Mithu Maheswaranathan, MD

Health literacy is an important social determinant of health which includes personal competencies and resources that are needed for individuals to access, understand, and use health information and services to make decisions about their health.

 Limited health literacy has been shown to be associated with worse health outcomes, including lower medication adherence, problems seeking preventive care, and poorer health outcomes. 

A recent study by Gorter and Bakker et al sought to build upon previous work identifying 10 distinct health literacy profiles of patients with rheumatic diseases, categorizing them based on strengths and weaknesses related to their health literacy.

 The aim of the study was to explore longitudinal associations between health literacy profiles, disease activity and medication prescription in patients with 

The study enrolled 108 patients with RA at a hospital in the Netherlands who previously completed the Health Literacy Questionnaire (HLQ) in 2019. They retrieved up to 1 year of follow-up data on disease activity and medication prescription from the electronic health record.Disease activity was assessed using Disease Activity Score-28 for Rheumatoid Arthritis with erythrocyte sedimentation rate (DAS28-ESR) scores. Medication prescription information was also retrieved.Linear mixed modelling was used to analyze association between health literacy groups and disease activity over 1 year. To compare medication prescription use between groups, Chi squared tests and logistic regression analysis were used.

The study found 21 patients had “several health literacy limitations,” 33 had “some health literacy limitations,” and 54 had “good health literacy.” The mean age was 66 years and 62% of the cohort were female; around half of patients were seropositive (rheumatoid factor [RF] 57%, cyclic citrullinated peptide [CCP] 54%). The linear mixed modelling showed significant effect of health literacy group on DAS28-ESR scores over time. Patients with “good health literacy” had significantly lower disease activity over time than those with “several health literacy limitations,” adjusting for age, gender, and education level. Interestingly, patients with “good health literacy” were most often prescribed a biologic DMARD (50%), whereas those with “some health literacy limitations” more commonly received a conventional synthentic disease-modifying antirheumatic drugs (csDMARDs) only (72.7%, odds ratio [OR] 4.24), and those with “several health literacy limitations” were more often prescribed steroids (52.4%, OR 3.56).

The authors explained how their results demonstrated patients with more health literacy needs had higher disease activity over time, independent of their education level.An intriguing finding was that patients with “several health literacy limitations” were prescribed prednisolone more often, which they postulate may be due to insufficient control of disease activity or patients with more health literacy needs asking for prednisolone more often. They found significantly more biologic DMARD (bDMARD) prescriptions in the “good health literacy” group, which could be due to reluctance amongst patients with lower health literacy to change therapy or having more concerns about bDMARDs.

They also highlighted some limitations, including need to replicate their findings, due to the small size of the groups, grouping different health literacy profiles into 3 groups analyzed, and the homogeneity of the population from a specific region of the Netherlands.

Finally, the authors of this article raised suggestions on how to “level the playing field” through health literacy, noting health literacy is a modifiable determinant of health but hard to improve within the limited timeframe of a clinic visit. They suggested improving our services to better respond to health literacy limitations of our patients, such as using understandable and actionable information materials (including plain language and illustrations) and offering patients additional guidance and support. Another suggestion was to use a “universal precautions” approach, assuming every patient is at risk of reduced access to care and potentially poor outcomes of care due to limited health literacy.

This study highlights the influence of health literacy in outcomes of patients with RA and even potential implications in specific DMARD therapy selection, and why rheumatologists should be aware of the impact of health literacy in clinical care.

Broder J, Chang P, Kickbusch I et al. IUHPE position statement on health literacy: a practical vision for a health literate world. Glob Health Promot, 2018.

Gorter A, Bakker MM, Ten Klooster PM. The impact of health literacy: associations with disease activity and medication prescription in patients with rheumatoid arthritis. Rheumatology, 2023.

Articles

Patients with “good health literacy” had significantly lower disease activity over time than those with “several health literacy limitations,” adjusting for age, gender and education level.  

Impact of Health Literacy in Disease Activity, Medications in Rheumatoid Arthritis

Pneumocystis jiroveci pneumonia (PJP) is an opportunistic fungal infection that typically affects immunocompromised patients. Guidelines recommend PJP prophylaxis in patients with ANCA-associated vasculitis,

 but no formal recommendations exist for giant cell arteritis (GCA) or polymyalgia rheumatica (PMR). Studies have demonstrated antibiotic prophylaxis reduces incidence of PJP in immunocompromised patients, but little data has evaluated the role of prophylaxis in GCA or PMR. The authors of a recent study by Natalie Anumolu et al sought to answer the question of PJP incidence in this population, given patients with GCA/PMR often receive prolonged courses of steroids, particularly GCA with high doses and often concomitant immunosuppression with tocilizumab.

In this study, authors utilized a United States-based electronic health records database (TriNetX), including de-identified information from 54 healthcare organizations and over 86 million patients across the United States. The cohort identified patients with GCA and PMR, using ICD-9/ICD-10 diagnosis codes, who had a glucocorticoid prescription. Patients were excluded if they had human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), any reported transplant, or leukemia. They also excluded patients with any PJP code within a specified time period surrounding the index date (defined as first glucocorticoid prescription, required to occur within 30 days after first diagnosis code). The team extracted demographic data, medications used, and type of prophylaxis as well as medical comorbidities and assessed incidence rate of PJP.To identify other cases of PJP, a systematic review was also performed.

The study found a total of 1168 incident cases of GCA and over 15,575 incident cases of PMR.During follow-up, steroid-sparing agents included tocilizumab (9.5% GCA, 0.7% PMR) and methotrexate (7.1% GCA, 6.7% PMR). A minority of patients received prophylaxis, including trimethoprim/sulfamethoxazole (TMP/SMX) (6.1% GCA, 1.6% PMR), atovaquone (0.4% GCA, 0.1% PMR), or dapsone (0.6% GCA, 0% PMR) for presumed PJP prophylaxis. Among 1168 patients with GCA, there were no cases, positive tests or hospitalizations for PJP (0/1,000 person-years). Among 15,575 patients with PMR, there was 1 case of PJP within 6 months and 1 positive case within 12 months, with no hospitalizations (0.07/1,000 person-years). Evaluating the systematic reviews, in GCA they found 28 total cases of PJP with 4 cases of mortality; in PMR, there were 4 cases of PJP prophylaxis and no deaths reported.

Combining results of the cohort study and systematic review, the authors conclude PJP infection occurred rarely among patients with GCA or PMR. They noted their cohort study identified no cases of PJP in those with GCA and only 5 cases in those with PMR, which may approximate rates observed in the general population. Patients with GCA/PMR often require high cumulative glucocorticoid dosage for treatment, and they hypothesize a few reasons for why the incidence rate of PJP is not higher, including: 1) medications do not affect T-cells to the same degree active HIV does and 2) patients with GCA/PMR lack disease-mediated lung disease. The authors noted some limitations, such as reasons prophylaxis treatment not being listed in some cases and having to be inferred, and lack of granular data on corticosteroid dosing. Additionally, I will note the low percentage of patients on tocilizumab or methotrexate in the GCA cohort. It is possible the rate of PJP incidence may vary in those on prednisone monotherapy versus prednisone in combination with other immunosuppressant.

Ultimately, as rheumatologists we are balancing control of underlying disease and risks of immunosuppressive treatment. This data suggests the risk of PJP in patients with GCA or PMR are low, and it is important to recognize the potential range of adverse events from PJP prophylaxis are vast, including methemoglobinemia and agranulocytosis. Given these findings, the authors concluded “these data do not support routine prescribing of PJP prophylaxis for patients with GCA or PMR.”

Chung SA, Langford CA, Maz M, Abril A, Gorelik M, Guyatt G, et al. American college of rheumatology/vasculitis foundation guideline for the management of antineutrophil cytoplasmic antibody–associated vasculitis. Arthritis Care Res 2021; 73:1088–105.

Anumolu N, Henry K, Sattui SE, Putman M. Is there a role for Pneumocystis jiroveci pneumonia prophylaxis in giant cell arteritis or polymyalgia rheumatica? Seminars in Arthritis and Rheumatism 2023; 58:152154.

Results of a recent study showed that the risk of pneumocystis jiroveci pneumonia (PJP) is low in patients with giant cell arteritis (GCA) and polymyalgia rheumatica (PMR), therefore discouraging the routine prescribing of PJP prophylaxis for this patient population. 