Influence of Vitamin D Status on Fatigue in Ankylosing Spondylitis
-
Rawdha Tekaya
,
Ons Hamdi
,
Ines Jemmali
,
Aicha Ben Tekaya
,
Leila Rouached
,
Olfa Saidane
,
Selma Bouden
,
Kahena Bouzid
,
Ines Mahmoud
,
Leila Abdelmoula
Abstract
Fatigue is a common symptom in ankylosing spondylitis. Hypovitaminosis D is one of the factors influencing fatigue during inflammatory rheumatisms. This study aimed to determine the influence of vitamin D deficiency on fatigue in ankylosing spondylitis. In this cross-sectional study, 40 patients with ankylosing spondylitis and 40 patients suffering from low back pain were recruited. Clinical and laboratory data, including vitamin D dosage, disease activity, functional impairment, and quality of life, were evaluated using specific and validated scores. Fatigue was assessed by the FACIT-F score. Both groups of patients were compound of 27 men and 13 women with a mean of 43.55±12.26 years in the study group and 47.77±13.63 years in the case group, respectively. Ankylosing spondylitis was active according to the ASDASCRP score in 67.5% of cases. All patients were suffering from fatigue with a mean FACIT-F score of 21.13. Severe levels of fatigue were noted in 50% of cases. 92.5% of patients were vitamin D deficient with a mean vitamin D of 16.57±7.15 ng/mL. Factors associated with fatigue were: female gender (P=0.05), spinal pain (P<0.001), enthesitis (P<0.001), disease activity (P<0.001), functional impairment (P<0.001), and quality of life (P<0.001). However, smoking was the only factor related to vitamin D deficiency (P=0.05). Vitamin D level was not correlated with fatigue (r= -0.02, P=0.91). In our study, vitamin D status did not seem to have an impact on fatigue in patients with ankylosing spondylitis.
1. Calin A, Edmunds L, Kennedy LG. Fatigue in ankylosing Spondylitis, why is it ignored? J Rheumatol 1993;20:991-5.
2. Jones SD, Koh WH, Steiner A, Garrett SL, Calin A. Fatigue in ankylosing spondylitis: its prevalence and relationship to disease activity, sleep, and other factors. J Rheumatol 1996;23:487-90.
3. Missaoui B, Revel M. Fatigue in ankylosing spondylitis. Ann Readapt Med Phys 2006;49:389-91.
4. Ibn Yacoub Y, Amine B, Laatiris A, Abouqal R, Hajjaj Hassouni N. Assessment of fatigue in Moroccan patients with ankylosing spondylitis. Clin Rheumatol 2010;29:1295-9.
5. Bianchi WA, Elias FR, Carneiro S, Bortoluzzo AB, Gonçalves CR, da Silva JA et al. Assessment of fatigue in a large series of 1492 Brazilian patients with spondyloarthritis. Mod Rheumatol 2014;24:980-4.
6. Davies H, Brophy S, Dennis M, Cooksey R, Irvine E, Siebert S. Patient perspectives of managing fatigue in Ankylosing Spondylitis, and views on potential interventions: a qualitative study. BMC Musculoskeletal Disorder 2013;14:163.
7. Gunaydin R, Goksel Karatepe A, Ceşmeli N, Kaya T. Fatigue in patients with ankylosing spondylitis: relationships with disease-specific variables, depression, and sleep disturbance. Clin Rheumatol 2009;28:1045-51.
8. Van Tubergen A, Coenen J, Landewe R, Spoorenberg A, Chorus A, Boonen A, et al. Assessment of fatigue in patients with ankylosing spondylitis: a psychometric analysis. Arthritis Care Res 2002;47:8-16.
9. Garret S, Jenkinson T, Kennedy LG, Whitelock H, Gaisford P, Calin A. A new approach to defining disease status in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Activity Index. J Rheumatol 1994;21:2286-91.
10. Chauffier K, Paternotte S, Burki V, Durnez A, Elhai M, Koumakis E, et al. Fatigue in spondyloarthritis: a marker of disease activity. A cross-sectional study of 266 patients. Clin Exp Rheumatol 2013;31:864-70.
11. Ruiz-Irastorza G, Gordo S, Olivares N, Egurbide MV, Aguirre C. Changes in vitamin D levels in patients with systemic lupus erythematosus: Effects on Fatigue, Disease Activity, and Damage. Arthritis Care Res 2010;62:1160-5.
12. Raczkiewicz A, Kisiel B, Kulig M, Tłustochowicz W. Vitamin D status and its association with quality of life, physical activity, and disease activity in rheumatoid arthritis patients. J Clin Rheumatol 2015;21:126-30.
13. Solmaz D, Avci O, Yalcin BC, Kara SP, Oran M. Vitamin D deficiency might contribute fatigue and disease activity in patients with fibromyalgia. Ann Rheum Dis 2015;74:1215.
14. Knippenberg S, Bol Y, Damoiseaux J, Hupperts R, Smolders J. Vitamin D status in patients with MS is negatively correlated with depression, but not with fatigue. ACTA Neurol Scand 2011;124:171-5.
15. Martínez Alonso M, Dusso A, Ariza G, Nabal M. Vitamin D deficiency and its association with fatigue and quality of life in advanced cancer patients under palliative care: A cross-sectional study. Palliat Med 2016;30:89-96.
16. Khan QJ, Reddy PS, Kimler BF, Sharma P, Baxa SE, O’Dea AP, et al. Effect of vitamin D supplementation on serum 25-hydroxy vitamin D levels, joint pain, and fatigue in women starting adjuvant letrozole treatment for breast cancer. Breast Cancer Res Treat 2010;119:111-8.
17. Zhao S, Duffield S.J, Moots R.J, Goodson N.J. Systematic review of association between vitamin D levels and susceptibility and disease activity of ankylosing spondylitis. Rheumatology (Oxford) 2014;53:1595-603.
18. Pokhai GG, Bandagi S, Abrudescu A. Vitamin D levels in ankylosing spondylitis: does deficiency correspond to disease activity? Rev Bras Reumatol 2014;54:330-4.
19. Ramagopalan SV, Goldacre R, Disanto G, Giovannoni G, Goldacre MJ. Hospital admissions for vitamin D related conditions and subsequent immune-mediated disease: record-linkage studies. BMC Med 2013;11:171.
20. Erten S, Kucuksahin O, Sahin A, Altunoglu A, Akyol M, Koca C. Decreased plasma vitamin D levels in patients with undifferentiated spondyloarthritis and ankylosing spondylitis. Intern Med 2013;52:339-44.
21. Durmus B, Altay Z, Baysal O, Ersoy Y. Does vitamin D affect disease severity in patients with ankylosing spondylitis? Chin Med J (Engl) 2012;125:2511-5.
22. Hmamouchi I, Allali F, Handaoui BE, Hanae A, Rostom S, Abouqal R, et al. The relation between disease activity, vitamin D levels and bone mineral density in men patients with ankylosing spondylitis. Rheumatol Rep 2013;5:e3.
23. Žagar I, Delimar V, Čota S, Perić D, Laktašić-Žerjavić N, Perić P. Correspondance of vitamin D status with functional scores and disease activity among Croatian patients with ankylosing spondylitis: A preliminary study. Psychiatr Danub 2018;6:105-11.
24. Lukas C, Landewé R, Sieper J, Dougados M, Davis J, Braun J, et al. Assessment of SpondyloArthritis international Society. Development of an ASAS-endorsed disease activity score (ASDAS) in patients with ankylosing spondylitis. Ann Rheum Dis 2009;68:18-24.
25. Calin A, Garrett S, Whitelock H, Kennedy LG, O’Hea J, Mallorie P, et al. A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index. J Rheumatol 1994;21:2281-5.
26. Daltroy LH, Larson MG, Roberts NW, Liang MH. A modification of the Health Assessment Questionnaire for the spondyloarthropathies. J Rheumatol 1990;17:946-50.
27. Doward LC, Spoorenberg A, Cook SA, Whalley D, Helliwell PS, Kay LJ, et al. Development of the ASQoL: a quality of life instrument specific to ankylosing spondylitis. Ann Rheum Dis 2003;62:20-6.
28. Coste J, Le Parc JM, Berge E, Delecoeuillerie G, Paolaggi JB. French validation of a disability rating scale for the evaluation of low back pain (EIFEL questionnaire). Rev Rhum Ed Fr 1993;60:335-41.
29. Dernis-Labous E, Messow M, Dougados M. Assessment of fatigue in the management of patients with ankylosing spondylitis. Rheumatology (Oxford) 2003;42:1523-8.
30. Da Costa D, Dritsa M, Ring A, Fitzcharles MA. Mental health status and leisure-time physical activity contribute to fatigue intensity in patients with spondylarthropathy. Arthritis Rheum 2004;51:1004-8.
31. Dagfinrud H, Vollestad NK, Loge JH, Kvien TK, Mengshoel AM. Fatigue in patients with ankylosing spondylitis: A comparison with the general population and associations with clinical and self-reported measures. Arthritis Rheum 2005;53:5-11.
32. Hamdi W, Ghannouchi M, Azzouz DH, Kochbati S, Daoud L, Saadellaoui K, et al. Evaluation de la fatigue chez 110 patients tunisiens atteints de spondylarthrite ankylosante (SPA). Rev Rhum 2007;74:1162.
33. Aissaoui N, Rostom S, Hakkou J, Berrada Ghziouel K, Bahiri R, Abouqal R, et al. Fatigue in patients with ankylosing spondylitis: prevalence and relationships with disease-specific variables, psychological status, and sleep disturbance. Rheumatol Int 2012;32:2117-24.
34. Alkan BM, Fidan F, Erten Ş, Aksekili H, Alemdar A, Eroğlu E, et al. Fatigue and correlation with disease-specific variables, spinal mobility measures, and health-related quality of life in ankylosing spondylitis. Mod Rheumatol 2013;23:1101-7.
35. Haywood KL, Packham JC, Jordan KP. Assessing fatigue in ankylosing spondylitis: the importance of frequency and severity. Rheumatology (Oxford) 2014;53:552-6.
36. Schneeberger EE, Marengo MF, Dal Pra F, Maldonado Cocco JA, Citera G. Fatigue assessment and its impact in the quality of life of patients with ankylosing spondylitis. Clin Rheumatol 2015;34:497-501.
37. Gossec L, Dougados M, D’Agostino MA, Fautrel B. Fatigue in early axial spondyloarthritis. Results from the French DESIR cohort. Joint Bone Spine 2016;83:427-31.
38. Mogard E, Lindqvist E, Bremander A, Bergman S. Risk factors for development and persistence of chronic widespread pain in spondyloarthritis: a population-based two-year follow-up study. Scand J Rheumatol 2019;48:460-8.
39. Revicki DA, Rentz AM, Luo MP, Wong RL. Psychometric characteristics of the short form 36 health survey and functional assessment of chronic illness Therapy-Fatigue subscale for patients with ankylosing spondylitis. Health Qual Life Outcomes 2011;9:36.
40. Bodur H, Ataman Ş, Rezvani A, Buğdaycı D, Çevik R, Birtane M, et al. Quality of life and related variables in patients with ankylosing spondylitis. Qual Life Res 2011;20:543-9.
41. Cho H, Kim T, Kim TH, Lee S, Lee KH. Spinal mobility, vertebral squaring, pulmonary function, pain, fatigue, and quality of life in patients with ankylosing spondylitis. Ann Rehabil Med 2013;37:675-82.
42. Madsen OR. Stability of fatigue, pain, patient global assessment and the Bath Ankylosing Spondylitis Functional Index (BASFI) in spondyloarthropathy patients with stable disease according to the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Rheumatol Int 2018;38:425-32.
43. Connolly D, Fitzpatrick C, O’Shea F. Disease activity, occupational participation, and quality of life for individuals with and without severe fatigue in ankylosing spondylitis. Occup Ther Int 2019;2019:3027280..
44. Stebbings SM, Treharne GJ, Jenks K, Highton J. Fatigue in patients with spondyloarthritis associates with disease activity, quality of life and inflammatory bowel symptoms. Clin Rheumatol 2014;33:1467-74.
45. Bedaiwi M, Sari I, Thavaneswaran A, Ayearst R, Haroon N, Inman RD. Fatigue in ankylosing spondylitis and nonradiographic axial spondyloarthritis: Analysis from a longitudinal observation cohort. J Rheumatol 2015;42:2354-6056.
46. Arends S, Spoorenberg A, Bruyn GA, Houtman PM, Leijsma MK, Kallenberg CG, et al. The relation between bone mineral density, bone turnover markers, and vitamin D status in ankylosing spondylitis patients with active disease: a cross-sectional analysis. Osteoporos Int 2011;22:1431-9.
47. Braun-Moscovici Y, Toledano K, Markovits D, Rozin A, Nahir AM, Balbir-Gurman A. Vitamin D level: is it related to disease activity in inflammatory joint disease? Rheumatol Int 2011;31:493-9.
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2. Jones SD, Koh WH, Steiner A, Garrett SL, Calin A. Fatigue in ankylosing spondylitis: its prevalence and relationship to disease activity, sleep, and other factors. J Rheumatol 1996;23:487-90.
3. Missaoui B, Revel M. Fatigue in ankylosing spondylitis. Ann Readapt Med Phys 2006;49:389-91.
4. Ibn Yacoub Y, Amine B, Laatiris A, Abouqal R, Hajjaj Hassouni N. Assessment of fatigue in Moroccan patients with ankylosing spondylitis. Clin Rheumatol 2010;29:1295-9.
5. Bianchi WA, Elias FR, Carneiro S, Bortoluzzo AB, Gonçalves CR, da Silva JA et al. Assessment of fatigue in a large series of 1492 Brazilian patients with spondyloarthritis. Mod Rheumatol 2014;24:980-4.
6. Davies H, Brophy S, Dennis M, Cooksey R, Irvine E, Siebert S. Patient perspectives of managing fatigue in Ankylosing Spondylitis, and views on potential interventions: a qualitative study. BMC Musculoskeletal Disorder 2013;14:163.
7. Gunaydin R, Goksel Karatepe A, Ceşmeli N, Kaya T. Fatigue in patients with ankylosing spondylitis: relationships with disease-specific variables, depression, and sleep disturbance. Clin Rheumatol 2009;28:1045-51.
8. Van Tubergen A, Coenen J, Landewe R, Spoorenberg A, Chorus A, Boonen A, et al. Assessment of fatigue in patients with ankylosing spondylitis: a psychometric analysis. Arthritis Care Res 2002;47:8-16.
9. Garret S, Jenkinson T, Kennedy LG, Whitelock H, Gaisford P, Calin A. A new approach to defining disease status in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Activity Index. J Rheumatol 1994;21:2286-91.
10. Chauffier K, Paternotte S, Burki V, Durnez A, Elhai M, Koumakis E, et al. Fatigue in spondyloarthritis: a marker of disease activity. A cross-sectional study of 266 patients. Clin Exp Rheumatol 2013;31:864-70.
11. Ruiz-Irastorza G, Gordo S, Olivares N, Egurbide MV, Aguirre C. Changes in vitamin D levels in patients with systemic lupus erythematosus: Effects on Fatigue, Disease Activity, and Damage. Arthritis Care Res 2010;62:1160-5.
12. Raczkiewicz A, Kisiel B, Kulig M, Tłustochowicz W. Vitamin D status and its association with quality of life, physical activity, and disease activity in rheumatoid arthritis patients. J Clin Rheumatol 2015;21:126-30.
13. Solmaz D, Avci O, Yalcin BC, Kara SP, Oran M. Vitamin D deficiency might contribute fatigue and disease activity in patients with fibromyalgia. Ann Rheum Dis 2015;74:1215.
14. Knippenberg S, Bol Y, Damoiseaux J, Hupperts R, Smolders J. Vitamin D status in patients with MS is negatively correlated with depression, but not with fatigue. ACTA Neurol Scand 2011;124:171-5.
15. Martínez Alonso M, Dusso A, Ariza G, Nabal M. Vitamin D deficiency and its association with fatigue and quality of life in advanced cancer patients under palliative care: A cross-sectional study. Palliat Med 2016;30:89-96.
16. Khan QJ, Reddy PS, Kimler BF, Sharma P, Baxa SE, O’Dea AP, et al. Effect of vitamin D supplementation on serum 25-hydroxy vitamin D levels, joint pain, and fatigue in women starting adjuvant letrozole treatment for breast cancer. Breast Cancer Res Treat 2010;119:111-8.
17. Zhao S, Duffield S.J, Moots R.J, Goodson N.J. Systematic review of association between vitamin D levels and susceptibility and disease activity of ankylosing spondylitis. Rheumatology (Oxford) 2014;53:1595-603.
18. Pokhai GG, Bandagi S, Abrudescu A. Vitamin D levels in ankylosing spondylitis: does deficiency correspond to disease activity? Rev Bras Reumatol 2014;54:330-4.
19. Ramagopalan SV, Goldacre R, Disanto G, Giovannoni G, Goldacre MJ. Hospital admissions for vitamin D related conditions and subsequent immune-mediated disease: record-linkage studies. BMC Med 2013;11:171.
20. Erten S, Kucuksahin O, Sahin A, Altunoglu A, Akyol M, Koca C. Decreased plasma vitamin D levels in patients with undifferentiated spondyloarthritis and ankylosing spondylitis. Intern Med 2013;52:339-44.
21. Durmus B, Altay Z, Baysal O, Ersoy Y. Does vitamin D affect disease severity in patients with ankylosing spondylitis? Chin Med J (Engl) 2012;125:2511-5.
22. Hmamouchi I, Allali F, Handaoui BE, Hanae A, Rostom S, Abouqal R, et al. The relation between disease activity, vitamin D levels and bone mineral density in men patients with ankylosing spondylitis. Rheumatol Rep 2013;5:e3.
23. Žagar I, Delimar V, Čota S, Perić D, Laktašić-Žerjavić N, Perić P. Correspondance of vitamin D status with functional scores and disease activity among Croatian patients with ankylosing spondylitis: A preliminary study. Psychiatr Danub 2018;6:105-11.
24. Lukas C, Landewé R, Sieper J, Dougados M, Davis J, Braun J, et al. Assessment of SpondyloArthritis international Society. Development of an ASAS-endorsed disease activity score (ASDAS) in patients with ankylosing spondylitis. Ann Rheum Dis 2009;68:18-24.
25. Calin A, Garrett S, Whitelock H, Kennedy LG, O’Hea J, Mallorie P, et al. A new approach to defining functional ability in ankylosing spondylitis: the development of the Bath Ankylosing Spondylitis Functional Index. J Rheumatol 1994;21:2281-5.
26. Daltroy LH, Larson MG, Roberts NW, Liang MH. A modification of the Health Assessment Questionnaire for the spondyloarthropathies. J Rheumatol 1990;17:946-50.
27. Doward LC, Spoorenberg A, Cook SA, Whalley D, Helliwell PS, Kay LJ, et al. Development of the ASQoL: a quality of life instrument specific to ankylosing spondylitis. Ann Rheum Dis 2003;62:20-6.
28. Coste J, Le Parc JM, Berge E, Delecoeuillerie G, Paolaggi JB. French validation of a disability rating scale for the evaluation of low back pain (EIFEL questionnaire). Rev Rhum Ed Fr 1993;60:335-41.
29. Dernis-Labous E, Messow M, Dougados M. Assessment of fatigue in the management of patients with ankylosing spondylitis. Rheumatology (Oxford) 2003;42:1523-8.
30. Da Costa D, Dritsa M, Ring A, Fitzcharles MA. Mental health status and leisure-time physical activity contribute to fatigue intensity in patients with spondylarthropathy. Arthritis Rheum 2004;51:1004-8.
31. Dagfinrud H, Vollestad NK, Loge JH, Kvien TK, Mengshoel AM. Fatigue in patients with ankylosing spondylitis: A comparison with the general population and associations with clinical and self-reported measures. Arthritis Rheum 2005;53:5-11.
32. Hamdi W, Ghannouchi M, Azzouz DH, Kochbati S, Daoud L, Saadellaoui K, et al. Evaluation de la fatigue chez 110 patients tunisiens atteints de spondylarthrite ankylosante (SPA). Rev Rhum 2007;74:1162.
33. Aissaoui N, Rostom S, Hakkou J, Berrada Ghziouel K, Bahiri R, Abouqal R, et al. Fatigue in patients with ankylosing spondylitis: prevalence and relationships with disease-specific variables, psychological status, and sleep disturbance. Rheumatol Int 2012;32:2117-24.
34. Alkan BM, Fidan F, Erten Ş, Aksekili H, Alemdar A, Eroğlu E, et al. Fatigue and correlation with disease-specific variables, spinal mobility measures, and health-related quality of life in ankylosing spondylitis. Mod Rheumatol 2013;23:1101-7.
35. Haywood KL, Packham JC, Jordan KP. Assessing fatigue in ankylosing spondylitis: the importance of frequency and severity. Rheumatology (Oxford) 2014;53:552-6.
36. Schneeberger EE, Marengo MF, Dal Pra F, Maldonado Cocco JA, Citera G. Fatigue assessment and its impact in the quality of life of patients with ankylosing spondylitis. Clin Rheumatol 2015;34:497-501.
37. Gossec L, Dougados M, D’Agostino MA, Fautrel B. Fatigue in early axial spondyloarthritis. Results from the French DESIR cohort. Joint Bone Spine 2016;83:427-31.
38. Mogard E, Lindqvist E, Bremander A, Bergman S. Risk factors for development and persistence of chronic widespread pain in spondyloarthritis: a population-based two-year follow-up study. Scand J Rheumatol 2019;48:460-8.
39. Revicki DA, Rentz AM, Luo MP, Wong RL. Psychometric characteristics of the short form 36 health survey and functional assessment of chronic illness Therapy-Fatigue subscale for patients with ankylosing spondylitis. Health Qual Life Outcomes 2011;9:36.
40. Bodur H, Ataman Ş, Rezvani A, Buğdaycı D, Çevik R, Birtane M, et al. Quality of life and related variables in patients with ankylosing spondylitis. Qual Life Res 2011;20:543-9.
41. Cho H, Kim T, Kim TH, Lee S, Lee KH. Spinal mobility, vertebral squaring, pulmonary function, pain, fatigue, and quality of life in patients with ankylosing spondylitis. Ann Rehabil Med 2013;37:675-82.
42. Madsen OR. Stability of fatigue, pain, patient global assessment and the Bath Ankylosing Spondylitis Functional Index (BASFI) in spondyloarthropathy patients with stable disease according to the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Rheumatol Int 2018;38:425-32.
43. Connolly D, Fitzpatrick C, O’Shea F. Disease activity, occupational participation, and quality of life for individuals with and without severe fatigue in ankylosing spondylitis. Occup Ther Int 2019;2019:3027280..
44. Stebbings SM, Treharne GJ, Jenks K, Highton J. Fatigue in patients with spondyloarthritis associates with disease activity, quality of life and inflammatory bowel symptoms. Clin Rheumatol 2014;33:1467-74.
45. Bedaiwi M, Sari I, Thavaneswaran A, Ayearst R, Haroon N, Inman RD. Fatigue in ankylosing spondylitis and nonradiographic axial spondyloarthritis: Analysis from a longitudinal observation cohort. J Rheumatol 2015;42:2354-6056.
46. Arends S, Spoorenberg A, Bruyn GA, Houtman PM, Leijsma MK, Kallenberg CG, et al. The relation between bone mineral density, bone turnover markers, and vitamin D status in ankylosing spondylitis patients with active disease: a cross-sectional analysis. Osteoporos Int 2011;22:1431-9.
47. Braun-Moscovici Y, Toledano K, Markovits D, Rozin A, Nahir AM, Balbir-Gurman A. Vitamin D level: is it related to disease activity in inflammatory joint disease? Rheumatol Int 2011;31:493-9.
48. Cai G, Wang L, Fan D, Xin L, Liu L, Hu Y, et al. Vitamin D in ankylosing spondylitis: Review and meta-analysis. Clin Chim Acta 2015;438:316-22.
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| Files | ||
| Issue | Vol 60, No 5 (2022) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/acta.v60i5.9555 | |
| Keywords | ||
| Ankylosing spondylitis Fatigue Vitamin D Low back pain | ||
| Rights and permissions | |
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Tekaya R, Hamdi O, Jemmali I, Ben Tekaya A, Rouached L, Saidane O, Bouden S, Bouzid K, Mahmoud I, Abdelmoula L. Influence of Vitamin D Status on Fatigue in Ankylosing Spondylitis. Acta Med Iran. 2022;60(5):283-292.
