Low socioeconomic status and female sex are associated with worse functional status in axial spondyloarthritis.

OBJECTIVE: We determined whether socioeconomic status (SES) and sex are associated with functional status (FS) in axial spondyloarthritis (axSpA). METHODS: We conducted a cohort study of patients with axSpA in the Rheumatology Informatics System for Effectiveness (RISE) registry. We performed cross-sectional and longitudinal analyses of FS through the Multi-Dimensional Health Assessment Questionnaire (MDHAQ) using GEE models. Area Deprivation Index (ADI) was used as an SES proxy. The cross-sectional analysis tested for a linear trend across ADI quintiles for MDHAQ. The longitudinal analysis' outcome was functional decline. We reported predictive margins and assessed for interaction with sex. In the longitudinal analysis, we reported odds of functional decline. RESULTS: In the cross-sectional analysis (N=5,658) mean (SD) age was 53.8 years (15.2), 55.8% were female, and 71.4% were non-Hispanic White. Average (SD) MDHAQ was 1.6 (2.0) in men vs. 2.1 (2.2) in women. Predicted mean MDHAQ score was 2.2 (95%CI 1.8-2.7) for the lowest ADI quintile and 1.8 (95%CI 1.4-2.1) for the highest. Women had lower FS compared to men across quintiles. In the longitudinal analysis (N= 2,341) the proportion with FS decline was 14.3% (95% CI 7.6%-25.5%) for the lowest SES quintile compared to 9.6% (95% CI 5.2%-17.1%) for the highest. Women had 1.7 (95%CI 1.3-2.2) times higher odds of functional decline compared to men. There was no interaction with sex. CONCLUSIONS: In this large sample of axSpA patients, those with lower SES had worse FS and functional decline. Women had worse FS than men, initially and over time.

Initiation of glucocorticoids before entering rheumatology care associates with long-term glucocorticoid use in older adults with early rheumatoid arthritis: A joint analysis of Medicare and the Rheumatology Informatics System for Effectiveness (RISE) data.

OBJECTIVE: To assess relationships between the timing of glucocorticoid (GC) initiation, entrance into rheumatology care, and the duration of GC use in older adults with early rheumatoid arthritis (eRA) in the U.S. METHODS: Data from the Rheumatology Informatics System for Effectiveness (RISE) registry and Medicare (2016-2018) were linked. Patients with ≥2 RA ICD codes in RISE were included; the first being the index date which signaled entrance into rheumatology care. GC initiation (between 3 months before to 6 months after the index date) and continuous GC use up to 12 months after the index date were captured using Medicare claims. Cox proportional hazards models with adjustment for confounders assessed differences in the duration of GC use for patients initiating GCs before versus after the index date. Average daily GC doses were estimated. RESULTS: 1,733 patients (67 % female; mean age 76 ± 6 years) were included. 41 % initiated GCs, on average 16 ± 58 days before entering rheumatologic care. The mean duration of GC use was 157 days (95 %-CI 143 to 170). GC initiation before rheumatologic care was associated with longer GC use, even after adjustment for confounders (hazard ratio 0.61; 95 %-CI [0.51 to 0.74]). For patients using GCs for ≥3 months, average daily GC doses were <5 mg/d prednisone equivalent. CONCLUSION: GCs are regularly used in eRA and most often initiated before patients enter rheumatology care. Long-term, low-dose GC use is common and associated with initiation before rheumatology care. Earlier referral to rheumatology might reduce GC exposure among U.S. patients with eRA.

The association of TNF inhibitor use with incident cardiovascular events in radiographic axial spondyloarthritis.

BACKGROUND: Whether tumor necrosis factor inhibitor (TNFi) use is cardioprotective among individuals with radiographic axial spondyloarthritis (r-axSpA), who have heightened cardiovascular (CV) risk, is unclear. We tested the association of TNFi use with incident CV outcomes in r-axSpA. METHODS: We identified a r-axSpA cohort within a Veterans Affairs database between 2002 and 2019 using novel phenotyping methods and secondarily using ICD codes. TNFi use was assessed as a time-varying exposure using pharmacy dispense records. The primary outcome was incident CV disease identified using ICD codes for coronary artery disease, myocardial infarction or stroke. We fit Cox models with inverse probability weights to estimate the risk of each outcome with TNFi use versus non-use. Analyses were performed in the overall cohort, and separately in two periods (2002-2010, 2011-2019) to account for secular trends. RESULTS: Using phenotyping we identified 26,928 individuals with an r-axSpA diagnosis (mean age 63.4 years, 94 % male); at baseline 3633 were TNFi users and 23,295 were non-users. During follow-up of a mean 3.3 ± 4.2 years, 674 (18.6 %) TNFi users had incident CVD versus 11,838 (50.8 %) non-users. In adjusted analyses, TNFi use versus non-use was associated with lower risk of incident CVD (HR 0.34, 95 % CI 0.29-0.40) in the cohort overall, and in the two time periods separately. CONCLUSION: In this r-axSpA cohort identified using phenotyping methods, TNFi use versus non-use had a lower risk of incident CVD. These findings provide reassurance regarding the CV safety of TNFi agents for r-axSpA treatment. Replication of these results in other cohorts is needed.

Proton Pump Inhibitor Use and Bone Health in Patients With Rheumatic Diseases: A Cross-Sectional Study.

OBJECTIVE: To assess the effect of proton pump inhibitor (PPI) use on bone mineral density (BMD) and bone microarchitecture as measured by the trabecular bone score (TBS) in patients with inflammatory rheumatic and musculoskeletal diseases (iRMDs). METHODS: Cross-sectional data from a prospective single-center cohort (2015 to 2022) of patients with iRMDs were used to evaluate 3 co-primary outcomes: BMD of the left femoral neck and the lumbar spine (as T-scores) and the TBS. Inverse probability weighting adjusted for numerous confounders including age, sex, body mass index, current and cumulative glucocorticoid (GC) dose, C-reactive protein levels, disability, and others. Analyses were based on general linear models, following a prespecified statistical analysis plan. RESULTS: The study included 1495 patients (75% women; mean age, 62.6±13.1 years; 49% and 63% with regular PPI and GC use, respectively). The PPI users had lower BMD at both spine (adjusted contrast -0.25; 95% CI, -0.47 to -0.04; P=.02) and femoral neck (-0.17 [-0.35 to 0.01]; P=.07). Differences between PPI users and nonusers were statistically significant only in patients concurrently using GCs at more than 7.5 mg/d prednisone equivalent. The TBS was similar in PPI users and nonusers (adjusted contrast, 0.00 [-0.04 to 0.04]; P=.97). CONCLUSION: Our results suggest that PPIs lead to a loss of BMD rather than an impairment of bone microarchitecture in patients with iRMDs. The negative association between PPI use and BMD appears to be dependent on concurrent GC use. Clinicians should carefully review the indication for PPI use in patients with iRMDs, especially in those receiving higher dose GCs.

Incidence Rate and Factors Associated With Fractures Among Medicare Beneficiaries With Ankylosing Spondylitis in the United States.

OBJECTIVE: We evaluated the incidence rate and factors associated with fractures among adults with ankylosing spondylitis (AS). METHODS: We performed a retrospective cohort study with data from the Rheumatology Informatics System for Effectiveness registry linked to Medicare claims from 2016 to 2018. Patients were required to have two AS International Classification of Diseases codes 30 or more days apart and a subsequent Medicare claim. Then, 1 year of baseline characteristics were included, after which patients were observed for fractures. First, we calculated the incidence rate of fractures. Second, we constructed logistic regression models to identify factors associated with the fracture, including age, sex, race and ethnicity, body mass index, Medicare/Medicaid dual eligibility, area deprivation index, Charlson comorbidity index, smoking status, osteoporosis, historical fracture, and use of osteoporosis treatment, glucocorticoids, and opioids. RESULTS: We identified 1,426 adults with prevalent AS. Mean ± SD age was 69.4 ± 9.8 years, 44.3% were female, and 77.3% were non-Hispanic White. Fractures occurred in 197 adults with AS. The overall incidence rate of fractures was 76.7 (95% confidence interval [CI] 66.4-88.6) per 1,000 person-years. Older age (odds ratio [OR] 2.8, 95% CI 1.39-5.65), historical fracture (OR 5.24, 95% CI 3.44-7.99), and use of more than 30 mg morphine equivalent (OR 1.86, 95% CI 1.08-3.19) conferred increased odds of fracture. CONCLUSIONS: In this large sample of Medicare beneficiaries with AS, increasing age, historical fracture, and use of opioids had higher odds of fracture. Men and women were equally likely to have a fracture. Because opioid use was associated with fracture in AS, this high-risk population should be considered for interventions to mitigate risk.

Sexual dimorphism in the prevalence, manifestation and outcomes of axial spondyloarthritis.

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that predominantly affects the axial skeleton, although it can affect peripheral joints, and extra-musculoskeletal manifestations also occur. Historically, axSpA was thought to be a disease predominantly seen in men, although with the advent of magnetic resonance imaging techniques and advances in research, this dogma has been challenged and refuted. Sex and gender are different concepts, and both can have a role in disease. In axSpA, consideration of the influence of sex and gender on the disease phenotype is necessary to predict outcomes and to enable the development of therapeutic approaches that are best suited to individual patients.

Relation of therapies for ankylosing spondylitis and psoriatic arthritis to risk of myocardial infarction: a nested case control study.

BACKGROUND: Risk of myocardial infarction (MI) is elevated in ankylosing spondylitis and psoriatic arthritis (AS/PsA) compared to the general population. We evaluated the risk of MI related to the use of tumor necrosis factor inhibitor (TNFi) and other therapies in AS/PsA. METHODS: We conducted a nested case-control study using 1994-2018 data from OptumLabs® Data Warehouse, which includes de-identified medical and pharmacy claims, laboratory results, and enrollment records for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on enrollees and patients, representing a diverse mixture of ages, ethnicities and geographical regions across the United States. Assessing AS/PsA separately, MI cases were matched to 4 controls by sex, age, diagnosis year and insurance type. We evaluated treatment within 6 months prior to MI including NSAIDs (AS referent), disease-modifying anti-rheumatic drug (DMARDs; PsA referent) and TNFi alone or in combinations. We evaluated the relation of treatment categories to MI risk using conditional logistical regression adjusting for confounders. RESULTS: Among 26,648 AS subjects, there were 237 MI cases and 894 matched controls. Among 43,734 PsA subjects, there were 404 cases and 1596 controls. In AS, relative to NSAID use, the adjusted odds ratio (aOR) for MI among TNFi only users was 0.85 (95% CI 0.39-1.85) and for DMARD only users was 1.04 (95% CI 0.65-1.68). In PsA, relative to DMARD use, the aOR among TNFi only was 1.09 (95% CI 0.74-1.60). Combination therapies also had no effect. CONCLUSIONS: Among AS/PsA, no combination of therapies appeared to be protective or harmful with regards to MI. Future studies should capture more AS and PsA patients and include longer term follow up to further investigate this question.

Relation of NSAIDs, DMARDs, and TNF Inhibitors for Ankylosing Spondylitis and Psoriatic Arthritis to Risk of Total Hip and Knee Arthroplasty.

OBJECTIVE: Ankylosing spondylitis (AS) and psoriatic arthritis (PsA) often affect the hip and/or knee. If effective, treatments might reduce risk of total hip or total knee arthroplasty (THA/TKA). We evaluated risk of THA/TKA related to use of medical therapies in AS/PsA. METHODS: We conducted a nested case-control study using 1994-2018 data from the OptumLabs Data Warehouse, which includes deidentified medical and pharmacy claims, laboratory results, and enrollment records for commercial and Medicare Advantage enrollees. Among those with AS/PsA, THA/TKA cases were matched up to 4 controls by sex, age, AS/PsA diagnosis, diagnosis year, insurance type, obesity, and prior THA/TKA. We assessed AS/PsA treatment 6 months prior to THA/TKA, including disease-modifying antirheumatic drugs (DMARDs) and tumor necrosis factor inhibitors (TNFi), alone or in combination, stratified by nonsteroidal antiinflammatory drug (NSAID) use. We evaluated the relation of treatment to risk of THA/TKA using conditional logistical regression with adjustment for confounders. RESULTS: Among 16,748 adults with AS, there were 444 THA/TKA cases and 1613 matched controls. Among 34,512 adults with PsA, there were 1003 cases and 3793 controls. Adjusted ORs for treatment category and THA/TKA ranged from 0.60 to 1.92; however, none were statistically significant. Results were similarly null in several sensitivity analyses. CONCLUSION: Odds of THA/TKA were not reduced with any combinations of NSAIDs, DMARDs, or TNFi among persons with AS or PsA. Given current utilization patterns in this population of US adults with AS and PsA, these medical therapies did not appear to be associated with less end-stage peripheral joint damage.

Predictors of adherence to a 26-week viniyoga intervention among post-treatment breast cancer survivors.

OBJECTIVES: This study aimed to identify demographic, psychological, health-related, and geographic predictors of adherence to home-based and supervised components of a yoga intervention in breast cancer survivors. METHODS: Participants were the 32 post-treatment breast cancer survivors who were randomized to the Viniyoga intervention arm of a controlled trial. Participants were asked to practice yoga 5 times per week for 6 months, including at least one weekly facility-based session. Adherence was monitored using sign-in sheets and logs. Height and weight were measured; other potential predictors of adherence were obtained from baseline questionnaires. RESULTS: Participants attended 19.6±13.0 yoga classes and performed 55.8±32.8 home-based yoga sessions. Participants adhered to 58% of the overall yoga practice goal (75% of the goal for yoga classes and 54% of the goal for home based-sessions). Higher class attendance and home practice were predicted by greater self-efficacy for yoga (p=0.004 and 0.06, respectively). Additionally, employment outside the home was associated with greater class attendance (p=0.004), while higher waist circumference was marginally associated with lower adherence to home-based yoga (p=0.05). CONCLUSIONS: High levels of facility- and home-based yoga practice were achieved. Breast cancer survivors who have lower self-efficacy for yoga or who have a higher waist circumference may benefit from additional support or intervention tailoring. Adherence may also be improved by ensuring that class times are convenient to both working and nonworking women.