Fractures in Patients with SSc
By Zsuzsanna McMahan, MD, MHS
Why was this study done? To minimize disability due to systemic sclerosis (SSc), it’s important to prevent and manage complications. Many SSc complications and related medications may increase the risk for osteoporosis and fracture. We sought to identify modifiable risk factors for fracture in patients with SSc to improve their quality of life and identify ways to minimize the long-term economic burden.
Study methods? Patients were part of an observational study as participants in FORWARD, a longitudinal, observational, patient-driven database for which a primary questionnaire is distributed to patients twice yearly. From this database we identified patients with SSc, as well as age- and gender-matched patients with osteoarthritis (OA) for comparison. The primary outcome was major osteoporotic fracture. Multivariable Cox proportional hazard models were used to examine the risk factors for fractures or osteoporosis in the SSc and control groups after adjusting for age and body mass index (BMI).
Key findings? We observed a higher fracture rate in patients with SSc relative to OA comparators. Comorbidity burden and higher physical disability were strongly associated with a high fracture rate in both scleroderma and OA. Diabetes and renal disease were also determined to increase fracture rates in patients with SSc, even after adjusting for age and BMI. After adjustment, significant disability and comorbidity burden were most strongly associated with fracture in SSc.
Main conclusions? Several specific factors are associated with fracture in patients with SSc. In particular, disability—as measured by Health Assessment Questionnaire-Disability Index (HAQ-DI)—is a particularly strong indicator of fracture rate, which suggests that improving the functional status of patients with SSc, when possible, may lead to better long-term outcomes.
Implications for patients? Physical disability is associated with a high fracture rate in patients with SSc. Musculoskeletal involvement is common in SSc and can lead to disability. Various therapeutic rehabilitation programs are reported to improve the function of patients with SSc, and home-based physical exercise regimens are reported to decrease disability and improve strength. These actionable interventions may help reduce fracture risk, but the optimal timing and application of such interventions remains unclear.
Implications for clinicians? Patients with high Rheumatic Disease Comorbidity Indices are more likely to have fractures than patients with fewer comorbidities. Early diagnosis and appropriate management of comorbidities in patients with SSc should be a priority, and interventions, such as multidisciplinary rehabilitation, may reduce the long-term fracture risk. A low threshold to screen for causes of disability and a focus on minimizing such complications may benefit high-risk patients.
The study: Rogers B, Famenini S, Perin J, et al. Clinical features associated with rate of fractures in patients with SSc: A United States cohort study. Arthritis Care Res (Hoboken). 2023 Apr 24. doi: 10.1002/acr.25137. Epub ahead of print. PMID: 37093022.
Clinical Response in JIA
By Robert Wong, MD, & Hermine Brunner, MD, MSc
Why was this study done? Measurement of the clinical effectiveness of treatments for polyarticular-course JIA (pcJIA) in clinical trials is based on response differences between patient groups. However, data on the frequency and trajectories of long-term clinical responses in individual patients with pcJIA are scarce. Thus, the ability of individual children with pcJIA being treated with abatacept to achieve and sustain simultaneously meaningful clinical and patient-reported outcome (PRO) end points was assessed.
Study methods? We conducted a post hoc analysis of children with pcJIA aged 2–17 years old treated with subcutaneous (SC; n=219) or intravenous (IV) abatacept (n=190). Novel composite end points that combined meaningful clinical and PRO end points were evaluated in individual patients. They included low disease activity (LDA) measured by the Juvenile Arthritis Disease Activity Score (JADAS), and 50% improvement as measured by the JIAACR Criteria (JIA-ACR50); PROs included a visual analog scale (VAS) of minimal pain and no disability in physical function as reflected in a Childhood HAQ-DI score of 0. Maintenance of these combined end points was assessed at months 13 and 21 in those individual patients who achieved them at month 4—the time of the original pharmacokinetic primary end point. Heat maps and Sankey diagrams were used to assess an individual child’s response and the summation of the course of individual patients meeting these end points over time, respectively.
Key findings? Composite end points (LDA+pain-min, LDA+CHAQ-DI0 and ACR50+pain-min) were achieved at month 4: 44.7%, 19.6% and 58.9% of the overall group of patients treated with SC abatacept, respectively. Of those who achieved LDA+pain-min at month 4, 84.7% (83/98) and 65.3% (64/98) maintained LDA+pain-min at months 13 and 21, respectively. The frequency of patients who met LDA+ CHAQ-DI0 increased from 19.6% at month 4 to 28.8% at month 21. Of the 58.9% who achieved ACR50+pain-min at month 4 in the SC arm, 84.5% maintained this at month 13 and 73.6% maintained this at month 21. Heat maps showed the majority of individual children who achieved LDA+painmin, LDA+ CHAQ-DI0 and ACR+pain-min at month 4 maintained this status at month 13 (87.8%, 84.0%, and 81.4%, respectively) and month 21 (72.4%, 72.0%, and 60.5%, respectively). Sankey diagrams showed the proportion of patients achieving LDA+pain-min increased from 44.7% at month 4 to 54.8% at month 21. Patients who were LDA+pain-min responders maintained their response over time. Likewise, the proportion meeting the LDA+CHAQ-DI0 end point increased from 19.6% at month 4 to 28.8% at month 21. Responders for the ACR+pain-min end point increased from 58.9% at month 4 to 63.5% at month 21. Results of the IV arm were similar to the SC arm.
Main conclusions? Individual patients with pcJIA treated with SC or IV abatacept who achieved one of the end points generally maintained them over 21 months. Implications for patients? Patients aged 2–17 years old with pcJIA who achieve both a meaningful clinical and PRO response relatively early after starting SC or IV abatacept are likely to continue to have a good long-term response to the treatment.
Implications for clinicians? Clinicians can feel confident that overall and individual patients with pJIA treated with either SC or IV abatacept who achieve both a meaningful clinical and PRO end point simultaneously at four months will likely maintain long-term benefits.
The study: Brunner HI, Tzaribachev N, Louw I, et al. Long-term maintenance of clinical responses by individual patients with polyarticular-course juvenile idiopathic arthritis treated with abatacept. Arthritis Care Res (Hoboken). 2023 May 23.
TV & the Public Perception of Gout
By Rachel Murdoch, MBChB, Borislav Mihov, BPhty, Anne M. Horne, MBChB, Keith J. Petrie, PhD, Gregory D. Gamble, MSc, & Nicola Dalbeth, MD
Why was this study done? Gout is frequently portrayed in the media as a humorous disease caused by overindulgence in food and alcohol. The impact of these depictions on public perceptions has not previously been explored.
Study methods? Two hundred members of the public were randomized to watch either a 19-minute commercial television comedy depicting gout as a humorous and embarrassing disease caused by a poor diet and managed through lifestyle changes, or a control episode from the same television series that did not mention gout. Participants completed a survey assessing illness perceptions and were asked about the likely causes and management strategies for gout.
Key findings? Participants who watched the gout episode were more likely to rate poor eating habits as the most important cause of gout than those viewing the control episode and were less likely to believe it was due to genetic factors or chance. They believed they had a greater understanding of gout and that the condition would have a greater effect on a person’s life. They also believed a change in diet would be a more effective management strategy than longterm medication use.
Main conclusions? Fictional depictions of gout have an important impact on perceptions of the public about the disease. Despite believing they had a greater understanding of gout, those who viewed the gout episode were less likely to believe long-term medication would be effective.
Implications for patients? Societal beliefs about gout affect patients because they may receive inaccurate advice about management strategies from family and friends. Embarrassment about gout can lead to a sense of stigma and reluctance to seek medical therapy. Accurately depicting gout may help the family and community of a patient support them in their treatment plan.
Implications for clinicians? Discussing common misconceptions with patients and their families and providing patients with access to accurate educational material about gout may encourage patients to agree and adhere to urate-lowering therapy.
The study: Murdoch R, Mihov B, Horne AM, et al. Impact of television depictions of gout on perceptions of illness: A randomized controlled trial. Arthritis Care Res (Hoboken). 2023 Apr 11. doi: 10.1002/acr.25130.
