The present cross-sectional study revealed the presence of possible dysphagia based on the EAT-10 questionnaire, in patients with RMDs. Notably, individuals diagnosed with SSc, pSS and RA had a significantly greater risk for developing dysphagia, while the likelihood of experiencing this condition increased progressively with advancing age.

Utilization of the EAT-10 questionnaire for dysphagia assessment in RMDs

Of the 340 patients included in the study, 120 exhibited dysphagia (i.e. about 35%), as indicated by the EAT-10 questionnaire, with the majority of those reporting difficulty in swallowing solid foods and food sticking in the throat. Additionally, people with dysphagia reported difficulty in maintaining their current weight, enjoying food, and socializing, and some reported that swallowing caused anxiety, adding another stressor to their current situation. Indeed, psychological distress may exacerbate perceived swallowing difficulties, while dysphagia itself may contribute to increased anxiety, suggesting a reciprocal relationship between dysphagia and anxiety [33].

To our knowledge, only four studies have used this specific tool to assess dysphagia in a similar patient population. The first study examined patients with ankylosing spondylarthritis and found a greater incidence of dysphagia in this group compared to healthy controls [17]. Two additional studies focused on patients with FMS [19, 20] and SSc [15] and reported dysphagia in 65.21% and 52% of the samples, respectively. Finally, in the study by Gilheaney et al. [21]. , 73% of patients with FMS experienced dysphagia, with the majority experiencing food sticking in the throat and difficulty swallowing pills and solids. Despite these findings, we were unable to specifically evaluate FMS-related dysphagia in our cohort due to the small sample of patients with an FMS diagnosis. Overall, autoimmune dysphagia has been reported in up to 73% of patients, with the prevalence varying, depending on the underlying disease and the assessment method used [13, 21]. Previous research has suggested reducing the EAT-10 cut-off value from 3 to 2, a change aimed at improving sensitivity, while maintaining specificity [34]. However, this adjustment has not yet been validated in the context of RMDs and requires further investigation to determine its applicability and clinical relevance in this patient population.

Determinants of dysphagia in RMDs

In the current sample, patient-reported GERD, advancing age, weight status, and certain diagnoses such as SSc, pSS, and SpA were associated with the development of dysphagia. GERD is a highly prevalent GI disorder that affects a great proportion of individuals with RMDs, a relationship that has been further supported by genetic studies [35, 36]. In addition, patients with SSc may be at increased risk for developing GERD due to hypomobility of the esophageal body, mainly affecting the smooth muscle fibers and reduced resting pressure of the lower esophageal sphincter [4]. Within this cohort, patients who reported GERD exhibited a 32% increased likelihood of experiencing dysphagia. Heartburn and regurgitation, common in GERD, are associated with non-obstructive dysphagia due to upper esophageal sphincter dysfunction, acid hypersensitivity, and esophageal dysmotility [37]. Recent findings by Reddy et al. [38]. indicate that the majority of patients with RMDs have a unique esophageal motility disorder that is primarily characterized by achalasia, hypo-contractile esophagus, and esophagogastric junction outflow obstruction. Elderly people are at increased risk of developing dysphagia, mainly due to age-related changes in swallowing function, both motor and sensorimotor [39]. Herein, we observed that for each additional year of age, the odds of dysphagia increased by 1% in the sample.

Interestingly, overweight and obesity status appeared to exert a protective effect against dysphagia, with patients in this weight status categories showing a 12% reduced risk of experiencing swallowing difficulties. To our knowledge, no previous studies have reported similar findings. In contrast, the existing literature [40] suggests that overweight status and obesity are linked to esophageal dysfunction, increased esophageal acid exposure, and other GI manifestations, all of which are known to contribute to dysphagia. Furthermore, underweight status has previously been associated with an increased risk of dysphagia [41]—a relationship not observed herein. However, after adjustment for co-founders, BMI did not appear to influence the odds of dysphagia. The unexpected findings regarding BMI and dysphagia risk may be attributed to an imbalance in the distribution of patients across BMI categories or the influence of confounding factors, such as medication use, lifestyle habits, or underlying comorbidities. Furthermore, it is highly likely that the increased BMI may actually be the result of lack of dysphagia, leading to an increased dietary intake and greater BMI. Further research is warranted to explore these potential explanations and to clarify the complex relationship between body weight and dysphagia.

In terms of rheumatic disease diagnoses, patients with SSc had more than a sixfold increased risk of developing dysphagia, while those with pSS had a 6.53-fold higher risk. Previous research has highlighted the significant GI discomfort experienced by individuals with these diagnoses [5, 6, 15]. SSc is a systemic autoimmune disorder characterized by vascular dysfunction, progressive fibrosis of the skin and internal organs, including involvement of the GI tract. In addition to cutaneous manifestations, patients often suffer from microstomia, oral ulcers, and esophageal dysfunction, all of which contribute to swallowing difficulties [15]. On the other hand, pSS is primarily defined by chronic inflammation and dysfunction of the salivary and lacrimal glands, resulting in severe oral and ocular dryness, as well as reduced secretions within the GI tract [42]. This persistent dryness significantly impairs bolus formation and swallowing, further predisposing patients to dysphagia [6].

In contrast, people with SpA appeared to be less likely to experience dysphagia. Given that SpA primarily affects the spine, with potential manifestations in the GI tract [43], this observation was particularly intriguing. Although the literature on this topic is limited, several case reports have highlighted the potential association between dysphagia and cervical spine involvement in SpA patients [44, 45], while the prevalence of dysphagia has been shown to be greater in individuals with the condition compared to those without [17]. Nevertheless, the backward elimination multivariate analysis showed no significant association between SpA and dysphagia.

Interestingly, the same model highlighted that patients with RA had a 13% increased risk of dysphagia. RA-related cricoarytenoid arthritis can affect the upper airway, while symptoms like xerostomia, impaired mastication, and masticatory pain have also been documented to contribute to dysphagia in this population [46]. Nonetheless, myositis, vasculitides, PsA, and SLE lacked association with dysphagia. Specifically in myositis, dysphagia is associated with several adverse events, most commonly aspiration [18]. Limited evidence, primarily from case reports, suggests an association between SLE and vasculitides with GI discomfort and dysphagia. Reported cases have included esophageal and oropharyngeal dysphagia, respectively, as well as the involvement of the secondary neurological syndromes [47,48,49]. However, more studies need to be conducted to elucidate this relationship. Furthermore, to our knowledge, no current research item has investigated a possible relationship between PsA and dysphagia, leaving this as an unexplored area for future research.

The interplay between dysphagia, malnutrition, and sarcopenia

Low serum albumin levels have been previously linked to impaired swallowing and an elevated risk of mortality in patients with dysphagia, particularly among older individuals [50, 51]. In the present study, albumin exhibited a modest negative correlation with dysphagia, and lower albumin levels were found to be independently associated with swallowing difficulties, after controlling for possible confounders.

A bidirectional relationship exists between dysphagia and malnutrition, whereby swallowing difficulties can result in inadequate nutrient intake, and nutritional deficiencies can further exacerbate the patient’s condition by impairing GI function and contributing to worsening dysphagia [52, 53]. This cycle can ultimately result in sarcopenia, as insufficient energy and macronutrient intake deprive the body of essential resources, leading to muscle wasting and frailty that is independent of aging [54]. Research in patients with SSc has revealed that malnutrition may be a useful predictor of GI involvement in routine clinical practice [16]. The strong interplay between dysphagia, malnutrition, and sarcopenia is of paramount importance, particularly in patients with RMDs, highlighting the need for timely and systematic hospital-based screening and management, as emphasized in previous studies [25, 26]. A recent study highlighted significant gaps in the knowledge of healthcare professionals regarding enteral and parenteral nutrition, with over 80% of participants reporting inadequate training in these domains [55]. With respect to the assessment of dysphagia, only 7% of clinicians relied on patient-reported symptoms, 19.2% employed direct observation of eating or drinking, and 42.3% utilized a combination of both methods [55]. These findings underscore the urgent need for enhanced educational and training initiatives, particularly among healthcare professionals treating high-risk patient populations, to address the critical aspects of dysphagia assessment and nutritional management.

Management strategies for dysphagia

Effective swallowing management plays a crucial role in maintaining both nutritional status and improving overall disease outcomes [12]. Proper swallowing function ensures the activation and strengthening of GI tract muscles, minimizes the risk of aspiration, and enhances nutrient absorption, thereby reducing the likelihood of malnutrition and sarcopenia. A multidisciplinary approach is necessary to address the challenges associated with dysphagia, involving speech-language pathologists who focus on behavioral strategies to mitigate choking risks and alleviate aspiration-related anxiety, along with nutritionists who optimize dietary adjustments for improved swallowing performance [39]. Several therapeutic strategies have been developed to enhance swallowing function. Postural adjustments can significantly affect the velocity, direction, and clearance of a bolus or liquid, facilitating safer swallowing. Patients suffering from upper oropharyngeal and esophageal dysfunction may benefit from targeted swallowing maneuvers that enhance upper esophageal sphincter function and promote bolus passage [39]. In patients whose dysphagia results from autoimmune-mediated muscle weakness, individualized swallowing interventions may help prevent GERD and the formation of esophageal diverticula [8]. With regard to oesophageal strictures, a common therapeutic approach is dilation, which can be achieved by techniques such as through-the-scope balloon dilation or bougienage [56]. In cases of severe or refractory symptoms, these interventions may help restore esophageal patency, alleviate dysphagia, and improve nutritional intake and overall quality of life.

In addition to these therapeutic measures, dietary modifications are also critical in the management of dysphagia. The use of thick liquids has been demonstrated to assist in regulating the flow of the bolus, thereby enhancing the control of mechanical swallowing. Furthermore, the modification of the texture of solid foods, such as making them more cohesive, homogenized, or moisture-enhanced, has been shown to reduce the risk of aspiration and facilitate safer consumption [39, 57]. In this context, the International Dysphagia Diet Standardisation Initiative (IDDSI) serves as a globally unified framework that standardizes the classification of texture-modified foods and thickened liquids, ensuring a shared understanding between clinicians and patients regarding dysphagia diets [58]. Such modifications may benefit patients with temporomandibular disorders, such as those observed in RA; however, they should be supervised by a qualified expert to ensure that nutritional adequacy is maintained [59]. On the other hand, individuals afflicted with esophageal dysmotility are advised to consume small, thoroughly chewed food bolus, abstain from dry foods, ensure sufficient fluid intake alongside solid meals, and refrain from assuming a prone position for an extended duration after meal [39].

In addition to behavioral and dietary interventions, pharmacological approaches hold promise in the management of swallowing disorders. Immunotherapy with agents such as methylprednisolone, methotrexate, tacrolimus, mycophenolate, cyclophosphamide, rituximab, and hydroxychloroquine, as well as high-dose intravenous immunoglobulin, have demonstrated therapeutic effects in selected patients [60]. Treatment with proton pump inhibitors (PPIs) is also known as a practical approach to managing dysphagia [61]. Additionally, prokinetic agents have demonstrated promising results in patients with SSc experiencing dysphagia [62]. Proper patient selection and careful procedural management are essential for minimizing the risk of complications, such as perforation or recurrent strictures.

The impact of dysphagia is critical in many aspects. Dysphagia has been demonstrated to be independently associated with increased LOS and healthcare costs, and it affects both patient-related expenses and organizational burdens, such as staffing, feeding protocols, and discharge planning [10]. There is currently no standardized approach to dysphagia management, which underscores the need for clinical guidelines and integrated multidisciplinary care. Future research and policy could build upon these findings to establish screening protocols for dysphagia in both acute care and primary care settings.

Limitations

The present study employs a cross-sectional design, precluding the establishment of causal relationships. However, it allows for the identification of factors associated with dysphagia in RMDs, including demographic characteristics and disease-related outcomes. Additionally, the assessment of dysphagia was not performed using objective measures of videofluoroscopy and fiberoptic endoscopy, or high-resolution esophageal manometry (HRM) and esophagogastroduodenoscopy (EGD), but rather using the validated EAT-10 questionnaire. Consequently, the precision of the findings may be limited. Furthermore, we did not collect data on esophageal amyloidosis secondary to RA mimicking achalasia, nor on severe esophagitis, Barrett’s esophagus, and strictures such as Schatzki rings, which are commonly observed in patients with SSc. These factors could serve as potential confounders.

In addition to that, the EAT-10 assessment does not distinguish between oropharyngeal and esophageal dysphagia. While it serves as a valuable, cost-effective tool for identifying possible dysphagia, it lacks the specificity needed for a comprehensive diagnosis. Therefore, further evaluation is essential to accurately determine the patient’s condition and develop a personalized care and treatment plan. Moreover, the absence of a control group limits the potential for comparative analyses that could yield valuable insights. Additionally, certain disease subcategories included a limited number of patients, which restricted further analyses to prevent a loss of statistical power.