Axial Spondyloarthritis and Quality of Life

Atul A. Deodhar, MD: Patients with ankylosing spondylitis and axial spondyloarthritis have not only musculoskeletal problems such as backache and peripheral arthritis, etc, but also all kinds of different comorbidities. I already touched on involvement of the eye in the form of iritis and uveitis, involvement of the gastrointestinal tract in the form of inflammatory bowel disease, and skin issues with psoriasis. But more and more, we are finding that the inflammation that these patients have leads to the increased risk of cardiovascular disease. This increased risk of cardiovascular disease in these patients has been known for a long time, and several studies have been published. But recently, a meta-analysis found out that patients with axial spondyloarthritis have a 44% increased risk of heart attack and a 40% increased risk of stroke. They have a 35% increased risk of death. So these are real comorbidities. This not only affects the patient’s day-to-day life and their health-related quality of life, but it reduces their quantity of life. It reduces their duration of life. This is one of the major reasons why we want to treat these patients early and reduce the inflammation. We hope that we not only are going to improve their health-related quality of life but will, hopefully, also change the natural course of the disease and reduce the risk for the other comorbidities that these patients may be facing.

There is a difference in how rheumatoid arthritis and psoriatic arthritis affect an individual compared with how axial spondyloarthritis affects an individual. The typical lesions in rheumatoid arthritis are erosive damage to the joint. The typical features of psoriatic arthritis are also erosive. Patients with psoriatic arthritis may also have a little bit of new bone formation. Patients with axial spondyloarthritis predominantly have anabolic damage, which means they develop new bone. So they develop syndesmophytes in the spine. They might develop fusion of their spine. They might develop fusion of their sacroiliac joints. There is also erosion in axial spondyloarthritis. In fact, before they develop new bone formation, there is erosion. Then there is this new bone formation that occurs in patients with axial spondyloarthritis, which ultimately leads to reduced mobility of the spine. Their neck cannot move, and they cannot bend forward. That affects their health-related quality of life and leads to reduced spinal function, mobility, etc.

Another point I want to make is we recently did a study to compare the health-related quality of life in rheumatoid arthritis versus psoriatic arthritis versus ankylosing spondylitis. We found out that patients with ankylosing spondylitis have more health-related quality-of-life loss—more physical disability—compared with patients with rheumatoid arthritis and psoriatic arthritis. As I said earlier, between ankylosing spondylitis and nonradiographic axial spondyloarthritis, the loss of health-related quality of life is quite comparable. In other words, axial spondyloarthritis, in general, and nonradiographic axial spondyloarthritis result in worse health-related quality of life compared with psoriatic arthritis.

The burden of disease of axial spondyloarthritis is quite high. One point that I mentioned earlier was that this disease starts in the second or third decade of the patient’s life. That is sort of prime time for when patients are going to work. In an ankylosing spondylitis situation, patients retire at the age of 36. That’s the median age, which is terrible because that’s the age at which people should be working. About 45% of patients with ankylosing spondylitis have some disability at work. The biggest impact, or the biggest cost to the society and to the person because of this disease, is mainly due to loss of productivity. That’s the biggest loss. So there is presenteeism, which means the patient shows up at work but cannot really work to their full capacity.

If you ask these patients, 40% to 60% of them, depending on which series you look at, would tell you that they go to their job but are not able to work to their full capacity. Several patients—40% of patients—change their job and go to a different type of job. During that process, they may lose their income and will have to do a job that is probably less physically demanding. A large percentage of patients become disabled at a younger age. As I said, age 36 is the average age at which these people claim disability or retire from work. It has also been shown that even day-to-day activities are affected. Just bending down and putting on socks is impossible. They cannot bend down and pick something up.

It’s very interesting. I have a friend who is a doctor. I was with him at a medical meeting. He said, “This morning, they slipped this bill under my door into my room, and I cannot pick it up. I cannot bend down.” These things that you and I take for granted, they just cannot do. Something fell from his hand, and he couldn’t pick it up. He had to call the hotel and request for someone to help him. These are ordinary things. So it’s not just at work. It’s also day-to-day, health-related quality of life. These patients really suffer. This is why we really have to have great treatments, so we can prevent all of this from happening. We can treat these patients early and give them a better quality of life.