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To investigate whether the association between depression and inflammatory joint disease (IJD; rheumatoid arthritis [RA], psoriatic arthritis [PsA], ankylosing spondylitis/spondyloarthropathies [AS], and juvenile idiopathic arthritis [JIA]) is affected by the severity or treatment-resistance of depression. Parallel cohort studies and case-control studies among 600,404 patients with a depressive episode identified in Swedish nationwide administrative registers. Prospective and retrospective risk for IJD in patients with depression was compared to matched population comparators, and the same associations were investigated in severe or treatment-resistant depression. Analyses were adjusted for comorbidities and sociodemographic covariates. Patients with depression had an increased risk for later IJD compared to population comparators (adjusted hazard ratio (aHR) for any IJD 1.34 [95% CI 1.30–1.39]; for RA 1.27 [1.15–1.41]; PsA 1.45 [1.29–1.63]; AS 1.32 [1.15–1.52]). In case-control studies, patients with depression more frequently had a history of IJD compared to population controls (adjusted odds ratio (aOR) for any IJD 1.43 [1.37–1.50]; RA 1.39 [1.29–1.49]; PsA 1.59 [1.46–1.73]; AS 1.49 [1.36–1.64]; JIA 1.52 [1.35–1.71]). These associations were not significantly different for severe depression or TRD. IJD and depression are bidirectionally associated, but this association does not seem to be influenced by the severity or treatment resistance of depression. [ABSTRACT FROM AUTHOR]

To investigate the association between chronic inflammatory rheumatic diseases (CIRD) and drug use disorder (DUD). Individuals aged ≥ 30 years in 2009 that met the following conditions were included: residing in the Skåne region, Sweden, with at least one healthcare contact in person and no history of DUD (ICD-10 codes F11-F16, F18-F19) during 1998–2009 (N = 649,891). CIRD was defined as the presence of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), or systemic lupus erythematosus. Treating CIRD as a time-varying exposure, we followed people from January 1, 2010 until a diagnosis of DUD, death, relocation outside the region, or December 31, 2019, whichever occurred first. We used flexible parametric survival models adjusted for attained age, sociodemographic characteristics, and coexisting conditions for data analysis. There were 64 (95% CI 62–66) and 104 (88–123) incident DUD per 100,000 person-years among those without and with CIRD, respectively. CIRD was associated with an increased risk of DUD in age-adjusted analysis (hazard ratio [HR] 1.77, 95% CI 1.49–2.09). Almost identical HR (1.71, 95% CI 1.45–2.03) was estimated after adjustment for sociodemographic characteristics, and it slightly attenuated when coexisting conditions were additionally accounted for (1.47, 95% CI 1.24–1.74). Fully adjusted HRs were 1.49 (1.21–1.85) for RA, 2.00 (1.38–2.90) for AS, and 1.58 (1.16–2.16) for PsA. More stringent definitions of CIRD didn't alter our findings. CIRD was associated with an increased risk of DUD independent of sociodemographic factors and coexisting conditions. Key Points • A register-based cohort study including 649,891 individuals aged≥30 residing in the Skåne region, Sweden, was conducted. • Chronic inflammatory rheumatic diseases were associated with higher risks of drug use disorder independent of sociodemographic factors and coexisting conditions. [ABSTRACT FROM AUTHOR]

Objectives Many axial spondylarthritis (axSpA) patients receive a conventional synthetic DMARD (csDMARD) in combination with a TNF inhibitor (TNFi). However, the value of this co-therapy remains unclear. The objectives were to describe the characteristics of axSpA patients initiating a first TNFi as monotherapy compared with co-therapy with csDMARD, to compare one-year TNFi retention and remission rates, and to explore the impact of peripheral arthritis. Methods Data was collected from 13 European registries. One-year outcomes included TNFi retention and hazard ratios (HR) for discontinuation with 95% CIs. Logistic regression was performed with adjusted odds ratios (OR) of achieving remission (Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP < 1.3 and/or BASDAI < 2) and stratified by treatment. Inter-registry heterogeneity was assessed using random-effect meta-analyses, combined results were presented when heterogeneity was not significant. Peripheral arthritis was defined as ≥1 swollen joint at baseline (=TNFi start). Results Amongst 24 171 axSpA patients, 32% received csDMARD co-therapy (range across countries: 13.5% to 71.2%). The co-therapy group had more baseline peripheral arthritis and higher CRP than the monotherapy group. One-year TNFi-retention rates (95% CI): 79% (78, 79%) for TNFi monotherapy vs 82% (81, 83%) with co-therapy (P  < 0.001). Remission was obtained in 20% on monotherapy and 22% on co-therapy (P  < 0.001); adjusted OR of 1.16 (1.07, 1.25). Remission rates at 12 months were similar in patients with/without peripheral arthritis. Conclusion This large European study of axial SpA patients showed similar one-year treatment outcomes for TNFi monotherapy and csDMARD co-therapy, although considerable heterogeneity across countries limited the identification of certain subgroups (e.g. peripheral arthritis) that may benefit from co-therapy. [ABSTRACT FROM AUTHOR]

Objectives To estimate the incidence and strength of association of extra-articular manifestations [EAMs, here: anterior uveitis (AU), IBD and psoriasis] in patients with AS, undifferentiated SpA (uSpA) and PsA, compared with controls. Methods Three mutually exclusive cohorts of patients aged 18–69 years with AS (n  = 8517), uSpA (n  = 10 245) and PsA (n  = 22 667) were identified in the Swedish National Patient Register 2001–2015. Age-, sex- and geography-matched controls were identified from the Swedish Population Register. Follow-up began 1 January 2006, or six months after the first SpA diagnosis, whichever occurred later, and ended at the first date of the EAM under study, death, emigration, 70 years of age, and 31 December 2016. Incidence rates (IRs) and incidence rate ratios were calculated for each EAM, and stratified by sex and age. Results Incidence rate ratios for incident AU, IBD and psoriasis were significantly increased in AS (20.2, 6.2, 2.5), uSpA (13.6, 5.7, 3.8) and PsA (2.5, 2.3, n.a) vs controls. Men with AS and uSpA had significantly higher IRs per 1000 person-years at risk for incident AU than women with AS (IR 15.8 vs 11.2) and uSpA (IR 10.1 vs 6.0), whereas no such sex difference was demonstrated in PsA or for the other EAMs. Conclusions AU, followed by IBD and psoriasis, is the EAM most strongly associated with AS and uSpA. Among the SpA subtypes, AS and uSpA display a largely similar pattern of EAMs, whereas PsA has a considerably weaker association with AU and IBD. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The aim of the present study was to validate the Swedish version of the educational needs assessment tool (SwENAT) in undifferentiated spondyloarthritis (USpA) and use it to study the educational needs of patients with USpA. Methods: This was a cross‐sectional study, recruiting a random sample of patients with USpA from a hospital register in Sweden. Educational needs data were collected, together with disease activity and function indices (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI] and Bath Ankylosing Spondylitis Functional Index [BASFI]). Rasch analysis was utilized to evaluate the construct validity, internal consistency and unidimensionality of the SwENAT before studying differences in educational needs between patient subgroups (gender, age and disease severity). Results: Complete responses were obtained from 77 patients (48 women), with a mean age (standard deviation [SD]) of 50 (12) years, a disease duration of 16 (11) years, a BASDAI score of 4.9 (1.9) and a BASFI score of 3.1 (2.3). The SwENAT satisfied the requirements of the Rasch model (χ2 = 11.488; p = 0.119), including strict unidimensionality. Overall, the mean (SD) SwENAT score was 86 (32). Women reported higher needs than men in the domains of pain (mean [SD] 13.1 [6.8] versus 10.1 [6.0]; p = 0.05); movement (mean [SD] 13.0 [5.5] versus 9.9 [5.7]; p = 0.02) and self‐help (mean [SD] 17.0 [5.8] versus 14.1 [5.0]; p = 0.03). Higher disease activity (BASDAI >4) was associated with higher educational needs (mean [SD] 92.6 [31.9] versus 73.7 [29.4]; p = 0.02). Conclusions: These data suggest that the SwENAT is valid in USpA. Women and patients with higher disease activity are more likely to have high levels of educational needs, so special attention and strategies to target patient education are warranted. [ABSTRACT FROM AUTHOR]

Objectives: Anxiety and depression symptoms are more common in patients with spondyloarthritis (SpA) than in the general population. This study describes prognostic factors for change in self-reported anxiety and depression over 2 years in a well-defined SpA cohort.Method: In 2009, 3716 adult patients from the SpAScania cohort received a postal questionnaire to assess quality of life (QoL) and physical and mental functioning. A follow-up survey was performed in 2011. The Hospital Anxiety and Depression Scale indicated 'no', 'possible', and 'probable' cases of anxiety and depression. Transitions between the three different categories were analysed and logistic regression analysis determined prognostic factors (patient-reported outcomes and characteristics) for improvement or deterioration.Results: In total, 1629 SpA patients responded to both surveys (44%) (mean ± SD age 55.8 ± 13.1 years, disease duration 14.6 ± 11.7 years); 27% had ankylosing spondylitis, 55% psoriatic arthritis, and 18% undifferentiated SpA. The proportion of patients reporting possible/probable anxiety decreased from 31% to 25% over 2 years, while no changes in depression were seen. Factors associated with deterioration or improvement were largely the same for anxiety as for depression: fatigue, general health, QoL, level of functioning, disease activity, and self-efficacy. However, reporting chronic widespread pain (CWP) at baseline increased the risk of becoming depressed and decreased the probability of recovering from anxiety.Conclusion: Self-reported anxiety and depression is common and fairly stable over time in SpA patients. The association between mental health and CWP indicates that both comorbidities need to be acknowledged and treated in the clinic. [ABSTRACT FROM AUTHOR]

Background: There is a demand for a flexible and individually tailored patient education to meet patients' specific needs and priorities, but this area has seldom been studied in patients with spondyloarthritis (SpA), a family of inflammatory rheumatic diseases. The aim of the present study was to identify needs and priorities in patient education in patients with SpA. A second aim was to investigate patients' experiences and preferences of receiving patient education.Methods: Data collection included a questionnaire survey with the Educational Needs Assessment Tool (ENAT) and interviews, using a mixed-methods design. Patients were identified through a specialist clinic register. Descriptive data are presented as mean with standard deviation, or frequencies. Chi-square test and independent-samples t-test were used for group comparisons. A manifest qualitative conventional content analysis was conducted to explore patients' experiences and needs in patient education, based on two focus groups (n = 6) and five individual interviews.Results: Almost half (43%) of the 183 SpA patients had educational needs, particularly regarding aspects of self-help, feelings, and the disease process. More educational needs were reported by women and in patients with higher disease activity, while duration of disease did not affect the needs. The qualitative analysis highlighted the importance of obtaining a guiding, reliable, and easily available patient education for management of SpA. Individual contacts with healthcare professionals were of importance, but newer media were also requested.Conclusion: There are considerable educational needs in patients with SpA, and education concerning self-help, feelings, and the diseases process were raised as important issues. Healthcare professionals need to consider the importance of presenting varied formats of education based on the experiences and preferences of patients with SpA. [ABSTRACT FROM AUTHOR]

Background: In the broader spectrum of back pain, inflammatory back pain (IBP) is a symptom that may indicate axial spondyloarthritis (SpA). The objectives of this study were to determine the frequency of current IBP, as a hallmark sign of possible axial SpA, in patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA) and other SpA and to compare self-reported health between the groups with current IBP.Methods: Five-thousand seven hundred seventy one patients identified in the regional healthcare register of the most southern county of Sweden, diagnosed at least once by a physician (based on ICD-codes) with any type of SpA in 2003-2007, were sent a postal survey in 2009. Patients with current IBP were identified, based on self-reported back pain ≥3 months in the preceding year and fulfilling the Berlin criteria for IBP. The frequencies of IBP in AS, PsA and other SpA (including the remaining subgroups of SpA) were determined, and the groups were compared with regard to patient reported outcome measures (PROMs).Results: The frequency and proportion of patients with current IBP in AS, PsA and other SpA were 319 (43 %), 409 (31 %) and 282 (39 %) respectively, within the responders to the survey (N = 2785). The proportion was statistically higher in AS, compared to PsA (p < 0.001), but not for AS compared to other SpA (p = 0.112). PsA and other SpA, with current IBP, had similar (BASFI, EQ-5D, patients global assessment, fatigue, spinal pain) or worse (BASDAI) PROMs, compared to AS with current IBP. PsA with current IBP received pharmacological, anti-rheumatic, treatment more frequently than AS with current IBP, while AS and other SpA received treatment to a similar degree.Conclusion: The proportion of patients with current IBP was substantial in all three groups and health reports in the non-AS groups were similar or worse compared to the AS group supporting the severity of IBP in these non-AS SpA groups. These findings may indicate a room for improvement concerning detection of axial disease within different subtypes of non-AS SpA, and possibly also for treatment. [ABSTRACT FROM AUTHOR]

Objectives: Epidemiological studies of spondyloarthritis (SpA), using ICD codes from the Swedish National Patient Register (NPR), offer unique possibilities but hinge upon an understanding of the validity of the codes. The aim of this study was to validate the ICD codes for ankylosing spondylitis (AS) and undifferentiated SpA (uSpA) in the NPR against the established classification criteria [modified New York (mNY), Assessment of SpondyloArthritis international Society (ASAS), Amor, and European Spondyloarthropathy Study Group (ESSG) criteria].Method: All patients with an ICD-8/9/10 code of AS or uSpA in the NPR 1966-2009 at a visit to a specialist in rheumatology or internal medicine or corresponding hospitalization, alive and living in Sweden 2009, were identified (n=20,089). Following a structured procedure to achieve geographical representativeness, 500 random patients with a diagnosis of AS or uSpA in 2007-2009 were selected. Based on a structured review of clinical records, positive predictive values (PPVs) for fulfilling the criteria sets were calculated.Results: For those having received an ICD code for AS, the PPVs for fulfilling the mNY criteria or any set of SpA criteria were 70% and 89%, respectively. For those with an uSpA diagnosis (and never an AS diagnosis), the corresponding PPVs were 20% and 79%. The subset with both AS and uSpA diagnoses (overlap=12%) were as likely to fulfil the mNY criteria as the group that had been coded as AS only.Conclusions: The diagnosis codes for AS or uSpA had high PPVs, suggesting that our case identification in the Swedish NPR can be used for nationwide, population-based, epidemiological studies of these diseases. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the efficacy and drug survival of anti-tumour necrosis factor (anti-TNF) therapy in non-radiographic axial spondyloarthritis (nr-axSpA) patients treated in clinical practice in Southern Sweden. Method: In this cohort study we prospectively included 112 patients with nr-axSpA and high disease activity as well as inadequate response or intolerance to non-steroidal anti-inflammatory drugs (NSAIDs) receiving their first course of anti-TNF therapy. Patients fulfilling modified New York criteria for ankylosing spondylitis (AS) were excluded. The Assessment of SpondyloArthritis International Society (ASAS) criteria for axial SpA were fulfilled by 77% (n = 86) of the included patients. Results: At baseline, the median age of the cohort was 38 years, 59% were males, 79% of the patients had imaging suggestive of sacroiliitis (primarily inflammation on magnetic resonance imaging, MRI), 71% were HLA-B27 positive, and the median disease duration was 6 years and 10 months. At 6 months of follow-up, the median Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) decreased from 5.6 to 3.2 (p = 0.002), the Bath Ankylosing Spondylitis Functional Index (BASFI) decreased from 3.9 to 1.8 (p = 0.005), and C-reactive protein (CRP) level decreased from 4.4 to 1.7 mg/L (p = 0.001). After 1 year of treatment the Kaplan-Meier estimated drug survival was 76%, and at 2 years of follow-up this value decreased to 65%. Patients with inflammatory MRI findings at baseline had significantly better drug survival [hazard ratio (HR) 0.24, 95% confidence interval (CI) 0.10-0.55, p = 0.001]. Male sex was also associated with higher drug survival (HR 0.45, 95% CI 0.24-0.85, p = 0.011). CRP level at baseline was not associated with drug survival. Conclusions: Anti-TNF treatment of patients with nr-axSpA in clinical practice resulted in reduced BASDAI and BASFI scores and good drug survival. The results from this study suggest that male gender and positive imaging at baseline are associated with a favourable treatment course. [ABSTRACT FROM AUTHOR]

Objective Data on lymphoma risk in ankylosing spondylitis (AS) and psoriatic arthritis (PsA) are scarce. This study was undertaken to assess the risk of lymphoma in AS and PsA overall and in relation to therapies, including tumor necrosis factor inhibitor (TNFi), for which lymphoma risks are a concern. Methods Through the Swedish National Patient Register we assembled nationwide prevalence cohorts of patients with AS (n = 8,707) and patients with PsA (n = 19,283) for whom data were obtained between 2001 and 2010. Each cohort member was matched to 5 population comparator subjects. Linkage with the nationwide Cancer Register identified all lymphomas recorded from 2001 to 2010. Through the Swedish Biologics Register (Anti-Rheumatic Therapy in Sweden [ARTIS]), we identified patients exposed to TNFi in the AS cohort (n = 1,908) and the PsA cohort (n = 2,605) before lymphoma diagnosis. Hazard ratios (HRs) for lymphoma were estimated by Cox regression. Crude incidences of lymphoma in TNFi-exposed and TNFi-naive patients were compared. Results For AS patients, the HR of having lymphoma versus the general population was 0.9 (95% confidence interval [95% CI] 0.5-1.6) (14 lymphomas). For PsA patients, the corresponding HR was 1.2 (95% CI 0.9-1.7) (45 lymphomas). For PsA patients treated with methotrexate and/or sulfasalazine, the HR of having lymphoma was 1.7 (95% CI 1.0-3.1). The numbers and incidence of lymphoma were not materially different in TNFi-exposed versus TNFi-naive AS and PsA patients, although the numbers of lymphomas were small. Conclusion In contrast to rheumatoid arthritis, the average risks of lymphoma in AS or PsA are not elevated, although increased risks in a subset of PsA patients cannot be excluded. Our findings indicate that TNFi does not affect the risk of lymphoma in AS or in PsA. [ABSTRACT FROM AUTHOR]

Objective. To assess work productivity and associated factors in patients with SpA.Methods. This cross-sectional postal survey included 1773 patients with SpA identified in a regional health care register. Items on presenteeism (reduced productivity at work, 0–100%, 0 = no reduction) were answered by 1447 individuals. Absenteeism was defined as register-based sick leave using data from a national register. Disease duration, disease activity (BASDAI), physical function (BASFI), health-related quality of life (EQ-5D), anxiety (HAD-a), depression (HAD-d), self-efficacy [Arthritis Self-efficacy Scale (ASES) pain and symptom], physical activity and education were also measured.Results. Forty-five per cent reported reduced productivity at work with a mean reduction of 20% (95% CI 18, 21) and women reported a higher mean reduction than men (mean 23% vs 17%, P < 0.001). Worse quality of life, disease activity, physical function and anxiety all correlated with reduced productivity (r = 0.52–0.66, P < 0.001), while sick leave did not. Worse outcomes on the EQ-5D (β-est −9.6, P < 0.001), BASDAI (β-est 7.8, P < 0.001), BASFI (β-est 7.3, P < 0.001), ASES pain (β-est −0.5, P < 0.001) and HAD-d (β-est 3.4, P < 0.001) were associated with reduced productivity at work in patients with SpA regardless of age, gender and disease subgroup. ASES symptoms, HAD-a and education level <12 years were associated with reduced productivity but were not significant in all strata for age, gender and disease subgroup.Conclusion. Work productivity was reduced in patients with SpA and more so in women. Worse quality of life, disease activity, physical function, self-efficacy and depression were all associated with reduced productivity at work in patients with SpA. [ABSTRACT FROM AUTHOR]

Objective. To study levels of sick leave and disability pension before and after TNF-antagonist therapy in AS patients.Methods. Using the population-based South Swedish Arthritis Treatment Group register, we identified 139 AS patients (aged 18–58 years, 78% men), who between January 2002 and December 2008 started their first treatment with adalimumab, etanercept or infliximab. We linked data to the payment register by the Swedish Social Insurance Agency and calculated the proportion on sick leave in 30-day intervals from 12 months before treatment start until 12 months after. For each AS patient, we randomly selected four subjects from the general population matched for age, sex and area of residence.Results. One to 3 months before treatment, an average of 24% of AS patients were on sick leave. During the first 6 months after treatment start, this fraction dropped to 15%, and further declined to 12% at 12 months (P < 0.001). Comparing AS patients with the general population, the relative risk of being on sick leave 3 months before treatment, treatment start and 12 months after treatment start was 8.0 (95% CI 4.6, 13.9), 9.2 (95% CI 5.4, 15.7) and 4.0 (95% CI 2.1, 6.3), respectively. The decrease in sick leave was not substantially offset by changes in disability pension.Conclusion. There is a decline in sick leave during the first 12 months after initiation of TNF-antagonist treatment in AS patients not explained by societal factors or secular trends. The proportion of AS patients on disability pension remained unchanged during the observation period. [ABSTRACT FROM PUBLISHER]

Objective To study the influence of antiinflammatory treatments, including methotrexate (MTX) and tumor necrosis factor (TNF) inhibitors, on antibody response following vaccination using a 7-valent conjugate pneumococcal vaccine in adult patients with established arthritis. Methods Patients with rheumatoid arthritis (RA) or spondylarthropathy (SpA) (including psoriatic arthritis) were vaccinated (n = 505). All patients were stratified into 6 prespecified groups based on diagnosis and treatment (RA patients receiving MTX, RA patients receiving anti-TNF agents and MTX, RA patients receiving TNF inhibitors as monotherapy, SpA patients receiving anti-TNF agents and MTX, SpA patients receiving TNF inhibitors as monotherapy, and SpA patients receiving nonsteroidal antiinflammatory drugs [NSAIDs] and/or analgesics). SpA patients receiving only NSAIDs/analgesics served as a control group. All patients received 1 dose (0.5 ml) of vaccine intramuscularly. Levels of IgG antibodies against 23F and 6B serotypes were measured at vaccination and at 4-6 weeks following vaccination, using standardized enzyme-linked immunosorbent assays. Results Positive antibody response was defined as an antibody response ratio (ARR) (i.e., ratio of post- to prevaccination antibody levels) of ≥2. The ARR differed significantly between the groups. A better ARR was seen among patients in the control group compared to those in groups treated with MTX or MTX in combination with TNF inhibitors. Among patients treated with TNF inhibitors as monotherapy, ARRs for both serotypes were lower numerically, but were not significantly different, compared to those in controls. Ongoing MTX treatment was predictive of reduced response (odds ratio 0.41 [95% confidence interval 0.24-0.68], P = 0.001). Higher age was associated with impaired positive antibody response. Concomitant prednisolone treatment elicited better positive antibody response in patients with RA. Conclusion Treatment with MTX and higher age were predictive of an impaired antibody response to the 7-valent conjugate pneumococcal vaccine in this cohort of patients with chronic arthritis. TNF inhibitors did not significantly affect antibody responses. [ABSTRACT FROM AUTHOR]

Objective: The objective was to prospectively evaluate the short as well as the long-term effects of intensive physiotherapy in a stable, sunny and warm climate on physical function and health related quality of life in patients with rheumatoid arthritis (RA) and spondylarthropathies (SpA).Methods: Ninety-three Swedish patients with RA and SpA receiving physiotherapy for 4 weeks in Israel or Tenerife were followed for 6 months. Physical function was evaluated by the Swedish version of Stanford Health Assessment Questionnaire (HAQ) and quality of life by the Nottingham Health Profile (NHP) questionnaire.Results: There were significant improvements in HAQ-scores and global NHP-scores as well as all subcategories of NHP immediately after the treatment abroad, effects that were still measurable after six months. At that time point nearly half of the patients had clinically meaningful reduction of HAQ-scores (> or = 0.25).Conclusion: Physiotherapy in a warm and stable climate, with many hours of daily sunshine, is a valuable treatment complement for Swedish patients with RA and SpA. [ABSTRACT FROM AUTHOR]