
==== Front
Arthritis Res Ther
Arthritis Res Ther
Arthritis Research & Therapy
1478-6354
1478-6362
BioMed Central London

3396
10.1186/s13075-024-03396-5
Research
Pain catastrophizing negatively impacts drug retention rate in patients with Psoriatic Arthritis and axial Spondyloarthritis: results from a 2-years perspective multicenter GIRRCS (Gruppo Italiano di Ricerca in Reumatologia Clinica) study
Currado Damiano 12
Saracino Francesca 12
Ruscitti Piero 3
Marino Annalisa 1
Pantano Ilenia 4
Vomero Marta 1
http://orcid.org/0000-0002-2808-1581
Berardicurti Onorina o.berardicurti@policlinicocampus.it

12
Pavlych Viktoriya 3
Di Vico Claudio 4
Caso Francesco 5
Costa Luisa 5
Tasso Marco 5
Camarda Federica 6
Misceo Francesca 7
De Vincenzo Francesco 8
Corrado Addolorata 9
Arcarese Luisa 1
Rigon Amelia 1
Vadacca Marta 1
Corberi Erika 12
Kun Lyubomyra 12
Trunfio Francesca 12
Pilato Andrea 12
Lamberti Ludovica 12
Cantatore Francesco Paolo 9
Perosa Federico 7
Guggino Giuliana 6
Scarpa Raffaele 5
Cipriani Paola 3
Ciccia Francesco 4
Giacomelli Roberto 12
Navarini Luca 12
1 grid.488514.4 0000000417684285 Clinical and Research Section of Rheumatology and Clinical Immunology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
2 https://ror.org/02p77k626 grid.6530.0 0000 0001 2300 0941 Department of Medicine, School of Medicine, Rheumatology and Clinical Immunology, University of Rome “Campus Bio-Medico”, Rome, Italy
3 https://ror.org/01j9p1r26 grid.158820.6 0000 0004 1757 2611 Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L’Aquila, L’Aquila, Italy
4 grid.9841.4 0000 0001 2200 8888 Department of Precision Medicine, Rheumatology Unit, University of Campania L. Vanvitelli, Caserta, Italy
5 https://ror.org/05290cv24 grid.4691.a 0000 0001 0790 385X Department of Clinical Medicine and Surgery, Rheumatology Research Unit, University of Naples Federico II, Naples, Italy
6 Department of Health Promotion, Mother and Child Care, Rheumatology Section, Internal Medicine and Medical Specialties, University Hospital “P. Giaccone”, Palermo, Italy
7 https://ror.org/027ynra39 grid.7644.1 0000 0001 0120 3326 Department of Biomedical Science and Human Oncology (DIMO), Rheumatic and Systemic Autoimmune Diseases Unit, University of Bari Medical School, Bari, Italy
8 https://ror.org/011at3t25 grid.459490.5 0000 0000 8789 9792 Department of Human Sciences, European University of Rome, Rome, Italy
9 https://ror.org/01xtv3204 grid.10796.39 0000 0001 2104 9995 Department of Medical and Surgical Sciences, Rheumatology Clinic, University of Foggia, Rione Biccari, Foggia, FG 71122 Italy
18 9 2024
18 9 2024
2024
26 16218 3 2024
3 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Chronic pain and inflammation are common features of rheumatic conditions such as Psoriatic Arthritis (PsA) and Axial Spondyloarthritis (axSpA), often needing prolonged medication treatment for effective management. Maintaining drug retention is essential for both achieving disease control and improving patients' quality of life. This study investigates the influence of pain catastrophizing, a psychological response to pain, on the drug retention rates of PsA and axSpA patients.

Methods

A two-year prospective multicenter observational study involved 135 PsA and 71 axSpA patients. Pain Catastrophizing Scale (PCS) was employed to assess pain catastrophizing. Univariable and multivariable regression analyses were utilized to identify factors associated with drug retention.

Results

In the PsA group, patients early discontinuing therapy showed higher baseline disease activity as well as higher incidence of comorbid fibromyalgia. Notably, pain catastrophizing, specifically the domains of Helplessness, Magnification, and Rumination, were significantly elevated in PsA patients who interrupted the treatment. Multivariable analysis confirmed pain catastrophizing as an independent predictor of drug suspension within two years.

In axSpA, drug discontinuation was associated with female gender, shorter disease duration, higher baseline disease activity as well as elevated levels of pain catastrophizing. Univariable analysis supported the role of pain catastrophizing, including its domains, as predictors of treatment interruption. However, limited events in axSpA patients precluded a multivariate analysis.

Conclusion

This prospective study emphasizes the impact of pain catastrophizing on drug retention in patients with PsA and axSpA.

Keywords

Psoriatic Arthritis
Axial Spondyloarthritis
Pain Catastrophizing
Retention Rate
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcBackground

Spondyloarthritis (SpA), a group of interconnected chronic rheumatic diseases, displaying various clinical features, shares common clinical signs and distinctive genetic traits [1, 2]. The most prevalent forms of SpA are Psoriatic Arthritis (PsA) and Axial Spondyloarthritis (axSpA). Individuals with SpA often show a higher prevalence of obesity, type 2 diabetes, hypertension, metabolic syndrome, an increased risk of cardiovascular issues, and psychological comorbidities [3–7]. These conditions significantly impact the pain perception and the quality of life in SpA patients. In recent years, several studies were published focusing the extended-term usage of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologic and targeted synthetic agents (bDMARDs and tsDMARDs) in spondyloarthritis, especially analasying the real-world data; despite of these works the factors associated to the retention rate of bDMARDs remain a pivotal question to be addressed [8].

Psychosocial factors are acknowledged as crucial elements influencing the pain experienced by patients with inflammatory arthritides, with particular attention given to pain catastrophizing (PC). The concept of catastrophizing was originally introduced by Albert Ellis and subsequently adapted by Aaron Beck to describe a maladaptive cognitive style observed in patients with anxiety and depressive disorders. Catastrophizing refers to the irrational anticipation of negative future events. In the context of pain, catastrophizing is broadly defined as an exaggeration of negative cognitive and emotional responses during actual or anticipated painful situations [9–11]. To assess catastrophization, the PC Scale (PCS) is employed, which evaluates three domains encompassing various aspects of pain catastrophizing. The first component, referred to as “rumination,” comprises four items related to ruminative thoughts, worry, and the inability to suppress pain-related thoughts. The second component, termed “magnification,” consists of three items reflecting the exaggeration of pain’s unpleasantness and the anticipation of negative outcomes. The third component, labeled “helplessness,” encompasses five items from the Coping Strategies Questionnaire (CSQ) and an additional item indicating the inability to cope with painful situations [12].

In a previous study we showed that PC negatively impatcs, the achievement of remission and/or low disease activity in inflammatory arthritis [13]. A largely unexplored topic is the relationship between PC and drug retention rate. Patients with PC may be more likely to struggle with adhering to their prescribed treatment plans; this may include non-compliance with medications, missing appointments, or reluctance in changing their lifestyle and engaging physical therapy. Thus, we planned a multicentric prospective observational study to address the possible impact of PC and its related domains on two years drug retention rate in patients with PsA and axSpA.

Methods

A multicenter, prospective (two years) observational study was conducted on enrolled participants with Psoriatic Arthritis and Axial Spondyloarthritis in 7 Rheumatology Clinics of Italy, widely distributed throughout the Country. Consecutive outpatients were recruited between January 2021 and July 2021. At the initial assessment, PsA participants met the Classification Criteria for Psoriatic Arthritis (CASPAR), while axSpA participants met the 2009 Assessment of Spondyloarthritis International Society (ASAS) Criteria [14, 15]. The study received approval from the Ethics Committee of the University Campus Bio-Medico of Rome (approval no. 78.20 OSS) and was conducted in accordance with the Declaration of Helsinki and its subsequent revisions. Inclusion criteria encompassed individuals of both genders, aged over 18 years, who fulfilled the CASPAR or 2009 ASAS criteria. Exclusion criteria included a history of psychiatric disorders as per DSM-V prior to recruitment, a history of malignancy, pregnancy, age exceeding 75, or an inability to provide informed consent for participation in the study. Upon enrollment, the following PsA disease activity scores were recorded by the examining clinicians: Disease Activity for Psoriatic Arthritis (DAPSA), Minimal Disease Activity (MDA), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Psoriasis Area Severity Index (PASI), and Leeds Enthesitis Index (LEI). Additionally, the following axSpA disease activity scores were collected: BASDAI, Bath Ankylosing Spondylitis Functional Index (BASFI), and Ankylosing Spondylitis Disease Activity Score-C-Reactive Protein (ASDAS-CRP) [16]. To assess the drug discontinuation rate (considering csDMARDs and/or bDMARDs), any occurrence of withdrawal therapy and adverse events recognized or suspected as linked to therapies were recorded during the two-years follow-up. PC, including its domains of Helplessness, Rumination, and Magnification (as continuous variables), was assessed using the PCS.

Patients fulfilling the 2016 American College of Rheumatology revised criteria for fibromyalgia were further identified in our cohort [17, 18].

Continuous variables were presented as the median with the interquartile range (25th–75th percentile), while categorical variables were expressed as percentages (%). The normality of the data was assessed using the Shapiro–Wilk test. Contingency tables were analyzed using the Chi-squared test, whereas rank-based comparisons were conducted using the Mann–Whitney test and Kruskal–Wallis test with Holm’s pairwise comparison adjustments. To identify variables associated with drug retention rate, both univariable and multivariable regression analyses were employed. In the multivariable analysis, variables with a p-value of less than 0.1 in the univariate analysis, along with age and sex, were considered. Multivariable analysis of retention predictors was computed using the Cox proportional-hazards model.

All the statistical analyses were carried out by using Stata version 14, and statistical significance was defined as p-values less than 0.05.

Results

The study population included 135 patents affected by Psoriatic Arthritis (PsA) and 71 by Axial Spondiloarthritis (axSpA). The main demographic, anthropometric and clinical characteristics of the study populations are reported in Table 1 for PsA and in Table 2 for axSpA. Table 1 Clinical characteristics of PsA participants

	PsA (135)	PsA 1 year Retention (107)	PsA 1 year suspension (28)	p	PsA 2 year Retention (94)	PsA 2 year Suspension (41)	p	
Age	56 (47–64)	55 (46–63)	61 (51.5–65)	0.11	55.5 (46–62)	61 (48–65)	0.12	
Female (%)	59.26	53.27	82.14	0.006	55.32	68.29	0.16	
Disease duration (months)	84 (48–144)	80 (48–144)	111.5 (52–150)	0.41	80 (48–144)	97 (51–144)	0.69	
BMI	26.6 (24.6–30.2)	26.4 (24.35–30.07)	27.14 (25–31.91)	0.60	26.2 (24.2–29.7)	27.2 (25–31.2)	0.40	
Fibromyalgia (%)	29.6	22.22	57.69	 < 0.0001	21.84	47.37	0.004	
Smokers (%) Yes	23.88	24.53	21.43	0.62	26.88	17.07	0.005	
ex	6.7	5.66	10.71		2.15	17.07		
Peripheral arthritis (%)	95.56	94.39	100	0.20	93.62	100	0.098	
Axial involvement (%)	48.89	46.73	57.14	0.33	48.94	48.78	0.99	
Enthesitis (%)	35.56	35.51	35.71	0.98	36.17	34.15	0.82	
Dactylitis (%)	14.07	14.95	10.71	0.57	15.96	9.76	0.34	
Psoriasis (%)	74.07	74.44	71.43	0.72	74.47	73.17	0.87	
Nail psoriasis (%)	12.59	14.02	7.14	0.33	14.89	7.32	0.22	
csDMARDs use (%)	49.63	47.66	57.14	0.37	44.68	60.98	0.08	
bDMARDs use(%)	74.07	71.96	82.14	0.27	71.28	80.49	0.26	
Ccs (%)	22.96	18.69	39.29	0.02	18.09	34.15	0.04	
NSAIDs (%)	34.81	30.84	50.00	0.06	31.91	41.46	0.24	
SNRI (%)	7.41	6.54	10.71	0.45	6.38	9.76	0.49	
Anticonvulsivant drugs use (%)	8.15	7.48	10.71	0.58	7.45	9.76	0.65	
TJ/68	2 (0–6)	1 (0–5)	3.5 ( 0–9)	0.08	1 (0–4)	4 (0–9)	0.01	
SJ/66	0 (0–0)	0 (0–0)	0 (0–1)	0.03	0 (0–0)	0 (0–1)	0.051	
PtGA	5 (2–7)	4.5 (2–7)	7 (5–8)	0.002	4 (2–7)	7 (5–8)	0.0003	
PP	6 (3–8)	5 (1–7)	8 (6–9)	0.0005	5 (1–7)	8 (5–9)	 < 0.0001	
EGA	1 (0–2)	1 (0–2)	2 (1–3)	0.012	0.5 (0–2)	2 (1–3)	0.001	
CRP	0.37 (0.14–0.8)	0.3 (0.12–0.64)	0.45 (0.31–0.92)	0.0351	0.315 (0.13–0.73)	0.4 (0.21–0.87)	0.33	
DAPSA	13.34 (5.21–22.2)	11.5 (3.4–21.51)	20.31(11.78–23.25)	0.0065	11.06 (3.36–19.85)	20.3 (11.56–23.86)	0.0011	
PCS	18 (6–31)	16 (5–29)	29.5 (17–38.5)	0.0001	16 (5–28)	29 (12–38)	0.0002	
Helplessness	9 (2–14)	7 (2.12)	13(9–26)	0.0001	7 (2–11)	13 (5–16)	0.0004	
Rumination	8 (2–13)	6 (2–12)	13(7–26)	0.0003	6 (2–11)	12.5 (5–16)	0.0005	
Magnification	3 (1–5)	2 (1–5)	5 (2–6)	0.0059	2 (1–4)	4 (2–6)	0.0127	
HADS anxiety	7 (3–11)	5 (3–10)	9.5 (7–14.5)	0.0002	5 (3–10)	9 (4.14)	0.003	
HADS depression	4 (1–8)	3.5 (1–7)	7 (3–10)	0.0091	3 (1–7)	6 (2–10)	0.02	
Acceptance and Action Questionnaire II (AAQ)	14 (9–24)	12 (9–22)	22 (9–30)	0.026	12 (9–22)	20 (9–28)	0.07	
Trait Hope Scale (THS)	24 (21–26)	24 (21.5–26)	22 (16.5- 25)	0.0392	24 (22–26)	22 (17–25)	0.02	
THS agency	12 (10–13)	12 (10–13)	11 (7.5- 12)	0.0361	12 (11–13)	12 (8–12)	0.1	
THS pathway	12 (11–13)	12 (11–14)	11 (8.5–13)	0.0449	12 (11–14)	11 (85–13)	0.01	
PsA Psoriatic Arthritis, BMI Body Mass Index, csDMARDs conventional synthetic disease-modifying anti-rheumatic drugs, bDMARDs biologic disease-modifying anti-rheumatic drugs, CCS corticosteroids, NSAIDs Non-steroidal anti-inflammatory drugs, SNRI Serotonin–norepinephrine reuptake inhibitor, TJ tender joints, SJ swollen joints, PtGA patient global assessment, PP patient pain, EGA Examiner global assessment, CRP C-reactive protein, DAPSA Disease Activity in PSoriatic Arthritis, PCS Pain Catastrophizing Scale, HADS Hospital Anxiety and Depression Scale

Table 2 Clinical characteristics of axSpA participants

	axSpA (71)	axSpa 1 year retention (60)	axSpa 1 year suspension (11)	p	axSpa 2 year retention (57)	axSpa 2 year suspension (14)	p	
Age	49 (37–58)	51 (38–60)	44 (35–46)	0.10	49 (37–58)	46 (43–56)	0.78	
Female (%)	43.66	40.32	66.67	0.13	37.93	69.23	0.040	
Disease duration (months)	72 (48–120)	87 (50–132)	48 (18–60)	0.0083	87 (50–132)	59 (21–75)	0.035	
BMI	26.04 (23.5–30.4)	26.22 (23.63–30.45)	24.7 (22.6–30.1)	0.61	26.4 (23.9–30.5)	24.14 (20.35–29.6)	0.20	
Fibromyalgia (%)	12.5	12.73	11.11	0.89	13.46	8.33	0.63	
Smokers (%) yes	28.17	25.81	44.44	0.36	25.86	38.46	0.34	
ex	9.86	11.29	0.00		12.07	0.00		
Peripheral arthritis (%)	54.53	0	100	 < 0.0001	0	100	 < 0.0001	
HLA B27 (%)	43.08	45.61	25	0.27	47.17	25.00	0.16	
Positive MRI (%)	74.65	74.19	77.78	0.82	75.86	69.23	0.62	
Positive Rx (%)	49.28	50	44.44	0.76	50	46.15	0.80	
Active Uveitis (%)	1.41	1.61	0	0.91	1.72	0	0.80	
Past uveitis (%)	19.72	19.35	22.22	0.91	20.69	15.38	0.80	
csDMARDs use (%)	22.12	12.96	11.76	0.90	25.86	15.38	0.42	
bDMARDs use (%)	91.23	42.86	9.38	0.011	93.10	76.92	0.08	
Ccs (%)	5.63	6.45	0	0.43	6.9	0	0.33	
NSAIDs (%)	47.89	45.16	66.67	0.23	44.83	61.54	0.28	
SNRI (%)	2.82	1.61	11.11	0.11	0	15.38	0.002	
Tricyclic antidepressant (%)	4.23	4.84	0	0.5	3.45	7.69	0.49	
Anticonvulsivant drugs use (%)	8.45	8.06	11.11	0.76	6.9	15.38	0.32	
Myorelaxant agent (%)	9.86	8.06	22.22	0.18	8.62	15.38	0.46	
Opioid drugs (%)	4.23	3.23	11.11	0.27	3.45	7.69	0.49	
LEI	0 (0–0)	0 (0–0)	0 (0–1.5)		0 (0–0)	0 (0–1.5)		
CRP	0.2 (0.08–0.5)	0.14 (0.07–0.44)	0.55 (0.42–2.23)	0.0213	0.13 (0.07–0.43)	0.5 (0.32–1.4)	0.017	
ESR	9 (4–19)	8 (4–19)	12(9–14)	0.20	8 (4–18)	14 (9–25)	0.07	
BASDAI	4.17 (2.1–6.3)	3.88 (2–5.8)	7 (6–9)	0.0023	3.75 (2–5.7)	7 (6–8.8)	0.0002	
PtGA	5 (3–8)	4.5 (2.5–7)	8 (7–10)	0.0081	4 (2–75)	8 (7–10)	0.0014	
PhyGA	1 (0–3)	1(0–3)	3 (1–6.5)	0.23	1 (0–3)	1 (25–6.5)	0.14	
ASDAS-PCR	2.32 (1.29–3.16)	2.25 (1.25–2.99)	3.37 (2.48–4.12)	0.0192	2.19 (1.24—2.84)	3.35 (2.45–3.91)	0.0042	
BASFI	5.7 (0.3–16)	4.9 (0.3–16)	7.9 (6.8–9.5)	0.18	4.9 (0.3–16)	6.8 (4.6–9.5)	0.32	
PCS	16 (6–28)	13.5 (6–25.5)	40 (30–44)	0.0002	12.5 (6–25.5)	31 (25–44)	0.0001	
Helplessness	7 (2–12)	5 (2–10)	18.5 (13.5–21)	0.0002	5 (2–10)	16 (11–20)	0.0004	
Rumination	7 (4–12)	6(3–11)	16 (9.5–18.5)	0.0018	6 (2–11)	13 (7–18)	0.0018	
Magnification	2 (0–4)	2 (0–3)	5.5 (2.5–6.5)	0.007	2 (0–3)	4 (2–6)	0.0712	
HADS anxiety	7 (4–10)	6 (3–10)	9 (8–11)	0.023	7 (3–10)	9 (5–11)	0.14	
HADS depression	5 (2–6)	4 (1–6)	6 (5–10)	0.044	4 (2–6)	5 (3–9)	0.27	
Acceptance and Action Questionnaire II (AAQ)	14 (9–22)	13 (9–22)	17(15–21)	0.22	13 (9–22)	17 (13–21)	0.41	
Trait Hope Scale (THS)	24 (22–28)	25 (22–28)	22 (19–24)	0.0371	25 (22–28)	22 (20–25)	0.14	
THS agency	12 (10–14)	12 (11–14)	10 (9–13)	0.1	12 (11–14)	11 (10–13)	0.33	
THS pathway	12 (11–14)	12 (11–15)	11 (10–12)	0.0192	12 (11–15)	12 (10–12)	0.081	
Compassionate Engagement and Action Scales – self compassion	74.5 (64–88)	75 (67–90)	68 (63–75)	0.17	75 (67–90)	68 (63–75)	0.09	
Compassionate Engagement and Action Scales- compassion from others	66 (52–83)	68.5 (55–83)	61 (52–69)	0.32	69 (55–83)	62 (52–69)	0.22	
axSpA axial Spondyloarthritis, BMI Body Mass Index, MRI Magnetic Resonance Imaging, csDMARDs conventional synthetic disease-modifying anti-rheumatic drugs, bDMARDs biologic disease-modifying anti-rheumatic drugs, CCS corticosteroids, NSAIDs Non-steroidal anti-inflammatory drugs, SNRI Serotonin–norepinephrine reuptake inhibitor, LEI Leeds enthesitis Index, CRP C-reactive protein, ESR erythrocyte sedimentation rate, BASDAI Bath Ankylosing Spondylitis Disease Activity Index, PtGA patient global assessment, PhyGA Physician global assessment, ASDAS Ankylosing Spondylitis Disease Activity Score, BASFI Bath Ankylosing Spondylitis Function Index, PCS Pain Catastrophizing Scale, HADS Hospital Anxiety and Depression Scale

In PsA patient cohort, the one-year Retention Rate was 79.26%. [Drug suspension related to primary failure in 7.20% of patients, secondary failure in 60.71% of patients, side effects in 14.23% and other reasons in 17.86% of patients]. Moreover, the two-year Retention Rate was 69.63% (n = 94), and most of the patients (73%) discontinued the drug for secondary failure. A large percentage of PsA patients discontinuing therapy were at the same time assuming steroid (drug suspenders 34.15% vs still treated 18.09%, p = 0.041), had higher values of baseline DAPSA (drug suspenders 20.3 still treated 11.06, p = 0.0011), and were more frequently affected by fibromyalgia (drug suspenders 47.37% vs still treated 21.84%, p = 0.004). The PCS showed significantly increased levels of PC (drug suspenders 29 vs still treated 16, p = 0.0002) and all its specific domains: Helplessness (drug suspenders 13 still treated 7, p = 0.0004), magnification (drug suspenders 4 vs still treated 2, p = 0.0127) and rumination (drug suspenders 12.5 vs still treated 6, p = 0.0005) in PsA patients discontinuing therapy.

To further evaluate the relationship between PC and the drug retention rate of these patients, univariable (Table 3) and multivariable linear regression (Table 4) analysis were also performed. Table 3 Univariable linear regression (PsA participants)

Two year discontinuation (PsA participants)	Univariable	
Independent variables	OR	95%CI	p	
Fibromyalgia	3.22	1.42 7.28	0.005	
CCS	2.35	1.02 5.40	0.04	
TJ	1.10	1.02 1.18	0.01	
PP	1.09	1.00 1.18	0.04	
PtGa	1.3	1.12 1.49	 < 0.0001	
DAPSA	1.06	1.02 1.10	0.001	
PCS	1.05	1.02 1.08	 < 0.0001	
Helplessness	1.12	1.05 1.19	0.001	
Rumination	1.13	1.05 1.21	 < 0.001	
Magnification	1.22	1.05 1.42	0.009	
PsA Psoriatic Arthritis, CCS corticosteroids, TJ tender joints, SJ swollen joints, PP patient pain, PtGA patient global assessment, DAPSA Disease Activity in PSoriatic Arthritis, PCS Pain Catastrophizing Scale

Table 4 Multivariable regression (PsA participants)

	OR	95%CI	P		OR	95% CI	P	
Age	1.02	0.98–1 05	0.32	Age	1.02	0.99–1.06	0.23	
Sex	0.99	0.41—2.40	0.99	Sex	1.02	0.39–2.63	0.97	
DAPSA	1.04	0.99–1 08	0.10	DAPSA	1.03	0.99–1 08	0.15	
PCS	1.04	1.00–1.07	0.03	Rumination	1.10	1.02–1.20	0.02	
CCS	1.98	0.78–4.99	0.15	CCS	1.99	0.76–5.20	0.16	
Age	1.02	0.99–1.06	0.20	Age	1.02	0.98–1.06	0.26	
Sex	1.17	0.47–2.94	0.72	Sex	1.29	0.53–3 14	0.58	
DAPSA	1.03	0.98–1.08	0.20	DAPSA	1.04	1.00–1.09	0.04	
Helplessness	1.09	1.01–1.18	0.03	Magnification	1.15	0.97–1.36	0.10	
CCS	1.91	0.78–4.95	0.18	CCS	1.87	0.72–4.81	0.20	
DAPSA Disease Activity in PSoriatic Arthritis, PCS Pain Catastrophizing Scale, CCS corticosteroids

The univariable linear regression, as reported in Table 3, confirmed fibromyalgia comorbidity, corticosteroids assumption, higher disease activity at baseline DAPSA and incremented PC levels as best predictors for drug suspension, within two years of follow-up. Of note, the multivariable logistic regression (adjusted for age, sex, DAPSA and CCS use) showed significant relationships between drug discontinuation and: high PCS, helplessness domain, rumination domain, but not for magnification domain.

As far as axSpA patients are concerned, the one-year Retention Rate was 84.51%. [Drug suspension related to primary failure in 9.09% of patients, secondary failure in 54,55% of patients, side effects in 27.27% and other reasons in 9.09% of patients]. Moreover, the two-year Retention Rate was 80.28%, and the most frequent cause of suspension (45%) was secondary failure. In axSpA, the drug discontinuation was significantly more frequent in female patients (69.23%, p = 0.04), in patient with a shorter disease duration (drug suspenders 59 months vs still in treatment 87 months, p = 0.035), with higher baseline BASDAI disease activity (7 vs 3.75, p = 0.0002) and higher level of PC (31 vs 17.5, p = 0.0001). Of note, the univariable logistic regression showed that female gender, increased baseline BASDAI, and higher PCS and all its components: helplessness, magnification, rumination) may be significant predictors of treatment discontinuation in the first two years of follow-up (Table 5). Table 5 Univariable linear regression (axSpA participants)

Two year discontinuation (AxSpA participants)	Univariable	
Independent variables	OR	95%CI	p	
Sex	3.68	1.01 13.40	0.04	
BASDAI	1.81	1.28 2.57	0.001	
Asdas CRP	2.49	1.30 4.72	0.006	
PCS	1.13	1.05 1.20	 < 0.0001	
Helplessness	1.24	1.09 1.40	0.001	
Rumination	1.25	1.07 1.45	0.004	
Magnification	1.35	1.02 1.78	0.03	
axSpA axial Spondyloarthritis, BASDAI Bath Ankylosing Spondylitis Disease Activity Index, ASDAS Ankylosing Spondylitis Disease Activity Score, PCS Pain Catastrophizing Scale

Due to the limited number of events (discontinuation of csDMARDs and/or bDMARDs at 2 years of follow up), a multivariate analysis was not performed for axSpA participants.

Discussion

Rheumatic conditions, including PsA and axSpA, are characterized by chronic pain and inflammation, which often require long-term pharmacological treatments. The drug retention, in these conditions, is crucial to achieve optimal disease control and a better quality of life ( 8, 19, 20). However, several factors may influence drug retention, and in this context, the role of PC is still largely unknown [9]. In this study we described, as primary aim, that PC, independent of treatments efficacy, is significantly associated with drug discontinuation both in PsA and axSpA patients. Furthermore, we observed that all the specific PC domains, such as Helplessness, Rumination and Magnification, were significantly associated with therapy discontinuation after 2 years follow-up. We observed that PsA patients suspending therapy, before the end of the second year of follow up, were more frequently affected by fibromyalgia and showing higher baseline disease activity, thus suggesting the correlations between fibromyalgia and higher levels of disease activity with drug discontinuation in PsA patients [21, 22]. Furthermore, in a previous paper, we published that PC specifically correlated with the number of tender joints, patient-reported pain, and patient global assessment, thus, confirming its predominantly impact on the subjective dimension of the disease activity scores, independent of inflammation [13, 23, 24]. In this setting we recently published how various aspects of the PCS may influence the achievement of low disease activity and remission, as measured by DAPSA and BASDAI. Of note, the significant correlation between PCS and the disease activity of other rheumatic diseases was already described in scientific literature [11, 25–27]. In detail, multivariable linear regression analyses showed that PC and its components helplessness and rumination were independent predictors of drug suspension within two years. In contrast, a predictive relationship was not observed for magnification. This discrepancy may be due to our decision to deliberately exclude individuals with a documented history of psychiatric disorders, as outlined in DSM-V. In fact, it has been reported that magnification shows a significant association with both physical and mental health-related quality of life (QOL) and depressed mood [28]. These results partially mirror what we already published in which females with longer disease durations significantly correlate with drug discontinuation [8]. Nonetheless, another study, despite demonstrating the mentioned relation between female and low retention rate for anti-TNFi assumption, did not found differences in both genders for methotrexate [29].

For axSpA, drug suspension was significantly associated with higher levels of PC, female gender, shorter disease duration, as well as higher baseline BASDAI. Univariable logistic regression analysis strongly confirmed that female gender, higher baseline BASDAI, and higher PC levels, along with its components, were predictors of treatment suspension within two years. Available literature already reported a higher retention rate in axSpA male patients, as well as the relationship between drug withdrawal and higher BASDAI levels [30–32].

Conclusions

Taking together all these data, we may assume that PC is not just a psychological response to pain but may have important consequences on the patient’s ability to adhere to treatments and a better knowledge of this problem may help healthcare providers in managing patients with rheumatic conditions.

We are aware that our study has some limitations including the relatively low number of participants, which does not allow us to derive robust conclusion; on the other hand, despite the limitations, the screening for any previous psychological intervention in our participants allow us to select a well-defined cohort to assess the role of PC. Moreover, our Italian multicenter approach had the advantage to grant a sample representative of the whole national population; these results could therefore be generalized to Caucasian populations.

In conclusion, PC has emerged as a significant factor affecting drug retention in PsA and axSpA patients.

These findings highlight the critical need for clinicians to assess and address PC to improve treatment outcomes. Given the potential impact on patient management and quality of life, further research is essential to explore the mechanisms underlying this relationship and to develop targeted interventions. Future studies should also examine the generalizability of these results to diverse populations.

Abbreviations

SPA Spondyloarthritis

PsA Psoriatic Arthritis

axSpA Axial Spondyloarthritis

csDMARDs Conventional synthetic disease-modifying anti-rheumatic drugs

bDMARDs Biologic disease-modifying anti-rheumatic drugs

PC Pain catastrophizing

PCS Pain Catastrophizing Scale

CSQ Coping Strategies Questionnaire

CASPAR Classification Criteria for Psoriatic Arthritis

ASAS Assessment of Spondyloarthritis International Society);

DAPSA Disease Activity for Psoriatic Arthritis

MDA Minimal Disease Activity

BASDAI Bath Ankylosing Spondylitis Disease Activity Index

PASI Psoriasis Area Severity Index

LEI Leeds Enthesitis Index

BASFI Bath Ankylosing Spondylitis Functional Index

ASDAS-CRP Ankylosing Spondylitis Disease Activity Score-C-Reactive Protein

BMI Body Mass Index

CCS Corticosteroids

NSAIDs Non-steroidal anti-inflammatory drugs

SNRI Serotonin–norepinephrine reuptake inhibitor

TJ Tender joints

SJ Swollen joints

PtGA Patient global assessment

PP Patient pain

EGA Examiner global assessment

CRP C-reactive protein

HADS Hospital Anxiety and Depression Scale

Acknowledgements

None.

Authors’ contributions

All authors made substantial contributions to the conception or design of the work, the acquisition, and interpretation of data. All authors contributed to the critical review and revision of the manuscript and approved the final version. All the authors agreed to be accountable for all aspects of the work. DC study design, data acquisition, statistical analysis, interpretation of data, writing of the first draft of the paper; FS study design, data acquisition, statistical analysis, interpretation of data, writing of the first draft of the paper; PR study design, data acquisition, interpretation of data; AM study design, data acquisition, interpretation of data; IP study design, data acquisition, interpretation of data; MV study design, interpretation of data; OB study design, interpretation of data, statistical analysis, interpretation of data, writing of the first draft of the paper; VP study design, data acquisition, interpretation of data; CDV study design, data acquisition, interpretation of data; FC study design, data acquisition, interpretation of data; LC study design, data acquisition, interpretation of data; MT study design, data acquisition, interpretation of data; FC study design, data acquisition, interpretation of data; FM study design, data acquisition, interpretation of data; FDV study design, data acquisition, interpretation of data; AC study design, data acquisition, interpretation of data; LS study design, data acquisition, interpretation of data; AR study design, data acquisition, interpretation of data; MV study design, data acquisition, interpretation of data; EC study design, data acquisition, interpretation of data; LK study design, data acquisition, interpretation of data; FT study design, data acquisition, interpretation of data; AP study design, data acquisition, interpretation of data; LL study design, data acquisition, interpretation of data; FPC study design, data acquisition, interpretation of data; FP study design, data acquisition, interpretation of data; GG study design, data acquisition, interpretation of data; RS study design, data acquisition, interpretation of data; PC study design, data acquisition, interpretation of data; FC study design, data acquisition, interpretation of data; RG study design, data acquisition, interpretation of data, interpretation of data, writing of the first draft of the paper; LN study design, data acquisition, interpretation of data, interpretation of data, writing of the first draft of the paper.

Funding

The authors received no specific funding for this work.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study received approval from the Ethics Committee of the University Campus Bio-Medico of Rome (approval no. 78.20 OSS) and was conducted in accordance with the Declaration of Helsinki and its subsequent revisions.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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References

1. Dougados M Baeten D Spondyloarthritis Lancet Lond Engl 2011 377 9783 2127 2137 10.1016/S0140-6736(11)60071-8
Dougados M, Baeten D. Spondyloarthritis. Lancet Lond Engl. 2011;377(9783):2127–37.
2. FitzGerald O Ogdie A Chandran V Coates LC Kavanaugh A Tillett W Psoriatic arthritis Nat Rev Dis Primer 2021 7 1 59 10.1038/s41572-021-00293-y
FitzGerald O, Ogdie A, Chandran V, Coates LC, Kavanaugh A, Tillett W, et al. Psoriatic arthritis Nat Rev Dis Primer. 2021;7(1):59.
3. Haque N Lories RJ de Vlam K Comorbidities Associated with Psoriatic Arthritis Compared with Non-psoriatic Spondyloarthritis: A Cross-sectional Study J Rheumatol 2016 43 2 376 382 10.3899/jrheum.141359 26669922
Haque N, Lories RJ, de Vlam K. Comorbidities associated with psoriatic arthritis compared with non-psoriatic spondyloarthritis: a cross-sectional study. J Rheumatol. 2016;43(2):376–82.26669922
4. Scriffignano S Perrotta FM De Socio A Lubrano E Role of comorbidities in spondyloarthritis including psoriatic arthritis Clin Rheumatol 2019 38 1 3 10 10.1007/s10067-018-4332-7 30338414
Scriffignano S, Perrotta FM, De Socio A, Lubrano E. Role of comorbidities in spondyloarthritis including psoriatic arthritis. Clin Rheumatol. 2019;38(1):3–10.30338414
5. Navarini L Caso F Costa L Currado D Stola L Perrotta F Cardiovascular Risk Prediction in Ankylosing Spondylitis: From Traditional Scores to Machine Learning Assessment Rheumatol Ther 2020 7 4 867 882 10.1007/s40744-020-00233-4 32939675
Navarini L, Caso F, Costa L, Currado D, Stola L, Perrotta F, et al. Cardiovascular risk prediction in ankylosing spondylitis: from traditional scores to machine learning assessment. Rheumatol Ther. 2020;7(4):867–82.32939675
6. Navarini L Margiotta DPE Caso F Currado D Tasso M Angeletti S Performances of five risk algorithms in predicting cardiovascular events in patients with Psoriatic Arthritis: An Italian bicentric study PLoS ONE 2018 13 10 e0205506 10.1371/journal.pone.0205506 30308025
Navarini L, Margiotta DPE, Caso F, Currado D, Tasso M, Angeletti S, et al. Performances of five risk algorithms in predicting cardiovascular events in patients with Psoriatic Arthritis: An Italian bicentric study. PLoS ONE. 2018;13(10):e0205506.30308025
7. Caso F Navarini L Carubbi F Picchianti-Diamanti A Chimenti MS Tasso M Mediterranean diet and Psoriatic Arthritis activity: a multicenter cross-sectional study Rheumatol Int 2020 40 6 951 958 10.1007/s00296-019-04458-7 31605152
Caso F, Navarini L, Carubbi F, Picchianti-Diamanti A, Chimenti MS, Tasso M, et al. Mediterranean diet and Psoriatic Arthritis activity: a multicenter cross-sectional study. Rheumatol Int. 2020;40(6):951–8.31605152
8. Navarini L Costa L Tasso M Chimenti MS Currado D Fonti GL Retention rates and identification of factors associated with anti-TNFα, anti-IL17, and anti-IL12/23R agents discontinuation in psoriatic arthritis patients: results from a real-world clinical setting Clin Rheumatol 2020 39 9 2663 2670 10.1007/s10067-020-05027-1 32189149
Navarini L, Costa L, Tasso M, Chimenti MS, Currado D, Fonti GL, et al. Retention rates and identification of factors associated with anti-TNFα, anti-IL17, and anti-IL12/23R agents discontinuation in psoriatic arthritis patients: results from a real-world clinical setting. Clin Rheumatol. 2020;39(9):2663–70.32189149
9. Linton SJ Nicholas MK MacDonald S Boersma K Bergbom S Maher C The role of depression and catastrophizing in musculoskeletal pain Eur J Pain Lond Engl 2011 15 4 416 422 10.1016/j.ejpain.2010.08.009
Linton SJ, Nicholas MK, MacDonald S, Boersma K, Bergbom S, Maher C, et al. The role of depression and catastrophizing in musculoskeletal pain. Eur J Pain Lond Engl. 2011;15(4):416–22.
10. Quartana PJ Campbell CM Edwards RR Pain catastrophizing: a critical review Expert Rev Neurother 2009 9 5 745 758 10.1586/ern.09.34 19402782
Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9(5):745–58.19402782
11. Wilk M Łosińska K Pripp AH Korkosz M Haugeberg G Pain catastrophizing in rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis: biopsychosocial perspective and impact on health-related quality of life Rheumatol Int 2022 42 4 669 682 10.1007/s00296-021-05070-4 35098329
Wilk M, Łosińska K, Pripp AH, Korkosz M, Haugeberg G. Pain catastrophizing in rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis: biopsychosocial perspective and impact on health-related quality of life. Rheumatol Int. 2022;42(4):669–82.35098329
12. Osman A Barrios FX Kopper BA Hauptmann W Jones J O’Neill E Factor structure, reliability, and validity of the Pain Catastrophizing Scale J Behav Med 1997 20 6 589 605 10.1023/A:1025570508954 9429990
Osman A, Barrios FX, Kopper BA, Hauptmann W, Jones J, O’Neill E. Factor structure, reliability, and validity of the Pain Catastrophizing Scale. J Behav Med. 1997;20(6):589–605.9429990
13. Currado D, Biaggi A, Pilato A, Marino A, Ruscitti P, Pantano I, et al. The negative impact of pain catastrophising on disease activity: analyses of data derived from patient-reported outcomes in psoriatic arthritis and axial spondyloarthritis. Clin Exp Rheumatol. 2023;41(9):1856–61.
14. Taylor W Gladman D Helliwell P Marchesoni A Mease P Mielants H Classification criteria for psoriatic arthritis: development of new criteria from a large international study Arthritis Rheum 2006 54 8 2665 2673 10.1002/art.21972 16871531
Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H, et al. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006;54(8):2665–73.16871531
15. Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos-Vargas R, et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis. 2009;68 Suppl 2:ii1–44.
16. Mease PJ Measures of psoriatic arthritis: Tender and Swollen Joint Assessment, Psoriasis Area and Severity Index (PASI), Nail Psoriasis Severity Index (NAPSI), Modified Nail Psoriasis Severity Index (mNAPSI), Mander/Newcastle Enthesitis Index (MEI), Leeds Enthesitis Index (LEI), Spondyloarthritis Research Consortium of Canada (SPARCC), Maastricht Ankylosing Spondylitis Enthesis Score (MASES), Leeds Dactylitis Index (LDI), Patient Global for Psoriatic Arthritis, Dermatology Life Quality Index (DLQI), Psoriatic Arthritis Quality of Life (PsAQOL), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Psoriatic Arthritis Response Criteria (PsARC), Psoriatic Arthritis Joint Activity Index (PsAJAI), Disease Activity in Psoriatic Arthritis (DAPSA), and Composite Psoriatic Disease Activity Index (CPDAI) Arthritis Care Res 2011 63 Suppl 11 S64 85
Mease PJ. Measures of psoriatic arthritis: Tender and Swollen Joint Assessment, Psoriasis Area and Severity Index (PASI), Nail Psoriasis Severity Index (NAPSI), Modified Nail Psoriasis Severity Index (mNAPSI), Mander/Newcastle Enthesitis Index (MEI), Leeds Enthesitis Index (LEI), Spondyloarthritis Research Consortium of Canada (SPARCC), Maastricht Ankylosing Spondylitis Enthesis Score (MASES), Leeds Dactylitis Index (LDI), Patient Global for Psoriatic Arthritis, Dermatology Life Quality Index (DLQI), Psoriatic Arthritis Quality of Life (PsAQOL), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Psoriatic Arthritis Response Criteria (PsARC), Psoriatic Arthritis Joint Activity Index (PsAJAI), Disease Activity in Psoriatic Arthritis (DAPSA), and Composite Psoriatic Disease Activity Index (CPDAI). Arthritis Care Res. 2011;63(Suppl 11):S64-85.
17. Bazzichi L, Giacomelli C, Consensi A, Giorgi V, Batticciotto A, Di Franco M, et al. One year in review 2020: fibromyalgia. Clin Exp Rheumatol. 2020;38 Suppl 123(1):3–8.
18. Wolfe F Clauw DJ Fitzcharles MA Goldenberg DL Häuser W Katz RL 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria Semin Arthritis Rheum 2016 46 3 319 329 10.1016/j.semarthrit.2016.08.012 27916278
Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RL, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016;46(3):319–29.27916278
19. Armağan B Kılıç L Farisoğulları B Yardımcı GK Bilgin E Bölek EÇ Drug retention rate and predictive factors of drug survival for secukinumab in radiographic axial spondyloarthritis Rheumatol Int 2023 43 1 147 156 10.1007/s00296-022-05213-1 36129541
Armağan B, Kılıç L, Farisoğulları B, Yardımcı GK, Bilgin E, Bölek EÇ, et al. Drug retention rate and predictive factors of drug survival for secukinumab in radiographic axial spondyloarthritis. Rheumatol Int. 2023;43(1):147–56.36129541
20. Athanassiou P Kotrotsios A Kallitsakis I Bounas A Dimitroulas T Garyfallos A The effects of golimumab on work productivity and quality of life among work-active axial spondyloarthritis and psoriatic arthritis patients treated in the routine care in Greece: the ‘GO-UP’ study Qual Life Res Int J Qual Life Asp Treat Care Rehabil 2022 31 5 1385 1399
Athanassiou P, Kotrotsios A, Kallitsakis I, Bounas A, Dimitroulas T, Garyfallos A, et al. The effects of golimumab on work productivity and quality of life among work-active axial spondyloarthritis and psoriatic arthritis patients treated in the routine care in Greece: the ‘GO-UP’ study. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 2022;31(5):1385–99.
21. Ferrito M, Cincinelli G, Manara M, Di Taranto R, Favalli EG, Caporali R. Retention rate of tumor necrosis factor inhibitors, anti-interleukin 17, and anti-interleukin 12/23 drugs in a single-center cohort of psoriatic arthritis patients. Reumatismo. 2023;75(2).
22. Mease PJ Collier DH Saunders KC Li G Kremer JM Greenberg JD Comparative effectiveness of biologic monotherapy versus combination therapy for patients with psoriatic arthritis: results from the Corrona registry RMD Open 2015 1 1 e000181 10.1136/rmdopen-2015-000181 26819748
Mease PJ, Collier DH, Saunders KC, Li G, Kremer JM, Greenberg JD. Comparative effectiveness of biologic monotherapy versus combination therapy for patients with psoriatic arthritis: results from the Corrona registry. RMD Open. 2015;1(1):e000181.26819748
23. Navarini L, Currado D, Pilato A, Marino A, Biaggi A, Di Donato S, et al. Association between Patient Acceptable Symptom State and disease activity in psoriatic arthritis is disrupted by confounders, including comorbid fibromyalgia. Clin Exp Rheumatol. 2024;42(6):1150–5.
24. Navarini L Currado D Caso F Costa L Chimenti MS D’Antonio A Duration of clinical remission and low disease activity impacts on quality of life and its domains in psoriatic arthritis patients: results from an Italian multicentre study Clin Exp Rheumatol 2022 40 7 1285 1292 34665697
Navarini L, Currado D, Caso F, Costa L, Chimenti MS, D’Antonio A, et al. Duration of clinical remission and low disease activity impacts on quality of life and its domains in psoriatic arthritis patients: results from an Italian multicentre study. Clin Exp Rheumatol. 2022;40(7):1285–92.34665697
25. Penhoat M Saraux A Le Goff B Augereau P Maugars Y Berthelot JM High pain catastrophizing scores in one-fourth of patients on biotherapy for spondylarthritis or rheumatoid arthritis Joint Bone Spine 2014 81 3 235 239 10.1016/j.jbspin.2013.10.004 24321439
Penhoat M, Saraux A, Le Goff B, Augereau P, Maugars Y, Berthelot JM. High pain catastrophizing scores in one-fourth of patients on biotherapy for spondylarthritis or rheumatoid arthritis. Joint Bone Spine. 2014;81(3):235–9.24321439
26. Hayashi K Morishima T Ikemoto T Miyagawa H Okamoto T Ushida T Pain Catastrophizing Is Independently Associated with Quality of Life in Patients with Severe Hip Osteoarthritis Pain Med Malden Mass 2019 20 11 2220 2227
Hayashi K, Morishima T, Ikemoto T, Miyagawa H, Okamoto T, Ushida T, et al. Pain Catastrophizing is independently associated with quality of life in patients with severe hip osteoarthritis. Pain Med Malden Mass. 2019;20(11):2220–7.
27. Kieskamp SC Paap D Carbo MJG Wink F Bos R Bootsma H Central sensitization, illness perception and obesity should be considered when interpreting disease activity in axial spondyloarthritis Rheumatol Oxf Engl 2021 60 10 4476 4485 10.1093/rheumatology/keab019
Kieskamp SC, Paap D, Carbo MJG, Wink F, Bos R, Bootsma H, et al. Central sensitization, illness perception and obesity should be considered when interpreting disease activity in axial spondyloarthritis. Rheumatol Oxf Engl. 2021;60(10):4476–85.
28. Craner JR Gilliam WP Sperry JA Rumination, Magnification, and Helplessness: How do Different Aspects of Pain Catastrophizing Relate to Pain Severity and Functioning? Clin J Pain 2016 32 12 1028 1035 10.1097/AJP.0000000000000355 26783987
Craner JR, Gilliam WP, Sperry JA. Rumination, magnification, and helplessness: How do Different aspects of pain catastrophizing relate to pain severity and functioning? Clin J Pain. 2016;32(12):1028–35.26783987
29. Generali E Sciré CA Cantarini L Selmi C Sex Differences in the Treatment of Psoriatic Arthritis: A Systematic Literature Review Isr Med Assoc J IMAJ 2016 18 3–4 203 208 27228644
Generali E, Sciré CA, Cantarini L, Selmi C. Sex differences in the treatment of psoriatic arthritis: a systematic literature review. Isr Med Assoc J IMAJ. 2016;18(3–4):203–8.27228644
30. Chimenti MS Fonti GL Conigliaro P Sunzini F Scrivo R Navarini L One-year effectiveness, retention rate, and safety of secukinumab in ankylosing spondylitis and psoriatic arthritis: a real-life multicenter study Expert Opin Biol Ther 2020 20 7 813 821 10.1080/14712598.2020.1761957 32401062
Chimenti MS, Fonti GL, Conigliaro P, Sunzini F, Scrivo R, Navarini L, et al. One-year effectiveness, retention rate, and safety of secukinumab in ankylosing spondylitis and psoriatic arthritis: a real-life multicenter study. Expert Opin Biol Ther. 2020;20(7):813–21.32401062
31. Fabbroni M Cantarini L Caso F Costa L Pagano VA Frediani B Drug retention rates and treatment discontinuation among anti-TNF-α agents in psoriatic arthritis and ankylosing spondylitis in clinical practice Mediators Inflamm 2014 2014 862969 10.1155/2014/862969 25110401
Fabbroni M, Cantarini L, Caso F, Costa L, Pagano VA, Frediani B, et al. Drug retention rates and treatment discontinuation among anti-TNF-α agents in psoriatic arthritis and ankylosing spondylitis in clinical practice. Mediators Inflamm. 2014;2014:862969.25110401
32. Favalli EG Selmi C Becciolini A Biggioggero M Ariani A Santilli D Eight-Year Retention Rate of First-Line Tumor Necrosis Factor Inhibitors in Spondyloarthritis: A Multicenter Retrospective Analysis Arthritis Care Res 2017 69 6 867 874 10.1002/acr.23090
Favalli EG, Selmi C, Becciolini A, Biggioggero M, Ariani A, Santilli D, et al. Eight-year retention rate of first-line tumor necrosis factor inhibitors in spondyloarthritis: a multicenter retrospective analysis. Arthritis Care Res. 2017;69(6):867–74.
