Patients with Rheumatoid Arthritis Patients with Rheumatoid Arthritis

in Comparison to in Comparison to

Other Connective Tissue Diseases Other Connective Tissue Diseases

Are Mostly Influenced by Are Mostly Influenced by

Concomitant FibromyalgiaConcomitant Fibromyalgia

Tomš J, Daňková M, Hrnčíř ZTomš J, Daňková M, Hrnčíř Z22ndnd Department of Medicine Department of Medicine

Faculty of Medicine and University HospitalFaculty of Medicine and University Hospital

Hradec Králové, Czech republicHradec Králové, Czech republic

Abstract

Background: A number of clinical studies documented that fibromyalgia (FM) can frequently accompany connective tissue diseases (CTD) as a concomitant syndrome. There is a lack of data about differencies in FM impact on individual CTD.

Objectives: To compare the impact of concomitant FM on CTD in terms of pain intensity, disease activity, function disability and quality of life (QOL) in a regional, monocentric, cross-sectional study.

Methods: 120 consecutive patients (pts) with rheumatoid arthritis (RA), 91 pts with systemic lupus (SLE), 30 pts with polymyositis/dermatomyositis (PM/DM) and 30 pts with systemic sclerosis (SSc) were examined in our outpatient rheumatology department on the presence of FM (ACR criteria,1990). Standard Manual Tender Point Survey was used for the examination of FM tender points. The following data were recorded: demographic data, tender point count (TPC), pain, fatigue and stiffness intensity on a 100 mm visual analog scale (VAS), Fibromyalgia Impact Questionnarie (FIQ) score and disease activity indices according to individual CTD representatives (DAS-28, SLEDAI, serum muscle enzymes). Health Assessment Questionnarie (HAQ) and Short Form 36 items (SF-36) were used for evaluation of functional disability and QOL, respectively. Statistical analysis was based on Kruskal-Wallis nonparametric tests comparing mutually all the CTD cohorts with and without FM. Patient file with SSc and FM was not included into the analysis due to small quantity.

Results: FM diagnosis was established in 25 (20.8%) pts with RA, 10 (11.0%) pts with SLE, 4 (13.3%) pts with PM/DM and 1 patient with SSc (3.6%). CTD groups with concomitant FM were shown to have significantly higher levels of pain, fatigue, stiffness, TPC and FIQ (p <0.05). RA/FM pts reached the highest average intensity of pain (VAS pain 63.7 mm), the worst disability level (HAQ 1.832) and the most reduced QOL in some of SF-36 domains. Disease activity assessment was significantly influenced only in RA pts (DAS-28 in RA with and without FM 5.35 1.1 vs. 3.67 1.4; p < 0.0001).

Conclusion: Concomitant FM appears most frequently in pts with RA in comparison to other CTD. RA patients are also mostly influenced by FM at the level of pain perception, disability and QOL. This FM impact contributes to significant difficulties in RA disease activity assessment unlike other CTD.

Background and Objectives

Background

A number of clinical studies documented that fibromyalgia (FM) can frequently accompany connective tissue diseases (CTD) as a concomitant syndrome (Table). There is a lack of data about differencies in FM impact on individual CTD.

Objectives

To compare the impact of concomitant FM on connective tissue diseases in terms of pain intensity, disease activity, fucntion disability and quality of life in regional, monocentric, cross-sectional study.

Rheumatoid arthritis

Systemic lupus erythematodes

Poly-/ dermato- myositis

Systemic sclerosis

Sjögren syndrome

Frequency of concomitant fibromyalgia in CTD (%)

6.6 – 57.0 1.0 – 25.0 8,0 – 13.3 1.0 - 4.0 6.9 – 22.0

Methods

• clinical examination of the patients with CTD attending outpatient rheumatology department (terciary centre)

• diagnosis of RA according to the criteria ACR 1987, SLE according to the criteria ACR 1982/1997, PM/DM according to Bohan´s and Peter´s criteria (1975), SSc according to the criteria ACR 1980

• examination focused on the presence of FM according to the criteria ACR 1990• FM tender point examination - the protocol MTPS (Standardised Manual Tender Point Survey) Okifuji et al. J Rheumatol 1997;24:377-83

• disease activity - DAS-28, SLEDAI, creatinkinase (myoglobin)• functional disability - HAQ (Health assessment questionnaire)• quality of life - SF-36 (Short Form 36 items)• FIQ (Fibromyalgia Impact Questionnaire)• SDS (Zung´s self-rating depression scale)• pain, fatigue and stiffness intenstity evaluated on a 100 mm horizontal visual analogue scale (VAS)

• statistical analysis was based on Kruskal-Wallis nonparametric tests comparing mutually all the CTD cohorts with and without FM• patient file with SSc and FM was not included into the analysis due to small quantity

Patient groups

RA SLE PM/DM SSc

n 120 9130

(PM = 18, DM = 12)30

Age (years – median, range)

57.0 (22 - 74)

43.0 (18 -75)

50.0 (19 - 74)

61.5 (41 - 76)

Sex ratio (M : F)

29 : 91 (24.2 : 75.8 %)

6 : 85 (6.6 : 93.4 %)

13 : 17 (43.3 : 56.7 %)

10 : 20 (33.3 : 66.6 %)

Disease duration (years – median,

range)

11.2 (0.1 - 57.1)

8.8 (0.3 - 36.0)

3.6 (0.3 - 21.0)

6.0 (1.0 - 25.0)

Disease activityDAS-28 4.02 ± 1.52

SLEDAI 3 (0 – 13)

CK = 2.15 µkat/l (0.55 – 30.9)

Myogl = 50.1 µkat/l (22.3 – 650.5)

Not

evaluated

Explanation: data of disease activity are median and 5th – 95th percentile

Results I.

RA/FM- RA/FM+ SLE/FM- SLE/FM+ PDM/FM- PDM/FM+ SSc/FM-

N 95 25 81 10 26 4 29

Age

(years)55.9 ± 13.6 61.4 ± 10.7 43.0 ± 14.3 44.8 ± 9.7 48.5 ± 16.8 54.3 ± 11.5 61.9 ± 9.9

Sex ratio

(M : F)25 : 70

4 : 21

6 : 75

0 : 10 13 : 13 0 : 410 : 19

Disease duration

(years)

10.9 ± 9.1 12.8 ± 12.5 10.1 ± 7.8 11.1 ± 7.0 2,5 11.2 7.1 ± 5.2

Disease activity

*DAS-28 3.67 ± 1.4

*DAS-28 5.35 ± 1.1

SLEDAI 3 (0 – 13)

SLEDAI 3.5 (0 –

9.0)

CK = 2.00 µkat/l (1.3 – 5.1)

Myogl = 52.6 µkat/l (30.0 –

135.0)

CK = 2.20 µkat/l (1.9 – 9.6)

Myogl = 37,2 µkat/l (27.0 – 96.0)

Not

Evaluated

Explanation: parameters characterized by more numbers: average ± standard deviation or median and5th-95th percentile

* Difference in DAS-28 is statistically significant: p < 0.0001

Results II.

0

10

20

30

40

50

60

70

VAS pain VAS fatigue VAS stiffness FIQ TPC

RA/FM+

RA/FM-

SLE/FM+

SLE/FM-

PDM/FM+

PMD/FM-

SSc/FM-

Explanation: CTD – connective tissue diseases, VAS - visual analogue scale, FIQ – Fibromyalgia Impact Questionnaire, TPC – tender point count

CTD groups with concomitant FM were shown to have significantly higher levels

of pain, fatigue, stiffness, TPC and FIQ (p <0.05).

RA/FM+ patients reached the highest average intensity of pain (VAS pain 63.7 mm).

Results III.

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

2

HAQ SDS

RA/FM+

RA/FM-

SLE/FM+

SLE/FM-

PDM/FM+

PMD/FM-

SSc/FM-

Explanation: HAQ - Health Assessment Questionnaire, SDS – Zung´s depression self-rating scale

RA/FM+ patients reached the worst disability level (HAQ 1.832), p < 0.05,and the highest depression score (SDS 0.508), p < 0.05.

p < 0,001

Values on individual axes are mean scores of quality of life domains. PF – physical functioning, RP – role physical, BP – bodily pain, GH – General health, VT – vitality, SF – social functioning, RE - role emotoinal, MH – mental health.

0

10

20

30

40

50

60

70

80PF

RP

BP

GH

VT

SF

RE

MH

RA/FM+

RA/FM-

SLE/FM+

SLE/FM-

PDM/FM+

PMD/FM-

Results IV.

Short Form 36 items (SF-36)

0

10

20

30

40

50

60

Cou

nt (

or m

m)

TJC SJC FW Pain - VAS

Components of DAS-28 index

RA

RA/FMp < 0.0001

p = 0.022

p = 0.438

p < 0.0001

Disease Activity in Rheumatoid arthritis

Explanation: DAS-28 – disease activity score evaluating 28 joints, TJC – tender joint count, SJC – swollen joint count, FW – erythrosite sedimentation rate, VAS - visual analogue scale

36

1

45

7

14

17

0%

20%

40%

60%

80%

100%

Re

lativn

í če

tno

st

(%)

DAS-28RAF+ 1 7 17

RAF- 36 45 14

< 3,2 3,2 - 5,1 > 5,1

0,0

20,0

40,0

60,0

0,0 1,0 2,0 3,0 4,0 5,0 6,0 7,0 8,0

DAS_28_RA

Rel

ativ

ni c

etno

st

0,0

20,0

40,0

60,0

0,0 1,0 2,0 3,0 4,0 5,0 6,0 7,0 8,0

DAS_28_FM

Re

lativ

ni c

etn

ost

Re

lati

ve

co

un

t

Re

lati

ve

co

un

t

Re

lati

ve

co

un

t %

Conclusion

• concomitant fibromyalgia appears most frequently

in patients with rheumatoid arthritis in comparison

to other connective tissue disease

• RA patients are mostly influenced by FM at the level

of pain perception, disability and in some domains of life

quality

• FM impact contributes to significant difficulties in RA

disease activity assessment unlike other connective

tissue diseases