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The April 2023 rheumatology month in review highlights recent data regarding physical activity levels among patients with JIA, a link between fibromyalgia and psychiatric disorders, and a feature focused on the treatment of polymyalgia rheumatica.
The April 2023 rheumatology month in review highlights recent data regarding physical activity levels among patients with juvenile idiopathic arthritis (JIA) and the improvements to cardiorespiratory fitness regular exercise can provide for patients with autoimmune disease. Additionally, current fibromyalgia studies have reported a strong association between a fibromyalgia diagnosis and psychiatric disorders and demonstrated the benefits of synbiotic supplementation to improve the symptoms of fibromyalgia, including quality of life and stress responses. Rounding out this month’s offerings is a feature focused on the treatment of polymyalgia rheumatica, including the recent approval of sarilumab, the first biologic to treat adult patients with this condition.
While the origin of fibromyalgia is unknown, studies have indicated abnormalities in muscle physiology and immune/inflammatory response could contribute to its pathogenesis. These patients are more likely to experience a variety of symptoms, including gut microbiome abnormalities, psychiatric disorders, and worse quality of life when compared with the general population.
The cross-sectional study recruited newly diagnosed female patients with fibromyalgia who visited a private outpatient rheumatology clinic in Sari, Iran, from 2018 through 2019. Patients were given psychiatric assessments by a psychiatrist, and diagnosis of any psychiatric disorders was based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), while sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI).
Results revealed that 92.45% of patients with fibromyalgia were simultaneously diagnosed with at least 1 type of psychiatric disorder, and most patients were diagnosed with 2 or more psychiatric disorders. A concurrent diagnosis of mood disorders (MDs) and sleep disorders occurred in 20% of patients. The most common MDs were major depressive disorder (MDD) and persistent depressive disorder (PDD).
“Several studies indicate that reduced production of human growth hormone (hGH) is evident in approximately 30% of individuals with fibromyalgia and may play a role in its pathophysiology,” wrote a team of investigators led by Susan Pekarovics, MD, attending physician and clinical instructor at Cedars-Sinai Medical Center. “Impaired hGH production in these individuals is hypothesized to contribute to common fibromyalgia symptoms and comorbidities, such as fatigue, disordered sleep, impaired cognition, decreased lean body mass, increased adipose tissue, muscle weakness, and poor general health.”
An orally administered amino acid-based test supplement was shown to increase insulin-like growth factor 1 (IGF-1) in patients with fibromyalgia and stress-associated low-normal hGH, which improved the clinical symptoms, including stress-related weight gain. IGF-1 is a common indicator of hGH levels caused by stress-related stimulation of the hormone somatostatin.
Investigators evaluated the effects of synbiotic nutritional supplementation (Gasteel Plus, Heel España SAU) via the pro-inflammatory and anti-inflammatory cytokines, interleukin-8 (IL-8) and IL-10, as well as the neuroendocrine biomarkers, cortisol and dehydroepiandrosterone (DHEA), to better understand the interaction between inflammatory and stress responses mediated by the cytokine-hypothalamic-pituitary-adrenal (HPA) axis in addition to mental and physical health. Mental and physical health were assessed using body composition analysis, validated questionnaires, and accelerometry.
Synbiotic supplements were shown to improve the dysregulated immunoneuroendocrine interaction regarding inflammatory and stress responses in female patients diagnosed with fibromyalgia, particularly for patients without chronic fatigue syndrome (CFS).
Although treatments have improved the overall outcomes of patients with JIA, a condition which commonly includes symptoms such as fatigue, joint stiffness and swelling, pain, and decreased physical function, it is theorized that pain-related fear of movement may hinder physical performance and the intensity of physical activity.
Adult patients with inflammatory joint disease (IJD), which includes conditions such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), and spondyloarthritis (SpA), also experience similar symptoms. These patients are at an increased risk of cardiovascular disease (CVD), partially due to the prevalence of obesity, hypertension, and dyslipidemia, which are known CVD risk factors.
Among a sample of patients with IJD, fat mass, and age were inversely associated with cardiorespiratory fitness (CRF), while physical activity level was positively associated with CRF. Patients that exhibited normal CRF reporting a more favorable health profile.
“Our results support data headlining inferior CRF levels in patients with IJD, further illustrating a continued need for exercise interventions to improve CRF,” wrote lead investigator Kristine Røren Nordén, PhD candidate, Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital in Norway, and colleagues.
“In recent years, biologic drug therapies have altered the course of JIA possibly also improving the patients’ physical fitness,” noted a group of Finnish investigators led by Kati Räsänen, MD, a specialist in pediatrics at the University of Eastern Finland and Kuopio University Hospital. “However, studies measuring both cardiorespiratory and muscular fitness in children with JIA are sparse and have failed to show consistent results.”
A cross-sectional, case-controlled cohort study evaluated the cardiorespiratory and neuromuscular fitness, in addition to contributing factors, in patients with JIA recruited from outpatient clinics in Kuopio and Tampere University Hospitals between 2017 and 2019.
The mean daily activity was lower and sedentary time was higher in patients with JIA compared with controls. While most (82%) controls met the recommended 60 minutes of daily physical activity, only 59% of patients with JIA achieved this goal.
While the prevalence of polymyalgia is low, with less than 1% of the population affected, on average, 2 out of 5 patients with polymyalgia may need to be treated with steroids for more than 2 years, which can create additional issues for patients, such as weight gain, mood swings, and increased risk of infection.
In February 2023, Sanofi and Regeneron Pharmaceuticals, Inc announced the US Food and Drug Administration (FDA) approval of sarilumab (Kevzara), which made the agent the first biologic to treat adult patients with polymyalgia rheumatica who had inadequate response to corticosteroids or could not tolerate a corticosteroid taper.
The decision was based on data from the phase 3 SAPHYR trial, which showed that treatment with sarilumab resulted in nearly 3 times as many patients achieving sustained remission when compared with placebo. For the trial, sustained remission was defined as remission by week 12, CRP normalization from weeks 12 to 52, absence of disease flare, and adherence to the corticosteroid tapering protocol from weeks 12 to 52.