Comorbidity burden in axial spondyloarthritis: a cluster analysis

Abstract

Objectives: To examine how comorbidities cluster in axial spondyloarthritis (axSpA) and whether these clusters are associated with quality of life, global health and other outcome measures.

Methods: We conducted a cross-sectional study of consecutive patients meeting ASAS criteria for axSpA in Liverpool, UK. Outcome measures included quality of life (EQ5D), global health and disease activity (BASDAI). We used hierarchical cluster analysis to group patients according to 38 pre-specified comorbidities. In multivariable linear models, the associations between distinct comorbidity clusters and each outcome measure were compared, using axSpA patients with no comorbidities as the reference group. Analyses were adjusted for age, gender, symptom duration, BMI, deprivation, NSAID-use and smoking.

Results: We studied 419 patients (69% male, mean age 46 years). 255 patients (61%) had at least one comorbidity, among whom the median number was 1 (range 1-6). Common comorbidities were hypertension (19%) and depression (16%). Of 15 clusters identified, the most prevalent clusters were hypertension-coronary heart disease and depression-anxiety. Compared with patients with no comorbidities, the fibromyalgia-irritable bowel syndrome cluster was associated with adverse patient-reported outcome measures; these patients reported 1.5-unit poorer global health (95%CI 0.01, 2.9), reduced quality of life (0.25-unit lower EQ5D; 95%CI -0.37, -0.12) and 1.8-unit higher BASDAI (95% CI 0.4, 3.3). Similar effect estimates were found for patients in the depression-anxiety cluster.

Conclusion: Comorbidity is common among axSpA patients. The two most common comorbidities were hypertension and depression. Patients in the depression-anxiety and fibromyalgia-IBS clusters reported poorer health and increased axSpA severity.

Keywords: ankylosing spondylitis; axial spondyloarthritis; cluster analysis; comorbidity; depression; fibromyalgia; multimorbidity.

Fig. 1

Diagram (dendrogram) from cluster analysis of 419 patients and 34 comorbidities From the bottom, clusters progressively join (at levels of similarity shown at their union) until a single cluster is formed at the top. The statistically optimum number of clusters is indicated by the dotted horizontal line. Clusters are labelled based on the dominant comorbidity in the cluster (C1: isolated axSpA, C2: dyspepsia, C3: depression-anxiety, C4: fibromyalgia-irritable bowel syndrome, C5: anxiety, C6: hypertension, C7: osteoporosis-alcohol problems, C8: thyroid disorders, C9: other substance misuse, C10: asthma, C11: atrial fibrillation, C12: chronic sinusitis, C13: blind or low vision, C14: multiple sclerosis, C15: learning disability).