Quality of life in spondyloarthritis: analysis of a large Brazilian cohort^☆

Abstract

Objective:

To analyze quality of life and demographic and clinical variables associated to its impairment in a large Brazilian cohort of patients with spondyloarthritis (SpA).

Methods:

A common protocol of investigation was applied to 1465 Brazilian patients classified as SpA according to the European Spondyloarthropaties Study Group (ESSG) criteria, attended at 29 reference centers for Rheumatology in Brazil. Clinical and demographic variables were recorded. Quality of life was analyzed through the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire.

Results:

The mean ASQoL score was 7.74 (± 5.39). When analyzing the specific diseases in the SpA group, the ASQoL scores did not present statistical significance. Demographic data showed worse scores of ASQoL associated with female gender (p = 0.014) and African-Brazilian ethnicity (p < 0.001). Regarding clinical symptoms, buttock pain (p = 0.032), cervical pain (p < 0.001) and hip pain (p = 0.001), were statistically associated with worse scores of ASQoL. Continuous use of nonsteroidal anti-inflammatory drugs (p < 0.001) and biologic agents (p = 0.044) were associated with higher scores of ASQoL, while the other medications did not interfere with the ASQoL scores.

Conclusion:

In this large series of patients with SpA, female gender and African-Brazilian ethnicity, as well as predominant axial symptoms, were associated with impaired quality of life.

Keywords:
Spondyloarthritis; Ankylosing spondylitis; Quality of life; ASQoL

Resumo

Objetivo:

Analisar as variáveis demográficas e clínicas associadas à diminuição da qualidade de vida em uma grande coorte brasileira de pacientes com espondiloartrite (EpA).

Métodos:

Foi aplicado um protocolo de pesquisa único a 1.465 pacientes brasileiros classificados como tendo EpA de acordo com os critérios do European Spondyloarthropaties Study Group (ESSG), atendidos em 29 centros de referência em reumatologia do Brasil. Foram registradas as variáveis clínicas e demográficas. A qualidade de vida foi analisada por meio do questionário Ankylosing Spondylitis Quality of Life (ASQoL).

Resultados:

A pontuação média do ASQoL foi de 7,74 (+ 5,39). Ao analisar doenças específicas no grupo de EpA, as pontuações do ASQoL não apresentaram diferença estatisticamente significativa. Os dados demográficos mostraram piores escores de ASQoL associados ao gênero feminino (p = 0,014) e etnia negra (p < 0,001). Quanto aos sintomas clínicos, a dor na região glútea (p = 0,032), a dor cervical (p < 0,001) e a dor no quadril (p = 0,001), estiveram estatisticamente associadas a piores escores no ASQoL. O uso contínuo de fármacos anti-inflamatórios não esteroides (p < 0,001) e agentes biológicos (p = 0,044) esteve associado a escores mais elevados de ASQoL, enquanto outros medicamentos não interferiram nos escores do ASQoL.

Conclusão:

Nesta grande série de pacientes com EpA, o sexo feminino e a etnia negra, bem como sintomas predominantemente axiais, estiveram associados a uma qualidade de vida reduzida.

Palavras-chave:
Espondiloartrite; Espondilite anquilosante; Qualidade de vida; ASQoL

Introduction

The spondyloarthritides (SpA) comprise a group of interrelated chronic inflammatory diseases, i.e. ankylosing spondylitis (AS), psoriatic arthritis (PsA), SpA associated with inflammatory bowel diseases (IBD), reactive arthritis (ReA), juvenile onset SpA, and undifferentiated SpA. These diseases share several clinical features such as inflammation of the axial joints, asymmetric oligoarthritis (especially of the lower limbs), and enthesitis. AS is a chronic inflammatory disease that affects predominantly the spine and usually starts in the young adult age, contributing to significant physical disability and decreased quality of life (QoL) in a significant number of patients.¹ With the advent of new and effective agents for the treatment of AS in the last decade, it became necessary to develop methods that could reflect the real improvement in the QoL of these patients.

In general, QoL can be measured by two groups of instruments: generic instruments, applicable to patients with various conditions, and disease specific instruments for use in specific diseases.¹ The generic instrument most commonly used to be evaluate QoL in patients with SpA is the Medical Outcome Short-Form 36 Health Survey (SF-36),² that measures health-related QoL through 8 domains (“physical functioning”, “physical role”, “body pain”, “general health”, “vitality”, “social functioning”, “emotional role” and “mental health”). In 2003, the Ankylosing Spondylitis Quality of Life (ASQoL),³ a specific instrument to analyze QoL in AS patients, was proposed; it comprises 18 questions, and the poor QoL is associated with the higher scores. ASQoL was developed in collaboration with AS patients, is feasible and sensitive to change over time.³ ASQoL has been validated in many countries.^4–6 And as we do not have specific questionnaires related to QoL in other diseases in the SpA group, ASQoL can be used for the evaluation of these SpA patients.

The objective of this study is to analyze the importance of demographic and clinical variables in the QoL in a large Brazilian cohort of patients with spondyloarthritis (SpA).

Methods

This is a prospective, observational, and multicentric cohort of 1465 consecutive patients with SpA recruited from 29 referral centers participating in the Brazilian Registry of Spondyloarthritis (RBE – Registro Brasileiro de Espondiloartrites). All patients, from all the 5 major geographic areas in Brazil, were classified according to the European Spondylarthropathy Study Group criteria,⁷ with data collected from June 2006 to December 2009. The RBE is part of the RESPONDIA group comprising 9 Latin American countries (Argentina, Brazil, Costa Rica, Chile, Ecuador, México, Peru, Uruguay, and Venezuela) and the 2 Iberian Peninsula countries (Spain and Portugal).

A common protocol of investigation was applied to 1465 SpA patients. The diagnosis of AS was considered if the patients fulfilled the New York modified criteria,⁸ and as psoriatic arthritis (PsA) in case they fulfilled the Moll and Wright criteria⁹; reactive arthritis (ReA) was considered when asymmetric inflammatory oligoarthritis of lower limbs was present, associated with enthesopathy and/or inflammatory low back pain following enteric or urogenital infections¹⁰; and enteropathic arthritis when the patient presented inflammatory axial and/or peripheral joint involvement associated with confirmed inflammatory bowel disease (IBD; Crohn's disease or ulcerative colitis).

Demographic and clinical data were collected, including time of disease duration, spinal pain, peripheral joint pain or swelling, tender and swollen joint count, visual analog scale for pain according to the patient (VAS for pain) and disease activity according to patient and physician (patient and physician VAS for disease activity). Peripheral articular involvement was assessed by the 66 tender/swollen joint count. Other clinical variables as dactylitis, uveitis, HLA-B27 were also evaluated, as well as drug use.

Quality of life was evaluated using the ASQoL questionnaire,³ that comprises 18 questions, each with a dichotomous “yes/no” response, scored “1” and “0”, respectively. Total score ranges from 0 to 18, with the higher scores indicating poor quality of life. ASQoL had previously been translated, cross-translated, validated, and culturally adapted to the Brazilian Portuguese language.¹¹

Statistical analysis

Categorical variables were compared by χ² and Fisher's exact test, and continuous variables were compared by ANOVA test. A value of p < 0.05 was considered significant, and 0.05 > p > 0.10 was considered a statistical trend.

Results

A total of 1465 patients were evaluated, comprising 1059 men and 406 women. AS was the most frequent disease in the group (67.6%), followed by PsA (18.8%), USpA (6.8%), ReA (3.4%), and enteropathic arthritis (3.4%). The mean score of ASQoL was 7.74 ± 5.39. There was no statistical significance comparing the ASQoL mean scores among the different diseases in the SpA group, as shown in Table 1.

Table 1
ASQoL scores, according to the SpA.

	N (%)	ASQoL score		p
		Mean	SD
AS	67.6	7.93	5.40	0.205
PsA	18.8	7.29	5.38
USpA	6.8	7.86	5.14
ReA	3.4	7.48	5.38
Arthritis – IBD	3.4	6.91	5.13
TOTAL	100	7.74	5.39

• ASQoL, Ankylosing Spondylitis Quality of Life; AS, ankylosing spondylitis; IBD, inflammatory bowel disease; PsA, psoriatic arthritis; ReA, reactive arthritis; USpA, undifferentiated spondyloarthritis.

The ASQoL mean scores were higher in the female gender (p = 0.014), African-Brazilian ethnicity (p < 0.001) and in those who practiced no exercises (p < 0.001). HLA-B27 and family history did not influenced the ASQoL scores (Table 2).

Table 2
ASQoL scores, according to demographic variables.

		N (%)	ASQoL score		p
			Mean	SD
Gender
	Male	72.3	7.53	5.40	0.014
	Female	27.7	8.29	5.34
Race
	Caucasian	67.4	7.10	5.40	<0.001
	African-Brazilian	32.6	8.56	5.33
Exercise
	Yes	40.8	6.90	5.29	<0.001
	No	59.2	8.36	5.37
HLA - B27a
	Positive	69.0	7.47	5.56	0.504
	Negative	31.0	7.77	5.39
Family history
	Yes	18.0	7.80	5.28	0.829
	No	82.0	7.73	5.42

• ^a
  Data available for 723 patients.

The ASQoL scores were significantly associated with buttock pain (p = 0.032), cervical pain (p < 0.001) and hip pain (p = 0.001) (Table 3). Clinical variables as inflammatory low back pain, enthesitis, dactylitis, upper limb arthritis, lower limb arthritis, uveitis, inflammatory bowel disease, psoriasis, and urethritis did not influence the ASQoL score (Table 2).

Table 3
ASQoL scores, according to clinical variables.

		N (%)	ASQoL score		p
			Mean	SD
Low back pain
	Yes	67.6	7.88	5.46	0.158
	No	22.4	7.46	5.24
Buttock pain
	Yes	33.1	8.18	5.66	0.032
	No	66.9	7.52	5.24
Cervical pain
	Yes	30.8	8.64	5.43	<0.001
	No	69.2	7.34	5.33
Hip pain
	Yes	25.1	8.56	5.49	0.001
	No	31.0	7.46	5.33
Arthritis lower limbs
	Yes	48.9	7.97	5.40	0.105
	No	51.1	7.52	5.37
Arthritis upper limbs
	Yes	22.1	8.00	5.39	0.327
	No	77.9	7.67	5.39
Enthesitis
	Yes	27.1	7.73	5.50	0.950
	No	72.9	7.75	5.36
Dactilitis
	Yes	9.1	7.29	5.58	0.331
	No	90.9	7.79	5.37
Uveitis
	Yes	19.1	7.70	5.38	0.888
	No	80.9	7.75	5.40
Psoriasis
	Yes	17.8	7.36	5.36	0.215
	No	82.2	7.82	5.40
IBD
	Yes	4.7	6.70	5.54	0.151
	No	95.3	7.79	5.38
Urethritis
	Yes	4.4	8.08	5.54	0.622
	No	95.6	7.73	5.42

• ASQoL, Ankylosing Spondylitis Quality of Life; IBD, inflammatory bowel disease.

Regarding treatment, patients who took NSAID continuously presented higher ASQoL scores (p < 0.001). The other medications, like corticosteroids, methotrexate, and sulfasalazine did not influence the ASQoL scores. Biologic agents, especially adalimumab, were associated with lower scores of ASQoL (p = 0.013) (Table 4).

Table 4
ASQoL scores, according to treatment.

		N (%)	ASQoL score		p
			Mean	SD
NSAID > 50%
	Yes	35.2	8.65	5.22	<0.001
	No	64.8	7.25	5.43
NSAID on demand
	Yes	24.9	7.68	5.22	0.795
	No	75.1	7.76	5.45
Corticosteroids
	Yes	35.4	7.93	5.41	0.324
	No	64.6	7.64	5.39
Methotrexate
	Yes	51.7	7.90	5.32	0.252
	No	48.3	7.57	5.47
Sulfasalazine
	Yes	44.7	8.02	5.41	0.078
	No	55.3	7.52	5.37
Infliximab
	Yes	15.3	7.20	5.49	0.105
	No	84.7	7.84	5.37
Etanercept
	Yes	2.8	9.44	5.82	0.065
	No	97.2	7.69	5.37
Adalimumab
	Yes	2.3	5.70	4.48	0.013
	No	97.7	7.79	5.40

• ASQoL, Ankylosing Spondylitis Quality of Life; NSAID, nonsteroidal anti-inflammatory drugs.

Discussion

Despite specific instruments to assess QoL cannot be easily applied to other diseases, ASQoL had a good performance in the evaluation of this large series of patients with SpA. Although AS patients presented higher ASQoL scores, there was no statistical significance among the ASQoL scores in the different diseases in the group; the mean ASQoL score (7.74 ± 5.39) indicated that the analyzed patients had a significant low quality of life.

Patients with the mixed (axial + peripheral and/or entheseal) articular presentation had higher ASQoL scores, as expected. Interestingly, the entheseal involvement was associated with the highest ASQoL scores, indicating that enthesitis can contribute to a significant decrease in the QoL of the affected patients.

While SpA is more frequent in male Caucasian patients, the ASQoL was worse in female African-Brazilian patients in the present series. These data can confirm that women usually demonstrate greater dissatisfaction with the disease than men. Some studies have analyzed the associated presence of fibromyalgia and AS,^12,13 a clinical situation that can possibly confound the results related to QoL. Another study, conducted in Brazil, evaluating 71 AS patients (45.5% males and 54.5% females), observed that fibromyalgia was more prevalent among women (3.8:1) and may have influenced the higher BASDAI, BASFI and ASQoL scores in the patients with associated fibromyalgia.¹⁴ Anxiety and depression can also be involved in the impairment of QoL in AS patients.¹⁵ Fibromyalgia, as well as specific questionnaires for anxiety and depression were not assessed in the present study.

The referred higher ASQoL scores observed in the African-Brazilians, indicating a lower QoL, can be explained by the genetic background and the influence of socio-economic factors, such as access to health services and access to specific treatments. This aspect deserves further studies addressing specifically the socio-economic profile of our patients with SpA.

The practice of exercise was associated with lower scores of ASQoL, similar to that observed in a Turkish study analyzing 942 AS patients.¹⁶ A recent British study with 612 AS patients showed that smoking has a dose-dependent relationship with increased disease activity, decreased function, and poor quality of life, independent of age, gender, deprivation level, and disease duration.¹⁷

In a group where a significant number of patients present axial and peripheral articular involvement, the ASQoL scores were significantly higher in those patients presenting buttock pain, cervical pain and hip pain. This can reflect the fact that the ASQoL was developed for patients with AS, a disease where the axial component represents its core symptoms. It is also important to mention that 18.8% of the studied patients had PsA, a disease with predominant peripheral component and that has a specific QoL instrument, the Psoriatic Arthritis Quality of Life (PsAQoL).¹⁸ However, considering that PsAQoL was not translated and validated to the Brazilian Portuguese at the time of the data collection, and the fact that 10 of the 18 questions of the ASQoL are quite similar to 10 of the 20 questions of the PsAQoL, we understood that ASQoL could be used in that heterogeneous group of SpA patients.

In general, the applicability of ASQoL uses to be very good.¹⁹ A recent study with 522 AS patients from Canada and Australia showed that contextual factors, such as helplessness and employment had an important and independent contribution to health-related QoL, explaining 47% of the ASQoL variance.²⁰

The continuous use of NSAID was associated with higher scores of ASQoL, while NSAID use on demand did not contribute to an impairment of ASQoL. It can be associated to the increased pain and functional limitation observed in patients who generally have continuous use of NSAID, contributing to a decreased quality of life in these patients. The use of biologic agents was associated with better QoL, as shown in previous studies.^21,22

Concluding, this large Brazilian series of patients with SpA showed that female gender and African-Brazilian ethnicity, as well as the mixed (axial + peripheral) clinical presentation, were associated with impaired quality of life.

• ☆
  The electronic version of the Brazilian Registry of Spondyloarthritis is maintained by an unrestricted grant of Wyeth/Pfizer Brazil, that does not influence in the statistical analysis and in the writing of the manuscripts.

Referências

• ¹
  Van der Heijde D, Landewé R. Assessment of disease activity, function and quality of life. In: Weisman MH, Reveille JD, van der Heijde D, editors. Ankylosing spondylitis and the spondyloarthropathies. 1^a ed. Filadélfia: Mosby Elsevier; 2006. 12. p. 206-13.
• ²
  Ware JE Jr, Sherbourne CD. The MOS 36-item Short Form 13. Health Survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473-83.
• ³
  Doward LC, Spoorenberg A, Cook SA, Whalley D, Helliwell PS, Kay LJ, et al. Development of the ASQoL: a quality of life instrument specific to ankylosing spondylitis. Ann Rheum Dis. 2003;62:20-6.
• ⁴
  Almodóvar R, Zarco P, Collantes E, González C, Mulero J, Fernández-Sueiro JL, et al. Relationship between spinal mobility and disease activity, function, quality of life and radiology. A cross-sectional Spanish registry of spondyloarthropathies (REGISPONSER). Clin Exp Rheumatol. 2009;27(3):439-45.
• ⁵
  Pham T, van der Heijde DM, Pouchot J, Guillemin F. Development and validation of the French ASQoL questionnaire. Clin Exp Rheumatol. 2010;28(3):379-85.
• ⁶
  Jenks K, Treharne GJ, Garcia J, Stebbings S. The ankylosing spondylitis quality of life questionnaire: validation in a New Zealand cohort. Int J Rheum Dis. 2010;13(4):361-6.
• ⁷
  Dougados M, van der Linden S, Julin R, Huitfeld B, Amor B, Calin A, et al. The European Spondyloarthropathy Study Group preliminary criteria for the classification of spondyloarthropathy. Arthritis Rheum. 1991;34:1218-27.
• ⁸
  van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984;27:361-8.
• ⁹
  Moll JMH, Wright V.Psoriatic arthritis. Semin Arthritis Rheum. 1973;3:55-78.
• ¹⁰
  Kingsley G, Sieper J. Third International Workshop on Reactive Arthritis, 23-26 September 1995, Berlin, Germany Ann Rheum Dis. 1996;55:564-84.
• ¹¹
  Cusmanich KG. Validacão para a língua portuguesa dos instrumentos de avaliacão de índice funcional e índice de atividade de doenca em pacientes com espondilite anquilosante. Dissertacão de Mestrado. Faculdade de Medicina da Universidade de São Paulo, 2006.
• ¹²
  Barlow JH, Macey SJ, Struthers GR. Gender, depression, and ankylosing spondylitis. Arthritis Care Res. 1993;6:45-51.
• ¹³
  Aloush A, Ablin J, Reitblat T, Caspi D, Elkayan O. Fibromyalgia in women with ankylosing spondylitis. Rheumatol Int. 2007;27:865-8.
• ¹⁴
  Azevedo VF, Paiva ES, Felippe LR, Moreira RA. Occurrence of fibromyalgia in patients with ankylosing spondylitis. Braz J Rheumatol. 2010;50:646-50.
• ¹⁵
  Baysal O, Durmus B, Ersoy Y, Altay Z, Senel K, Nas K, et al. Relationship between psychologic status and disease activity and quality of life in ankylosing spondylitis. Rheumatol Int. 2011;31:795-800.
• ¹⁶
  Bodur H, Ataman S, Rezvani A, Bugdayci DS, Cevik R, Birtane M, et al. Quality of life and related variables in patients with ankylosing spondylitis. Qual Life Res. 2011;20:543-9.
• ¹⁷
  Mattey DL, Dawson SR, Healey EL, Packam JC. Relationship between smoking and patient-reported measures of disease outcome in ankylosing spondylitis. J Rheumatol. 2011;38:2608-15.
• ¹⁸
  McKenna SP, Doward LC, Whalley T, Tennant A, Emery P, Veale DJ. Development of the PsAQoL: a qualit of life instrument specific to psoriatic arthritis. Ann Rheum Dis. 2004;63:162-9.
• ¹⁹
  Zochling J. Measures of symptoms and disease status in ankylosing spondylitis. Arthritis Care Res. 2011;63:S47-58.
• ²⁰
  Gordeev VS, Maksymowych WP, Evers SMA, Ament A, Schachna L, Boonen A. Role of contextual factors in health-related quality of life in ankylosing spondylitis. Ann Rheum Dis. 2010;69:108-12.
• ²¹
  Van der Heidje D, Revicki DA, Gooch KL, Wong RL, Kupper H, Harnam N, et al. Physical function, diseas activity, and health-related quality of life outcomes after 3 years of adalimumab treatment in patients with ankylosing spondylitis. Arthritis Res Ther. 2009;11:R124.
• ²²
  Maksymowych WP, Gooch KL, Wong RL, Kupper H, van der Heijde D. Impact of age, sex, physical function, health-related quality of life, and treatment with adalimumab on work status and work productivity of patients with ankylosing spondylitis. J Rheumatol. 2010;37:385-92.

Publication Dates

• Publication in this collection
  Jan-Feb 2016

History

• Received
  11 Apr 2014
• Accepted
  1 Mar 2015