Understanding differences between men and women with axial spondyloarthritis

Characterising axial psoriatic arthritis: correlation between whole spine MRI abnormalities and clinical, laboratory and radiographic findings

OBJECTIVE

To describe the prevalence of inflammatory and structural lesions using whole spine MRI in patients with psoriatic disease, and to assess their correlation with clinical features and with axial spondyloarthritis (axSpA) classification criteria.

METHODS

This retrospective analysis included patients with whole spine and sacroiliac joints (SIJ) MRI, selected from 2 populations: (1) active psoriatic arthritis (PsA), irrespective of axial symptoms; (2) psoriasis with confirmed or suspected PsA and axSpA symptoms. MRI spondylitis and/or sacroiliitis (MRI-SpA) was defined according to Assessment of Spondyloarthritis International Society (ASAS) consensus and by radiologist impression. Agreement between MRI-SpA and different inflammatory back pain (IBP) definitions (Berlin/ASAS/rheumatologist criteria) and the axSpA classification criteria were calculated considering MRI as gold standard. Logistic regression determined MRI-SpA-associated factors.

RESULTS

93 patients were analysed (69.9% PsA; 30.1% psoriasis). Back pain was present in 81.7%, defined as IBP in 36.6%-57%. MRI-SpA was found in 9.7% of patients by ASAS definition and in 12.9% by radiologist impression, of which 25% had isolated spondylitis.Low agreement was found between the three IBP definitions and MRI-SpA. Rheumatologist criteria was the most sensitive (50%-55.6%) while ASAS and Berlin criteria were the most specific (61.9%-63%). axSpA criteria had poor sensitivity for MRI-SpA (22.2%-25%). Late onset of back pain or asymptomatic patients accounted for most cases with MRI-SpA not meeting axSpA or IBP criteria. Male sex was associated with MRI-SpA (OR 6.91; 95% CI 1.42 to 33.59) in multivariable regression analysis.

CONCLUSION

Prevalence of MRI-defined axSpA was low and showed poor agreement with IBP and axSpA criteria.

A Road Map of the Axial Spondyloarthritis Continuum

Axial spondyloarthritis (axSpA) is a chronic, immune-mediated inflammatory disease characterized by inflammatory low back pain, inflammation in peripheral joints and entheses, and other extra-articular or systemic manifestations. Although our understanding of the natural history of axSpA has been limited by incomplete knowledge of disease pathogenesis, axSpA is increasingly understood as a spectrum of axial, peripheral, and extra-articular inflammatory conditions that includes nonradiographic axSpA and radiographic axSpA, also known as ankylosing spondylitis. In this narrative review, we present a road map of this axSpA continuum, highlighting genetic risk factors for the development of axSpA, triggers of disease, and reasons for and implications of diagnostic delay. We present a detailed overview of the spectrum of axSpA clinical manifestations and highlight factors known to influence the risk of disease progression. Finally, we provide some expert commentary on the practical use of this road map to assist health care providers in the identification of axSpA in clinical practice.

Is There a Correlation Between Patient-Reported Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) Score and MRI Findings in Axial Spondyloarthropathy in Routine Clinical Practice?

Background

The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is the patient-reported outcome (PRO) that is routinely used in clinical practice to monitor and measure disease activity in axial spondyloarthropathy (axSpA). BASDAI scores greater than four are thought to indicate active disease and require better control. Magnetic resonance imaging (MRI) is the most objective measure of disease activity in axSpA with its ability to pick up active inflammation both in the spine and sacroiliac joints. Previous studies have shown conflicting correlations between BASDAI and MRI, and therefore, there is the question of whether BASDAI is the best tool to monitor disease activity when it is subjective and potentially influenced by other patient factors. We, therefore, conducted a retrospective study to investigate the correlation between BASDAI and MRI in axSpA patients.

Methodology

Data were collected by retrospective analysis of axSpA patients attending University of Leicester (UHL) axSpA services. BASDAI scores were done within a year and closest to the time of MRI spine + sacroiliac joints were collected. The results prior to the initiation of biologic therapy were used. Data of one hundred and forty-nine patients were collected on their MRI results and BASDAI scores. Data were analysed using Statistical Package for the Social Sciences (SPSS) software and Pearson’s chi-squared applied to assess the correlation between BASDAI and MRI findings.

Results

Out of one hundred and forty-nine patients, 61.7% had active sacroiliitis on their MRI, 57.7% had chronic sacroiliitis, 53% had active spinal inflammation, and 17.4% had other MRI findings of active disease. There was a significant correlation between active sacroiliitis and BASDAI (p=0.014), but similar results were not found with other radiological features. A significant correlation was also found with males having higher BASDAI scores compared to females (p=0.027).

Conclusion

This study demonstrates a statistically significant correlation between BASDAI and active sacroiliitis with those having higher scores more likely to have active disease on their MRI. 

Geographic Variations in Diagnosis and Treatment of Ankylosing Spondylitis in the United States: A Real-World Study

Introduction

Diagnosis difficulties are common for ankylosing spondylitis (AS) patients, leading to inadequate and inconsistent treatment. We evaluated the national and geographic variability in disease diagnosis and treatment in the United States.

Methods

This retrospective, cross-sectional analysis utilized the IBM® MarketScan® Administrative Claims Database from 2014 to 2019. AS patients ≥ 18 years of age with continuous medical and pharmacy enrollment during the calendar year and complete geographic information during the study period were included. Patient cohorts assessed were D1 (≥ 1 AS diagnoses within each calendar year of assessment between 2014 and 2019), D2 (≥ 2 non-rheumatologist AS diagnoses), and D3 (≥ 2 rheumatologist AS diagnoses). For D2 and D3, diagnoses were ≥ 6 months apart, but within 18 months. Annual AS diagnostic prevalence and treatment rates were determined from 2014 to 2019 nationally and per state in 2019. Treatments assessed were disease-modifying antirheumatic drugs (DMARDs), opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and methotrexate.

Results

Nationally, AS diagnostic prevalence increased from 2014 to 2019, with 2019 rates of 9.6 (D1), 5.1 (D2), and 3.5 (D3) per 10,000 persons. Diagnostic prevalence varied between states, which was not explained by age, sex, racial distribution, or rheumatologists per capita. Nationally, a greater percentage of D3 patients vs. D1 and D2 patients received biologic/targeted synthetic DMARDs (bDMARD/tsDMARDs) and conventional synthetic DMARD. Opioid use ranged from 37 to 40% in 2019 and decreased from 2014 for all cohorts. Corticosteroid and methotrexate use decreased slightly, while NSAID and bDMARD/tsDMARD use generally increased from 2014 to 2019.

Conclusions

AS diagnostic prevalence is increasing nationally, though it remains low among some states. bDMARD/tsDMARDs use was more common among patients treated by rheumatologists. Opioid and corticosteroid use is decreasing, though national rates remain high with significant state variability. Further education is needed, particularly in states with low prevalence and inadequate treatment, to improve diagnosis and treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00406-9.

Gender Differences in Ankylosing Spondylitis Patients with Advanced Hip Involvement: Results from A Matched Retrospective Cohort Study

Objective

To determine the gender differences in ankylosing spondylitis (AS) patients with advanced hip involvement.

Methods

We retrospectively analyzed the 373 consecutive AS patients with advanced hip involvement from 2012 to 2017 and divided them into two groups by sex with 340 men and 33 women. Research data on hip involvement in the patients were obtained from medical records and radiographs. The severity of radiographic hip involvement was evaluated by the Bath Ankylosing Spondylitis Radiology Hip Index (BASRI‐hip) scoring system. The data on clinical characteristics, radiographic hip involvement, and laboratory values were compared between the two groups. The comparison was performed again between the two groups after adjusting for the onset age and disease duration by propensity score matching (PSM).

Results

Men underwent total hip arthroplasty earlier than women in the patients, with a median age of 31 years (range, 19–67 years) vs 36 years (range, 23–67 years), respectively (P < 0.05). Hip involvement was found to be younger in men than that in women, with a median age of 18 years (range, 7–56 years) vs 23 years (range, 5–55 years) (P < 0.05), and men with bilateral onset in hips had a higher frequency than women with that (66.2% vs 39.4%) (P < 0.05). There was no gender difference in the proportion of bilateral advanced hip involvement (85.3% vs 72.7%) (P > 0.05). The proportion of the patients who had spinal involvement (89.1% vs 69.7%), flexion contracture in the hip (43.8% vs 24.2%), hip range of motion =0° (53.5% vs 30.3%), and an elevated level of C‐reactive protein (CRP) (69.1% vs 51.5%) was significantly higher in men than that in women (P < 0.05). After adjusting for the onset age and disease duration by PSM (1:1), men with bilateral onset in hips still had a higher frequency than women with that (76.7% vs 40.0%), and the proportion of the patients who had spinal involvement (90.0% vs 66.7%) and an elevated level of CRP (80.0% vs 53.3%) was significantly higher in men than that in women (P < 0.05).

Conclusions

The disease pattern of hip involvement in AS has gender differences, with bilateral onset being the dominant pattern in men and unilateral onset being more common in women. However, the frequency of bilateral advanced hip involvement has no gender difference eventually. The higher prevalence of spinal involvement in men with AS may be responsible for the more severe functional impairment compared with women.

An Italian Disease-Based Registry of Axial and Peripheral Spondyloarthritis: The SIRENA Study

Introduction: Data about the clinical presentation and management of early and mild spondyloarthritis (SpA) are limited.

Objectives: The objective of this study was to describe the baseline characteristics of disease-modifying antirheumatic drug (DMARD)-naïve patients with axial or peripheral SpA.

Methods: The Spondyloarthritis Italian Registry: Evidence from a National Pathway (SIRENA) study is an ongoing, Italian, multicenter, prospective registry of patients with a first or newly confirmed diagnosis of SpA according to the Assessment of SpondyloArthritis International Society (ASAS) criteria. To be included, patients had to be naïve to conventional, targeted, and biological DMARDs for SpA. Patients were enrolled between June 2017 and June 2019 and classified into groups according to disease presentation: predominantly axial or peripheral manifestations. The study is ongoing, and patients are being followed for 2 years, with an evaluation every 6 months according to clinical practice. Differences in baseline demographics, lifestyle, and clinical characteristics between axial and peripheral SpA were evaluated.

Results: In this study, 350 patients were enrolled, of which 123 (35.1%) were axial and 227 (64.9%) were peripheral patients. Patients with axial SpA were significantly younger at enrollment (median age: 44 vs. 53 years), had significantly more anxiety/depression (13 vs. 2.6%), and expressed higher disease activity compared to patients with peripheral SpA. Patients with peripheral SpA had significantly more cardiometabolic disorders (33 vs. 18.7%), skin psoriasis (65.2 vs. 21.1%), and nail psoriasis (35.5 vs. 17.1%) than patients with axial SpA. Dactylitis, enthesitis, and fibromyalgia were observed, respectively, in 17.6, 51.2, and 5.7% of patients with axial SpA and 24.3, 40, and 3.1% of patients with peripheral SpA. In both disease groups, women tended to report depression, joint tenderness, and higher disease activity more frequently than their male counterparts. At inclusion, a new diagnosis of SpA was performed in 58% of axial and 77% of peripheral patients, with a median time from symptom onset to diagnosis of 36 and 24 months, respectively. At baseline, most patients with axial SpA (77%) started a biological DMARD, while over half of the peripheral patients started a conventional DMARD.

Conclusions: Based on a well-characterized clinical registry of SpA, we provided real-world insights on the clinical features of DMARD-naïve SpA patients, pointing out major differences between axial and peripheral disease in terms of clinical characteristics and treatment pattern. Future prospective evaluations within the SIRENA study will improve knowledge on SpA and contribute to defining the best therapeutic approach.

Ixekizumab improves sleep and work productivity in patients with non-radiographic axial spondyloarthritis: results from the COAST-X trial at 52 weeks

BACKGROUND

Patients with non-radiographic axial spondyloarthritis experience negative impacts on sleep, work productivity, and activity impairment. Ixekizumab, a monoclonal antibody selectively targeting interleukin-17A, has shown efficacy in treating the signs and symptoms of non-radiographic axial spondyloarthritis. This analysis evaluated the effect of ixekizumab treatment on sleep, work productivity, and activity impairment in patients with non-radiographic axial spondyloarthritis.

METHODS

COAST-X ( NCT02757352 ) was a 52-week, phase 3, multicenter, randomised placebo-controlled trial evaluating 80-mg ixekizumab every 2 weeks and every 4 weeks in patients with active non-radiographic axial spondyloarthritis. Sleep disturbance was measured with the Jenkins Sleep Evaluation Questionnaire (JSEQ) and analysed using mixed-effects models for repeated measures. Work productivity and activity impairment were measured using the Work Productivity and Activity Impairment Questionnaire for Spondyloarthritis and analysed using analysis of covariance. Absenteeism, presenteeism, and overall work impairment were assessed for patients reporting paid work; activity impairment was assessed regardless of work status.

RESULTS

Overall, patients treated with both dosing regimens of ixekizumab reported numerically greater improvements in sleep than placebo through Week 52. At Weeks 16 and 52, patients treated with ixekizumab every 4 weeks had significantly greater improvements in presenteeism (p = 0.007 and p = 0.003, respectively) and overall work impairment (p = 0.014 and p = 0.005, respectively) and numeric improvements in absenteeism than placebo. Patients treated with ixekizumab every 2 weeks had numerically greater improvements in absenteeism, presenteeism, and overall work impairment than placebo. Both dosing regimens of ixekizumab were associated with significantly greater improvements in activity impairment than placebo (ixekizumab every 4 weeks: p = 0.003 at Week 16 and p = 0.004 at Week 52; ixekizumab every 2 weeks: p = 0.007 at Week 16 and p = 0.006 at Week 52).

CONCLUSIONS

Treatment with ixekizumab improved sleep, work productivity, and activity impairment in patients with nr-axSpA. Improvements in presenteeism and overall work impairment were sustained and consistent in the patients treated with ixekizumab every 4 weeks from Week 16 to Week 52. Improvements in activity impairment were sustained and consistent in both ixekizumab-treated groups from Week 16 to Week 52.

TRIAL REGISTRATION

NCT02757352 , May 2, 2016.

Investigating diagnosis, treatment, and burden of disease in patients with ankylosing spondylitis in Central Eastern Europe and the United States: a real-world study

Introduction/Objectives

Ankylosing spondylitis (AS) is a chronic inflammatory immune-mediated condition. We compared AS diagnosis, treatment, and burden in Central Eastern European countries (CEE), where this has been less researched, and the United States (US) from a real-world perspective.

Methods

Point-in-time survey of rheumatologists and their AS patients was conducted in the US (Apr–Oct 2018) and CEE (Aug–Nov 2019) via physician- and patient-completed record forms, including clinical and patient-reported outcomes. Statistical analysis included descriptive statistics, t-tests, Fisher’s exact tests, and generalized linear models.

Results

In total, 487 patients were recruited from 88 rheumatologists in the US and 922 patients from 126 rheumatologists in CEE. Time from onset of symptoms to final AS diagnosis was longer in CEE than the US (4.2 vs 2.7 years, p < 0.05). At diagnosis, a greater use of conventional synthetic disease-modifying antirheumatic drugs (DMARDs) and injected steroids was reported in CEE vs the US (43.7% vs 27.6%, p < 0.05; 19.3% vs 8.7%, p < 0.05). 22.9% of US patients received a biologic DMARD at diagnosis vs 10% of CEE patients (p < 0.05). At current consultation, biologic DMARD use in CEE was lower vs the US (27.9% vs 71.0%, p < 0.05). CEE vs US patients had greater disease activity (mean Bath Ankylosing Spondylitis Disease Activity Index 4.2 vs 3.1, p < 0.05) and worse quality of life (QoL; mean Ankylosing Spondylitis Quality of Life Questionnaire score 6.2 vs 8.4, p < 0.05).

Conclusions

AS patients in CEE vs the US faced slower diagnosis and worse access to biologics, disease activity, and QoL. Whether early access to biologics can improve symptoms, QoL, and daily activities in AS patients in CEE remains to be seen.

Key Points • The study provided evidence on the real-world approach to the diagnosis, treatment, and burden of axSpA (axial spondyloarthritis) in CEE compared with the US. • The study reported patients in CEE experienced longer delays in diagnosis and poorer access to biologics than in the US. • This may have resulted in higher disease activity, greater levels of pain, and poorer outcomes, as reported by patients with axSpA in CEE.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10067-021-05864-8.

Gender Differences in Disease Activity and Impact in Axial Spondyloarthritis

Ankylosing spondylitis (AS), characterized by inflammatory back pain and sacroiliitis on radiography, was traditionally considered a condition predominant in men. Since the introduction of the 2009 Assessment in Spondyloarthritis international Society classification criteria¹ aiming to facilitate earlier classification of cases without radiographic sacroiliitis, more women have been classified as having axial spondyloarthritis (axSpA).

HLA-B27 is associated with reduced disease activity in axial spondyloarthritis

HLA-B27 is associated with increased susceptibility and disease activity of ankylosing spondylitis, but the effect of HLA-B27 on the activity of the broader category now called axial spondyloarthritis (AxSpA) is apparently the opposite. A modified Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) was used to assess disease activity among 3435 patients with spondyloarthritis (SpA) who participated in a survey designed to assess the effect of their disease and its treatment on the susceptibility and severity of Covid-19. Chi square testing was used to compare BASDAI scores between HLA-B27 positive and negative subjects. 2836 survey respondents were HLA B27 positive. The average BASDAI for the HLA-B27 negative cohort was 4.92 compared to 4.34 for the HLA-B27 positive subjects. Based on linear regression, a subject’s sex could not fully account for the differing BASDAI score in HLA-B27 negative subjects compared to those who are HLA-B27 positive. The difference between B27 positive and negative subjects was skewed by those with a BASDAI score of one or two. HLA-B27 positive subjects were more than twice as likely to have a BASDAI score of 1 compared to HLA B27 negative subjects and about 60% more likely to have a BASDAI score of 2 (p < 0.0001). HLA-B27 positive subjects have less active spondyloarthritis compared to HLA-B27 negative subjects as measured by a BASDAI score. Our data indicate that patients with mild back pain and a diagnosis of AxSpA are disproportionately HLA-B27 positive. The HLA-B27 test facilitates the diagnosis of axial spondyloarthritis such that patients from a community survey with mild back pain may be disproportionately diagnosed as having AxSpA if they are HLA-B27 positive. The test result likely introduces a cognitive bias into medical decision making and could explain our observations.

Reduction of anterior uveitis flares in patients with axial spondyloarthritis on certolizumab pegol treatment: final 2-year results from the multicenter phase IV C-VIEW study

Introduction:

Acute anterior uveitis (AAU), affecting up to 40% of patients with axial spondyloarthritis (axSpA), risks permanent visual deficits if not adequately treated. We report 2-year results from C-VIEW, the first study to prospectively investigate certolizumab pegol (CZP) on AAU in patients with active axSpA at high risk of recurrent AAU.

Patients and methods:

C-VIEW (NCT03020992) was a 104-week (96 weeks plus 8-week safety follow-up), open-label, multicenter study. Eligible patients had active axSpA, human leukocyte antigen-B27 (HLA-B27) positivity and a history of recurrent AAU (⩾2 AAU flares in total; ⩾1 in the year prior to baseline). Patients received CZP 400 mg at weeks 0, 2 and 4, then 200 mg every 2 weeks to week 96. The primary efficacy endpoint was the AAU flare event rate during 96 weeks’ CZP versus 2 years pre-baseline.

Results:

Of 115 enrolled patients, 89 initiated CZP (male: 63%; radiographic/non-radiographic axSpA: 85%/15%; mean disease duration: 9.1 years); 83 completed week 96. There was a significant 82% reduction in AAU flare event rate during CZP versus pre-baseline [rate ratio (95% confidence interval): 0.18 (0.12–0.28), p < 0.001]. One hundred percent and 59.6% of patients experienced ⩾1 and ⩾2 AAU flares pre-baseline, respectively, compared to 20.2% and 11.2% during treatment. Age, sex and axSpA population subgroup analyses were consistent with the primary analysis. There were substantial improvements in axSpA disease activity with no new safety signal identified.

Conclusion:

CZP treatment significantly reduced AAU flare event rate in patients with axSpA and a history of AAU, indicating CZP is a suitable treatment option for patients at risk of recurrent AAU.

Trial Registration ClinicalTrials.gov:

NCT03020992, URL: https://clinicaltrials.gov/ct2/show/NCT03020992

The Role of TNF-α and Anti-TNF-α Agents during Preconception, Pregnancy, and Breastfeeding

Tumor necrosis factor-alpha (TNF-α) is a multifunctional Th1 cytokine and one of the most important inflammatory cytokines. In pregnancy, TNF-α influences hormone synthesis, placental architecture, and embryonic development. It was also shown that increased levels of TNF-α are associated with pregnancy loss and preeclampsia. Increased TNF-α levels in complicated pregnancy draw attention to trophoblast biology, especially migratory activity, syncytialisation, and endocrine function. Additionally, elevated TNF-α levels may affect the maternal-fetal relationship by altering the secretory profile of placental immunomodulatory factors, which in turn affects maternal immune cells. There is growing evidence that metabolic/pro-inflammatory cytokines can program early placental functions and growth in the first trimester of pregnancy. Furthermore, early pregnancy placenta has a direct impact on fetal development and maternal immune system diseases that release inflammatory (e.g., TNF-α) and immunomodulatory factors, such as chronic inflammatory rheumatic, gastroenterological, or dermatological diseases, and may result in an abnormal release of cytokines and chemokines in syncytiotrophoblasts. Pregnancy poses a challenge in the treatment of chronic disease in patients who plan to have children. The activity of the disease, the impact of pregnancy on the course of the disease, and the safety of pharmacotherapy, including anti-rheumatic agents, in pregnancy should be considered.