Jean Liew, MD, on Disease Activity in Axial Spondyloarthritis During the Pandemic


How have the stressors of the COVID-19 pandemic affected the patient-reported disease activity among individuals with axial spondyloarthritis (axSpA)? In this podcast, Jean Liew, MD, explains what she and her team discovered about the association between stress, anxiety, and axSpA during the pandemic and what it suggests about the importance of stress/anxiety management among patients with axSpA. 

Additional Resources:

Listen to part 2 of our conversation here.

Liew JW, Castillo M, Zaccagnino E, Katz P, Haroon N, Gensler LS. Patient‐reported disease activity in an axial spondyloarthritis cohort during the COVID‐19 pandemic. ACR Open Rheumatol. 2020;2(9):533-539.

Mikuls TR, Johnson SR, Fraenkel L, et al. American College of Rheumatology guidance for the management of rheumatic disease in adult patients during the COVID‐19 pandemic: version 2. Arthritis Rheumatol. Published online July 30, 2020.

Jean W. Liew, MD, MS, is an assistant professor of medicine, rheumatology, at the Boston University School of Medicine. 


Colleen Murphy: Hello, everyone. Welcome to another installment of “Podcasts360,” your go‑to resource for medical news and clinical updates. I’m your moderator, Colleen Murphy, with Consultant360 Specialty Network. It’s quite the understatement to say that the COVID‑19 pandemic has completely changed our lives. One example, at the pandemic’s peak, many people in the United States were mandated to stay at home. This shelter‑in‑place order many were under may have affected people’s work status, physical activity, and medication regimen. A group of researchers wondered whether major stressors like these changes to the daily life of patients with axial spondyloarthritis had an impact on their disease activity. Dr Jean Liew, an assistant professor of medicine at the Boston University School of Medicine, was one of those researchers. She joins me today to talk about the association between stress, anxiety, and patient‑reported disease activity that she and her team observed during the COVID‑19 stay‑at‑home period. Thank you for joining me, Dr. Liew. Jean Liew: Hi, thank you for having me. CM: First, as a quick review, what do we already know about the relationship between stress and its impact on rheumatic disease? In your study, you wrote that prior literature has suggested conflicting reports. Again, what do we already know? What are the controversies, and what knowledge gaps were you trying to bridge? JL: In other diseases, not specifically axial spondyloarthritis, in diseases such as RA, the association of stress and disease activity has been better studied and better reported. In these RA studies, we have seen that there have been significant associations between stress and disease activity. More towards our specific study, there have been also some smaller studies looking at major natural disasters like earthquakes and tsunamis among people with RA or with lupus and looking at what their disease activity was like over a short period of time. Those studies are small, so the findings were mixed and inconclusive. That’s the thesis that we were building on. CM: Your team had interesting findings. Would you be able to briefly go over those findings and explain what they highlight about the importance of stress and anxiety management for patients with axial spondyloarthritis? JL: Our overall aim was to examine whether stress, anxiety, and depressive symptom were each associated with patient‑reported disease activity among individuals of axial spondyloarthritis during the COVID‑19 pandemic. To do this, we had a prospective cohort of people with axial spondyloarthritis with single site at UCSF. We administered the survey asking them questions about their job status change, any changes in exercise, medication use, and then we had questions to assess disease activities, stress, depressive symptoms, and anxiety. We administered this web‑based survey starting in mid‑April. We analyzed whether after controlling for important confounders, there were significant associations between each one of stress, anxiety, and depressive symptoms with the outcome of the disease activities. We found that during the early phase of the COVID‑19 pandemic, i.e., April and May, individuals with higher levels of stress, anxiety had significantly higher disease activity levels after accounting for other important factors. To go back to your question on what does it highlight about stress and anxiety management for these patients? We have to speak to axial spondyloarthritis management in general that disease activity may be partially driven by perceived stress or anxiety after accounting for things like disease characteristics, medications they’re taking, their level of physical activity, or type of physical activity. These are things we’re thinking about even before the pandemic, before we add this stress that affects this entire population. In terms of management, how rheumatologist counseled patients has become much harder in light of the pandemic. For example, people are dealing with job loss or changes in how their job is functioning. For example, if there are teachers who might be dealing with new scenarios in their virtual classrooms or teaching in‑person again, just various things that would lead to increased stressors. To speak more about physical activity and exercise for the management of disease activity and axial spondyloarthritis, this is something that’s in our guidelines. We have been recommending this for many years. Now during the pandemic, it’s about knowing what options are available and maybe having to be creative with options. For example, if you can’t do in‑person physical therapy, is telemedicine physical therapy available? Might this particular patient lack the access due to, for example, unstable internet connections or inability to navigate an online platform? For those who are able, could they attend virtual exercise classes, obtain home exercise equipment, or do an exercise class that’s physically distant and outdoor, although in many areas of the country, that’s going to be limited with winter coming? CM: You just touched on some factors that influenced perceived stress and anxiety, and why considering those management is important. To further highlight your specific findings, of the 203 patients who responded to the survey, 56% reported decreasing or stopping their exercise as compared with 6 months prior, and 13% reported a change in their job. Compared with those with low stress, a greater percentage of those with high stress were more likely to have decreased or stopped exercise, to have had a change in their job, or to have not been working. Patients who reported having high stress were also more likely to reduce or stop taking their NSAIDs. As the pandemic evolves, and based off of these and your other findings, what should clinicians keep in mind when managing their patients with axial spondyloarthritis? Any specific types of conversations or screenings that should be held or treatment considerations that should be made? JL: Yeah. Those were univariate associations. We just basically compared: Did people change their medications or stop their medications? Did they decrease or stop their exercise? Did they experience any change in their job status comparing people with the lower‑bottom category of stress levels versus a higher category of stress levels? We accounted for each of these things in our multivariable model in which we found a significant association between stress and disease activity and between anxiety and disease activity. Even after accounting for stopping your medications, not exercising, or experiencing the changing your job status, we still see these associations. In terms of what to do as the pandemic evolves, I’d like to highlight that the ACR, American College of Rheumatology, has its health or substance issuing guidelines on clinical guidance. That’s for rheumatologists in clinical practice that address questions about what to do with their medication shortages; how to counsel patients on whether to continue, hold, or stop the medication for various scenarios, like if they have not had any exposure or any infection, if they’ve been potentially exposed, or if they do have an infection to get diagnosed with COVID‑19. The CDC also has COVID‑19 guidelines as well, although they are more extensive but also touch upon some of the medications that people who manage disease might use like biologics. I find that that’s a very helpful resource. In terms of what do our findings tell us as the pandemic evolves, we should keep in mind first that this study and other studies like in other survey studies have been done during the early phases of pandemic like February, March, April, May. Long‑term, especially in the [United States], we don’t have data yet. People are still doing studies or still going to keep getting more information as we go, but this is not something with an end date. We’re really adjusting as we go. The next phase of research has really concentrated on studies about telemedicine, access to care. Investigators are also wondering about studies relating to potential vaccines for COVID‑19 and what might be the different risks and benefits in people with rheumatic disease as compared to the general population. Overall, a hard task but trying to keep up to date with the quickly evolving research is becoming really important in order to counsel patients as time goes on. CM: What about medicating patients for stress or anxiety? Is that something that should be considered? How should that risk reward be waived here? JL: This is something that should be a multidisciplinary approach. Patients should be encouraged to connect with their primary care providers, with mental or behavioral health specialists in terms of what would be the best way to approach, either counseling‑based approach or pharmacological approach to stress, and anxiety, and depression. We need to continue doing what worked before the pandemic. In terms of access to care, if you’re not, for example, able to see someone in‑person, might there be telemedicine services that would work? If someone was participating in counseling before, are they able to access those services via telemedicine? I’ve heard that some people have said that being able to access telemedicine has been better in terms of getting access to care because they don’t have to physically go into the office or make time in the schedule to get ready and to make that visit. They can do it at home or from a place where they are already comfortable. Encouraging these different approaches would be ideal. CM: Please make sure to listen into part 2 of our conversation with Dr Liew at the link above.