More Rigorous Evaluation for Comorbidities Needed in Spondyloarthritis

In a study examining comorbidities of spondyloarthritis (SpA) in participants across the globe, researchers found a high prevalence of comorbidities; they therefore concluded that rigorously applying a systematic evaluation of comorbidities in patients with SpA may permit earlier detection, and may therefore ultimately result in improved outcomes.

According to Anna Moltó, MD, PhD, from the Rheumatology B Department at Paris Descartes University, Cochin Hospital, in Paris, France, and colleagues, “The international Assessment in SpondyloArthritis International Society (ASAS)-COMOSPA study had 3 main objectives, and because of its goals, was set up to be the largest in the field. [Its first goal was] to evaluate the prevalence of comorbidities and their risk factors in patients with SpA; second, to evaluate the gap between the available recommendations and their implementation in daily practice; and third, to evaluate the number of patients in whom a risk factor was detected due to the systematic evaluation of risk factors during this initiative.”

The scientific committee of ASAS selected national principal investigators for each participating country to participate in the study. The national principal investigators invited rheumatologists in their country to participate in the study, and participants of at least 18 years and who fulfilled the ASAS criteria for either axial or peripheral SpA were included. Investigators from 22 countries recruited a total of 4028 participants from January 2013 to September 2014, and after excluding 44 participants because of missing data, 3984 participants were included in the analysis.

The researchers found that the most prevalent comorbidities were osteoporosis (13.4%) and a history of gastrointestinal ulcer (10.7%), which are the 2 comorbidities classically reported to be more frequent in patients with SpA. “Osteoporosis was more frequent than what has been reported in healthy young men (around 5%), but with a prevalence comparable with what has been reported in the literature in SpA. Gastrointestinal ulcer was the second most prevalent comorbidity, but there was a major intercountry variability (from 47% in Egypt to 2% in China),” the researchers wrote.

The researchers also found that the prevalence of CV disease was not higher than in the general population, although they noted that their study population was very young (mean age 44 years). “Regarding the worldwide distribution of comorbidities, as described in the literature, CV and cancer diseases were strikingly more frequent in Northern Europe and in the USA compared with Asian and Northern African countries,” the authors wrote. “However, these particular comorbidities (CV and cancer) are well known to be age-related, and in our study Asian patients were younger than European patients (eg, mean age of 29 years for China vs 53 years for Belgium or 52 years for the Netherlands).”

The researchers also found that a high percentage of patients were not monitored according to prevailing recommendations. Optimal monitoring of CV disease was only attained in 50% of patients, and optimal cancer screening (eg, according to general population recommendations for most cancers and treatment-related-specific recommendations for skin cancer) was only attained in 11-44% of patients. “Even lower percentages were found for optimal vaccination, particularly for the diphtheria–tetanus–poliomyelitis (DTP) (8%),” the researchers wrote. “This wide gap between recommendations for cancer screening and vaccination programs and performance in real life has already been reported for the general population, and in patients with rheumatic diseases21 and/or under immunosuppressive treatment.”

The researchers also noted that the systematic evaluation performed in their study allowed them to detect some abnormalities in the parameters defining CV risk factors in patients without any previous history.

Summary & Clinical Applicability

“These results reinforce the idea that systematic evaluation and screening of comorbidities and risk factors in patients with SpA may allow an earlier detection, which may result in an improved outcome of these patients,” the authors concluded.

Limitations & Disclosures

The limitations of the study include the following:

• The prevalence of some comorbidities may have been overestimated due to diagnostic bias: that is, patients with SpA might have been screened more frequently for comorbidities that have been classically related to the disease, such as osteoporosis.
• Conversely, the prevalence of some comorbidities may have been underestimated by selection: patients with relevant comorbidities may have been unable to participate or may have even passed away prematurely, preventing them from participating in the study.
• The authors noted that large disparities existed across countries, which may be explained by ethnicity and socioeconomic differences, but is also possible that this would be explained by patient selection depending on the country.
• Finally, recommendations for optimal monitoring were at times based on local recommendations and were applied to the global group. Results could have been different if country-specific recommendations were used. However, the authors noted that it is unlikely that using recommendations by country would have yielded optimal screening percentages because there is still much room for improvement in detecting and monitoring comorbidities in SpA.

Reference

Moltó A, Etcheto A, van der Heijde D, et al. Prevalence of comorbidities and evaluation of their screening in spondyloarthritis: results of the international cross-sectional ASAS-COMOSPA study. Ann Rheum Dis. 2016;75(6):1016-23. doi:10.1136/annrheumdis-2015-208174. Epub 2015 Oct 21.