In patients with rheumatoid arthritis (RA), fatigue is a significant predictor of high healthcare costs, reduced physical functioning, and poor quality of life. Fatigue has also been shown to persist in this patient population, even when disease remission is achieved, according to the results of a recent study by Katie L. Druce, MSc, PhD, Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, United Kingdom, and colleagues (Druce KL, et al. Rheumatology [Oxford]. 2016 Jun 21. Epub ahead of print).
“In a large cohort of participants commencing anti-TNF [tumor necrosis factor] therapy, we have shown that fatigue continues to be a problem despite patients achieving disease remission. Patients who report such residual fatigue are characterized by poorer scores on all patient-reported health status variables; histories of depression, stroke and hypertension and baseline use of antidepressants and steroids,” Dr Druce and colleagues explained.
The primary goal of the study was to define the reduction of fatigue in patients with RA who achieved disease remission with anti-TNF therapy. A secondary aim was to characterize potential causes of residual fatigue through the comparison of patients with and without continued symptom burden.
Using The British Society for Rheumatology Biologics Register for Rheumatoid Arthritis, Dr Druce and colleagues analyzed data from >13,000 patients (recruited into the register between October 2000 and November 2008) who were about to begin anti-TNF therapy. The researchers captured information on patient age, sex, ethnicity, and work status at baseline through self-report questionnaires, and used the vitality subscale of the 36-Item Short Form Health Survey to measure fatigue. They also used the disability index of the Health Assessment Questionnaire (at baseline and follow-up), and collected other clinician-recorded data (eg, clinical status, medications, and comorbidities). A total of 2652 participants with severe baseline fatigue met the criteria for the study. The majority of these patients were white (97.3%) and women (79.6%), with a median disease duration of 12 years (interquartile range, 6-20).
Six months after starting anti-TNF therapy, 271 (10.2%) patients in the study achieved disease remission. Of these patients, 225 (83.0%) achieved partial fatigue remission. The researchers noted that, with the exception of a history of hypertension (which was more common in patients who did not achieve partial fatigue remission than in those who did), there were no demographic or clinical variables that distinguished the patient group.
Complete remission of fatigue was reported by only 101 (37.3%) of all 271 patients in disease remission (44.9% of those achieving partial remission), whereas nonremission of fatigue was reported by 170 (62.7%) patients. Comparisons between those reporting incomplete fatigue remission and complete fatigue remission demonstrated that a history of hypertension (35.1% vs 20.8%), stroke (4.1% vs 0.0%), and depression (15.9% vs 6.9%) was more prevalent in patients who did not report complete fatigue remission. Those who reported incomplete fatigue remission also had higher baseline rates of antidepressant and steroid use than their counterparts who reported complete fatigue remission.
“Given the significant impact of fatigue on both patients and society, the results support the increasingly prominent argument that fatigue is a symptom that must be targeted in its own right rather than being improved as part of a secondary benefit to existing interventions,” Dr Druce and colleagues reported. “Although important in overall disease control, reductions in disease activity are rarely sufficient to ameliorate fatigue. Instead, in the future, it is essential that an augmented and targeted approach to fatigue management is adopted.”