Fatigue in Saudi Patients with Primary Sjögren's Syndrome and Its Correlation with Disease Characteristics and Outcome Measures: A Cross-Sectional Study

Laboratory features and pharmacological management of early and late-onset primary Sjögren's syndrome

BACKGROUND

Primary Sjögren's Syndrome (pSS) is a systemic chronic autoimmune disorder that contributes to dry mouth (xerostomia) and eyes (xerophthalmia). It mainly affects females between 40 and 60 years old. So far, there is no treatment to cure SS; however, there is a list of medications that can ameliorate the symptoms. In addition, there has been no single test until now to detect pSS, but clinical and immunological investigations are applied as diagnostic tools. Therefore, this study aimed to explore the characteristics of pSS in Saudi patients based on the onset of the disease through laboratory findings and pharmaceutical management.

METHODOLOGY

This retrospective study examined diagnosed patients with pSS between 2018 and 2023 from the National Guard Hospital, Saudi Arabia. Data of pSS patients was categorized into two groups: early (under 40 years old) and late-onset (40 years old and above). Data on demographic information, mortality rate, and blood tests such as complete blood count (CBC), creatinine, erythrocyte sedimentation rate (ESR), and vitamin levels, in addition to prescribed medications, were collected from the patient's medical record. Chi-square and t-tests were mainly used, and statistical significance was determined at a P-value less than 0.05.

RESULTS

A total of 453 patients were included in the study, where the early-onset group comprised 136 and the late-onset group comprised 317 patients. The mean age of the early and late onset was 34.2 and 60.4, respectively. ESR was significantly higher in the early (46.3 mm/hr) and late-onset (49.8 mm/hr). The most common medication used by all pSS patients was hydroxychloroquine. However, artificial tears were mainly observed in the late-onset group. Other medications, such as pilocarpine, methotrexate, and azathioprine, were prescribed to pSS patients to a lesser extent.

CONCLUSION

This study suggests that the onset of pSS could occur even before the age of 40 among Saudi citizens. Notably, elevated ESR levels appeared to be a feature of pSS, which was consistent with other previous findings. The variability of some medications between early-onset and late-onset pSS may indicate disease progression. However, further investigations are required to confirm this observation.

Development and validation of a nomogram for predicting fatigue in patients with primary Sjögren's syndrome

OBJECTIVE

To develop and validate a nomogram to predict fatigue in patients with primary Sjögren's syndrome (pSS).

METHODS

In this cross-sectional study, 251 patients with SS from the Affiliated Hospital of Nantong University were recruited. The patients were randomly divided into two groups: training group (n = 167) and validation group (n = 84). In the training group, univariate analysis and multivariate Cox regression analysis were performed on sociodemographic factors, disease activity, anxiety/depression, clinical indicators, and so on. According to the risk factors of fatigue in SS patients, a nomograph was established. In the training group and validation group, the performance of the nomogram was verified by three forms: receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA).

RESULT

The incidence of fatigue was 40.6%. EULAR Sjögren's Syndrome Disease Activity Index, EULAR SS patient reported index, and depression were independent risk factors of fatigue in SS patients. The C-index of nomogram was 0.8532 in training set and 0.7381 in verification set, respectively. As to the Hosmer-Lemeshow test, the P value of modeling patients is 0.996 in verification (P > 0.05). DCA further validated the clinical utility of this nomogram.

CONCLUSION

The nomogram constructed in this study can effectively predict the occurrence of fatigue in SS patients, which is helpful for clinical decision-making and subsequent intervention implementation. Key Points • Fatigue was widespread in patients with primary Sjögren's syndrome, and the incidence of fatigue was 40.6%. • Disease activity and depression were independent risk factors of fatigue in patients with Sjögren's syndrome. • This was the first comprehensive nomogram to predict fatigue for Sjögren's syndrome patients.

Single nucleotide polymorphisms in cytokine genes and their association with primary Sjögren's syndrome in Saudi patients: A cross-sectional study

OBJECTIVES

To determine the allelic frequencies and effects of genotypic variations in cytokine gene polymorphisms in a Saudi Arabian population.

METHODS

This cross-sectional study involved 41 patients with Primary Sjögren's syndrome (pSS) and 71 healthy controls between October 2018 and May 2019. Single nucleotide polymorphisms genotyping was performed using the SEQUENOM MassARRAY® System, targeting nine polymorphisms in different cytokine genes. Chi-square tests were used to compare the patients and controls.

RESULTS

The interleukin-1 beta (IL-1β) rs1143627 CT (control, 52.7%; patients, 21.2%) and TT + CT (p= 0.003; p=0.033) genotypes were less frequent in patients with pSS than in healthy controls. The C allele in rs10488631 in the interferon regulatory factor 5 (IRF5) gene and the A allele in rs12583006 in the B-cell activating factor (BAFF) gene were associated with an increased risk of pSS development in the patient group.

CONCLUSION

The CT genotype at -31 (rs1143627) in the IL-1β gene was not associated with a high risk of pSS development in the Saudi population, in contrast to what has been verified in other ethnicities. However, the C allele in rs10488631 in IRF-5 and the A allele in rs12583006 in BAFF were associated.

Depression is the most significant independent predictor of fatigue in patients with primary Sjögren's syndrome

Objectives

The study aimed to evaluate the level of fatigue and the relationship between mood, pain, fibromyalgia, insomnia, disease activity, and dryness with fatigue in primary Sjögren's syndrome (PSS) patients.

Patients and methods

In this case-control study, the participants were recruited between January 2021 and July 2021. Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F), pain DETECT questionnaire, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Insomnia Severity Index (ISI) were administered to 50 PSS patients (48 females, 2 males; mean age: 48.9±10.8 years; median age: 47 years; range, 29 to 71 years) and 60 healthy controls (HCs; 57 females, 3 males; mean age: 49.8±8.4 years, median age: 52 years; range, 32 to 72 years). In addition, EULAR Sjögren's syndrome disease activity index (ESSPRI), EULAR Sjögren's Syndrome Patient Reported Index (ESSDAI), pain thresholds, Schirmer tests, and whole unstimulated salivary flow rate measurements were determined in PSS patients. Independent predictors of fatigue (fatigue subscale scores <30.5) were investigated by logistic regression analysis.

Results

The frequency of fatigue in PSS patients and HCs was 54.0% and 8.3%, respectively. The rates of mood disturbance (BDI ≥11) in PSS patients with and without fatigue were 70.4% and 13.1%, respectively. BDI (Rho=-0.804), BAI (Rho=-0.586), ISI (Rho=-0.483), and ESSDAI (Rho=-0.345) were negatively correlated with the fatigue subscale score. Depression [Odds ratio (OR): 1.214, confidence interval (CI): 1.007-1.463], fibromyalgia (OR: 21.674, CI: 1.470-319.469), disease activity (OR: 1.440; CI: 1.005-2.065), and insomnia (OR: 1.223, CI: 1.003-1.4922) were identified as independent predictors of fatigue in PSS patients. It was determined that BD alone could predict fatigue by 84% in PSS patients.

Conclusion

Depression can be a prominent predictor of fatigue in PSS patients. There is a need for studies evaluating the effect of antidepressant treatment approaches on fatigue accompanied by mood disturbance in PSS patients.

Functional and psychosocial impact of COVID-19 pandemic on rheumatic patients' quality of life in Saudi Arabia

PURPOSE

The COVID-19 pandemic might add to the stressors experienced by people living with rheumatic diseases. This study aimed to examine rheumatic patients' functional and psychosocial states during the pandemic and assess its impact on their quality of life.

METHODS

Our time-series study included a patient-centered electronic survey, sampling adult rheumatic patients living in Saudi Arabia at different time points from March to August 2020. Patient-reported outcomes included physical function, anxiety, depression, fatigue, sleep disturbance, ability to participate in social roles, and pain interference domains were measured using the Patient-Reported Outcomes Measurement Information System (PROMIS-29 Profile v2.1).

RESULTS

A total of 1278 respondents were enrolled. Results showed significant variation in patients' experiences. Our analyses revealed that the physical well-being of rheumatic patients was significantly impacted, and such effect was persistent over time irrespective of public health measures to control the COVID-19 outbreak.

CONCLUSION

Our findings consistently demonstrated the need for psychological and social consideration to improve rheumatic patients' quality of life. Nevertheless, there is still a lot to be learned about the extent of COVID-19 impact on rheumatic patients and the implications it has on long-term disease outcomes.

Disease phenotype and diagnostic delay in Saudi patients with primary Sjögren's syndrome: An exploratory cross-sectional study

Objectives:

To describe primary Sjögren’s syndrome (pSS) cohort in Saudi Arabiain view in of clinical/serological/histopathological phentotype, and, diagnostic delay.

Methods:

A cross-sectional study conducted between October 2018 and May 2019. Diagnostic delay was calculated from symptoms onset to clinical diagnosis. The European League Against Rheumatism (EULAR) Sjögren’s Syndrome Disease Activity Index (ESSDAI) and EULAR Sjogren’s Syndrome Patient Reported Index (ESSPRI) were calculated.

Results:

Forty-one patients were included in the study. There were predominantly females (78%) with a mean (±SD) age of 58.76±12.7 and disease duration of 4.6±2.28 years. The mean diagnostic delay was 2.2±2.4 (range 1-11) years. Minor salivary gland biopsy was performed on 38 (92.7%) patients with a mean focus score of 2.3± 1.2 points. Interstitial lung disease and arthritis were the most common extra-glandular manifestations (EGM) affecting 27 (65.9%) patients for both. The mean ESSDAI was 9.95±7.73 and ESSPRI was 5.17±2.4.

Conclusion:

Saudi primary Sjogren’s syndrome patients have a high prevalence of EGM predominantly arthritis and ILD. The diagnostic delay is variable in our cohort.