The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general

[Late onset spondyloarthropathy misdiagnosed as polymyalgia rheumatica]

PURPOSE

Polymyalgia rheumatica (PMR) is a frequent cause for long-term corticosteroid therapy. Management of PMR is difficult and recommendations (regarding diagnosis and treatment) from the British Society of Rheumatology have been recently published in order to avoid false diagnosis and unnecessary corticosteroid therapy. On the other hand, late onset spondyloarthropathies are difficult to diagnose due to their various presentation (peripheral and axial manifestations, usually associated with severe systemic manifestations) and the absence of validated diagnosis criteria in the elderly.

METHODS

We report on eight patients, who all of them initially responding to Bird's criteria for PMR, and whose outcome was refractory PMR with multiple flares, poor therapeutic response, with inability to taper steroids.

RESULTS

After a mean follow-up of 25 months, a diagnosis of late onset spondyloarthropathy was done in all theses patients based on clinical history, physical examination, and spine MRI. In four of the cases the use of TNFα blockers allowed to taper corticosteroid and to control the disease. Retrospectively, the diagnosis at presentation was difficult.

CONCLUSION

Among PMR patients with poor response to corticosteroids and multiple flares, the possibility of a late onset spondyloarthropathy should be discussed. There is an unmet need for validated diagnosis criteria in such patients.

Axial spondyloarthritis: is there a treatment of choice?

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease predominantly affecting the axial skeleton (sacroiliac joints and spine). Nonradiographic axSpA (axSpA without radiographic sacroiliitis) and ankylosing spondylitis (AS; radiographic form of axSpA) are considered nowadays as two consecutive stages of one disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) are highly effective against the major symptoms of axSpA (pain and stiffness) and may have disease-modifying properties including retarding progression of structural damage in the spine. Therefore, NSAIDs, unless contraindicated, are the treatment of choice for the majority of patients with axSpA. Beyond NSAIDs, only tumour necrosis factor (TNF) α blockers are effective and approved for the treatment of active axSpA. Several novel drugs (i.e. monoclonal antibodies targeting interleukin-17, interleukin-12/23, inhibitors of phosphodiesterase-4 and kinases), which might be effective in axSpA, are currently under investigation. Pharmacological therapy of axSpA should always be combined with nonpharmacological treatment including education and regular exercise/physiotherapy.

Differences in physical activity patterns in patients with spondylarthritis

OBJECTIVE

To study patient-reported physical activity in patients with spondylarthritis (SpA) and possible differences in physical activity patterns between the SpA subtypes and sexes.

METHODS

In 2009, a questionnaire including inquiries concerning physical activity was sent to patients with a SpA diagnosis (n = 3,711). The World Health Organization (WHO) global recommendations of physical activity for health requiring 150 minutes of moderate-intensity physical activity (MI-PA) or 75 minutes of vigorous-intensity physical activity (VI-PA) per week were used as recommended levels. Standardized risk ratios (RRs) were calculated by using physical activity data from the Swedish population. The association within the SpA group between sex, age, disease-related variables, anxiety, and depression and meeting recommended levels of MI-PA and VI-PA (dependent variables) was studied with multivariate analysis.

RESULTS

A total of 2,167 patients with SpA (48% men, mean ± SD age 55 ± 14 years) responded to the questionnaire. Sixty-eight percent of the patients met the WHO recommendations, more frequently in women than in men (70% versus 66%). The recommendations were more often met in the SpA group (RR 1.09, 95% confidence interval [95% CI] 1.04-1.15) compared with the Swedish population. There was a tendency for young women to meet the WHO recommendations less often than the Swedish population (RR 0.94, 95% CI 0.63-1.25). Different factors were found to influence whether the patients were exercising with a moderate or vigorous intensity.

CONCLUSION

Seven of 10 patients with SpA met the WHO recommendations of physical activity for health, but we found sex and disease subtype differences. This information can be useful in clinical practice when coaching patients to have a healthier lifestyle.

Current concept of spondyloarthritis: special emphasis on early referral and diagnosis

Ankylosing spondylitis is the prototype of inflammatory rheumatic diseases grouped under the term spondyloarthritis or spondyloarthropathy (SpA). New classification criteria for SpA have now been proposed; the patients are subgrouped into (1) a predominantly axial disease, termed axial SpA, which includes AS, and (2) peripheral SpA. There is an unacceptable delay in the diagnosis of axial SpA, and there are still no validated diagnostic criteria for SpA. An early diagnosis has now become increasingly important because effective therapies in the form of TNF antagonists have become available that are even more effective if used in early stages of the disease. Therefore, new strategies are being proposed that will assist in making an early diagnosis and will also help primary care physicians in screening for these patients so that they can be referred to rheumatologists when the disease is still in its early stages. These strategies may be less efficient for early referral of children and adolescents suffering from SpA, because their most important early manifestation is not inflammatory back pain but peripheral arthritis and enthesitis. There is, therefore, a need to develop a different strategy for children and adolescents with SpA through the use, preferably, of the ASAS/EULAR classification criteria for peripheral SpA, more so than the classification criteria for axSpA.

A 17 year old with isolated proximal tibiofibular joint arthritis

The proximal tibiofibular joint (TFJ) is rarely affected in rheumatic diseases, and we frequently interpret pain of the lateral knee as the result of overuse or trauma. Nonetheless, the TFJ is a synovial joint that communicates with the tibiofemoral joint in a proportion of patients. While proximal TFJ arthritis has been rarely associated with existing spondyloarthritis, isolated TFJ arthritis as the presenting manifestation of spondyloarthritis has not yet been described. Here, we report the clinical and radiographic presentation of an adolescent with chronic proximal TFJ arthritis heralding spondyloarthritis highly suggestive of ankylosing spondylitis.

Phenotypic and clinical differences between Caucasian and South Asian patients with psoriatic arthritis living in North East London

To test for demographic and clinical differences between Caucasian and South Asian patients with psoriatic arthritis (PsA) living in the same environment and for differences between sexes. The demographic characteristics of patients attending outpatient clinics were obtained using a semi-structured questionnaire. Clinical parameters included disease activity (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), erythrocyte sedimentation rate (ESR), C-reactive protein), function (Bath Ankylosing Spondylitis Functional Index (BASFI)) and visual analogue scale (VAS) scores for well-being and night pain (10 cm, where 10 = worst possible response). The first symptom experienced at disease onset and the main symptoms during the disease course were recorded in the questionnaire. A total of 217 patents were assessed of whom 151 were Caucasians and 66 were Asians. South Asian patients were significantly younger [(mean) 45.9 years [(SD)(±11.4)] for Asians and 53.1 years (±14.2) for Caucasians (p < 0.005)] and were diagnosed at an earlier age [40.7 years (±11.7) for Asians and 46.7 years (±15.8) for Caucasians (p < 0.05)] compared to Caucasians patients. Asian females with PsA had worse disease in terms of activity (ESR = 23.9 mmHg/h; BASDAI = 6.7), function (BASFI = 5.5), night pain (7.1 on VAS) and well-being (6.6 on VAS) compared with Asian males (13.2 mmHg/h, 5.3, 3.6, 4.1, 4.6, respectively) or Caucasian males and females (15.8 mmHg/h, 5.9, 5.3, 5.4, 5.4; 18.9 mmHg/h, 6.1, 6.1, 5.3, 5.8, respectively). There were no significant differences in symptoms at disease onset or the main symptoms during the disease course between Caucasian and Asian patients, although there was a trend towards more frequent enthesitis in Asian females during the course of disease suggested by pain with pressure compared to Asian males. South Asian patients may develop PsA earlier in life than Caucasian patients do, but their clinical characteristics are generally similar. Asian females with PsA have worse disease activity, function, night pain and well-being than Asian males and Caucasian males and females.

Management and evaluation of extra-articular manifestations in spondyloarthritis

Spondyloarthritis (SpA) is a chronic inflammatory disease with either predominantly axial symptoms of the spine and sacroiliac joints (axial SpA, including ankylosing spondylitis) or predominantly arthritis (peripheral SpA). Next to these spinal and articular symptoms, many patients with SpA also have extra-articular manifestations (EAMs). EAMs associated with SpA include anterior uveitis (25-30%), psoriasis (10-25%) or inflammatory bowel disease (IBD) (5-10%) and cardiovascular manifestations. Peripheral arthritis occurs in approximately 30% of patients, especially in large joints, and shows an asymmetrical, oligoarticular pattern. Other common joint complaints are due to enthesitis, which manifest as extra-articular bony tenderness in areas such as the Achilles tendon. Acute anterior uveitis presents with acute pain, loss of vision and redness in one eye that usually subsides spontaneously after several weeks. Rapid treatment by an ophthalmologist is required to prevent synechiae formation which could ultimately result in glaucoma and blindness. Although less common, organ involvement in SpA can also be located in the heart, lungs or kidneys. The risk of cardiovascular events is increased in SpA. Cardiac manifestations can involve the aortic valve (1-10%) or the atrioventricular node and the risk of atherosclerotic events is increased in this group. Treatment of SpA includes physical exercise and nonsteroidal anti-inflammatory drugs (NSAIDs), and in case of peripheral arthritis, sulphasalazine can be added. When there is insufficient response to NSAIDs, tumor necrosis factor blockers, especially infliximab, etanercept, adalimumab and golimumab, are very effective in treating axial manifestations, arthritis, enthesitis and psoriasis. Anterior uveitis in SpA can be treated adequately by the ophthalmologist and in the case of refractory uveitis, treatment with adalimumab and infliximab seems to be more effective compared with etanercept. When IBD occurs with SpA, the use of NSAIDs should be minimized, except for celecoxib, and infliximab or adalimumab are preferred to etanercept. The incidence of atherosclerotic events or SpA-specific cardiac manifestations may be decreased by cardiovascular risk management or effective antirheumatic treatment. Overall it is important to realize that extra-articular manifestations frequently occur in patients with SpA and should be taken into account in the choice of treatment.

Do patients with non-radiographic axial spondylarthritis differ from patients with ankylosing spondylitis?

OBJECTIVE

Patients with axial spondylarthritis (SpA) who have structural changes in the sacroiliac joints and/or the spine have been classified as having ankylosing spondylitis (AS), while those without such changes are now classified as having nonradiographic axial SpA (nr-axSpA). The differentiating features are incompletely understood.

METHODS

Data from 100 consecutive patients with axial SpA not treated with tumor necrosis factor antagonists were compared clinically and with laboratory parameters, spinal radiographs, and magnetic resonance imaging (MRI) of the spine. Standardized clinical assessment tools were used to assess health status.

RESULTS

AS was diagnosed in 56 patients and nr-axSpA in 44 patients. Signs of inflammation were significantly higher in patients with AS than in patients with nr-axSpA, with a median C-reactive protein level of 8.0 versus 3.8 mg/liter, a median Ankylosing Spondylitis Disease Activity Score of 2.2 versus 2.8, respectively, and a median amount of spinal inflammatory lesions on MRI of 2.0 versus 0.0, respectively. Significant differences between these 2 groups were seen in sex (76.8% male AS patients versus 31.8% male nr-axSpA patients). Clinical variables did not differ between patients with AS and nr-axSpA (Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, Ankylosing Spondylitis Quality of Life questionnaire, Short Form 36 health survey).

CONCLUSION

Patients with nr-axSpA were characterized by the low proportion of male patients and the low burden of inflammation compared to patients with AS. While both groups did not differ regarding health status, disease activity, and physical function, they did differ in signs of inflammation; all were higher in patients with AS. Since many patients with nr-axSpA had not developed structural changes after years of symptoms, we propose that those patients should not be regarded as having preradiographic AS but rather as having nr-axSpA.

Double-blind, placebo-controlled randomized trial with adalimumab for treatment of juvenile onset ankylosing spondylitis (JoAS): significant short term improvement

INTRODUCTION

While adalimumab is licensed for ankylosing spondylitis (AS), open uncontrolled studies suggest therapeutic efficacy of TNF-inhibitors in juvenile onset AS (JoAS).

METHODS

A total of 32 patients aged 12 to 17 years with severe, active and refractory JoAS were enrolled in a multicenter, randomized, double-blind, placebo-controlled parallel study of 12 weeks, followed by open-label adalimumab until week 24 for all patients. ASAS40 was used as the primary, and ASAS20, PedACR and single items were used as the secondary outcome measures for the intention to treat population.

RESULTS

A total of 17 patients were randomized to receive adalimumab 40 mg/2 weeks and 15 patients received placebo. Two patients (one of each group) discontinued prematurely due to insufficient efficacy and were labeled as non-responders. In the double-blind part, more patients on adalimumab achieved an ASAS40 at week 4 (41%), week 8 (53%) and week 12 (53%) than on placebo (20%, 33%, 33%), while differences at week 8 only reached borderline significance (P = 0.05). Also, at 4, 8 and 12 weeks ASAS20/PedACR30/70 response rates were higher in the adalimumab group (53%/53%/29%; 59%/76%/41%; 53%/65%/53%) compared to placebo (27%/27%/7%; 27%/33%/13%; 33%/40%/27%). In the adalimumab group a significant decrease of all disease activity parameters was noted at week 12 and was even more pronounced at week 24. At week 12 the Bath Ankylosing Spondylitis Disease activity spinal inflammation score decreased by 65% (P <0.001), the back pain score decreased by 50% (P <0.005), the Bath AS Functional Index (BASFI) score decreased by 47% (P <0.02), while the Childhood Health Assessment Questionnaire-Disability Index (CHAQ-DI) score improved by 65% (P <0.005). ANCOVA analysis demonstrated superiority of adalimumab over placebo for the physician global assessment of disease activity, parents' global assessment of subject's overall well-being, active joint count (all P <0.05) and erythrocyte sedimentation rate (ESR) (P <0.01).

CONCLUSIONS

Adalimumab was well tolerated and highly effective in a double-blind randomized trial in patients with JoAS. Treatment effects rapidly occurred and persisted for at least 24 weeks of treatment.

TRIAL REGISTRATION

EudraCT 2007-003358-27.

The use of ultrasound for the assessment of enthesitis in patients with spondyloarthritis

Seronegative spondyloarthritis (SpA) represents a group of diseases that share certain genetic, clinical, and radiographic features. Enthesitis, inflammation at the site of tendon insertion into the bone, involving both the axial and the peripheral joints, is an important sign of SpA. Clinical diagnosis of enthesitis, however, is neither sensitive nor specific; thus, the diagnosis of enthesitis often relies on typical abnormalities in imaging studies. Due to its low costs and availability, ultrasound is emerging as the preferred technique for detection of enthesitis for both clinical and research purposes. Ultrasonographic features of enthesitis include tendon hypoechogenicity and thickening, calcifications, bone erosions, and Doppler signal. Several semi-quantitative scoring systems have been developed to quantify ultrasonographic abnormalities of the entheses. These methods have been used for early diagnosis and classification of SpA as well as for monitoring response to treatment.

Motivations and objections to implement a spondyloarthritis integrated care pathway. A qualitative study with primary care physicians

BACKGROUND AND OBJECTIVES

Previous to the development of a clinical pathway (CP) for early spondyloarthritis (SpA), a qualitative study was performed to know the attitude of primary care physicians (PCP) with respect to CP implementation.

METHODS

5 discussion groups (2 in Madrid, 2 in Barcelona and 1 in Sevilla) and 3 interviews in Bilbao, were performed. PCP with different profiles were included. Groups and interviews were carried out by experts on qualitative methodology.

RESULTS

PCP know little about CP. Motivations of professionals to work on a SpA CP were: to improve patients care, availability of a specialist consultant, possibility of learning and doing research, remuneration, and professional recognition. Objections to CP implementation were: extra work, excessive bureaucracy, absence of a specialist consultant, computer difficulties, and no remuneration. SpA knowledge by PCP was defective. PCP associated the term «spondylitis» with osteoarthritis, low-back pain, ankylosing spondylitis and psoriatic arthritis. They only referred patients to the rheumatologist to confirm the diagnosis, when patients complained and when treatment was ineffective.

CONCLUSIONS

For an optimal CP implementation, the following is deemed necessary: 1) a practical, simple program that eases the interaction with the rheumatologist without an increase on the PCP work load; 2) to provide continuous feedback by the specialist and 3) to provide knowledge on SpA to PCP.

Classification criteria for spondyloarthropathies

Spondyloarthropathies (SpA) are a group of inflammatory arthritis which consist of ankylosing spondylitis (AS), reactive arthritis, arthritis/spondylitis associated with psoriasis (PsA), and arthritis/spondylitis associated with inflammatory bowel diseases. It is now more important than ever to diagnose and treat SpA early. New therapeutic agents including blockers of tumor necrosis factor have yielded tremendous responses not only in advanced disease but also in the early stages of the disease. Sacroiliitis on conventional radiography is the result of structural changes which may appear late in the disease process. However, magnetic resonance imaging (MRI) can visualize active inflammation at sacroiliac joints and spine in recent onset disease. The modified New York criteria, the European Spondyloarthropathy Study Group criteria and the Amor criteria do not include advanced imaging techniques like MRI which is very sensitive to the early Inflammatory changes. Assessment of SpondyloArthritis international Society has defined MRI methods for the assessment of sacroiliac joints and spine, criteria for inflammatory back pain and developed new criteria for classification of axial and peripheral spondyloarthritis. These new criteria are intended to be used for patients with SpA at the very early stage of their disease. Also, classification of psoriatic arthritis study group developed criteria for the classification of PsA. The widespread use of these criteria in clinical trials will provide evidence for a better definition of early disease and recognize many patients who may further develop classical AS or PsA. These efforts will guide therapeutic trials of potent drugs like biological agents in the early stage of these diseases.

Can we reduce the dosage of biologics in spondyloarthritis?

TNF blockers have revolutionized the management of spondyloarthritis (SpA). To date, four anti-TNFα agents (etanercept, infliximab, adalimumab, golimumab) have been approved for the management of ankylosing spondylitis (AS) and psoriatic arthritis (PsA). The first objective in the management of AS and PsA with TNF inhibitors is to reduce disease activity to clinical remission or low disease activity. After remission has been achieved, this state should be maintained as long as possible. However, the financial burden associated with the cost of anti-TNF agents as well as concerns about their long-term safety suggest reducing the dosage of the drug or discontinuing the therapy in the hopes of drug-free remission. The aim of this review is to examine what has, till now, been published on this topic in axial SpA, which includes AS and non-radiographic axial SpA (nr-axSpA), peripheral SpA and PsA. Discontinuation of therapy in axial SpA is not possible in the majority of patients, while on the contrary, reducing the dosage often is. In some patients with peripheral SpA and PsA it is also possible to discontinue therapy and to achieve drug-free remission.

Epidemiology of spondyloarthritis

Spondyloarthritis (SpA) represents a group of interrelated diseases with common clinical features and a close association with HLA-B27. Reports of incidence and prevalence of diseases vary depending on methodological differences between studies, the case definition used to classify disease, and the prevalence of HLA-B27 in the population studied. Newly proposed criteria for axial SpA and peripheral SpA present a new approach to facilitate classification of the SpA into 2 main subtypes and the criteria allow earlier detection of patents with inflammatory back pain. These criteria were developed for use in a (specialized) clinical setting and not for large epidemiologic studies.

Performance of classification criteria for peripheral spondyloarthritis and psoriatic arthritis in the Leiden Early Arthritis cohort

OBJECTIVES

The performance of spondyloarthritis (SpA) classification criteria is not well-established in general early arthritis cohorts. Therefore, the authors tested their performance in the Leiden Early Arthritis Clinic (EAC) cohort and assessed whether these criteria can assist rheumatologists in diagnosing patients.

METHODS

The authors identified all SpA and psoriatic arthritis (PsA) patients in the EAC cohort according to the diagnosis of the treating rheumatologist. A control group consisting of arthritis patients with other diagnoses was matched to the SpA and PsA patients on gender, age and symptom duration. The authors assessed the fulfilment of SpA criteria in all three groups.

RESULTS

Of the patients in the EAC cohort (n=2011), 7.5% was diagnosed with PsA and 3.8% with SpA. In the PsA group, the ClASsification criteria for Psoratic ARthritis (CASPAR) criteria had the highest sensitivity (88.7%). In the SpA group, the Assessment of SpondyloArthritis international Society (ASAS) peripheral SpA and European Spondylarthropathy Study Group (ESSG) criteria had the highest sensitivity (both 48.7%). Specificity of all criteria sets was good: ranging from 88.5% (ESSG) to 100% (Amor).

CONCLUSIONS

In early arthritis, sensitivity of SpA classification criteria is modest except for the CASPAR criteria in PsA. However, specificity of classification criteria, including the new ASAS-peripheral SpA criteria, is high.

Dosage adjustment of anti-tumor necrosis factor-α inhibitor in ankylosing spondylitis is effective in maintaining remission in clinical practice

OBJECTIVE

While remission is possible in patients with ankylosing spondylitis (AS), it is often unclear what attitude should be adopted once remission has occurred. We investigated whether dosage adjustment is an effective means of maintaining remission.

METHODS

This was a retrospective study drawn from clinical situations. Remission was defined using clinical measures [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≤ 20/100 and no peripheral joint disease] and biological measures [C-reactive protein (CRP) levels ≤ normal value]. The tumor necrosis factor-α (TNF-α) inhibitors used were infliximab, adalimumab, and etanercept. Response predictors of remission were evaluated by logistic regression (age, CRP, HLA-B27 positivity, sex, duration of disease, and anti-TNF-α naivety). CRP and BASDAI were evaluated before and after dosage adjustment at about 6, 12, 24, and 36 months.

RESULTS

One hundred eighty-nine patients with AS were included in the study, with a mean followup of 43.5 (± 17.9) months after the introduction of the first anti-TNF-α inhibitor. Mean age was 45.6 (± 12.5) years. Remission had occurred in 65 patients (35%). Significant response predictors of remission were male sex (p = 0.003) and anti-TNF-α naivety (p < 0.001). Dosage adjustment was observed 49 times, and progressively reducing treatment frequency was effective to maintain remission in a large number of patients for 36 months. The cumulative probability of continuing anti-TNF-α after dosage adjustment was 79.0% at 12 months, 70.5% at 24 months, and 58.8% at 36 months.

CONCLUSION

Remission had occurred in 35% of the patients with AS under anti-TNF-α inhibitor therapy. Dosage adjustment and progressively reducing treatment frequency was effective in maintaining remission.

Early spondyloarthritis

Spondyloarthritis (SpA) is a large family of chronic inflammatory diseases characterized by inflammation of the axial skeleton, a typically asymmetric peripheral arthritis of the lower limbs, enthesitis, typical extra-articular manifestations, and shared genetic background. The prevalence in the general population is up to 2% for the entire group. SpA, particularly ankylosing spondylitis, has been associated with a diagnostic delay of up to 10 years. Important efforts toward shortening this delay have been made, including the development of new classification criteria. This article discusses the current concept of the disease, typical manifestations, advances in diagnosis, and current treatment recommendations.

The assessment of the spondyloarthritis international society concept and criteria for the classification of axial spondyloarthritis and peripheral spondyloarthritis: A critical appraisal for the pediatric rheumatologist

This review refers to the origin and current state of the assessment of the SpondyloArthritis International Society (ASAS) criteria for the classification of axial and peripheral spondyloarthritis (SpA) and the possible implications in the pediatric population. The ASAS criteria evolved from the idea that the earlier the recognition of patients with ankylosing spondylitis, the better the efficacy of tumor necrosis factor blockers. Strategies included the development of new concepts, definitions, and techniques for the study of clinical signs and symptoms. Of relevance, the new definition of inflammatory back pain (IBP) and the introduction of sacroiliitis by magnetic resonance imaging represented the most important advance in the early identification of AS in the "pre-radiographic stage" of the disease. AS is considered in this paper as a disease continuum with symptoms depending on age at onset. The application of those specific strategies in children and adolescents with SpA seems limited because the most important manifestation in the early stage of disease is not IBP, but peripheral arthritis and enthesitis. In this instance, the logical approach to juvenile onset SpA according to ASAS criteria should not be through the axial criteria but rather the peripheral set of criteria.

A historical perspective of the spondyloarthritis

PURPOSE OF REVIEW

The history of ankylosing spondylitis, the main representative of the spondyloarthritides, is dating back to several thousand years BC and recently proven for medieval skeleton by HLA-B27 typing with modern molecular techniques. In modern time, the history of spondyloarthritis (SpA) is characterized by fluctuation between lumping and splitting. Actually, the recent advent of new classification criteria demands to discuss the consequences and clinical implications in the historical context of the development of the concept of SpA including the controversy of lumping and splitting.

RECENT FINDINGS

The new Assessment of SpondyloArthritis International Society classification criteria for axial and peripheral SpA are primarily developed to provide support for clinical trials with biologicals and other treatment modalities, which intend to cover the whole spectrum, especially early clinical manifestations of spondyloarthritides. New insights into genetics and the evolving etiological role of Chlamydia in SpA including the most recent finding of the effective combination antibiotic therapy are major advances in the evolving history of SpA.

SUMMARY

The concept of SpA is well accepted for the classification, diagnosis, and therapeutic management of a high proportion of individuals with inflammatory rheumatic conditions. For further advances research technologies are now available to enlarge the current body of clinical, immunologic, and genetic studies using pivotal microbiologic research and new antimicrobial therapeutic strategies.

Developments in therapies for spondyloarthritis

First-line therapy for spondyloarthritis (SpA) has not yet altered in the wake of new classification criteria; NSAIDs and physical therapy are recommended. Anti-TNF agents can be used when NSAIDs fail, but their efficacy has potentially been limited in previous trials by inclusion criteria requiring the presence of established, active disease. Now, not only patients with axial SpA (axSpA) with radiographic signs of sacroiliitis (that is, with ankylosing spondylitis), but also patients in whom structural damage is not-yet-visible radiographically (non-radiographic axSpA) can be included in trials of therapy for axSpA. TNF blockers, it seems already, are at least similarly effective in patients with non-radiographic axSpA as in those with established AS. Short symptom duration and a positive C-reactive protein test at baseline are currently the best predictors for a good response to TNF-blocking agents. Biologic agents besides anti-TNF therapies have so far failed in the treatment of axSpA. New bone formation seems currently to be best prevented by NSAIDs, not by TNF blockers. Whether earlier effective treatment of bony inflammation with anti-TNF therapy will be able to prevent ossification at a later stage has yet to be determined. New classification criteria for peripheral SpA will also allow treatment trials to be conducted more systematically than has previously been possible in this subgroup of patients.

Advances in the treatment of inflammatory arthritis

The inflammatory arthritides are a diverse group of conditions characterised by joint inflammation which can lead to pain, deformity and disability. Of these diseases, rheumatoid arthritis (RA) and spondyloarthritis are two of the most common. While the clinical and demographic features of these diseases differ, the central role of inflammation in their pathogenesis has allowed the development of highly effective treatment strategies with wide applicability. These strategies include the use of biological agents which target the cytokine tumour necrosis factor (TNF), a key mediator of inflammation. With the advent of effective agents, therapy has become more aggressive, reducing disease activity and allowing, at least in RA, remission in many patients. While the array of available effective treatments is extensive, the use of objective measures of disease activity can guide treatment decisions (treat to target) and lead to improved outcomes.

Diagnosis and classification in spondyloarthritis: identifying a chameleon

Spondyloarthritis (SpA) defines a group of interrelated diseases, including ankylosing spondylitis (AS), psoriatic arthritis, reactive arthritis, enteropathic-related spondylitis and arthritis, and undifferentiated SpA. The clinical presentation of SpA is heterogeneous, and no single shared distinguishing feature exists for the conditions comprising SpA; in daily practice, diagnosis is usually made on the basis of a combination of symptoms, the findings of physical examination, imaging and laboratory investigations. Several classification criteria have been developed for AS and SpA, which are useful in a research setting but cannot be automatically applied to the diagnosis of individual patients. Currently, MRI is the most sensitive imaging modality available for detection of sacroiliitis, often enabling detection of axial inflammation long before structural lesions are observed radiographically, thus facilitating early diagnosis of axial SpA. However, MRI will never capture all facets of SpA and the expert opinion of a rheumatologist will remain the crucial step in recognition of this disease. In this Review, we discuss diagnosis and classification of AS and SpA, and highlight how MRI might facilitate both processes.

Is IL-6 an appropriate target to treat spondyloarthritis patients refractory to anti-TNF therapy? A multicentre retrospective observational study

INTRODUCTION

The aim of this study was to evaluate, under real-life conditions, the safety and efficacy of tocilizumab in patients having failed anti-TNFα therapy for spondyloarthritis.

METHODS

French rheumatologists and internal-medicine practitioners registered on the Club Rhumatismes et Inflammations website were asked to report on patients given tocilizumab (4 or 8 mg/kg) to treat active disease meeting Assessment of SpondyloArthritis International Society (ASAS) criteria for axial or peripheral spondyloarthritis, after anti-TNFα treatment failure. Safety and efficacy after 3 and 6 months were assessed retrospectively using standardised questionnaires.

RESULTS

Data were obtained for 21 patients, 13 with axial spondyloarthritis (46% men; median age, 42 years; disease duration, 11 years; HLA-B27-positive, 92.3%) and eight with peripheral spondyloarthritis (25% men; median age, 40 years; disease duration, 10 years; HLA-B27-positive, 62.5%). No patients with axial disease had at least a 20 mm decrease in the BASDAI, nor a BASDAI50 response or major ASAS-endorsed disease activity score improvements after 3 or 6 months; an ASAS-endorsed disease activity score clinically important improvement was noted at month 3 in five of 13 patients and at month 6 in one of four patients. A good DAS28 response was achieved in four patients with peripheral disease, including one in EULAR remission at month 3. Four patients were still taking tocilizumab at month 6, including one in EULAR remission and one with a good DAS28 response. Tocilizumab was well tolerated, with no serious adverse events. Initially elevated acute-phase reactants declined during tocilizumab therapy.

CONCLUSION

In patients having failed anti-TNFα therapy, tocilizumab decreased acute-phase reactants but failed to substantially improve axial spondyloarthritis and was inconsistently effective in peripheral spondyloarthritis.

Spondyloarthropathies in autoimmune diseases and vice versa

Polyautoimmunity is one of the major clinical characteristics of autoimmune diseases (ADs). The aim of this study was to investigate the prevalence of ADs in spondyloarthropathies (SpAs) and vice versa. This was a two-phase cross-sectional study. First, we examined the presence of ADs in a cohort of patients with SpAs (N = 148). Second, we searched for the presence of SpAs in a well-defined group of patients with ADs (N = 1077) including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and Sjögren's syndrome (SS). Among patients with SpAs, ankylosing spondylitis was observed in the majority of them (55.6%). There were two patients presenting with SS in the SpA group (1.4%) and 5 patients with autoimmune thyroiditis (3.5%). The global prevalence of ADs in SpAs was 4.86%. In the ADs group, there were 5 patients with SpAs (0.46%). Our results suggest a lack of association between SpAs and ADs. Accordingly, SpAs might correspond more to autoinflammatory diseases rather than to ADs.

Current therapeutics for spondyloarthritis

INTRODUCTION

Ankylosing spondylitis (AS) belongs to a clinically related group of disorders named spondyloarthritis (SpA) that mainly affect the axial skeleton and present with specific extra-articular manifestations. The therapeutic management of AS and other SpA has considerably progressed over the past 10 years.

AREAS COVERED

This paper provides a review of the available treatments for AS including traditional treatments (NSAIDs, sulfasalazine and methotrexate, local corticosteroids) and biological therapies (TNF-α antagonists), as well as nonpharmacological procedures (education and physical therapy) and specific recommendations for this therapeutic management.

EXPERT OPINION

NSAIDs remain the first-line treatment in patients with AS, especially with axial disease. There is an increasing amount of evidence showing the short-term and long-term efficacy of TNF-α antagonists in AS, with the control of pain, extra-articular manifestations and spinal inflammation as evidenced by MRI. By contrast, there is no proof for the control of radiographic progression at the spine with these agents. An early diagnosis is now possible using the new classification criteria for SpA. However, it remains to be established if an early intervention might control the progression of the disease. Since about 20 - 25% of patients are considered as nonmajor responders to TNF-α blockers, there is an unmet need for developing new biological therapies. Targeting the IL-17 pathway may be an interesting option. International recommendations for the management of AS by the Assessment of Spondyloarthritis (ASAS) group were recently updated and discussed the respective place of each current therapeutic option in AS.

Clinical utility of the new ASAS criteria for spondyloarthritis and the disease activity score

The advent of new therapeutic agents that are efficacious in the treatment of ankylosing spondylitis and related spondyloarthropathies has highlighted important unmet needs in our understanding of these conditions. Chief among these is the possibility of making a diagnosis at the early, nonradiographic phase, when the burden of disease is substantial and comparable to that of more advanced stages. The new Assessments in Spondyloarthritis International Society (ASAS) classification criteria provide a unique tool to allow research standardization in this area and may also be of clinical utility. The development of the disease activity index ASDAS (Ankylosing Spondylitis Disease Activity Score) aims to provide a composite measure that can discriminate and show sensitivity to change while incorporating measurable biomarkers. Both instruments represent a major step forward in the research field of spondyloarthritis, although further validation is now required.