Predictors of Fatigue in Rheumatoid Arthritis Patients in Remission or in a Low Disease Activity State

Abstract

ObjectiveFatigue is a frequently occurring symptom in patients with rheumatoid arthritis (RA). Our aims were to assess the level of reported fatigue in RA patients who had achieved remission or low disease activity after 6 months of treatment with disease‐modifying antirheumatic drugs (DMARDs), and to explore associations between fatigue and demographics, disease activity, and other patient‐reported outcomes in this patient group.MethodsA total of 2,193 RA patients (ages ≥18 years) starting either methotrexate (MTX) monotherapy or a tumor necrosis factor inhibitor in combination with MTX were retrieved from the Norwegian Disease‐Modifying Antirheumatic Drugs Register (NOR‐DMARD). At the 6‐month followup, 699 patients (31.9%) were in remission or in a low disease activity state. Bivariate and multivariate linear regression analyses were conducted, with the fatigue visual analog scale (VAS) at 6 months as the dependent variable. Age, sex, disease duration, treatment group, erythrocyte sedimentation rate (ESR), the swollen and tender joint count in 28 joints, the pain VAS score, and disability at baseline and at 6 months were tested as predictors of fatigue at 6 months.ResultsAt 6 months, the median (25th, 75th percentile) level of fatigue was 20.0 mm (6.0, 43.0), and a fatigue VAS score of ≥40 mm was reported by 27.9% of patients. In the multivariate analysis, lower ESR and higher pain at baseline were statistically significant predictors of higher levels of fatigue (P < 0.001). In the multivariate cross‐sectional analysis at 6 months, younger age and greater pain were significantly associated with higher levels of fatigue (P < 0.001).ConclusionPain levels at baseline and at 6 months were associated with a higher level of fatigue. Patients in remission or in a low disease activity state may need nonpharmacologic interventions to manage their pain and fatigue.

Relationship between disease activity and patient-reported outcomes in rheumatoid arthritis: Post hoc analyses of overall and Japanese results from two phase 3 clinical trials

“…The low level of improvement in SF-36 MCS is likely because, consistent with previous findings [30,33], SF-36 MCS scores were close to normal at baseline; hence, there was limited scope for improvement. Other studies have also found that patients achieving remission or LDA have residual symptoms as determined by PROs assessing pain, disability, fatigue, and global disease activity [17][18][19]. Taken together, our findings and those from other studies indicate that, despite achieving remission (assessed by composite measures of disease activity), some patients with RA still have residual symptoms.…”

“…Norwegian and North American registry studies of patients have also provided evidence of residual symptoms. In Norway, $30% of patients starting new disease-modifying antirheumatic drug (DMARD) therapy who achieved remission (DAS28) after 6 months reported high levels of fatigue (VAS) [18]. In North America, 57-76% of patients starting biologic therapy who achieved lower disease activity [86% LDA or remission (CDAI)] after 12-15 months did not achieve the minimum clinically important difference (MCID) for various PROs {physical function [modified Health Assessment Questionnaire (HAQ): 76%], pain (VAS: 58%), fatigue (VAS: 57%), and patient's assessment of disease activity [Patient's Global Assessment of Disease Activity (PtGA)]: 57%} [19].…”

Management of Fatigue in Rheumatoid Arthritis

“…Virtually all treatments in RA will reduce fatigue, including conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), targeted synthetic DMARDs, biologic DMARDs and corticosteroids. 37 39–54 The average effect of treatment on fatigue in active RA with various advanced therapies is meaningful but not large. 39 Treatment of disease activity in RA has a small impact on fatigue, whereas physical inactivity, poor sleep and depressed mood explain most of the fatigue.…”

Peer Review #1 of "Patient-reported fatigue in patients with rheumatoid arthritis who commence biologic therapy: a longitudinal study (v0.1)"

“…However, the participants were recruited consecutively and were all in need of their first biologic treatment, and had no major comorbidities. The patients in the study live along the west coast of Norway, but we assume the selection is not very different from the majority of RA patients living in other parts of Norway (Brinkmann et al, 2018, Olsen et al, 2016.…”