PsA Morbidity: Fatigue Ranked High Among Overall Patient Concerns

psoriasis RA biologic treatment
psoriasis RA biologic treatment
High fatigue levels are common among people with psoriatic arthritis, with patients raking it as second in importance after pain.

Almost 50% of patients with psoriatic arthritis (PsA) report high levels of fatigue, according to a study published in the April issue of Joint Bone Spine.1 Investigators led by Tania Gudu, MD, from Sorbonne University in Paris, France, found that 44.7% of PsA patients reported fatigue levels of 5 or higher on a 10-point numerical rating scale (NRS).

The relative importance of fatigue was also high: of 9 health domains assessed, fatigue was ranked second — after pain, and before skin problems. The findings suggest that clinicians should address fatigue at each patient visit, in addition to disease activity and therapeutic management.

Fatigue is an important issue for patients who suffer from rheumatic diseases, and this is one of the first studies to assess its priority from a patient perspective, Dr Gudu and colleague Laure Gossec, MD, PhD, told Clinical Pain Advisor.

“Clinicians should keep in mind that no matter the causes, fatigue is a very important aspect of the disease from PsA patients’ perspective. These patients report high levels of fatigue and consider it a high-priority problem, more important than skin problems, work/leisure activities, or functional capacity,” Dr Gossec pointed out.

“In clinical practice, clinicians should consider the importance of fatigue for PsA patients and try to address it [using methods such as an] NRS question at each assessment. This could strengthen the relationship between doctors and their patients and might improve patients’ adherence to treatment,” Dr Gossec added.

One in 3 patients develop psoriatic arthritis

The National Psoriasis Foundation estimates that about 30% of patients with psoriasis also develop psoriatic arthritis2, which causes stiffness, pain, and swelling in and around the joints. Psoriatic arthritis most commonly develops between the ages of 30 and 50 years.

Michael Siegel, PhD, the Foundation’s director of research programs, told Clinical Pain Advisor that not much is known about the relationship between fatigue and PsA, and that the current study is a step in the right direction.

“Understanding that fatigue is an element of the spectrum of symptoms of PsA, even though we may not know where it is in the chain of causation, will help doctors treat their patients in the most complete way possible,” Dr Siegel said.

Fatigue is Multifactorial

The current research was an ancillary analysis of the cross-sectional Psoriatic Arthritis Impact of Disease (PsAID) study, designed to evaluate the effect of PsA on domains of health from the patient’s perspective.

Data was obtained from 246 PsA patients in 13 European countries, with a mean disease duration of 9.9 ± 10.1 y. Disease activity was moderate on average, and 34.4% of participants were receiving biologic therapy. The majority (84.2%) had current psoriatic skin lesions affecting more than 5% of the body surface.

Mean fatigue on the NRS scale was 5.0 ± 3.0, with 44.7% of patients reporting high fatigue (> 5); age and disease duration were not significant factors.

Multivariate analysis revealed that independent factors accounting for 73% of high-fatigue cases included skin psoriasis > 5% of body surface area (odds ratio [OR] = 4.67 (95% CI, 1.05 – 20.72); tender joints count (OR per 5 extra joints = 1.30; 95% CI, 1.01 – 1.68); and years of education (OR for each year less = 1.09; 95% CI, 1.02-1.23). Female gender did not reach statistical significance (P=.06).

In multiple linear regression analyses, 79% of fatigue was explained by skin psoriasis (β = 2.62; 95% CI, 1.17 – 4.06), tender joints (β = 0.07; 95% CI, 0.02 – 0.13), enthesitis (β = 0.99; 95% CI, 0.11 – 1.89), female gender (β = 1.66; 95% CI, 0.90 – 2.42), and years of education (β = –0.10; 95% CI, –0.20 to –0.08).

More Research Needed

“Fatigue is very important for PsA patients because it interferes with daily activities, work and leisure, and social participation. Moreover, fatigue is very difficult to manage [because] conventional treatments, including biologic drugs, have a small, non-significant effect,” Dr Gudu pointed out.

“Clinicians should not only acknowledge the presence and importance of fatigue, but they should also try to find a therapeutic approach,” Dr Gudu added, noting that behavioral approaches have shown efficacy in patients with rheumatoid arthritis (RA).

“Patients with more active disease report higher levels of fatigue, suggesting that disease activity may be an important cause. However, in RA it has been shown that the high priority attributed to fatigue by patients is not related to high levels of fatigue, and that patients in remission may still experience fatigue,” Dr Gudu said.

Patient characteristics — demographic, psychological, and social factors — may also play a role, as well as comorbidities.

Despite an increasing interest in qualitative studies to evaluate the impact of fatigue in RA, studies in PsA patients remain limited and their experience might be quite different, Dr. Gudu said. Dr Siegel concurred, stating a need for similar studies that include a more comprehensive evaluation of PsA fatigue-related factors, as well as clinical assessments of patient-reported outcomes.

The PsAID study and analysis were supported by the European League Against Rheumatism (EULAR).

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1. Gudu T, Etcheto A, de Wit M, et al. Fatigue in psoriatic arthritis – a cross-sectional study of 246 patients from 13 countries. Joint Bone Spine 2016; Epub ahead of print April 4, 2016. doi: 10.1016/j.jbspin.2015.07.017

2. The National Psoriasis Foundation. About Psoriatic Arthritis. The National Psoriasis Foundation. Accessed May 11, 2016.

This article originally appeared on Clinical Pain Advisor