|Year : 2022 | Volume
| Issue : 2 | Page : 110-117
Individuals with reactive arthritis suffer from poor health-related quality of life akin to individuals with ankylosing spondylitis: A multigroup study
Prakash Gupta1, Rajat Kharbanda2, Maryam Abbasi3, Roma Raj4, Latika Gupta5
1 MBBS Medical Graduates, Saint Louis University Hospital of the Sacred Heart-Baguio City, Virgen Milagrosa University Foundation-College of Medicine, San Carlos City, Pangasinan, Philippines
2 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate institute of Medical Sciences, Lucknow, UttarPradesh, India
3 MBBS Medical Graduates, Dubai Medical College, Dubai, United Arab Emirates
4 Department of General Surgery, Sindh Institute of Urology&Transplantation, Karachi, India, Pakistan
5 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate institute of Medical Sciences, Lucknow, Uttar Pradesh, India; Department of Rheumatology, Royal Wolver hampton Hospitals NHS Trust, Wolverhampton; Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, The University of Manchester, Manchester; City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
|Date of Submission||27-Sep-2021|
|Date of Acceptance||16-Nov-2021|
|Date of Web Publication||05-Apr-2022|
Dr. Latika Gupta
Department of Rheumatology, Royal Wolverhampt on Hospitals NHS Trust, Wolverhampt on Road, Wolverhampton WV100QP
Source of Support: None, Conflict of Interest: None
Background: Reactive arthritis (ReA) and ankylosing spondylitis (AS), both spondyloarthropathies predominantly affecting young men seriously hamper mobility during the active phases of disease. While AS is thoroughly researched, specific studies on ReA are relatively scarce despite its pervasive nature and ever evolving epidemiology. Thus, it is imperative to understand the quality of life (QoL) of ReA patients in comparison to those with AS and healthy controls (HC) to reduce the disparity in patient care.
Methods: An inception cohort of adults with ReA (Braun’s criteria) was surveyed to collect the data on demographics, clinical profile, disease activity (Bath AS Disease Activity Index [BASDAI], pain Visual Analog Scale [VAS]), functional status Bath AS Functional Index (BASFI), and QoL (ASQoL instrument) between November 2019 and January 2020. HC and AS were surveyed for the same parameters using an anonymized e-survey (SurveyMonkey.com). All the data are expressed as medians and interquartile range.
Results: A total of 147 participants (62 ReA, 45 AS and 40 HC) were included. Patients with ReA were younger than those with AS and HC - 25, 29, and 28 years, respectively, and had a shorter disease duration (P < 0.0001). Baseline clinical characteristics (peripheral arthritis and enthesitis), pain VAS (body pain and back pain) were comparable in ReA and AS groups. All the clinical characteristics of ReA and AS cohorts were significant in comparison to the HC cohort. Notably, functional and activity scores of AS and ReA patients were similar, whereas all functional scores of patients with either spondyloarthropathy were significantly worse than HC (BASDAI, BASFI, ASQoL, P < 0.0001). ASQoL scores were comparable across all domains of ReA and AS except in upper limb activities where patients with ReA fared better than AS. No difference in QoL was observed between acute or chronic ReA.
Conclusion: QoL in ReA and AS is comparable, thus the impact of disease on physical function must be recognized to improve patient care. Patients with ReA exhibit significantly worse QoL than HC using ASQoL instrument.
Keywords: Ankylosing spondylitis, arthritis, chronic pain, quality of life, reactive
|How to cite this article:|
Gupta P, Kharbanda R, Abbasi M, Raj R, Gupta L. Individuals with reactive arthritis suffer from poor health-related quality of life akin to individuals with ankylosing spondylitis: A multigroup study. Indian J Rheumatol 2022;17:110-7
|How to cite this URL:|
Gupta P, Kharbanda R, Abbasi M, Raj R, Gupta L. Individuals with reactive arthritis suffer from poor health-related quality of life akin to individuals with ankylosing spondylitis: A multigroup study. Indian J Rheumatol [serial online] 2022 [cited 2022 Aug 11];17:110-7. Available from: https://www.indianjrheumatol.com/text.asp?2022/17/2/110/342532
| Introduction|| |
Reactive arthritis (ReA) is a sterile, postinfectious and self-limiting subgroup of spondyloarthritis (SpA) manifesting as inflammatory arthritis days to weeks after gastrointestinal and genitourinary infections in young adults. Despite assuming a benign course in most individuals, ReA may progress to a chronic course in 25% of cases. The decline in ReA incidence in developed countries can be attributed to the decrease in gut infections, whereas ReA continues to be of concern in India due to the delay in the treatment of underlying infections despite evidence of effective decline in ReA incidence with early antibiotic administration.
ReA most frequently afflicts people of the male, young adult, working-class demographic. In a patriarchal society such as India, this demographic constitutes a significant proportion of the country’s workforce, making up 79% of “regular wage earners.” With a population of 7 billion people and incidence estimates of 0.6–027/100,000 from population-based studies, working estimates of ReA burden range between 7000 and 350,000 patients in India. Thus, the disease-related morbidity even in a proportion of these patients can incur considerable financial consequences on individual and national levels, as well as mental health and academic ramifications in younger individuals. Discerning the degree of QoL impairment, such as ocular and cardiac complications of the disease,, among these patients is the first step toward managing disease burden.
Thus, it is imperative to systematically analyze the QoL in young individuals with ReA in comparison to healthy and diseased controls with other SpAs. In our study, we compare and contrast QoL among patients with ReA with ankylosing spondylitis (AS) and healthy controls (HC).
| Methods|| |
A cross-sectional study of patients presenting to the rheumatology department with active symptoms of ReA between January 2019 and March 2020 was conducted. Active symptoms of ReA were defined by previous literature, or as per the agreement of two or more rheumatologists, to assemble the cohorts of ReA patients to participate in an Institutional Review Board certified study (IEC 2018-124-IMP-105). Data for AS and HC cohorts were obtained using SurveyMonkey.com, a cloud-based website, due to the breakout of the COVID-19 pandemic during the study. Internet Protocol and E-mail addresses of the respondents were monitored to avoid multiple entries by the same respondent and subsequently anonymized by the platform. The survey questions were made “mandatory to answer” and partial responses were rejected by the Survey Monkey platform. Standard guidelines for reporting survey-based studies were applied in this study.
Patients with ReA were divided into two cohorts − an inception cohort was formed of patients presenting to the department with first-time symptoms and new diagnosis of ReA, and a prevalent cohort was formed of patients presenting with previous ReA, relapse or routine follow-up. Those with disease duration exceeding 6 months were classified as chronic ReA.
A prespecified medical record form was used to obtain demographic and clinical data, regarding the presence of preceding infection (enteritis and urethritis), time interval between the triggering infection and onset of arthritis, duration of symptoms, family history, other musculoskeletal symptoms, and extra-articular manifestations in ReA patients.
The Bath AS Functional Index (BASFI), Bath AS Disease Activity Index (BASDAI) and AS Quality of Life (ASQoL) questionnaire were translated into Hindi (by two individuals, after forward and backward translations as per the standard guidelines) and used as part of the survey to deduce the disease activity and functional status of respondents. The Quality of Life (QoL) survey consisted of 14 questions – seven multiple choice questions with single correct answer, three questions based on numerical rating scale of 0–10, and three open-ended questions.
All qualitative variables were expressed as percentages and the quantitative variables as median (interquartile range). Statistical tools used included GraphPad and descriptive statistics of the data obtained from Survey Monkey. The Chi-Square test or Fisher’s test were used to compare the qualitative variables, and the Mann-Whitney U test was applied to nonparametric data. P ≤ 0.05 was considered statistically significant.
| Results|| |
This study compared a total of 147 respondents – 62 ReA, 45 AS and 40 HC. A higher proportion of males were observed in ReA and AS cohorts - 88.87% and 91.11%, respectively. The respondents with ReA were generally younger than those with AS and HC – the median age of respondents was 25, 29, and 28 years, respectively.
In respect to education, HC had the highest proportion of postgraduate level respondents – 45%, whilst AS had 37.78% and ReA had only 3.23%. The same trend was exhibited at the doctorate level of education – 12.5%, 4.44%, and 1.61%, respectively. 43.5% of ReA had a graduate level of education as compared to 42.2% of AS and 37.5% of HC. 33.87% of ReA, 8.89% of AS and only 5% of the HC had only a higher secondary education. No HC had an education below this level, although 2.44% of AS had no formal education and 2.22% had only secondary education. 3.32% of ReA had completed only primary education and 14.52% only had a secondary education (ReA vs. AS P < 0001; ReA vs. HC P < 0001) [Table 1].
|Table 1: Baseline demographics and clinical profiles of patients with reactive arthritis, ankylosing spondylitis, and healthy controls|
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The AS group was comprised of 11 (24.44%) students, compared to 20 (50%) among the HC, of which 5 (11.11%) of the students with AS reported an inability to work following the onset of disease. A higher proportion of HC (85%) resided in cities than patients with AS (60%) and ReA (58.06%). However, residence was no different between ReA and AS groups (ReA vs. AS P = 0.918; ReA vs. HC P = 0.014) [Table 1].
Clinical profile of reactive arthritis versus ankylosing spondylitis
Patients with ReA had a shorter disease duration compared to AS (1 [1-2] vs. 60 [36–120] months; P < 0.0001). Baseline clinical characteristics (peripheral arthritis and enthesitis) and pain Visual Analog Scale (VAS) (body pain and back pain) in ReA and AS did not yield any significant difference; however, fatigue was reported more frequently in ReA than AS (91.9% vs. 77.8%; P = 0.04) [Table 1].
On comparison of QoL, disease activity and functional indices, no significant difference was found between ReA and AS. However, ReA reported lower ASQoL scores for upper limb activities, finding tasks such washing their hair significantly more difficult than those with AS (38.71% v 20%, P = 0.039) [Table 2].
|Table 2: Functional scores of patients with reactive arthritis, ankylosing spondylitis, and healthy controls|
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Clinical profile of reactive arthritis versus healthy controls
All the clinical parameters including fatigue (91.9% v 35%, P < 0.0001), peripheral arthritis (95.2% v 5%, P < 0.0001), back pain (87.1% v 12.5%, P < 0.0001), enthesitis (80.6% v 7.5%, P < 0.0001), and pain VAS (6 [4–8] vs. 6 [3–9]) were exhibited more frequently and significantly in ReA than HC [Table 1].
The BASDAI score in patients with ReA was significantly higher compared to HC (5.05 [3.125–6.5) vs. 0; P < 0.0001). Patients with ReA displayed a lower BASFI than HC, (5.1 [3.4–6.6] vs. 0; P < 0.0001). Poorer QoL was observed in patients with ReA with respect to ASQoL (12 vs. 0, P < 0.0001) [Table 2].
Clinical profile of ankylosing spondylitis versus healthy controls
The clinical parameters of AS patients were poorer in comparison to HC across all domains [Table 1] and [Table 2].
Subgroup analysis of Reactive arthritis
Clinical profile of prevalent cohort versus inception cohort
The comparison of the prevalent and inception cohorts did not yield any significant difference in the incidence of enthesitis, peripheral arthritis, back pain, fatigue or pain VAS [Supplementary Table 1], nor any difference in QoL, or functional or disease activity indices [Supplementary Table 1].
Clinical profile of patients with acute versus chronic reactive arthritis
Although fatigue (95.65% vs. 87.18%) and neck pain (95.65% vs. 79.49%) were reported in a higher frequency among patients with acute ReA in comparison to the chronic group, the difference was not statistically significant. Similarly, no difference in QoL, functional or disease activity indices were noted when comparing acute ReA to chronic ReA [Supplementary Table 2].
Clinical Profile of patients with reactive arthritis preceded by enteritis versus reactive arthritis preceded by urethritis
In the ReA cohort, patients reported enteritis (n = 35) more frequently than urethritis (n = 27) as the preceding infection. Patients that experienced enteritis were younger (19 [17–27] years) as compared to the urethritis group (30 [24.5–36.5] years). There was no difference in symptoms or pain VAS evident between the groups, nor in QoL, functional or disease activity indices [Supplementary Table 3].
| Discussion|| |
From this cross-sectional study comparing the QoL of patients suffering from ReA and AS with HC, we can deduce that those afflicted with either spondyloarthropathy experience a comparably lower QoL and have significant restrictions in all functional capabilities than the HCs. Neither subgroup of SpA had a lower QoL compared to the other, even though ReA patients present acutely in the majority of cases, while AS has a chronic course. The HC cohort demonstrated reasonably good outcomes in most clinical parameters and performed better in all the domains of BASDAI and BASFI than either SpA.
This is a serious point of concern as ReA patients were comparatively younger at the time of presentation and had experienced disease for a shorter duration, yet had a comparable degree of reduced QoL to AS, a chronic illness with a notoriously poor QoL in India. Numerous studies have also demonstrated the younger age of onset in ReA but a similar clinical profile to various subtypes of SpA,, yet research with ReA as a focal point remains elusive.
Patients with ReA and AS presented with articular manifestations – such as enthesitis, peripheral arthritis and back pain-akin to one another, though ReA patients experienced fatigue far more frequently than AS patients. Future studies should attempt to understand the major causes of chronic pain and morbidity in ReA, specifically the presentation of enthesitis, arthritis, muscle atrophy, nonspecific peripheral pain, back pain and damaged joints (from both comorbid and disease-associated osteoarthritis) and triangulate these with pain scores and the underlying sociodemographic implications at play.
It is noteworthy that no marked differences were found between functional scores of the ReA and AS groups, except in the duration of early morning stiffness which the ReA group experienced for double the amount of time AS patients reported (5 vs. 2.5 h). ASQoL scores were comparable across all the domains of AS and ReA except in upper limb-related activities such as washing hair, which patients with ReA found much more arduous than AS patients.
This finding was in line with previous studies, which also reported poorer ASQoL in AS patients compared to HC. Since ReA can involve upper limb joints as well, it is more likely to cause decreased global function and impact productivity in the short term. The possibility that these symptoms may persist long term in the subset of acute ReA that will progress to chronicity is noteworthy, as we found no significant difference in QoL between acute and chronic ReA cohorts, indicating that acute ReA patients are faced with the same QoL as chronic ReA patients that experience persistent disease activity and are significantly disabled. The comparably low QoL in both ReA and AS, yet disproportionate attention given to AS warrants further research into ReA to reduce the disparity in patient care.
Another characteristic of ReA that remains vastly understudied despite the debilitating nature of the illness is its chronic course, as it is thought to be less common and less severe than AS, despite numerous studies documenting comparable impairment of QoL between the SpAs. ReA is considered chronic once symptoms persist for more than 6 months and warrants far more rigorous treatment with the likes of DMARDs or surgery in some cases and has forced sufferers completely out of the workforce due to its debilitating nature. Although considered uncommon, chronic ReA may not be as evasive as we have become accustomed to believe due to the widely accepted notion that ReA is largely self-limiting. As previously reported by Thomas et al., a whole third of patients with ReA exhibit chronic symptoms. The situation in childhood ReA is no better, as substantiated by previous reports suggesting ReA and other spondyloarthritides of childhood have minor differences in clinical and laboratory profiles, suggesting a shared pathogenesis.
With the disease predominantly affecting men of working age, that form the foremost and largest portion of India’s workforce, ReA may carry far-reaching implications concerning reduced productivity, academic performance as well as financial well-being of patients. Analysis of socioeconomic or education-related predisposition may also pave the way for better prevention of the disease, as it was found that HCs had higher levels of education than those experiencing ReA. We fully acknowledge the limitations of self-reporting bias and differences in the sociodemographic profiles of the cohorts. In a country where ReA and its triggering infections are still common, and poverty is already rife, the unclear causes and risk factors of an acute case of ReA progressing to the chronic form must be investigated. We hope that this study brings attention to the poor QoL in ReA, a matter of great relevance in the Indian subcontinent and initiates larger multicenter collaborative studies assess the roles of education and other sociodemographic variables may play in defining the QoL of ReA patients.
| Conclusion|| |
Patients with ReA and AS experience comparable QoL to each other, although they exhibit significantly worse QoL than HC. There is a crucial need to recognize the impact of disease on physical functions to improve patient care.
The authors gratefully acknowledge Dr AJ Matthew, Dr KN Thomas and Connecting Researchers Initiative for all their assistance in this work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Manasson J, Shen N, Ferrer HR, Ubeda C, Iraheta I, Heguy A, et al
. Gut microbiota perturbations in reactive arthritis and post-infectious spondyloarthritis. Arthritis Rheumatol 2018;70:242-54.
Hannu T, Inman R, GranforsK, Leirisalo-Repo M. Reactive arthritis or post-infectious arthritis? Best Pract Res Clin Rheumatol 2006;20:419-33.
Misra R, Gupta L. Time to revisit the concept of reactive arthritis. Nat Rev Rheumatol 2017;13:327-8.
Roychowdhury S, Mukhopadhyay I. Gender wage gap: Some recent evidences from India. J Quant Econ 2019;17:121-51.
Thomas KN, Anuja AK, Gupta L. Clinical profile of adults and children with reactive arthritis in India a cohort study. Indian J Rheumatol 2020;15:304-9. [Full text]
Braun J, Kingsley G, van der Heijde D, Sieper J. On the difficulties of establishing a consensus on the definition of and diagnostic investigations for reactive arthritis. Results and discussion of a questionnaire prepared for the 4th
International Workshop on Reactive Arthritis, Berlin, Germany, July 3-6, 1999. J Rheumatol 2000;27:2185-92.
Gaur PS, Zimba O, Agarwal V, Gupta L. Reporting survey based studies a primer for authors. J Korean Med Sci 2020;35:e398.
Thomas KN, Jain N, Mohindra N, Misra D, Agarwal V, Gupta L. MRI and sonography of the knee in acute reactive arthritis: An observational cohort study. J Clin Rheumatol 2021.
Gupta L, Ahmed S, Choudhury GD, Misra DP, Agarwal V. Poor quality of life in Indian ankylosing spondylitis patients. Indian J Rheumatol 2018;13:101-6. [Full text]
Bentaleb I, Abdelghani KB, Rostom S, Amine B, Laatar A, Bahiri R. Reactive arthritis: Update. Curr Clin Microbiol Rep 2020:1-9.
Malakar A, Kakati S, Barman B, Dutta A. Clinical presentation and subtypes of spondyloarthritis patients in North East India. Egypt Rheumatol 2020;42:271-4.
Law L, Rehnman JB, Deminger A, Klingberg E, Jacobsson LT, Forsblad-d’Elia H. Factors related to health-related quality of life in ankylosing spondylitis, overall and stratified by sex. Arthritis Res Ther 2018;20:284.
Kaarela K, Jäntti JK, Kotaniemi KM. Similarity between chronic reactive arthritis and ankylosing spondylitis. A 32-35-year follow-up study. Clin Exp Rheumatol 2009;27:325-8.
Gupta L, Naveen R, Ahmed S, Zanwar A, Mishra R, Aggarwal A. Juvenile reactive arthritis is it different from other childhood spondyloarthropathies? 28-year experience from a retrospective dataset of children with spondylarthritis at a large tertiary care centre in Northern India. Med J Rheumatol Article in Press.
[Table 1], [Table 2]