Selected Immune Disorders and Disability (2022) / Chapter Skim
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2 Cross-Cutting Issues
2 Cross-Cutting Issues
Pages 29-64
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. The prevalence of depression and anxiety in the rheumatic diseases is about twice that of the general population (Geenan et al., 2012)
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. Psychiatric comorbidities are also commonly reported in childhood-onset rheumatic diseases, with a pooled prevalence of 13 percent for anxiety disorders and 20 percent for mood disorders (Jansson et al., 2022)
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It is important to acknowledge the role of depression and anxiety in rheumatic diseases and the synergistic impact on functioning of having both 2 PHQ-9 = Patient Health Questionnaire-9; GAD-7 = General Anxiety Disorder-7.
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. Chronic pain related to rheumatic diseases also may exacerbate depression and anxiety (Lewin et al., 2020)
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Chronic pain in immunologic conditions can stem from all three sources. In rheumatoid arthritis, pain is considered a primary feature of the disease, particularly in those experiencing a flare in symptoms (Iver and Lee, 2021)
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Therefore, the treatment of chronic pain is also highly individualized, although it generally involves a combination of therapies aimed at alleviating symptoms plus therapies that target functional improvement as their goal. Biomedical approaches are necessary in the treatment of rheumatic diseases to ensure that the underlying disease and its clinical manifestations (e.g., pain, fatigue)
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. Fibromyalgia is a critical topic in the discus sion of rheumatic diseases, given the high prevalence of primary chronic pain syndromes in this population.
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. In a study using the National Databank for Rheumatic Diseases, researchers found that 22.1 percent of patients with SLE met the criteria for fibromyalgia and 17 percent of patients with RA did (Middleton et al., 1994; Wolfe et al., 2009)
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. Taken together, those data suggest that patients across a variety of rheumatic diseases are likely to present with fibromyalgia.
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In a study of 7,753 patients enrolled in a multi national registry, functional measures and well-being rated significantly worse in patients with juvenile fibromyalgia compared to patients with other rheumatic diseases (Connelly and Weiss, 2019)
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. In patients with pediatric rheumatic diseases, fatigue is associated with increased pain and decreased quality of life (Nijhof et al., 2016)
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Disease-specific factors do appear to be related to fatigue, as do some of the overlapping manifestations, such as pain, stiffness, and functional limitations. Clinical measures of disease activity and also biomarkers, including specific cytokines, antibodies, and gene expression profiles, have been linked to fatigue in a number of immune disorders (Bodewes et al., 2019; Evers et al., 2013; Karshikoff et al., 2017; Morris et al., 2016; Pertovaara and Korpela, 2019; Schwarting et al., 2019)
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, a cytokine that is implicated in a number of autoimmune diseases. The usual approach to treatment is to reduce RA disease activity as much as possible, followed by a gradual increase in physical activity.
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. A constellation of clinical and psychological factors may be associated with cognitive impairment in RA, including cardiovascular disease, chronic pain, depression, and a range of autoimmune and inflammatory factors, along with changes in hormone levels and drug side effects, specifically glucocorticoids and methotrexate
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For other immune disorders, evidence is sparse, but where it exists it tends to show increased rates of cognitive dysfunction. The proposed mechanisms of action are similar across conditions -- inflammation, cardiovascular disease, and chronic pain (Basile et al., 2021; Gorelick, 2010; Hanly et al., 2019; Khedr et al., 2020; Oláh et al., 2020; Petersen et al., 2018; Wallin et al., 2012)
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Some targeted biologic medications can be administered orally or subcutaneously by the patient at home, whereas other medications require IV infusion and may be administered in a hospital, infusion center, doctor's office, or home setting with nurse supervision. IV cyclophosphamide and rituximab are almost always administered at an inpatient or at an infusion center as they have higher rates of infusion reactions than some other commonly administered IV medications and require monitoring.
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Targeted DMARDs These include targeted biologic The biologic agents are agents as well as targeted associated with injection and synthetic agents. Biologic agents infusion reactions and increased include inhibitors of circulating risk of infections as well as cytokines such as tumor necrosis additional drug-specific events.
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Each episode of flare can lead to increased disease progression, functional impairment, and permanent organ or joint damage (ChristopherStine et al., 2020; Cooksey et al., 2010; Markusse et al., 2015; Ugarte-Gil
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, health-related quality of life, coping, anger, depression, withdrawn Physician assessment Physician global assessment Fatigue Physical fatigue, emotional fatigue Other Frequent, rare and random, manageable, flu-like symptoms/ fever, muscle spasm, cramp, burning or tightness in the muscle, sweats, loss of appetite, grey pallor, shortness of breath, throughout the entire body NOTE: DAS28 = Disease Activity Score 28, a measure of disease activity in rheumatoid arthritis that requires examination of 28 joints; ESR = erythrocyte sedimentation rate, a test that indirectly measures the degree of inflammation present in the body; CRP = C-reactive protein, a high test result is a sign of acute inflammation. SOURCE: Reproduced from Costa et al., 2018, with permission.
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. Medium to high doses of steroids and severe immunosuppression are also high risk factors for hospitalization in children with pediatric rheumatic diseases (Villacis-Nunez et al., 2021)
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2016. Biologic interventions for fatigue in rheumatoid arthritis.
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2019. Predictors of fatigue and severe fatigue in a large international cohort of patients with systemic lupus erythematosus and a systematic review of the literature.
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2011. Depression predicts self-reported disease activity in systemic lupus erythematosus.
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2019. Pain, functional disability, and their association in juvenile fibromyalgia compared to other pediatric rheumatic diseases.
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2012. Psychological interventions for patients with rheumatic diseases and anxiety or depression.
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2010. Assessment of cognitive function in systemic lupus erythematosus, rheumatoid arthritis, and multiple sclerosis by computerized neuropsychological tests.
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2015. Depression in rheumatoid arthritis and its relation to disease activity.
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2012. Validity of brief screening tools for cognitive impairment in rheumatoid arthritis and systemic lupus erythematosus.
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2016. Correlations between fatigue and disease duration, disease activity, and pain in patients with rheumatoid arthritis: A systematic review.
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2016. Prevalence of severe fatigue among adolescents with pediatric rheumatic diseases.
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2013. Central pain mechanisms in the rheumatic diseases: Future directions.
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2021. Neuro psychiatric syndromes in childhood-onset systemic lupus erythematosus: A systematic review and meta-analysis.
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2017. The patient perspective on absence of disease activity in rheumatoid arthritis: A survey to identify key domains of patient-perceived remission.
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Annals of the Rheumatic Diseases 78(7)
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2017. Prevalence of depression and anxiety in systemic lupus erythematosus: A systematic review and meta-analysis.
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