Rev. Bras. Reumatol. vol.56 número1

w w w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Original

article

Quality

of

life

in

spondyloarthritis:

analysis

of

a

large

Brazilian

cohort

夽

Sandra

L.E.

Ribeiro

_,

_Elisa

_N.

_Albuquerque

_,

_Adriana

_B.

_Bortoluzzo

_,

Célio

R.

Gonc¸alves

_,

_José

_Antonio

_Braga

_da

_Silva

_,

_Antonio

_Carlos

_Ximenes

_,

Manoel

B.

Bértolo

_,

_Mauro

_Keiserman

_,

_Rita

_Menin

_,

_Thelma

_L.

_Skare

_,

_Sueli

_Carneiro

_,

Valderílio

F.

Azevedo

_,

_Walber

_P.

_Vieira

_,

_Washington

_A.

_Bianchi

_,

_Rubens

_Bonfiglioli

_,

Cristiano

Campanholo

_,

_Hellen

_M.S.

_Carvalho

_,

_Izaias

_P.

_Costa

_,

Angela

L.B.

Pinto

Duarte

_,

_Charles

_L.

_Kohem

_,

_Nocy

_H.

_Leite

_,

_Sonia

_A.L.

_Lima

_,

Eduardo

S.

Meirelles

_,

_Ivânio

_A.

_Pereira

_,

_Marcelo

_M.

_Pinheiro

_,

_Elizandra

_Polito

_,

Gustavo

G.

Resende

_,

_Francisco

_Airton

_C.

_Rocha

_,

_Mittermayer

_B.

_Santiago

_,

Maria

de

Fátima

L.C.

Sauma

_,

_Valéria

_Valim

_,

_Percival

_D.

_{Sampaio-Barros}

,

from

the

Brazilian

Registry

of

Spondyloarthritis

b_{UniversidadedoEstadodoRiodeJaneiro,RiodeJaneiro,RJ,Brazil}

c_{InstitutoInsperdeEducac¸ãoePesquisa,SãoPaulo,SP,Brazil}

d_{DisciplinadeReumatologia,FaculdadedeMedicina,UniversidadedeSãoPaulo,SãoPaulo,SP,Brazil}

e_{UniversidadedeBrasília,Brasília,DF,Brazil}

f_{HospitalGeraldeGoiânia,Goiânia,GO,Brazil}

g_{UniversidadedeCampinas,Campinas,SP,Brazil}

h_{PontifíciaUniversidadeCatólica,PortoAlegre,RS,Brazil}

i_{FaculdadedeMedicinadeSãoJosédoRioPreto,SãoJosédoRioPreto,SP,Brazil}

j_{HospitalEvangélicodeCuritiba,Curitiba,PR,Brazil}

k_{UniversidadeFederaldoRiodeJaneiro,RiodeJaneiro,RJ,Brazil}

l_{UniversidadeFederaldoParaná,Curitiba,PR,Brazil}

m_{HospitalGeraldeFortaleza,Fortaleza,CE,Brazil}

n_{SantaCasadoRiodeJaneiro,RiodeJaneiro,RJ,Brazil}

o_{PontifíciaUniversidadeCatólica,Campinas,SP,Brazil}

p_{SantaCasadeSãoPaulo,SãoPaulo,SP,Brazil}

q_{HospitaldeBasedoDistritoFederal,Brasília,DF,Brazil}

r_{UniversidadeFederaldoMatoGrossodoSul,CampoGrande,MS,Brazil}

s_{UniversidadeFederaldePernambuco,Recife,PE,Brazil}

t_{UniversidadeFederaldoRioGrandedoSul,PortoAlegre,RS,Brazil}

u_{FaculdadedeMedicinaSouzaMarques,RiodeJaneiro,RJ,Brazil}

夽

TheelectronicversionoftheBrazilianRegistryofSpondyloarthritisismaintainedbyanunrestrictedgrantofWyeth/PfizerBrazil,that doesnotinfluenceinthestatisticalanalysisandinthewritingofthemanuscripts.

∗ _{Correspondingauthor.}

E-mail:pdsampaiobarros@uol.com.br(P.D.Sampaio-Barros).

http://dx.doi.org/10.1016/j.rbre.2015.07.013

v_{HospitaldoServidorPúblicoEstadual,SãoPaulo,SP,Brazil}

w_{InstitutodeOrtopediaeTraumatologia,UniversidadedeSãoPaulo,SãoPaulo,SP,Brazil}

x_{UniversidadeFederaldeSantaCatarina,Florianópolis,SC,Brazil}

y_{UniversidadeFederaldeSãoPaulo,SãoPaulo,SP,Brazil}

z_{SantaCasadeBeloHorizonte,BeloHorizonte,MG,Brazil}

aa_{UniversidadeFederaldeMinasGerais,BeloHorizonte,MG,Brazil}

bb_{UniversidadeFederaldoCeará,Fortaleza,CE,Brazil}

cc_{EscoladeMedicinaeSaúdePública,Salvador,BA,Brazil}

dd_{UniversidadeFederaldoPará,Belém,PA,Brazil}

ee_{UniversidadeFederaldoEspíritoSanto,Vitória,ES,Brazil}

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Articlehistory:

Received11April2014 Accepted1March2015

Availableonline4September2015

Keywords:

Spondyloarthritis Ankylosingspondylitis Qualityoflife

ASQoL

a

b

s

t

r

a

c

t

Objective:Toanalyzequalityoflifeanddemographicandclinicalvariablesassociatedtoits impairmentinalargeBraziliancohortofpatientswithspondyloarthritis(SpA).

Methods:Acommonprotocolofinvestigationwasappliedto1465Brazilianpatients clas-sifiedasSpAaccordingtotheEuropeanSpondyloarthropatiesStudyGroup(ESSG)criteria, attendedat29referencecentersforRheumatologyinBrazil.Clinicalanddemographic vari-ableswererecorded.QualityoflifewasanalyzedthroughtheAnkylosingSpondylitisQuality ofLife(ASQoL)questionnaire.

Results:ThemeanASQoLscorewas7.74(+5.39).Whenanalyzingthespecificdiseasesin the SpA group,theASQoL scoresdidnot present statisticalsignificance.Demographic datashowedworsescoresofASQoLassociatedwithfemalegender(p=0.014)and African-Brazilianethnicity(p<0.001).Theanalysisoftheclinicalsymptomsshowedthatbuttock pain (p=0.032),cervicalpain(p<0.001)andhippain (p=0.001)werestatistically associ-atedwithworsescoresofASQoL.Continuoususeofnonsteroidalanti-inflammatorydrugs (p<0.001)andbiologicagents(p=0.044)wereassociatedwithhigherscoresofASQoL,while theothermedicationsdidnotinterferewiththeASQoLscores.

Conclusion: InthislargeseriesofpatientswithSpA,femalegenderandAfrican-Brazilian ethnicity,aswellaspredominantaxialsymptoms,wereassociatedwithimpairedquality oflife.

©2015ElsevierEditoraLtda.Allrightsreserved.

Qualidade

de

vida

nas

espondiloartrites:

análise

de

uma

grande

coorte

brasileira

Palavras-chave:

Espondiloartrite Espondiliteanquilosante Qualidadedevida ASQoL

r

e

s

u

m

e

n

Objetivo:Analisaraqualidadedevidaeasvariáveisdemográficaseclínicasassociadasà diminuic¸ãodacapacidadeemumagrandecoortebrasileiradepacientescom espondiloar-trite(EspA).

Métodos:Foiaplicadoumprotocolodepesquisaúnicoa1.465pacientesbrasileiros classifi-cadoscomotendoEspAdeacordocomoscritériosdoEuropeanSpondyloarthropatiesStudy Group(ESSG),atendidosem29centrosdereferênciaemReumatologiadoBrasil.Foram reg-istradasasvariáveisclínicasedemográficas.Aqualidadedevidafoianalisadapormeiodo questionárioAnkylosingSpondylitisQualityofLife(ASQoL).

Conclusão: Neste grandesérie depacientescomEspA,osexofemininoe aetnia afro-brasileira,bemcomoalgunssintomasclínicosaxiaiseperiféricos,estiveramassociados aumaqualidadedevidareduzida.

©2015ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

Thespondyloarthritides(SpA)comprise agroup of interre-latedchronicinflammatorydiseases,i.e.ankylosing spondyli-tis (AS), psoriatic arthritis (PsA), SpA associated with inflammatorybowel diseases (IBD), reactive arthritis(ReA), juvenileonsetSpA,andundifferentiatedSpA.Thesediseases share severalclinical featuressuchasinflammationofthe axialjoints,asymmetricoligoarthritis(especiallyofthelower limbs),andenthesitis.ASisachronicinflammatorydisease thataffectspredominantlythespineandusuallystartsinthe youngadultage,contributingtosignificantphysical disabil-ityanddecreasedqualityoflife(QoL)inasignificantnumber ofpatients.1_{Withtheadventofnewandeffectiveagentsfor} thetreatmentofASinthelastdecade,itbecamenecessaryto developmethodsthatcouldreflecttherealimprovementin theQoLofthesepatients.

In general, QoL can be measured by two groups of instruments:genericinstruments,applicabletopatientswith variousconditions,anddiseasespecificinstrumentsforuse inspecificdiseases.1_{Thegenericinstrumentmostcommonly} usedtobeevaluateQoLinpatientswithSpAistheMedical OutcomeShort-Form36HealthSurvey(SF-36),2_thatmeasures health-relatedQoLthrough8domains(“physicalfunctioning”, “physicalrole”,“bodypain”,“generalhealth”,“vitality”,“social functioning”,“emotionalrole”and“mentalhealth”).In2003, theAnkylosingSpondylitisQualityofLife(ASQoL),3_aspecific instrumenttoanalyzeQoLinASpatients,wasproposed;it comprises18questions,andthepoorQoLisassociatedwith thehigherscores.ASQoLwasdevelopedincollaborationwith ASpatients, isfeasibleandsensitive tochangeover time.3 ASQoLhasbeenvalidatedinmanycountries.4–6_Andaswedo nothavespecificquestionnairesrelatedtoQoLinother dis-easesintheSpAgroup,ASQoLcanbeusedfortheevaluation oftheseSpApatients.

Theobjective ofthis studyistoanalyzethe importance ofdemographicandclinical variablesinthe QoLinalarge Braziliancohortofpatientswithspondyloarthritis(SpA).

Methods

Thisisaprospective,observational,andmulticentriccohortof 1465consecutivepatientswithSpArecruitedfrom29referral centers participating in the Brazilian Registry of Spondy-loarthritis (RBE – Registro Brasileiro de Espondiloartrites). All patients, from all the 5 major geographic areas in Brazil, wereclassifiedaccordingtotheEuropeanSpondylarthropathy StudyGroupcriteria,7_{withdatacollectedfromJune2006to} December2009.TheRBEispartoftheRESPONDIAgroup com-prising9LatinAmericancountries(Argentina,Brazil,Costa

Rica,Chile, Ecuador,México,Peru, Uruguay,andVenezuela) andthe2IberianPeninsulacountries(SpainandPortugal).

Acommonprotocolofinvestigationwasappliedto1465 SpA patients. The diagnosis of AS was considered if the patientsfulfilledtheNewYorkmodifiedcriteria,8_andas pso-riaticarthritis(PsA)incasetheyfulfilledtheMollandWright criteria9_{;reactivearthritis(ReA)wasconsideredwhen} asym-metricinflammatoryoligoarthritisoflowerlimbswaspresent, associatedwithenthesopathyand/orinflammatorylowback painfollowingentericorurogenitalinfections10_;and entero-pathic arthritis when the patient presented inflammatory axialand/orperipheraljointinvolvementassociatedwith con-firmedinflammatorybowel disease(IBD;Crohn’sdiseaseor ulcerativecolitis).

Demographicand clinicaldata were collected,including timeofdiseaseduration,spinalpain,peripheraljointpainor swelling,tenderandswollenjointcount,visualanalogscale forpainaccordingtothepatient(VASforpain)anddisease activityaccordingtopatientandphysician(patientand physi-cianVASfordiseaseactivity).Peripheralarticularinvolvement was assessed by the 66 tender/swollen joint count. Other clinicalvariablesasdactylitis,uveitis,HLA-B27werealso eval-uated,aswellasdruguse.

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”, respec-tively.Totalscorerangesfrom0to18,withthehigherscores indicating poor quality oflife. ASQoL had previously been translated,cross-translated,validated,andculturallyadapted totheBrazilianPortugueselanguage.11

Statisticalanalysis

Categoricalvariableswerecomparedby2andFisher’sexact test, and continuous variables were compared by ANOVA test. A value of p<0.05 was considered significant, and 0.05>p>0.10wasconsideredastatisticaltrend.

Results

Atotalof1465patientswereevaluated,comprising1059men and406women.ASwasthemostfrequentdiseaseinthegroup (67.6%),followedbyPsA(18.8%),USpA(6.8%),ReA(3.4%),and enteropathicarthritis(3.4%).ThemeanscoreofASQoLwas 7.74±5.39.Therewasnostatisticalsignificancecomparingthe ASQoLmeanscoresamongthedifferentdiseasesintheSpA group,asshowninTable1.

Table1–ASQoLscores,accordingtotheSpA.

N(%) ASQoLscore 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, ankylos-ing spondylitis; IBD, inflammatory bowel disease; PsA, pso-riatic arthritis; ReA, reactive arthritis; USpA, undifferentiated spondyloarthritis.

Table2–ASQoLscores,accordingtodemographic

variables.

N(%) ASQoLscore 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

Familyhistory

Yes 18.0 7.80 5.28 0.829

No 82.0 7.73 5.42

a_{Dataavailablefor723patients.}

TheASQoLscoresweresignificantlyassociatedwith but-tock pain (p=0.032), cervical pain (p<0.001) and hip pain (p=0.001)(Table3).Clinicalvariablesasinflammatorylowback pain, enthesitis, dactylitis, upperlimbarthritis, lower limb arthritis,uveitis,inflammatoryboweldisease,psoriasis,and urethritisdidnotinfluencetheASQoLscore(Table2).

Regardingtreatment, patientswho tookNSAID continu-ously presented higher ASQoL scores (p<0.001). The other medications, like corticosteroids, methotrexate, and sul-fasalazinedidnotinfluencetheASQoLscores.Biologicagents, especiallyadalimumab,wereassociatedwithlowerscoresof ASQoL(p=0.013)(Table4).

Discussion

DespitespecificinstrumentstoassessQoLcannotbeeasily appliedto other diseases, ASQoL had a good performance inthe evaluationofthis large seriesof patientswith SpA. AlthoughASpatientspresentedhigherASQoLscores,there was no statisticalsignificance amongthe ASQoL scores in thedifferent diseasesin thegroup; the meanASQoLscore

Table3–ASQoLscores,accordingtoclinicalvariables.

N(%) ASQoLscore p

Mean SD

Lowbackpain

Yes 67.6 7.88 5.46 0.158

No 22.4 7.46 5.24

Buttockpain

Yes 33.1 8.18 5.66 0.032

No 66.9 7.52 5.24

Cervicalpain

Yes 30.8 8.64 5.43 <0.001

No 69.2 7.34 5.33

Hippain

Yes 25.1 8.56 5.49 0.001

No 31.0 7.46 5.33

Arthritislowerlimbs

Yes 48.9 7.97 5.40 0.105

No 51.1 7.52 5.37

Arthritisupperlimbs

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,AnkylosingSpondylitisQualityofLife;IBD,inflammatory boweldisease.

(7.74±5.39)indicatedthattheanalyzedpatientshada signif-icantlowqualityoflife.

Patientswiththemixed(axial+peripheraland/or enthe-seal) articular presentation had higher ASQoL scores, as expected.Interestingly,theenthesealinvolvementwas associ-atedwiththehighestASQoLscores,indicatingthatenthesitis can contribute to a significant decrease in the QoL of the affectedpatients.

Table4–ASQoLscores,accordingtotreatment.

N(%) ASQoLscore p

Mean SD

NSAID>50%

Yes 35.2 8.65 5.22 <0.001

No 64.8 7.25 5.43

NSAIDondemand

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,AnkylosingSpondylitisQualityofLife;NSAID,nonsteroidal anti-inflammatorydrugs.

conductedinBrazil,evaluating71ASpatients(45.5%males and 54.5% females), observed that fibromyalgia was more prevalent among women (3.8:1) and may have influenced thehigherBASDAI,BASFIandASQoLscoresinthepatients withassociatedfibromyalgia.14_{Anxietyanddepressioncan} alsobeinvolvedintheimpairmentofQoLinASpatients.15 Fibromyalgia,aswell asspecific questionnairesforanxiety anddepressionwerenotassessedinthepresentstudy.

ThereferredhigherASQoLscoresobservedinthe African-Brazilians,indicating alower QoL,canbeexplainedbythe geneticbackgroundandtheinfluenceofsocio-economic fac-tors,suchasaccesstohealthservicesandaccesstospecific treatments.Thisaspectdeservesfurtherstudiesaddressing specificallythe socio-economic profileofourpatients with SpA.

Thepracticeofexercisewasassociatedwithlowerscores ofASQoL,similartothatobservedinaTurkishstudyanalyzing 942ASpatients.16_{ArecentBritishstudywith612ASpatients} showedthatsmokinghasadose-dependentrelationshipwith increaseddiseaseactivity,decreasedfunction,andpoor qual-ityoflife,independentofage,gender,deprivationlevel,and diseaseduration.17

Inagroupwhereasignificantnumberofpatientspresent axialandperipheralarticularinvolvement,theASQoLscores weresignificantlyhigherinthosepatientspresentingbuttock pain,cervicalpainandhippain.Thiscanreflectthefactthat theASQoLwasdevelopedforpatientswithAS,adiseasewhere

theaxialcomponentrepresentsitscoresymptoms.Itisalso importanttomentionthat18.8%ofthestudiedpatientshad PsA,adiseasewithpredominantperipheralcomponentand thathasaspecificQoLinstrument,thePsoriaticArthritis Qual-ityofLife(PsAQoL).18_{However,consideringthatPsAQoLwas} nottranslatedandvalidatedtotheBrazilianPortugueseatthe timeofthedatacollection,andthefactthat10ofthe18 ques-tionsoftheASQoLarequitesimilarto10ofthe20questionsof thePsAQoL,weunderstoodthatASQoLcouldbeusedinthat heterogeneousgroupofSpApatients.

Ingeneral,theapplicabilityofASQoLusestobeverygood.19 Arecentstudywith522ASpatientsfromCanadaand Aus-traliashowed thatcontextualfactors,suchashelplessness andemploymenthadanimportantandindependent contri-bution tohealth-related QoL,explaining 47%ofthe ASQoL variance.20

ThecontinuoususeofNSAIDwasassociatedwithhigher scoresofASQoL,whileNSAIDuseondemanddidnot con-tributetoanimpairmentofASQoL.Itcanbeassociatedtothe increasedpainandfunctionallimitationobservedinpatients whogenerallyhavecontinuoususeofNSAID,contributingto adecreasedqualityoflifeinthesepatients.Theuseofbiologic agentswasassociatedwithbetterQoL,asshowninprevious studies.21,22

Concluding,thislargeBrazilianseriesofpatientswithSpA showed thatfemale genderandAfrican-Brazilianethnicity, aswellasthemixed(axial+peripheral)clinicalpresentation, wereassociatedwithimpairedqualityoflife.

Conflicts

of

interest

Dr.Sampaio-Barrosisarecipientofaresearchgrantfrom Fed-ericoFoundation. Theotherauthors declareno conflictsof interest.

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