The health assessment questionnaire (HAQ) is strongly predictive of good outcome in early diffuse scleroderma: results from an analysis of two randomized controlled trials in early diffuse scleroderma

The long-term course of the Health Assessment Questionnaire in patients with systemic sclerosis

Objective

The Health Assessment Questionnaire-Disability Index is an important outcome measure reflecting functional disability, but knowledge on its course over time in patients with systemic sclerosis is scarce. Therefore, we investigated the long-term course of the Health Assessment Questionnaire-Disability Index and its association with baseline characteristics in systemic sclerosis patients.

Methods

Systemic sclerosis patients, fulfilling the European League Against Rheumatism and the American College of Rheumatology 2013 criteria, were included from the Leiden Combined Care in Systemic Sclerosis cohort with annual assessments including the Scleroderma Health Assessment Questionnaire-Disability Index (range = 0-3). The course of the Health Assessment Questionnaire-Disability Index was evaluated over the total follow-up (baseline to last available Health Assessment Questionnaire-Disability Index) and between yearly visits. Based on a minimal clinical important difference of 0.22, courses were categorized into worsening, stable or improvement. The course of the Health Assessment Questionnaire-Disability Index over time was evaluated with linear mixed models. Baseline characteristics were compared between patients with a worsening or improvement of the Health Assessment Questionnaire-Disability Index over the total follow-up period with logistic regression analyses.

Results

A total of 517 systemic sclerosis patients were included, with a median follow-up of 7 years (interquartile range = 4-9; 2649 visits) and a baseline Health Assessment Questionnaire-Disability Index of 0.625 (interquartile range = 0.125-1.25). On group level, the Health Assessment Questionnaire-Disability Index is stable with an annual increase of 0.019 (95% confidence interval = 0.011 to 0.027). Looking at subgroups, patients >65 years or who died/were physically unable to come during follow-up had a worse mean Health Assessment Questionnaire-Disability Index. In individual courses from baseline to the last follow-up, the proportions of patients with a clinically meaningful worsening, stable or improved Health Assessment Questionnaire-Disability Index were 35%, 42% and 23%, respectively. Patients with immunosuppressants (odds ratio = 0.5, 95% confidence interval = 0.3 to 0.9) or gastrointestinal involvement (odds ratio = 0.6, 95% confidence interval = 0.4 to 0.9) at baseline showed a reduced chance of worsening of the Health Assessment Questionnaire-Disability Index over the total follow-up period.

Conclusion

Over time, the average course of the Health Assessment Questionnaire-Disability Index was stable in systemic sclerosis patients. However, individual courses vary, with worsening occurring in one-third. Worsening occurred less often in individuals using immunosuppressants or with gastrointestinal involvement at baseline.

Serum metabolomic profiling reveals potential biomarkers in systemic sclerosis

BACKGROUND

Systemic sclerosis (SSc) is a chronic and systemic autoimmune disease marked by the skin and visceral fibrosis. Metabolic alterations have been found in SSc patients; however, serum metabolomic profiling has not been thoroughly conducted. Our study aimed to identify alterations in the metabolic profile in both SSc patients before and during treatment, as well as in mouse models of fibrosis. Furthermore, the associations between metabolites and clinical parameters and disease progression were explored.

METHODS

High-performance liquid chromatography quadrupole time-of-flight mass spectrometry (HPLC-Q-TOF-MS)/MS was performed in the serum of 326 human samples and 33 mouse samples. Human samples were collected from 142 healthy controls (HC), 127 newly diagnosed SSc patients without treatment (SSc baseline), and 57 treated SSc patients (SSc treatment). Mouse serum samples were collected from 11 control mice (NaCl), 11 mice with bleomycin (BLM)-induced fibrosis and 11 mice with hypochlorous acid (HOCl)-induced fibrosis. Both univariate analysis and multivariate analysis (orthogonal partial least-squares discriminate analysis (OPLS-DA)) were conducted to unravel differently expressed metabolites. KEGG pathway enrichment analysis was performed to characterize the dysregulated metabolic pathways in SSc. Associations between metabolites and clinical parameters of SSc patients were identified by Pearson's or Spearman's correlation analysis. Machine learning (ML) algorithms were applied to identify the important metabolites that have the potential to predict the progression of skin fibrosis.

RESULTS

The newly diagnosed SSc patients without treatment showed a unique serum metabolic profile compared to HC. Treatment partially corrected the metabolic changes in SSc. Some metabolites (phloretin 2'-O-glucuronide, retinoyl b-glucuronide, all-trans-retinoic acid, and betaine) and metabolic pathways (starch and sucrose metabolism, proline metabolism, androgen and estrogen metabolism, and tryptophan metabolism) were dysregulated in new-onset SSc, but restored upon treatment. Some metabolic changes were associated with treatment response in SSc patients. Metabolic changes observed in SSc patients were mimicked in murine models of SSc, indicating that they may reflect general metabolic changes associated with fibrotic tissue remodeling. Several metabolic changes were associated with SSc clinical parameters. The levels of allysine and all-trans-retinoic acid were negatively correlated, while D-glucuronic acid and hexanoyl carnitine were positively correlated with modified Rodnan skin score (mRSS). In addition, a panel of metabolites including proline betaine, phloretin 2'-O-glucuronide, gamma-linolenic acid and L-cystathionine were associated with the presence of interstitial lung disease (ILD) in SSc. Specific metabolites identified by ML algorithms, such as medicagenic acid 3-O-b-D-glucuronide, 4'-O-methyl-(-)-epicatechin-3'-O-beta-glucuronide, valproic acid glucuronide, have the potential to predict the progression of skin fibrosis.

CONCLUSIONS

Serum of SSc patients demonstrates profound metabolic changes. Treatment partially restored the metabolic changes in SSc. Moreover, certain metabolic changes were associated with clinical manifestations such as skin fibrosis and ILD, and could predict the progression of skin fibrosis.

Efficacy of Local Oxygen-Ozone Therapy for the Treatment of Digital Ulcers Refractory to Medical Therapy in Systemic Sclerosis: A Randomized Controlled Study

BACKGROUND

This study aimed to investigate the efficacy of local oxygen-ozone therapy in systemic sclerosis (SSc) patients with digital ulcers (DUs) who were resistant to medical therapy and had impairment in activities of daily living.

METHODS

Participants' demographic data, medical treatment, and clinical parameters (duration and number of Reynaud's Phenomenon (RP) attacks, ulcer pain, grade, and diameter) were recorded. Twenty-five SSc patients with DUs were randomized to the ozone group (I) (n = 13) to receive medical treatment plus local oxygen-ozone therapy and the control group (II) (n = 12) to receive medical treatment only. Hand functions were assessed using the Health Assessment Questionnaire (HAQ) and Modified Hand Mobility in Scleroderma (HAMISm) test. Ulcer grade, clinical parameters, HAQ, mHAMIS scores were re-evaluated in all participants 4 weeks after the initiation of treatment.

RESULTS

Demographic and clinical characteristics of the two groups showed no significant differences. At 4 weeks after the initial treatment, the efficacy rate was significantly higher in the ozone group than in the control group (92% versus 42%, p = 0.010). Clinical parameters, HAQ, and HAMISm scores were significantly improved in the treatment group compared to the control group (p < 0.05).

CONCLUSION

Local oxygen-ozone therapy was effective in the treatment of SSc patients with resistant DUs and improved clinical parameters and functional disability.

An update on the pharmacotherapeutic options and treatment strategies for systemic sclerosis

INTRODUCTION

Systemic sclerosis (SSc) is a multi-dimensional connective tissue disease of unknown etiology. Given the immense clinical complexity of SSc, the treatment of this condition is not standardized and considerable heterogeneity exists in SSc management approaches. The purpose of this article is to highlight novel therapeutic strategies and new medications under development for the treatment of systemic sclerosis (SSc).

AREAS COVERED

Herein, the authors focus primarily on recently completed clinical trials and phase 3 and 4 clinical trials of therapeutic agents that show promise in SSc. This review is organized by the clinical complications that occur in SSc, for which novel treatment strategies are under study.

EXPERT OPINION

Combining therapies to address the individual manifestations of SSc is a cornerstone to the comprehensive management of this condition. Therapeutic strategies must take into account the organs involved, the level of disease activity in each area, and the disease stage. Controlling the complex biological network, progressive vasculopathy and fibrosis, as well as manifestations of end-organ dysfunction are all critical considerations when determining the best treatment approach for SSc.

Immunosuppressive treatment in diffuse cutaneous systemic sclerosis is associated with an improved composite response index (CRISS)

Background

Outcomes of therapeutic studies in diffuse cutaneous systemic sclerosis (dcSSc) have mainly been measured for specific organs, particularly the skin and lungs. A new composite response index in dcSSc (CRISS) has been developed for clinical trials. The goal of this study was to determine whether, in an observational dcSSc cohort, immunosuppression was associated with global disease improvement measured with the CRISS.

Methods

We conducted a retrospective cohort study in a multi-centered SSc registry comparing 47 patients newly exposed to immunosuppression for ≥ 1 year to 254 unexposed patients. Inverse probability of treatment weighting (IPTW) was performed to create comparable exposed and unexposed groups by balancing for age, sex, disease duration, modified Rodnan skin score (mRSS), forced vital capacity, patient and physician global assessments, and Health Assessment Questionnaire score. A CRISS score ≥ 0.6 at 1 year was defined as improvement.

Results

Exposed patients had shorter disease duration (5.5 versus 11.7 years, p < 0.01), more interstitial lung disease (67.4% versus 40.3%, p < 0.01), and worse physician global severity scores (4.2 versus 2.5 points, p < 0.01) compared to unexposed patients. Improvement in CRISS scores was more common in exposed patients after IPTW (odds ratio 1.85, 95% confidence interval 1.11, 3.09). Of the individual CRISS variables, only mean patient global assessment scores were significantly better among exposed than unexposed patients (− 0.4 versus 0 points, p = 0.03) while other variables including mRSS were similar.

Conclusion

Using a composite response measure, immunosuppression was associated with better outcomes at 1 year in a dcSSc cohort. These results provide real-world data that align with clinical trials to support our current use of immunosuppression.

Systemic sclerosis

Systemic sclerosis, also called scleroderma, is an immune-mediated rheumatic disease that is characterised by fibrosis of the skin and internal organs and vasculopathy. Although systemic sclerosis is uncommon, it has a high morbidity and mortality. Improved understanding of systemic sclerosis has allowed better management of the disease, including improved classification and more systematic assessment and follow-up. Additionally, treatments for specific complications have emerged and a growing evidence base supports the use of immune suppression for the treatment of skin and lung fibrosis. Some manifestations of the disease, such as scleroderma renal crisis, pulmonary arterial hypertension, digital ulceration, and gastro-oesophageal reflux, are now treatable. However, the burden of non-lethal complications associated with systemic sclerosis is substantial and is likely to become more of a challenge. Here, we review the clinical features of systemic sclerosis and describe the best practice approaches for its management. Furthermore, we identify future areas for development.

Assessment of skin involvement in systemic sclerosis

Skin involvement in SSc is an important marker of disease activity, severity and prognosis, making the assessment of skin a key issue in SSc clinical research. We reviewed the published data assessing skin involvement in clinical trials and summarized the major conclusions important in SSc clinical research. A systematic literature review identified randomized controlled trials using skin outcomes in SSc. Analysis examined the validity of the different skin measures based on literature findings. Twenty-two randomized controlled trials were found. The average study duration was 10.2 (s.d. 4.5) months, mean (s.d.) sample size 32.4 (32.6) and 26.7 (27.8) in intervention and control arms, respectively. The 17-site modified Rodnan skin score is a fully validated primary outcome measure in diffuse cutaneous SSc. Skin histology seems to be an appropriate method for evaluation of skin thickness. These findings have important implications for clinical trial design targeting skin involvement in SSc.

Muscle function in women with systemic sclerosis: Association with fatigue and general physical function

BACKGROUND

Individuals with systemic sclerosis have muscle functions with varying degrees of muscle weakness and atrophy, which in turn can have a negative impact on functional and health-related quality of life. This study aimed to evaluate peripheral muscle performance using isokinetic dynamometry of the knee in women with systemic sclerosis and to correlate peripheral muscle dysfunction with disability levels and general fatigue.

METHODS

Twenty-six women with systemic sclerosis and a matched control group with an equal number of women underwent knee isokinetic dynamometry at angular speeds of 75°/s and 240°/s, isometric handgrip strength, the Health Assessment Questionnaire Disability Index, the Functional Assessment of Chronic Illness Therapy-Fatigue scale, and the Fatigue Impact Scale.

FINDINGS

Women with systemic sclerosis showed significant reductions in almost all isokinetic parameters for the two angular velocities tested compared with the controls. An agonist/antagonist ratio with values <40% was observed in approximately one-third of the patients. These patients had lower isometric handgrip strength. These patients also performed worse on the two general fatigue scales evaluated. Significant correlations were observed between the isokinetic parameters and the measured isometric handgrip strength, and the Health Assessment Questionnaire Disability Index.

INTERPRETATION

Systemic sclerosis patients have reduced strength and endurance as well as a muscle imbalance between the quadriceps and hamstrings. In these patients, lower muscle dysfunction of the knee joint is associated with lower handgrip strength and physical incapacity.

Systemic sclerosis: Association between physical function, handgrip strength and pulmonary function

BACKGROUND

Systemic sclerosis (SSc) is a multisystem disease affecting the skin, respiratory system and skeletal muscles. In SSc patients, hand function disability is the major factor limiting daily activities.

AIM

To evaluate the association of physical function with handgrip strength and pulmonary function in SSc patients. A further aim was to assess the relationship between handgrip strength and pulmonary function in patients with SSc.

METHOD

A cross-sectional study in which 28 patients with SSc underwent isometric handgrip strength (IHGS) measurement and pulmonary function tests and completed the Health Assessment Questionnaire Disability Index (HAQ-DI) to measure physical function.

RESULTS

The HAQ-DI scores were associated with the IHGS (r_s = -0.599, P = 0.001) and pulmonary function parameters, particularly the diffusion capacity for carbon monoxide (DLco; r_s = -0.642, P = 0.0004).

CONCLUSION

In patients with SSc, the degree of physical disability is associated with both hand grip strength and pulmonary function. However, there is no relationship between handgrip strength and pulmonary function in these patients.

Independent Association of Severity of Muscle Weakness With Disability as Measured by the Health Assessment Questionnaire Disability Index in Scleroderma

OBJECTIVE

To determine whether the presence and degree of muscle weakness in scleroderma is associated with disability.

METHODS

The study included a cohort of 1,718 scleroderma patients who had available data on muscle strength and disability. The primary independent variable was muscle weakness as defined by the maximum Medsger muscle severity score and the outcome was disability as measured by the last recorded Health Assessment Questionnaire disability index (HAQ DI) score. Univariate regression analyses were performed to assess the association of HAQ DI scores with the Medsger muscle severity score and other scleroderma characteristics. A multivariate regression analysis was performed to determine whether an association existed between the degree of muscle weakness and disability, while controlling for confounders.

RESULTS

In 1,718 patients with scleroderma, 22.8% (392 of 1,718) had muscle weakness, as defined by a Medsger muscle severity score of ≥1. This subset was more likely than those without weakness to have diffuse cutaneous scleroderma (55.6% versus 35.1%; P < 0.0001), higher modified Rodnan skin thickness scores (mean ± SD 16.3 ± 13.7 versus 10.3 ± 10.6; P < 0.00001), shorter disease duration (mean ± SD 5.21 ± 6.75 versus 6.22 ± 7.67 years; P = 0.02), synovitis (17.7% versus 11.4%; P = 0.001), forced vital capacity <70% (46.2% versus 30.6%; P = 0.0001), and higher creatine kinase values (mean ± SD 441 ± 1,211 versus 151 ± 255; P = 0.00001). Both univariate and multivariate analyses revealed that for every unit of increase in the Medsger muscle severity score, there was a clinically significant (minimum clinically important difference ± 0.14) increase in the mean HAQ DI score at last followup visit.

CONCLUSION

The presence of muscle weakness associates with several features of worse disease burden and independently associates with disability as measured by the HAQ DI.

Prediction of improvement in skin fibrosis in diffuse cutaneous systemic sclerosis: a EUSTAR analysis

Objectives

Improvement of skin fibrosis is part of the natural course of diffuse cutaneous systemic sclerosis (dcSSc). Recognising those patients most likely to improve could help tailoring clinical management and cohort enrichment for clinical trials. In this study, we aimed to identify predictors for improvement of skin fibrosis in patients with dcSSc.

Methods

We performed a longitudinal analysis of the European Scleroderma Trials And Research (EUSTAR) registry including patients with dcSSc, fulfilling American College of Rheumatology criteria, baseline modified Rodnan skin score (mRSS) ≥7 and follow-up mRSS at 12±2 months. The primary outcome was skin improvement (decrease in mRSS of >5 points and ≥25%) at 1 year follow-up. A respective increase in mRSS was considered progression. Candidate predictors for skin improvement were selected by expert opinion and logistic regression with bootstrap validation was applied.

Results

From the 919 patients included, 218 (24%) improved and 95 (10%) progressed. Eleven candidate predictors for skin improvement were analysed. The final model identified high baseline mRSS and absence of tendon friction rubs as independent predictors of skin improvement. The baseline mRSS was the strongest predictor of skin improvement, independent of disease duration. An upper threshold between 18 and 25 performed best in enriching for progressors over regressors.

Conclusions

Patients with advanced skin fibrosis at baseline and absence of tendon friction rubs are more likely to regress in the next year than patients with milder skin fibrosis. These evidence-based data can be implemented in clinical trial design to minimise the inclusion of patients who would regress under standard of care.

A modified rheumatoid arthritis disease activity score without acute-phase reactants (mDAS28) for epidemiological research

OBJECTIVE

To develop and validate a modified version of the Disease Activity Score with 28 joint count (mDAS28), for use in epidemiological research, when acute-phase reactant values are unavailable.

METHODS

In a cross-sectional development cohort (5729 patients), statistically significant predictors of the logarithm of erythrocyte sedimentation rate (lnESR) were identified. After computation of the mDAS28, a cross-sectional validation cohort (5578 patients) was used to evaluate internal, criterion, and construct validities. The ability of the mDAS28 to discriminate between disease states was also assessed. A second validation cohort (longitudinal, 336 pairs of patient visits) was used to assess sensitivity to change.

RESULTS

Significant predictors of lnESR included tender and swollen joints with 28 counts, patient's and physician's assessments of global health, and patient's assessment of pain (visual analog scale 0-100 mm) and a physical function (modified Health Assessment Questionnaire 0-3; mHAQ). Satisfactory internal validity (alpha = 0.72) and strong criterion validity compared to the DAS28, the Simplified Disease Activity Index (SDAI), and the Clinical Disease Activity Index (CDAI) (r = 0.87-0.96) were found. Predictive validity was demonstrated by good correlation with the mHAQ (r = 0.58). The mDAS28 showed substantial agreement with the DAS28, SDAI, and CDAI in discriminating between disease states (kappa = 0.70-0.77) and moderate to substantial agreement between response levels (kappa = 0.52-0.73). Both mDAS28 and DAS28 measures classified patients similarly in remission compared to the SDAI and CDAI. The mDAS28 was superior in detecting change (standardized response mean = 0.58) followed by the DAS28, CDAI, and SDAI.

CONCLUSION

The mDAS28 is a valid and sensitive tool to assess disease activity in epidemiological research, as an alternative to the DAS28, when acute-phase reactant values are unavailable.

The EUSTAR model for teaching and implementing the modified Rodnan skin score in systemic sclerosis

OBJECTIVE

To evaluate the ability to teach scleroderma experts and young rheumatologists to perform the modified Rodnan skin score test.

METHODS

Three international "teaching courses for teachers" were conducted with 6-9 experts who performed 3-9 skin score tests each. In addition, an international course for 90 young rheumatologists, in which 18 patients with systemic sclerosis (SSc) participated, was also organised. Finally, a local repeated training course for 5-9 rheumatologists was performed, in which 6-7 patients with SSc participated.

RESULTS

When 6-9 scleroderma specialists investigated the patients, the intraclass correlation coefficient (ICC) showed "good" to "excellent" values (0.865 and 0.710, respectively). When 90 young rheumatologists were involved in one teaching course, the coefficient of variation (CV) was relatively satisfactory (35%) owing to the high number of investigators, and with a considerable within-patient SD value of 5.4. Repeated teaching of 5-9 young rheumatologists in local courses clearly improved the consistency. The ICC increased from 0.496 to a "good" level of 0.722. The within-patient SD values for intraobserver variability ranged between 2.5 and 2.9. The intraobserver CV was about 20%.

CONCLUSIONS

This study strongly supports the need for standardisation among different centres when using skin scoring for clinical trials. The intraobserver variability and within-patient SD values can be significantly reduced by repeated teaching. For inexperienced rheumatologists, at least one repeated teaching course is needed.

Influence of clinical features on the health status of patients with limited cutaneous systemic sclerosis

OBJECTIVE

To determine the effect of limited cutaneous systemic sclerosis (lcSSc) on patients' health status, and to identify the contributions to health status of different manifestations of lcSSc.

METHODS

The Short Form 36 questionnaire was completed by 213 patients with lcSSc or Raynaud's syndrome and an antinuclear antibody typical of lcSSc as part of the baseline visit of the Quinapril in Scleroderma trial. Results were analyzed after correcting for age and sex using the Welsh Health Survey. Patients' results were related to their clinical characteristics.

RESULTS

The mean physical component score (PCS) was 44.0 (95% confidence interval [95% CI] 42.5, 45.5), which was lower than the population norm of 50, and the median mental component score (MCS) was 52.2 (95% CI 48.5, 54.3). Raynaud's disease visual analog scale (VAS) scores, lung function, the number of organ systems affected, and skin score were significantly correlated with PCS. The total score (TDS) of an SSc severity scale showed the highest correlation. The effect of lcSSc on PCS was worse in younger patients. Multiple regression including age demonstrated that Raynaud's disease severity could predict a reduction in PCS beyond that predicted by TDS. Raynaud's disease severity and duration of lcSSc were linked to low MCS. Arthritis reduced PCS and esophageal involvement reduced PCS and MCS.

CONCLUSION

Physical health status of patients with lcSSc was reduced, with 30% of the variation predicted by TDS, age, and severity of Raynaud's disease VAS. Mental health status was not reduced in this population.

The health assessment questionnaire disability index and scleroderma health assessment questionnaire in scleroderma trials: An evaluation of their measurement properties

OBJECTIVE

To evaluate the measurement properties of the Health Assessment Questionnaire (HAQ) disability index (DI) for group comparisons in scleroderma trials, and to determine if the Scleroderma Health Assessment Questionnaire (SHAQ) visual analog scales confer any measurement advantage over the HAQ DI.

METHODS

A computer search for articles describing the use of the HAQ DI and SHAQ in scleroderma was performed. Evidence supporting the sensibility, reliability, validity, and responsiveness of these measures was evaluated.

RESULTS

The SHAQ has incremental face and content validity over the HAQ DI because it addresses scleroderma-specific manifestations that also contribute to disability. The HAQ DI has good concurrent validity, construct validity, and predictive validity. Whether SHAQ confers incremental construct, concurrent, or predictive validity over the HAQ DI is uncertain. The HAQ DI appears more reliable than the SHAQ; however, reliability studies provide insufficient data to ascertain if minimum standards have been achieved. Responsiveness of the HAQ DI subscales has been demonstrated.

CONCLUSION

The SHAQ has incremental face and content validity over the HAQ DI. The HAQ DI has greater reliability and demonstrated construct, concurrent, and predictive validity. Further investigation into the measurement properties of the HAQ DI and SHAQ visual analog scales, and their relation to the required standards of measurement is needed.