Transcript Document

Fibromyalgianess, Systemic Lupus Erythematosus & the Evaluation of SLE Activity
E
3
Karlson ,
G
2John
4
Alarcón ,
E
5
Chakravarty ,
J
6
Goldman ,
F
7
Wolfe ,
SLE in the Community Study Group
3Brigham
4University
Medical Center, Chicago;
Hopkins Univ, Baltimore;
and Womens Hospital, Boston;
of Alabama - Birmingham;
5Stanford Univ, Stanford; 6Emory Univ, Atlanta; 7National Data Bank for Rheumatic Diseases, Wichita
CONCLUSION. SLAQ variables are more common in SLE than in other
rheumatic disorders and easily distinguish SLE from other conditions except for
FS.
SSCORE Variables in Different Rheumatic Conditions
SSCORE Variable
Percent Percent
P-value
Percent P-value for
in SLE in
for
in FS
SLE
arthritis
difference
FS difference
Anorexia
24
12
<0.001
21
0.081
Fatigue
80
50
<0.001
86
<0.001
Fever
23
5
<0.001
13
<0.001
Bruising
62
41
<0.001
47
<0.001
Hair loss
34
17
<0.001
24
<0.001
Abdominal pain
41
18
<0.001
48
<0.001
Headache
58
29
<0.001
63
0.008
SLE rash
60
19
<0.001
35
<0.001
Dyspnea
38
18
<0.001
34
0.012
Stroke/Numbness
54
29
<0.001
61
<0.001
Cognitive problems
57
29
<0.001
65
<0.001
Muscle
62
36
<0.001
79
<0.001
pain/Weakness
Joint pain/Swelling
77
57
<0.001
73
0.016
Raynaud's
39
9
<0.001
18
<0.001
We next compared the relative association of SLESS variables with the diagnosis of
SLE and fibromyalgia, as shown in Figure 3. This direct comparison indicates that
headache, abdominal pain, stroke or paresthesias, fatigue, cognitive problems and
muscle pain/weakness are more common in fibromyalgia than SLE. Figure 4,
comparing persons with fibromyalgia and arthritis, confirms the importance of these
variables in fibromyalgia. In addition patients with fibromyalgia are more likely to
report oral ulcers (OR 2.0 (95% CI 1.8 to 2.2)) and pleurisy (OR 2.9 (95% CI 2.6 to
3.2) than patients with arthritis. With respect to the SLESS, the bold lines in Table 2
separate variables that are more or less common in SLE compared with fibromyalgia.
Therefore, these analyses define sets of variables found in the SLESS and the SLAQ
that are more or less associated with fibromyalgia in patients with SLE.
We next examined the relationship between fibromyalgianess and SLE using the latent
variable fibromyalgianess as assessed by the SI scale (Table 2). Compared with
arthritis, the SI was slightly increased (0.4 units) in SLE compared with arthritis, but
substantially increased in fibromyalgia (2.2 units) compared with arthritis. The
relation of fibromyalgianess to the 3 diagnostic groups can also be seen in Figure 5.
Using the suggested cutoff for diagnosis of survey fibromyalgia of ≥8 for the regional
pain scale and ≥6 for fatigue, 22.1% of SLE patients and 17.0% of arthritis patients
would satisfy those criteria. When only data on women are analyzed, the respective
proportions are 22.0% and 18.3%.
40.4
55.0
39.3
48.6
Table 2. Severity, SLE symptoms and
fibromyalgia-related scales
Fibromyalgia
N
Patient Global (0-10)
SLE symptom scale (0-16)
Symptom intensity Scale (0-9.75)
Regional pain scale (0-19)
Fatigue Scale (0-10)
Mean (SD)
2,397
5.0 (2.5)
7.3 (3.0)
5.8 2.3)
10.7 (5.6)
6.3 (2.7)
SLE
Mean (SD)
838
3.6 (2.6)†
7.2 (3.7)*
4.0 (2.5)*†
6.8 (5.6)*†
4.6 (3.0)†
RA + NIRD
(Arthritis)
Mean (SD)
20,096
3.7 (2.5)
4.5 (3.0)
3.6 (2.3)
5.6 (5.1)
4.5 (3.0)
* P<0.05 compared with arthritis.
† P<0.05 compared with fibromyalgia.
.15
15
.1
Density
0
20
SLAQ score
30
40
0
Symptoms in SLE compared with arthritis
Raynauds
Rash
Fever
Headache
Seizures
Rash (other)
Fatigue
Hair Loss
Abdominal pain
Cognitive problems
Easy bruising
Muscle pain or weakness
Shortness of breath
Stroke/paresthesias
Anorexia
Joint pain or swelling
2
4
6
Sympton intensity scale
8
10
Relation between fibromyalgianess and SLAQ score
0.0
1.0
2.0
4.0
Odds Ratio
6.0
8.0
0
37.1
59.4
38.3
47.5
10
0
Symptoms in SLE compared with fibromyalgia
Raynauds
Rash
Fever
Easy bruising
Hair Loss
Rash (other)
Shortness of breath
Seizures
Anorexia
Joint pain or swelling
Headache
Abdominal pain
Stroke/paresthesias
Fatigue
Cognitive problems
Muscle pain or weakness
2
4
6
Symptom intensity (SI) score
8
0.0
Ratio of fibromyalgia symptoms to SLE symptoms
as a function of fibromyalgia severity in SLE
1.0
2.0
Odds Ratio
3.0
4.0
0
2
4
6
Symptom intensity scale
8
Symptoms in fibromyalgia compared with arthritis
By contrast, as shown in Table 2, SLE and arthritis did not differ
significantly in patient global severity and fatigue; SLE and
fibromyalgia did not differ for the SLESS, but both had considerably
higher scores compared with arthritis. We also studied the ratio of
the fibromyalgia variables (headache, abdominal pain,
paresthesias/stroke, fatigue, cognitive problems and muscle pain or
weakness) to the SLE variables (Raynaud’s, rash, fever, easy
bruising and hair loss), as determined in Figure 3, as a function of
fibromyalgianess, or fibromyalgia severity. As shown in Figure 6,
there was no evidence of a disproportionate fibromyalgia symptom
reporting associated with increasing fibromyalgianess.
Self-reported SLE was associated with an increased prevalence of
fibromyalgia when unconfirmed by physician compared to
confirmed SLE.
Muscle pain or weakness
Fatigue
Cognitive problems
Headache
Abdominal pain
Stroke/paresthesias
Fever
Seizures
Raynauds
Rash (other)
Anorexia
Shortness of breath
Rash
Hair Loss
Joint pain or swelling
Easy bruising
0.0 1.0 2.0
4.0
6.0
Odds Ratio
8.0
10.0
Conclusions
The proportion of patients with SLE (22.1%) is only slightly increased compared
with patients with arthritis (17.0%). Similarly, there is not substantially more
fibromyalgianess in SLE than in non-SLE patients. SLE questionnaire
assessment is not biased by the extent of fibromyalgianess. The prevalence of
survey fibromyalgia is greater in self-referred SLE patients with diagnostic
confirmation compared to self referred patients with diagnostic confirmation.
10
6
67.4
86.0
72.6
88.5
0
4
54.0
77.2
57.4
65.5
.05
Stroke/paresthesias (%)
Fatigue (%)
Cognitive problems (%)
Muscle pain or weakness (%)
SLE >
40
5.4
42.0
17.4
7.0
24.0
0.6
12.8
74.8
29.2
23.7
30
12.3
47.7
23.8
14.2
38.1
1.4
21.4
81.0
62.1
53.8
2
As the SLE SS and SLAQ scores were highly correlated, we next undertook a series
of analyses to evaluate the relationship of SLE symptoms and fibromyalgia in patients
with SLE, arthritis and fibromyalgia using the complete set of NDB patients. The
mean age and percent males for the three diagnostic groups was as follows: SLE 50.3
(13.6) years, 6.2%; fibromyalgia 56.8 (12.9) years, 4.7% male; and arthritis 57.9
(10.3) years, 22.8% male.
The percent of patients reporting specific symptoms from the SLESS is shown in
Table 1. Preliminary to evaluating the relationship between SLE and fibromyalgia, we
first examined the level of symptoms in SLE and arthritis patients (Table 2). Not
surprisingly as the SLESS was designed to evaluate SLE symptoms, the SLESS was
considerably higher in SLE patients compared with those with arthritis, 7.2 (3.7) vs.
4.5 (3.1), p <0.001. The individual scale items and their odds ratios for these
diagnoses are shown in Figure 2. All symptoms were more common in SLE, but
Reynaud’s, rash and fever were particularly increased.
18.6
60.0
31.7
15.4
39.3
1.4
20.6
79.9
53.4
41.1
20
was 50.4 (12.3) years, and 95.3% were women. Current therapies included
hydroxychloroquine (64.1%), prednisone (49.4%), MTX (12.3%), rituximab (0.8%),
mycophenolate (11.8%), azathioprine (11.0%), cyclophosphamide (11.2%) and
leflunomide (1.9%).
The composite SLAQ score and the single item SLAQ activity score was 12.1 (7.6)
and 3.8 (2.8), respectively. A mild, moderate and severe SLE flare was reported by
34.1%, 22.0% and 9.1% during the preceding 3 months. Alpha reliability of SLAQ
score items was 82.5. The SLESS score was 7.5 (3.6) and its alpha reliability in the
same SLE group was 83.9. The SLAQ score and SLE SS were correlated at r=0.738
(Figure 1), and the correlation was not improved by non-linear analyses.
More
common in
FS
4.0
37.2
13.0
5.7
24.4
0.6
9.7
76.6
28.6
24.9
Fever (%)
Easy bruising (%)
Hair Loss (%)
Rash (other) (%)
Shortness of breath (%)
Seizures (%)
Anorexia (%)
Joint pain or swelling (%)
Headache (%)
Abdominal pain (%)
Arthritis >
10
Results. The mean (SD) age of the 599 SLE participants completing the SLAQ
Equally
common in
SLE & FS
NIRD %
(N=3,206 )
6.0
20.0
0
RESULTS. The mean age of participants completing the SLAQ was 51.3 years,
and 92.5% were women. Current therapies included hydroxychloroquine (62.5%),
prednisone (51.1%), immunomodulators excluding MTX (27.7%), and MTX
(11.8%). The mean (SD) composite SLAQ score and the single item SLAQ
activity score was 10.9 (6.8) and 3.6 (2.7), respectively. A mild, moderate and
severe SLE flare was reported by 37.7%, 18.7% and 7.3% during the last 3
months. Alpha reliability of SLAQ score items was 85.6. SLAQ score and
SSCORE were correlated at r=0.747. Correlations of the SSCORE in SLE and
non-SLE were: Joint score from the RADAI (r=0.585, 0.663), Regional Pain Scale
(r=0.646, 0.615), Symptom Intensity Scale (r=0.624, 0.663), VAS pain scale
(r=0.549, 0.502), HAQ-II (0.550, 0.460), EuroQol (r=0.533, 0.516), and SF-36
physical component score (r=0.583, 0.469). Analysis of individual items showed
substantially more SLE patients with SLAQ/SSCORE items than arthritis patients
(RA + NONI) (Table 1). However, the symptom differences were inconsistent
when compared with FS, with higher percents noted in FS for fatigue, headaches,
stroke/numbness and cognitive problems. The mean SSCOREs were SLE 7.6,
arthritis 4.5, and FS 7.3. These group scores differed from each other significantly
(p<0.001).
SLAQ and used that scale to investigate the relation between SLE symptoms and
fibromyalgianess in 23,321 rheumatic disease patients. Fibromyalgia was diagnosed
by survey fibromyalgia criteria and fibromyalgianess was measured using the
Symptom Intensity Scale (SI). As comparison groups, we combined patients with
rheumatoid arthritis and non-inflammatory rheumatic disorders into an “arthritis”
group and also utilized a physician-diagnosed group of fibromyalgia patients..
RA %
(N=16,884)
9.2
25.4
SLAQ score
METHODS. We studied the SLAQ in 325 patients with SLE. To compare
construct validity of SLAQ items, we used binary symptom variables similar to
SLAQ items and constructed an SLE-like symptom score (SSCORE) in patients
with SLE (N=1,047), RA (N=22,846), non-inflammatory disorders (NONI)
without fibromyalgia (FS) (N=3,716) and NONI with FS (N=2,862).
Method. We developed a 16-item SLE symptom scale (SLESS) modeled on the
Reynaud's (%)
Rash (%)
FS %
(N=2,397)
18.2
37.9
Distribution of fibromyalgianess in rheumatic disorders
Fibromyalgia >
Symptom ratio
PURPOSE. The patient-reported systemic lupus activity (SLE) questionnaire
(SLAQ) is a validated 24-item weighted lupus symptom index based on the
physician-reported systemic lupus activity measure (SLAM). However, physicians
and patients report differently, and findings might not be specific to SLE. Many of
the SLAQ items are not thought to be related to SLE disease activity (fatigue,
abdominal pain, headache, cognitive problems, muscle pain, and Raynaud’s). We
examined the SLAQ properties and construct validity by studying SLAQ variables
in patients without SLE.
More
common in
SLE
SLE %
(N= 838)
39.5
62.6
Relation between SLE symptom count and SLAQ score
10
Performance of the SLAQ in SLE and Non-SLE Subjects in a Longitudinal
Databank
compared with non-SLE patients, whether fibromyalgianess biases the systemic lupus
erythematosus activity questionnaire (SLAQ), and to determine if the SLAQ is overly
sensitive to fibromyalgia symptoms.
Percent of patients positive for SLE
Symptom Scale by Diagnostic Category
5
Original Abstract
Purpose. To determine if fibromyalgia or fibromyalgianess is increased in SLE
0
1Rush
M
2
Petri ,
SLE symptom count
R
1
Katz ,
Notice
This poster extends the data of the original
abstract by adding subjects and analyses
10