Lupus Fog?
By Laura C. Plantinga, PhD, Patricia P. Katz, PhD, S. Sam Lim, MD, MPH, C. Barrett Bowling, MD, MSPH, & Jinoos Yazdany, MD, MPH
Why was this study done? Perceived cognitive impairment (i.e., lupus fog) is common in systemic lupus erythematosus (SLE). However, comprehensive, multidomain assessments of objective cognitive function are rarely performed. Particularly, little is known about SLE and fluid cognition (i.e., the capacity to reason and solve problems in novel situations), which is largely independent of acquired knowledge and acculturation.
What were the study methods? Participants from a population-based SLE cohort completed the NIH Toolbox Fluid Cognition Battery—with assessments of episodic memory (i.e., remembering objects, people or events experienced at particular times and places); working memory (i.e., remembering and seeing connections between items or ideas); attention and inhibitory control (i.e., focusing on relevant stimuli in the presence of irrelevant stimuli); processing speed (i.e., taking in and using information); and cognitive flexibility (i.e., shifting thoughts and adapting behavior to new conditions). Age-corrected standard scores (mean score of individuals of the same age from the general U.S. population=100; SD=15) were calculated. Potential impairment was defined as a standard score >1.5 SD below the mean. Descriptive statistics were calculated, and associations of various participant characteristics with potential fluid cognition impairment were assessed with multivariable logistic regression.
What were the key findings? The mean overall fluid cognition score of participants (N=199; mean age, 46; 87% female, 86% Black, 5% Hispanic) was 87.2 (episodic memory, 96.2; working memory, 91.4; attention and inhibitory control, 82.0; processing speed, 93.4; and cognitive flexibility, 94.7). Working status (OR=0.30 [95% CI, 0.14–0.64]) and higher self-reported physical functioning (OR=0.46 [95% CI, 0.28–0.75]) and physical performance (OR=0.72 [95% CI 0.59–0.87]) were associated with lower odds of potential impairment; lower educational attainment was associated with higher odds (OR=3.82 [95% CI, 1.67–8.75]). Self-reported forgetfulness, neuropsychiatric damage and depressive symptoms were not statistically significantly associated with potential impairment.
What were the main conclusions? Scores for fluid cognition were ~1 SD lower than those in the similarly aged general U.S. population. Potential impairment was less frequent among those who were working, had higher physical functioning and performance, and had higher educational attainment.
What are the implications for patients and clinicians? Impairment in fluid cognition may be common in SLE and has implications for self-management. Future work is needed to track fluid cognition among those with SLE to develop and implement interventions that can support fluid cognition and, hopefully, establish treatments that prevent impairment.
The study: Plantinga LC, Yazdany J, Pearce BD, et al. Fluid cognition among individuals with systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2024 Mar 25.
Prevalence of SLE & Severe Restrictive Lung Disease in Hispanic Patients with SSc
By Bochra Jandali, MD, & Shervin Assassi, MD, MS
Why was this study done? It is well known that systemic sclerosis (SSc) manifestations vary in different ethnic groups around the world. In the U.S., previous studies have shown that patients who are Black have earlier disease onset and overall worse disease outcomes when compared with patients who are white. Few studies have examined disease characteristics in Hispanic patients, and those had conflicting results. Our prospective, observational study focused on SSc disease features and outcomes in Hispanic Americans in comparison with non-Hispanic white and Black American patients.
What were the study methods? We enrolled patients who fulfilled the classification criteria for SSc and had a disease duration less than five years who self-identified as white, Black or Hispanic. Demographics, disease duration, autoantibodies and comorbidities were captured at the baseline visit. Longitudinal clinical characteristics were collected prospectively every six months for three years, then annually. Autoantibodies were determined using reference methods in our research laboratory. Generalized linear mixed models for the longitudinal analysis and Cox proportional hazards regression for the mortality analysis were used.
What were the key findings? A cohort of 427 patients, comprising 124 Hispanic, 220 non-Hispanic white, and 83 non-Hispanic Black participants was examined. We found that Hispanic patients were significantly younger, but had longer disease duration at enrollment, higher frequency of U1-RNP positivity and more frequent concurrent systemic lupus erythematosus (SLE) diagnosis. They also had lower income and educational levels in comparison with non-Hispanic white patients. In the longitudinal analysis, Hispanic patients had significantly lower forced vital capacity percent predicted (average 9.3% lower FVC% over time) than non-Hispanic white, but not Black patients. Hispanic patients also had higher mortality rates than white Americans, even after adjustment for age, gender and socioeconomic status.
What were the main conclusions? Hispanic American patients differ in disease characteristics from white patients. They are younger at diagnosis, more likely to have U1-RNP positivity and overlap with SLE. Moreover, Hispanic patients have more severe restrictive lung disease and higher mortality even after adjustment for demographic and socioeconomic factors.
What are the implications for patients and clinicians? Our study revealed significant differences in demographics, SSc clinical presentation and severity in Hispanic patients when compared with white patients. These results support the importance of enhancing physician awareness of the higher prevalence of SLE overlap in Hispanic SSc patients and the tendency to have more severe restrictive lung disease. This may help risk stratify patients to receive more aggressive monitoring/treatment strategies, with the ultimate goal of improving disease outcomes and survival.
The study: Jandali B, Lyons M, Charles J, et al. A prospective observational study of disease severity and mortality in Hispanic American patients with systemic sclerosis. Arthritis Care Res (Hoboken). 2024 Jun;76(6):768–776.
TB Screening Lapses in New DMARD Users
By Eric T. Roberts, PhD, MPH, Gabriela Schmajuk, MD, MSc, Jing Li, MPH, Matthew Murrill, MD, PhD, & Jinoos Yazdany, MD, MPH
Why was this study done? Many biologic or targeted synthetic disease-modifying anti-rheumatic drugs (DMARDs) increase the risk of reactivation of latent tuberculosis (TB) infection, putting patients at risk for adverse events, including death. With a growing number of drugs available in rheumatology, it is important to investigate whether TB screening practices have kept pace with recommendations to minimize preventable patient safety events.
What were the study methods? Our population was patients in the RISE registry and Medicare patients who were incident users of a biologic or targeted synthetic DMARD. TB screening was assessed in both groups one and three years before the medication start date. We calculated the proportion screened overall by medication class and practice. We tested for demographic differences in screening using logistic regression.
What were the key findings? Among 2,853 new biologic or targeted synthetic DMARD users, 65.6% of patients had TB screening within one year; within three years, 72.9% were screened. By drug type, rates of screening within one year were reduced for Janus kinase (JAK) inhibitors (46%) and interleukin (IL) 17 inhibitors (11.5%). A lower proportion of patients who were Hispanic and Asian (vs. white) were screened. Practice screening rates ranged from 20.0% to 92.9% of patients within one year.
What were the main conclusions? We report higher TB screening rates than previously published because we combined Medicare claims and electronic health record data. However, important safety gaps remain, namely, lower than expected screening among new users of a JAK or IL-17 inhibitor and among patients who were Asian and Hispanic. We cannot rule out that these patients were screened remotely (more than three years before drug initiation), but it may still be in the best interest of patients to update screening in those who have been off DMARDs for some time and are starting therapy, especially given the rising incidence of TB in some U.S. areas.
What are the implications for patients and clinicians? Our findings highlight important safety gaps and serve as a reminder of the importance of preventive screening before initiating therapy with DMARDs for all patients. Ideally, we will get to the place of zero preventable harm by building systems to ensure eligible patients are consistently screened across the country.
The study: Roberts ET, Schmajuk G, Li J, et al. Latent tuberculosis screening among new users of a biologic or targeted synthetic disease-modifying antirheumatic drug: Gaps in screening overall and among Janus kinase inhibitors. Arthritis Care Res (Hoboken). 2024 Jul;76(7): 1037–1044.
