Towards a comprehensive approach to the management and prognosis of systemic sclerosis's patients: The role of comorbidities in the SPRING-SIR registry

Prevalence and clinical relevance of digital ulcers in systemic sclerosis patients from the real-life: the experience of the SPRING Registry of the Italian Society for Rheumatology

Introduction

Digital ulcers (DU) are one of the most frequent manifestations in systemic sclerosis (SSc). The presence of DU seems to be a sentinel sign of internal organ involvement and is related to a poor prognosis of the disease. The aim of this study was to evaluate the prevalence and the relationship of DU with clinical manifestations/variants in a large SSc cohort from the SPRING registry.

Methods

SSc patients fulfilling the ACR/EULAR 2013 classification criteria without missing data on digital ulcers were enrolled in a cross-sectional study. Logistic regression models were built to test the association between the presence of DU and SSc-related features.

Results

Among 1873 eligible SSc patients, the presence of DU was significantly associated with gastrointestinal involvement (OR 1.88, 2.04 and 1.74; p < 0.001) and serum ATA positivity (OR 2.15; p < 0.001), as well as with telangiectasias, sclerodactyly, digital pitting scar, and calcinosis (OR 1.40, p = 0.005; OR 3.43, p < 0.001, OR 9.12, p < 0.001 and OR 2.77, p < 0.001; respectively). In the multivariable regression models, even after adjustment for covariates, ATA positivity (OR 1.76, p = 0.039), puffy fingers (OR 2.82, p < 0.001), and a higher revEUSTAR-AI (OR 6.63, p < 0.001) emerged as risk factors for the presence of DU. Moreover, a low presence of DU was recorded in SSc patients with a history of previous immunosuppressive treatments (OR 0.53, p = 0.032).

Conclusion

In our Italian SSc cohort, DUs were significantly associated with the presence of puffy fingers, high revEUSTR-AI, and ATA seropositivity. Noteworthy, immunosuppressive treatments were associated with a low rate of DU, suggesting that they might contribute to the prevention of these harmful manifestations.

Key Points • Digital ulcers were significantly associated with the presence of puffy fingers, high disease activity, and anti-Scl70 seropositivity.• Immunosuppressive treatments were associated with a low rate of digital ulcers, suggesting that they might contribute to the prevention of these harmful manifestations.

The Prognostic and Functional Impact of Multimorbidity in Systemic Sclerosis

OBJECTIVE

Our objective was to define the frequency and impact of multimorbidity in systemic sclerosis (SSc).

METHOD

Australian Scleroderma Cohort Study participants meeting American College of Rheumatology/EULAR criteria were included. Charlson Comorbidity Index scores were calculated at each visit, with multimorbidity defined as scores ≥4. Generalized estimating equations were used to model longitudinal data in multivariable models including age, sex, subclass, interstitial lung disease, and pulmonary arterial hypertension status. Survival was analyzed using Cox hazard modeling.

RESULTS

Of 2,000 participants, 85% were female, 27% had diffuse SSc, and 20% had multimorbidity. Among those with multimorbidity, key comorbidities were hypertension (81%), dyslipidemia (67%), obstructive lung disease (50%), malignancy (49%), and ischemic heart disease (IHD) (40%). Multimorbidity was associated with worse survival (hazard ratio [HR] 1.57, 95% confidence interval [CI] 1.30-1.91, P < 0.01). Renal disease had the largest impact (HR 2.41, 95% CI 1.46-3.98, P < 0.01), followed by left ventricular dysfunction (HR 1.76, 95% CI 1.21-2.57, P < 0.01), anticoagulation (HR 1.64, 95% CI 1.28-2.08, P < 0.01), and IHD (HR 1.45, 95% CI 1.16-1.80, P < 0.01). In multivariable modeling, multimorbidity was associated with poorer physical function (regression coefficient [RC] +0.17 units, 95% CI 0.13-0.21, P < 0.01). Peripheral vascular disease had the largest impact on physical function (RC +0.26 units, 95% CI 0.18-0.34, P < 0.01), followed by left ventricular dysfunction (RC +0.23 units, 95% CI 0.14-0.33, P = 0.01), IHD (RC +0.22 units, 95% CI 0.17-0.28, P < 0.01), and obstructive lung disease (RC +0.19 units, 95% CI 0.14-0.24, P < 0.01).

CONCLUSION

Multimorbidity occurred in 20% of patients in a large SSc cohort and was an important determinant of both prognosis and physical function. Effective treatment of non-SSc morbidity may improve outcomes for patients with SSc. Graphical Abstract. *p-value <0.05. Multimorbidity defined as Charlson Comorbidity Index scores ≥4.

ABBREVIATIONS

CI (confidence interval), CKD (chronic kidney disease), COPD (chronic obstructive pulmonary disease), HAQ-DI (health assessment questionnaire disability index), HR (hazard ratio), LVEF (left ventricular ejection fraction), IHD (ischaemic heart disease), HR (hazard ratio), IQR (interquartile range), PVD (peripheral vascular disease), SSc (systemic sclerosis).