >4 of 10. Pain and function were the main correlates of PtGA, with inflammation‐related variables contributing less to the model (R2 = 0.57). Conclusion PtGA is moderately related to joint inflammation overall, but only weakly so in low levels of disease activity. A considerable proportion of patients otherwise in biologic remission still perceive high PtGA, putting them at risk of excessive immunosuppressive treatment.

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In rheumatoid arthritis, country of residence has an important influence on fatigue: results from the multinational COMORA study

Abstract: Country of residence has an important influence on fatigue. Paradoxically, patients from wealthier countries had higher fatigue.

Cited by 26 publications

References 26 publications

Suppressing Inflammation in Rheumatoid Arthritis: Does Patient Global Assessment Blur the Target? A Practice‐Based Call for a Paradigm Change

Suppressing Inflammation in Rheumatoid Arthritis: Does Patient Global Assessment Blur the Target? A Practice‐Based Call for a Paradigm Change

Psoriasis: inequality or individualized care?

Impact of Patient's Global Assessment on Achieving Remission in Patients With Rheumatoid Arthritis: A Multinational Study Using the METEOR Database

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