Jean Liew, MD, on Managing Axial Spondyloarthritis During High-Stress Times


In part 1, Jean Liew, MD, discussed her research that showed that stress and anxiety were independent predictors of patient‐reported disease activity among individuals with axial spondyloarthritis (axSpA) during the COVID‐19 pandemic. In part 2 of our podcast conversation, Dr Liew explains how her findings can be translated to other major stressors that patients with axSpA may experience and how you can best care for these patients during high-stress times.

Additional Resources:

  1. 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.
  2. Zeboulon-Ktorza N, Boelle PY, Nahal RS, et al. Influence of environmental factors on disease activity in spondyloarthritis: a prospective cohort study. J Rheumatol. 2013;40(4):469-475.
  3. COVID-19 Global Rheumatology Alliance. Accessed October 20, 2020.

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


Colleen Murphy: Welcome back to my conversation with Dr Liew. In part 1, we talked about your findings that showed that stress and anxiety are independent predictors of patient‑reported disease activity among individuals with axial spondyloarthritis during the COVID‑19 pandemic. In part 2, let’s look to the future. You conducted your survey during the peak of the pandemic. To what degree do you think these results can be translated to other major stressors that patients might experience in their life? Jean Liew: Our study was initially about a short‑term stress which has now become a long‑term stress. Of course, we didn’t know that at the time we started. The idea of this study really came about around the time that the San Francisco and the whole Bay Area went into lockdown in the middle of March. Prior studies have looked at more acute stressors like I had mentioned. Natural disasters, things that might be more traumatic, very traumatic but happen at a given point in time and don’t really continue happening. If we want to translate these findings to other major stressors, we can look at what’s already been done. For example, there were a couple of studies from a French prospective spondyloarthritis cohort from several years ago where they were using every 3‑month’s web surveys to look at environmental factors including stressful and traumatic life events or infections like viral infections on changes in disease activity and these people with spondyloarthritis. These researchers found that these abrupt or unexpected traumatic events were significantly associated with higher disease activity measures. Pretty similar to our study. I guess the answer to that is, probably, we can translate our findings to other major stressors including more short‑term and abrupt stressors. CM: We’ve already talked about what a rheumatologist can do when a patient is experiencing a major stressor. Sometimes, you can predict when a major stressor will happen. For example, experts believe that we are entering another wave of this pandemic, or you can sometimes tell when a natural disaster like a hurricane will happen. What can clinicians do in preparation of such events to ensure that their patients with axial spondyloarthritis will get through the stressor with as little negative disease impact as possible? JL: There are things that the clinicians themselves can do and that they can counsel their patients on what to do. We’ve been talking about how the course of pandemic is hard to predict. We started this study, and we made a plan for what the study would look like. Things have just changed that we couldn’t account for. Same with clinic policies that are changing all the time; we just try to keep up with them as clinicians. We should try to be open with our lines of communication as much as we can and know, for example, what would happen if in our area, there were to be another peek in cases? What our accesses to care that we would provide would look like? Would we have to shift back to more telemedicine and less in‑person? What would that mean for a patient? In terms of counseling patients, we always have to think about medication access. Can they get their refills? Will there be shortages? This is something that was more of a concern, maybe not so much for axial spondyloarthritis but more for other diseases like rheumatoid arthritis and lupus, earlier on in the spring months. Hopefully, going forward, there won’t be further shortages of medications. If there should be supply issues, how would you counsel patients to manage that and to check in with their mail order pharmacy or their regular pharmacy and being able to get what they need? In terms of counseling them on health care access, making sure that they know what the game plan would be if their schedule has to change abruptly. If they’re having to switch to telemedicine again and not being able to be seen in‑person, are there things that you can teach them in terms of how to assess their disease activity on their own if they can't come in to clinic to be examined? Things like that that you have to think forward to. It’s really about patient’s education but also educating yourself on what to anticipate. CM: Absolutely, that’s helpful. As we wrap up here, are there any other parting thoughts you would like to leave the listeners with? JL: One last thing that I’d like our listeners to think about. If you haven’t already, there is a COVID‑19 Global Rheumatology Alliance registry in which we’ve been asking rheumatologists to submit cases of patients with rheumatic disease who have been diagnosed either by clinical symptoms or with a PCR‑based test with COVID‑19. These cases are submitted online through a secure survey, and you can access that if you go to our website at www.rheum‑ We really appreciate those who have submitted cases thus far because this has led to a much better understanding of how our patients are doing in terms of COVID‑19. CM: Listeners, you can go to the bottom of this page and find the link as well. Dr Liew, I want to thank you for your time. This has been a very insightful conversation. JL: You’re welcome.