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  1. M. Haroon1,
  2. F. Hashmi1,
  3. S. Ullah1,
  4. A. Ashraf2,
  5. H. J. Shaheen1,
  6. S. Asif1,
  7. S. Batool1
  1. 1Fatima Memorial Hospital & FMH College of Medicine and Dentistry, Department of Rheumatology, Lahore, Pakistan
  2. 2CMH Lahore Medical College & Institute of Dentistry, Medicine, Lahore, Pakistan


Background: In chronic inflammatory diseases like rheumatoid arthritis (RA), psychological stress is widely recognised as an important risk factor to negatively affect the disease course. Stress activates the hypothalamic-pituitary adrenal axis and the autonomic nervous system, which associate with the release of neurotransmitters (i.e. norepinephrine), hormones (i.e. cortisol) and activation of immune cells. Perceived stress can potentially induce the disease exacerbation, but on the other hand, the disease itself might produce significant stress to patients thus the vicious circle is formed and maintained.

Objectives: We aimed to examine the prevalence of mental/emotional stress at home and its associations among patients with Rheumatoid arthritis. We addressed this question using real-world data from the PRIME registry.

Methods: This was a cross-sectional study conducted using data collected at the time of patient enrolment in the PRIME registry. The PRIME Registry is a large, independent, prospective, observational cohort initiated in October 2019 that comprises patients diagnosed with RA, SLE, PsA or AS by a rheumatologist, and is being actively followed up. IRB approval and informed consent was obtained. We assessed the data for RA patients. The clinical variables studied were gender, age, smoking habits, body mass index, education status, marital status, disease duration, comorbidities (using Charlson Comorbidity Index). Education status was stratified by whether participants completed secondary (high) school education. Evaluation of disease activity and severity was made as per internationally agreed definitions, such as: swollen joint counts, tender joint counts, deformed joint counts, and DAS-28. All participants were directly inquired at the interview during the time of patient enrolment about the presence or otherwise of mental/emotional stress at home, and to rate it from 1-3 (mild, moderate, severe). For better understanding and ease of statistical analysis, dichotomous variable was made with moderate-to-severe stress patients were categorised into one group and none-to-mild stress patients into second group.

Results: The data of consecutive 507 RA patients (mean age 42.3±12.6 years, 73.6% female, disease duration of 80±22 months) was reviewed. Forty-eight percent of patients accepted to have moderate-severe stress at home (moderate stress=29.9%, severe stress=18.3%). On univariate analysis, significant association of moderate-severe stress at home was noted with deformed joint counts (p=0.036), higher DAS-28 scores (p<0.001), and being married (p=0.001). Weak statistical association of age (p=0.11), disease duration (p=0.13), low education status (p=0.14), female gender (p=0.24) was noted. On multiple logistic regression analysis, a significant association of moderate-severe stress at home was observed with higher DAS-28 scores (OR 1.76, CI 1.29-2.41, p<0.001) and deformed joint counts (OR 1.15, CI 1.00-1.31, p=0.040). Following variables were included in multiple stepwise regression analysis: age, disease duration, low education status, married, Das-28 scores, and deformed joint counts. However, when gender was included in the regression analysis, a significant association of moderate-severe stress at home was observed with female gender (OR 3.99, CI 1.47-10.83, p=0.007), higher DAS-28 scores (OR 1.8, CI 1.31-2.51, p<0.001), with marginal association with deformed joint counts (OR 1.13, CI 0.99-1.30, p=0.061).

Conclusion: Stress at home is common among patients with RA, and nearly half of the cohort was noted to have moderate-severe level of stress at home. Ongoing stress at home has significant association with higher RA disease activity and deformities suggesting a bidirectional relationship. These findings demonstrate an important need for integration of rheumatologic, social workers and mental health services

Disclosure of Interests: Muhammad Haroon Speakers bureau: Roche, Novartis, Grant/research support from: Abbvie, Pfizer, Farzana Hashmi: None declared, Saadat Ullah: None declared, Arfa Ashraf: None declared, Hafiza Javeria Shaheen: None declared, Sadia Asif: None declared, Shabnam Batool: None declared

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