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  1. L. Hedenstierna1,2,3,
  2. A. K. Hedström4,
  3. L. Klareskog1,2,
  4. L. Alfredsson3,5,
  5. J. Askling6,7,
  6. S. Ernestam2,
  7. S. Saevarsdottir8,
  8. L. Ljung2,6,9
  1. 1Karolinska Institutet, Department of medicine, Solna, Stockholm, Sweden
  2. 2Stockholm Health Services, Academic Specialist Center, Stockholm, Sweden
  3. 3Karolinska Institutet, Institute of Environmental Medicine, Stockholm, Sweden
  4. 4Karolinska Institutet, Department of Clinical Neuroscience, Stockholm, Sweden
  5. 5Karolinska Institutet, Center for Occupational and Environmental Medicine, Stockholm, Sweden
  6. 6Karolinska Institutet, Department of Medicine, Solna, Division of Clinical Epidemiology, Stockholm, Sweden
  7. 7Karolinska University hospital, Unit of Rheumatology, Stockholm, Sweden
  8. 8School of Health Sciences, University of Iceland, Faculty of Medicine, Reykjavik, Iceland
  9. 9Umeå Univeristy, Department for Public Health and Clinical Medicine/Rheumatology, Umeå, Sweden


Background: The role of psychosocial conditions on the disease course of rheumatoid arthritis (RA) is getting increased attention. In our previous study, low social support and low decision latitude at work were associated with known modifiable risk factors for RA disease development, such as smoking and low educational level (1). Further, smoking and low educational level have previously been shown to be associated with worse RA disease outcome (2-4). Whether psychosocial characteristics are related to RA disease outcome needs further investigation.

Objectives: To investigate the relationship between two psychosocial characteristics: low social support and low decision latitude at work, and achievement of remission in patients with RA.

Methods: At inclusion in the Swedish EIRA study, incident RA cases (N=3724) and controls (N=5937), matched for age, sex and residential area, responded to a questionnaire including questions on social support and decision latitude at work. The answers were recoded into separate scores and the distribution of the scores among controls were used to define the exposures. Low social support and low decision latitude at work, respectively, among patients, were set as the level corresponding to the lowest quartile among controls, and were compared with scores corresponding to the remaining three quartiles.

The outcome, disease activity score 28-joint count (DAS28) remission, defined as DAS28<2.6, was captured through linkage with the Swedish Rheumatology Quality Register (SRQ) with data available from diagnosis for 2693 out of 3700 cases for social support and for 847 out of 1248 cases for decision latitude at work.

Logistic regression was used to evaluate the association between low social support or low decision latitude at work, respectively, and the chance of remission at the time-points 3 months, 12 months and 60 months after inclusion. All results were adjusted for age, sex and residential area and the fully adjusted models were also adjusted for smoking, obesity, physical activity and educational level.

Results: Low social support (n=655) was associated with a reduced chance for remission at all three time points in the model adjusted for age, sex and residential area; OR 3 months 0.77 (95% CI 0.61-0.97), OR 12 months 0.78 (95% CI 0.64-0.95) OR 60 months 0.77 (95% CI 0.59-0.99). This association was diminished after further adjustment. After stratifying for sex, this association was enhanced in women but inverse among men (Figure 1).

No association between low decision latitude at work (n=166) and chance for remission was observed neither in the analyses stratified for matching variables, nor in the full model. This result was only marginally changed after stratifying for sex (Figure 1).

Conclusion: Low social support was associated with lower chance of remission in early RA, but the association was not independent of other risk factors for worse outcome (smoking, physical activity, obesity and low educational level).

The interrelationship between social stressors and previously known risk factors for worse outcome highlights the importance of supportive actions at many levels to increase the possibility for the individual to make healthy decisions.

References: [1]Hedenstierna. et al. Scand J Rheumatol. 2021:1-5.

[2]Saevarsdottir, et al. Ann Rheum Dis. 2011;70(3):469-75.

[3]Saevarsdottir, et al. Arthritis Rheum. 2011;63(1):26-36.

[4]Jiang, et al. Arthritis Res Ther. 2015;17:317.

Figure 1.

Odds ratios for assiciation between social stressors and DAS 28 remission

Acknowledgements: We want to thank all the participants of the EIRA study and the clinical collaborators for their valuable contribution. We also want to thank the staff for their dedicated work with the data collection.

Disclosure of Interests: None declared

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