Article No. 355
13 July 2020
Among the the topics included in the Global aHUS Patients’ Research Agenda are the following :
Can the side effects of treatment using a complement inhibitor be distinguished from those temporary and permanent ongoing ailments which follow initial onset?
Does the anxiety and self-esteem of aHUS patients vary significantly between treatment types and what can be done to reduce and boost them respectively?
How does living with aHUS impact on education and work?
Recently an article about aHUS Fatigue featured on this website ( Read HERE). Research revealed that prior to treatment extreme tiredness was an evident symptom of an aHUS onset; but with treatment and time, patients could return to the kind of fatigue that normal people live with. This suggests that it is a temporary ailment and not a side of effect of their complement inhibitor.
A report of that study of aHUS Fatigue was published in Kidney International Reports and can be read at the following link
But there was more to that publication than just the “aHUS Fatigue” ailment.
Apart from the FACIT – Fatigue instrument, which the Alexion Registry uses to gather data about Patient Reported Outcomes, another set of questionnaires is used to gather patients’ experience of other symptoms of aHUS and its treatment. These questionnaires cover incidents of symptoms associated with serious illness , and also what these aHUS patients do e.g work and other activities.
Using a study cohort of 511 patients and the same subcategories created for the aHUS FACIT Fatigue analysis, i.e. those on eculizumab BEFORE enrollment, in the Registry , those starting eculizumab treatment AFTER enrollment and those NEVER receiving eculizumab, their reported outcomes are described and compared.
aHUS SYMPTOMS AND AILMENTS
Starting with data about temporary and possible on going symptoms/ailments, including Anxiety (which will be looked at separately. Patients were asked to indicate , from a predetermined list of possible symptoms, which of them they might have had an incident of in the time since they last completed the questionnaire.
The generic list includes Abdominal pain, Anxiety, Confusion, Diarrhea, Easy bruising/ Abdominal bleeding, Fatigue ,Headache, Irritability, Nausea/Vomiting, Shortness of breath , Swelling, Weakness, Jaundice and Other.
From that list the top three most reported symptoms were Fatigue, Headache and Weakness. The following Table 1 displays the percentage of patients reporting such incidents at baseline and in a follow up questionnaire.
More patients (70% plus) in the starting treatment after enrollment group reported these symptom incidents. Fatigue at 95% was clearly the most likely symptom that aHUS patients would experience when ill.
Though such incidents drop as health returns, only fatigue and weakness fall to the levels experienced by those never ,or ,receiving eculizumab before enrollment. Headaches although falling ,remain much higher. The similarities between never and ever on eculizumab suggest the symptoms are more to do with the effect of aHUS than the treatment.
Patients also reported incidents of the all the other symptoms but fewer than half of them did so. For brevity ,in Table 2 ,these have been put into “decile” groupings e.g. 0-10 % etc to show the overall relative incidence reported after treatment . Incidents of all symptoms fall with recovery from illness with some reported as significantly down compared with pre-treatment levels at the start of treatment.
|0 to 10%||At start||Direction||Significant|
|20 to 30%||At start||Direction||Significant|
|30% plus||At start||Direction||Significant|
|Shortness of breath||55||Down||No|
The symptom “Anxiety” has been kept separate from the other ailments reported above because it is referred to separately in the patients’ research agenda. The patient reported outcome questionnaire does not include the psychological condition of self esteem ( nor its inverse state “depression”) but it does include data about aHUS patients anxiety.
Table 3 shows that prior to treatment with an aHUS onset, more than half of patients experience it. It falls after after treatment , but not quickly and it seems to stay at a level where 1 in 3 patients report feelings of anxiety even as time passes. It seems it is not dependent on whether patients have been or never been on eculizumab so that it would appear not to be a side effect.
This data does not indicate how severe these incidents are, nor what, if any, interventions there have been. It can be perfectly normal to feel anxious for any number of reasons. It is when it becomes constant,or debilitating that it becomes a problem. General anxiety disorder is estimated to affect 5% to 18 % of the population.
Given the continued levels reported there may be something more specific to aHUS given the experience of onset and its serious threat to the patient’s life. Anyone’s confidence can be rocked after that. Increasingly there are reports that there will be a surge of stress in those survivors of COVID 19 with the trauma of experiencing the severe near death form of the illness. So there could be something in that. Those that recover can be reassuring to those in the midst and aftermath of that encounter.
Further follow up by this study will reveal what course this symptom will take in the long term. But for now hopefully patients will be receiving help if needed or take control by pursuing self- help if they choose.
WORK, EDUCATION etc.
A third questionnaire completed by participants in the Alexion Registry relates to work and other activity.
It is rare , if at all, to see such data reported about aHUS patients. Table 4 below gives details of how 511 of the patients in the study spend their time. This is the overall position as the researchers found little difference between those who were ever or never receiving eculizumab.
|Activity||No. of Patients||% of total|
|Working full time||108||21.1|
|Working part time||56||11.0|
|Unemployed not aHUS related||31||6.1|
|Unemployed aHUS related||53||10.3|
|Other : mostly self employed,homemaker or disabled||120||23.5|
Over half of aHUS patients are working or in education, possibly nearly two thirds , if some of those in the “other“ category who are self employed and homemakers are included. This is surprising but welcoming data which shows what normality aHUS patients are reaching.
Having said that 16 % reported being unemployed just under 2 in 3 of them giving aHUS as the reason. Some of the “others” regard themselves as disabled. 1 in 20 aHUS patients are retired.
Two articles written by two aHUS patients, Wim and Kamal, come to mind to show how they chose to recover from their aHUS experience ,whether ever or never on eculizumab. The articles below may be of inspiration to other aHUS patients today who are just starting off their recovery.
There is still more to look at in this study and Global Action will return to it.