Global Prevalence of Spondyloarthritis: A Systematic Review and Meta-Regression Analysis

Molecular mimicry in the pathogenesis of autoimmune rheumatic diseases

Autoimmune rheumatic diseases (ARDs) are a heterogeneous group of conditions characterized by excessive and misdirected immune responses against the body's own musculoskeletal tissues. Their exact aetiology remains unclear, with genetic, demographic, behavioural and environmental factors implicated in disease onset. One prominent hypothesis for the initial breach of immune tolerance (leading to autoimmunity) is molecular mimicry, which describes structural or sequence similarities between human and microbial proteins (mimotopes). This similarity can lead to cross-reactive antibodies and T-cell receptors, resulting in an immune response against autoantigens. Both commensal microbes in the human microbiome and pathogens can trigger molecular mimicry, thereby potentially contributing to the onset of ARDs. In this review, we focus on the role of molecular mimicry in the onset of rheumatoid arthritis and systemic lupus erythematosus. Moreover, implications of molecular mimicry are also briefly discussed for ankylosing spondylitis, systemic sclerosis and myositis.

Designing an integrated care pathway for spondyloarthritis: A Lean Thinking approach

INTRODUCTION

Integrated care pathways (ICPs) are crucial for delivering individualised care. However, the development of ICPs is challenging and must be well designed to provide the expected benefits. Regarding this, healthcare organisations are increasingly adopting management systems based on Lean Thinking to improve their organisational processes by eliminating non-value-added steps. This study elucidates the process and evaluates the impact of applying Lean Thinking to redesign an ICP for patients with spondyloarthritis, a chronic inflammatory disease affecting young adults.

METHODS

A multidisciplinary team was assembled and trained in Lean Thinking. Patient's perspective was gathered through a focus group. Guided by an expert methodologist, the team constructed a value stream map of the entire care pathway and analysed each step. Five work streams were defined to increase value at each step, leading to targeted process improvements. Key process and outcome metrics were collected and compared in 2-month baseline and post-implementation audits.

RESULTS

A total of 118 patients were included in the baseline audit (September-October 2022), and 116 in the post-implementation audit (January-February 2023). Process redesign resulted in statistically significant improvements (p < 0.05), including a reduction in the mean number of hospital visits per patient over a 2-month period from 2.54 (SD = 0.93) to 1.84 (SD = 0.79), an increase in complementary exams scheduled on the same day (81.4% to 94.8%) and an increase in baseline disease and treatment education (from 22.2% to 84.2% and from 18.2% to 84.6%, respectively). Regarding standardisation of clinical practice, there were significant increases in collecting data for medical records on composite activity indices (76.3% to 95.7%), reporting of pharmacological treatment adherence (68.6% to 94%) and providing nonpharmacological recommendations (31.3% to 95.7%).

CONCLUSIONS

The application of Lean Thinking to redesign the spondyloarthritis ICP led to significant improvements in outpatient appointment scheduling, reduced patient hospital visits, improved interdepartmental coordination and standardised clinical practice.

Efficacy and safety of upadacitinib, a selective JAK-1 inhibitor in treatment of ankylosing spondylitis: a meta-analysis

OBJECTIVE

To systemically assess efficacy and safety of upadacitinib (UPA), a selective inhibitor of Janus kinase 1 (JAK1) in treatment of ankylosing spondylitis (AS).

METHODS

Available databases were used to retrieve literatures of randomized controlled trials (RCTs) of UPA for AS treatment until February 2024. After that, the data were extracted and the Revman 5.4 software was used to conduct a meta-analysis.

RESULTS

A total of 6 articles and 1653 patients (920 in a UPA group (15 mg, q.d) and 733 in a placebo group) were selected in this study. Respectively, UPA treatment significantly increased numbers of the AS patients having 40%, 20%, or partial remission (PR) improvement in assessment of spondylo arthritis international society (ASAS) (ASAS 40: 95%CI: 2.41-4.3, p < 0.00001; ASAS 20: 95%CI: 2.12-3.62, p < 0.00001; ASAS PR: 95%CI: 2.81-7.48, p < 0.00001), Bath ankylosing spondylitis disease activity index (BASDAI50) (95%CI: 2.28 ~ 4.10, p < 0.00001), quality of life (95%CI: 2.06 ~ 3.17, p < 0.00001), AS disease activity score low disease activity (ASDAS LDA) (95%CI: 3.07~9.96, p < 0.00001), ASDAS inactive disease (ID) (95%CI: 2.03 ~ 17.22, p = 0.001), short-form 36 physical component summary (SF-36PCS) (95%CI: 1.53 ~2.81, p < 0.00001), and markedly reduced ASDAS C-reactive protein (CRP) (95%CI: -1.22 ~ -0.42, p < 0.0001), total back pain score (95%CI: -2.01 ~ -0.51, p = 0.001), nighttime back pain score (95%CI: -1.96 ~ -0.54, p = 0.0006), spondylo arthritis research consortium of Canada magnetic resonance imaging (SPARCC MRI) spine score (95%CI: -7.78--3.50, p < 0.00001) and SPARCC MRI sacroiliac joint score (95%CI: -5.99 - -3.09, p < 0.00001), Bath ankylosing spondylitis function index (BASFI) score (95%CI: -1.45 ~ -0.81, p < 0.00001), Maastricht ankylosing spondylitis enthesitis score (MASES) (95%CI: -2.34~-0.35, p = 0.008). Except for neutropenia (95%CI: 1.25 ~ 15.60, p = 0.02), no other adverse effects (AEs) were significantly different between the UPA treatment and placebo.

CONCLUSIONS

Through a literature analysis, it reveals that UPA offers significant therapeutic benefits to AS patients with a relatively high safety profile.

Tumor necrosis factor (TNF) inhibitors for psoriatic arthritis

BACKGROUND

Psoriatic arthritis (PsA) is a chronic arthritis affecting people with psoriasis. If untreated, it may lead to disability. Recommended drugs are non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), biologic DMARDs (bDMARDs), and targeted synthetic DMARDs (tsDMARDs). Tumour necrosis factor inhibitors (TNFi) are the first choice bDMARDs.

OBJECTIVES

To assess the benefits and harms of TNFi in adults with psoriatic arthritis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and the World Health Organization trials portal up to 28 March 2024.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in adults with PsA, comparing TNFi to placebo, physiotherapy, NSAIDs, corticosteroids, and cs/b/tsDMARDs. Major outcomes included clinical improvement, minimal disease activity, physical function, health-related quality of life, radiographic progression, serious adverse events, and withdrawals due to adverse events.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary comparison was TNFi versus placebo. The primary time point was 12 weeks for clinical improvement; 24 weeks for minimal disease activity, function, quality of life, and radiographic progression; and the end of the trial period for serious adverse events and withdrawals due to adverse events.

MAIN RESULTS

We included 25 RCTs randomizing 7857 participants. Four studies compared TNFi to methotrexate and one to ustekinumab in DMARD-naïve participants. In csDMARD-inadequate responders, 11 studies compared TNFi to placebo; four studies compared TNFi to placebo and ixekizumab, bimekizumab, tofacitinib, or upadacitinib; and three studies compared TNFi to ixekizumab, secukinumab, and ustekinumab. Two studies compared different TNFi. We found no studies with b/tsDMARD-inadequate responders (b/tsDMARD-IR). No studies compared TNFi to NSAIDs, corticosteroids, or physiotherapy. Performance (32%), detection (56%) and reporting (80%) biases were at high or unclear risk across studies. Only one study had a low risk of bias in all domains. We limit reporting to the primary comparison, TNFi versus placebo. DMARD-naïve We found no studies comparing TNFi with placebo in DMARD-naïve participants. csDMARD-inadequate responders TNFi probably result in a large clinical improvement compared to placebo. At 12 weeks, 149/1926 (8%) participants in the placebo group showed a clinical improvement (ACR50) compared to 784/2141 (37%) participants in the TNFi group (risk ratio (RR) 5.63, 95% confidence interval (CI) 3.98 to 7.96; I2 = 65%; 14 studies, 4067 participants; moderate-certainty evidence). TNFi probably result in a higher proportion of participants in minimal disease activity. At 24 weeks, 95/1017 (9%) participants in the placebo group were in minimal disease activity compared to 428/1336 (32%) participants in the TNFi group (RR 3.76, 95% CI 2.39 to 5.92; I2 = 72%; 5 studies, 2353 participants; moderate-certainty evidence). At 24 weeks, TNFi may improve function compared to placebo. The mean change in function from baseline (assessed with the Health Assessment Questionnaire; score from 0 to 3, 0 = no disability; minimal clinically important difference (MCID) = 0.35) was -0.14 points with placebo and 0.33 points lower (0.41 lower to 0.25 lower) with TNFi (I2 = 72%; 8 studies, 2949 participants; low-certainty evidence). TNFi probably result in a clinically important improvement in health-related quality of life. The mean change in quality of life from baseline (assessed with the Short Form 36-item Mental Component Summary questionnaire; score from 0 to 100, 100 = best score; MCID = 1.7) was 2.4 points with placebo and 3.29 points higher (2.18 points higher to 4.40 points higher) with TNFi (I2 = 52%; 8 studies, 2928 participants; moderate-certainty evidence). TNFi probably slightly reduce radiographic progression. The mean change in radiographic progression (assessed with the Sharp/Van der Heijde-PsA score; scale from 0 to 528, 0 = no damage) was 0.25 points with placebo and 0.37 points lower with TNFi (0.48 lower to 0.25 lower) (I2 = 32%; 7 studies, 2478 participants; moderate-certainty evidence) at 24 weeks. We downgraded the evidence to moderate certainty for clinical improvement, minimal disease activity, quality of life, and radiographic progression due to risk of bias. For function, we downgraded the evidence to low certainty for risk of bias and imprecision. TNFi may result in little to no difference in serious adverse events, but may slightly increase withdrawals due to adverse events, compared to placebo. At the end of follow-up: 56/1826 participants (3%) given placebo and 69/1900 (4%) participants given TNFi experienced serious adverse events (RR 1.00, 95% CI 0.70 to 1.42; I2 = 0%; 13 studies, 3866 participants; low-certainty evidence); and 35/1926 (2%) participants given placebo and 65/2140 (3%) given TNFi withdrew due to adverse events (RR 1.53, 95% CI 1.01 to 2.33; I2 = 0%; 14 studies, 4066 participants; low-certainty evidence). We downgraded the evidence to low certainty for risk of bias and imprecision.

AUTHORS' CONCLUSIONS

In csDMARD-inadequate responders, moderate-certainty evidence showed that TNFi probably result in a large clinical improvement, lower disease activity, small decrease in radiographic progression, and better quality of life compared to placebo. Low-certainty evidence showed that TNFi may lead to a slight improvement in physical function compared to placebo. Low-certainty evidence suggested that TNFi may lead to a slight increase in withdrawals due to adverse events, whereas they may result in little to no difference in serious adverse events compared to placebo. No trials assessed TNFi compared to placebo in DMARD-naïve participants or in b/tsDMARD-IR.

Exploring the molecular mechanism of Epimedium for the treatment of ankylosing spondylitis based on network pharmacology, molecular docking, and molecular dynamics simulations

Ankylosing spondylitis (AS) is a rheumatic disease that causes inflammation and bone formation in the spine. Despite significant advances in treatment, adverse side effects have triggered research into natural compounds. Epimedium (EP) is a traditional Chinese herb with a variety of pharmacological activities, including antirheumatic, anti-inflammatory, and immunomodulatory activities; however, its direct effects on AS treatment and the underlying molecular mechanisms have not been systematically studied. Thus, here, we used network pharmacology, molecular docking, and molecular dynamics simulations to explore the targets of EP for treating AS. We constructed an interaction network to elucidate the complex relationship between EP and AS. Sixteen active ingredients in EP were screened; 80 potential targets were identified. In particular, 8-(3-methylbut-2-enyl)-2-phenylchromone, anhydroicaritin, and luteolin were the core components and TNF, IL-6, IL-1β, MMP9, and PTGS2 were the core targets. The GO and KEGG analyses indicated that EP may modulate multiple biological processes and pathways, including the AGE-RAGE, TNF, NF-κB/MAPK, and TLR signaling pathways, for AS treatment. Molecular docking and molecular dynamics simulations showed good affinity between the active components and core targets of EP, with stable binding within 100 nanoseconds. In particular, 8-(3-methylbut-2-enyl)-2-phenylchromone possessed the highest free energy of binding to PTGS2 and TNF (-115.575 and - 87.676 kcal/mol, respectively). Thus, EP may affect AS through multiple pathways, including the alleviation of inflammation, oxidative stress, and immune responses. In summary, we identified the active components and potential targets of EP, highlighting new strategies for the further experimental validation and exploration of lead compounds for treating AS.

Prevalence of hidradenitis suppurativa in patients with axial spondyloarthritis

OBJECTIVES

To determine the prevalence of hidradenitis suppurativa (HS) in patients with axial spondyloarthritis (AxSpA) and to describe clinical, laboratory, and radiographic characteristics of patients diagnosed with HS.

PATIENTS AND METHODS

We performed a cross-sectional study of a cohort of 265 patients with AxSpA in follow-up at a tertiary hospital. Patients were screened for HS using a questionnaire, with subsequent diagnostic confirmation by a dermatologist. We collected demographic, clinical, laboratory, and radiographic data. Patients were classified by diagnosis of HS. A descriptive analysis and comparison were performed for both groups.

RESULTS

A total of 148 of the 265 patients (55.8%) completed the screening questionnaire. Screening was positive in 9 patients (6.1%), although the diagnosis of HS was confirmed in only 4 (2.7%). Three patients were diagnosed during the study, with a mean diagnostic delay of 14.25 years. All the patients had mild HS (Hurley stage I). When patients with and without HS were compared, the HS group had more smokers (75% vs 18%; p = 0.005), greater disease activity according to BASDAI (5.6 ± 2.3 vs 3.2 ± 2.1; p = 0.026), less structural damage according to the axial BASRI (1.5 ± 1.3 vs 5.5 ± 3.5; p < 0.018) and shorter time since diagnosis of AxSpA (14.7 ± 2.6 vs 27.8 ± 13.5 years; p = 0.001). No significant differences were found for the remaining variables studied.

CONCLUSION

This study suggests that prevalence of HS in patients with axSpA is higher than the one observed in general population. The knowledge of this association should encourage clinicians to inquire about symptoms of HS and actively search for lesions.

Dysregulation of amino acid and lipid metabolism in patients with spondyloarthritis

OBJECTIVE

To conduct a metabolomics analysis in patients with spondyloarthritis (SpA) and compare results with those from healthy controls. The overall goal was to identify small-molecule substances that may have potential pathogenic and diagnostic significance in SpA.

METHODS

This was an observational, cross-sectional, single-centre study that included patients with axial (ankylosing spondylitis [AS]), peripheral (psoriatic arthritis [PsA]) and healthy controls.

RESULTS

The study included 50 patients with AS, 50 patients with PsA, and 164 controls. When compared with healthy controls, patients with SpA showed significant differences in 35 metabolites, primarily associated with amino acid and lipid metabolism. However, only two differences were found between the AS and PsA cohorts (glucose and glycerol).

CONCLUSIONS

Our data suggest that patients with SpA exhibit significant disruptions in amino acid and lipid metabolism. The large number of identified metabolites offers promising opportunities, both for discovering new SpA biomarkers and for gaining a deeper understanding of the pathophysiology of these chronic inflammatory diseases.

Characteristics and multi-omics analysis of spontaneous spondyloarthritis in non-human primates: Case report

Spondyloarthritis is a prevalent and persistent condition that significantly impacts the quality of life. Its intricate pathological mechanisms have led to a scarcity of animal models capable of replicating the disease progression in humans, making it a prominent area of research interest in the field. To delve into the pathological and physiological traits of spontaneous non-human primate spondyloarthritis, this study meticulously examined the disease features of this natural disease model through an array of techniques including X-ray imaging, MRI imaging, blood biochemistry, markers of bone metabolism, transcriptomics, proteomics, and metabolomics. X-ray imaging results revealed that crab-eating monkeys (Macaca fascicularis) with spontaneous spondyloarthritis developed bone spurs in the spine and experienced bone destruction in peripheral joints. MRI imaging further confirmed inflammatory changes in the spine and facet joints of these monkeys, along with inflammation and bone destruction in peripheral joints. Blood biochemistry analysis showed abnormalities in liver function and kidney function indicators in crab-eating monkeys with spontaneous spondyloarthritis. Analysis of bone metabolism-related markers showed a decrease in bone formation (BGP) and bone resorption (β-CTx). A thorough correlation analysis was conducted on the transcriptome and proteome expression data, revealing a significant positive correlation between the two datasets. A total of eight genes and proteins with high expression levels were identified as common to both the transcriptome and proteome. Subsequent Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were performed on these co-expressed genes and proteins, indicating a predominant enrichment in the IL-17 signaling pathway, with S100A8 and S100A9 identified as the core proteins. Further analysis using clinical data in conjunction with proteome data through Weighted Gene Co-expression Network Analysis (WGCNA) demonstrated a significant positive correlation between the high expression of S100A8 and S100A9 and the clinical phenotypes of spinal abnormalities, thereby corroborating the close association of S100A8 and S100A9 with the phenotype of spondyloarthritis. Human clinical studies have already established a link between S100A8 and S100A9 and autoimmune-related arthritic diseases, suggesting that the spontaneous spondyloarthritis observed in crab-eating macaques may be related to autoimmune diseases. It is hypothesized that S100A8 and S100A9 could serve as potential predictive biomarkers for spondyloarthritis in non-human primates.

Ankylosing spondylitis: From pathogenesis to therapy

Ankylosing spondylitis (AS) is an autoimmune rheumatic disease that primarily affects the axial joints, with its etiology complex and still not fully understood. The unknown pathogenesis of AS limits the development of treatment strategies, so keeping up-to-date with the current research on AS can help in searching for potential therapeutic targets. In addition to the classic HLA-B27 genetic susceptibility and Th17-related inflammatory signals, increasing research is focusing on the influence of autoantigen-centered autoimmune responses and bone stromal cells on the onset of AS. Autoantigens derived from gut microbiota and preferential TCR both exacerbate the autoimmune response in patients with AS. Furthermore, dysregulated bone metabolism also promotes pathological new bone formation in AS. Current treatments approved for AS almost focus on the management of inflammation with inconsistent treatment results due to the heterogeneity of patients. In this review, we systematically summarized various pathogenesis and management of AS, meanwhile discussed the underlying risk factors and potential therapeutic targets.

Obesity and Chronic Inflammation: Implications for Rheumatoid Arthritis, Spondyloarthritis, and Ulcerative Colitis

BACKGROUND

Immune-mediated inflammatory diseases (IMIDs) are a group of chronic conditions characterized by dysregulated immune responses and persistent inflammation. Rheumatoid arthritis (RA), spondyloarthritis (SpA), and ulcerative colitis (UC) exemplify prominent IMIDs, each presenting unique challenges for their management, that impact patient's quality of life (QoL). Obesity, marked by persistent low-grade inflammation, influences the progression, response to treatment, and clinical management of patients with RA, SpA, and UC. Besides, the emerging role of sarcopenic obesity, a special subtype of obesity with malnutrition, should be considered in the definition of the appropriated therapeutic interventions.

METHODS

This narrative literature review summarizes recent evidence on the interplay between obesity-induced inflammation and IMIDs.

RESULTS

Obesity contributes to elevated levels of proinflammatory cytokines, influencing the inflammatory pathways common to IMIDs. White adipose tissue, acting as an endocrine organ, produces cytokines like TNF-α and IL-6, fueling chronic inflammation. The dysregulation of adipokines, such as leptin and adiponectin, further complicates this interplay, impacting immune responses and metabolic processes.

CONCLUSIONS

Understanding the cross-talk between inflammatory pathways in obesity and IMIDs can provide insight into potential targets for intervention. This includes lifestyle modifications aimed to regulate weight gain, paving the way for comprehensive strategies to manage IMIDs in the context of obesity.

A small-scale preliminary study utilizing mass cytometry to distinguish two forms of arthritis

OBJECTIVES

Spondyloarthritis (SpA) and rheumatoid arthritis (RA) are hallmarked by immune cell infiltration in synovial joints. Although, in general, different sites are affected, misclassification or delayed diagnosis due to overlapping clinical manifestations is not uncommon. Here, we investigated the diagnostic potential of mass cytometry (MC) in early peripheral SpA (pSpA) and RA patients in a small pilot study.

METHODS

Peripheral blood and synovial fluid mononuclear cells (PBMC and SFMC) of 4 pSpA, 7 RA, and 1 undifferentiated arthritis (UA) patient(s) were evaluated using a 37-marker MC panel. Data were analyzed through Visualyte services, including dimension reduction, clustering, and Cytofast workflow.

RESULTS

PBMC data indicated naive CD4 T cell, B cell, and monocyte subsets to be differentially present in RA as compared with SpA. CD4 + Tem cell and NK cell subsets appeared more prominently present in pSpA SFMC. Merged PBMC and SFMC data showed overlapping immune profiles of an UA patient with pSpA patients. These results were in accordance with the formal clinical pSpA diagnosis the UA patient received after this study.

CONCLUSIONS

Utilizing MC, several differences in immune cell composition in both SFMC and PBMC between RA and pSpA patients were observed. Combining PBMC and SFMC data in an unsupervised analysis resulted in the correct classification of the UA patient as pSpA patient prior to formal clinical pSpA diagnosis. This pilot study provides an example of how deep phenotyping with MC aids in differentiating arthritis patients and offers a rationale to further explore these findings.

KEY POINTS

•Due to overlapping symptoms and the absence of disease-specific biomarkers, the clinical diagnosis of peripheral spondyloarthritis (pSpA) and rheumatoid arthritis (RA) can be difficult. •Visualizing immune cell profiles of peripheral blood (PB) and synovial fluid (SF) by mass cytometry (MC) suggests differences in immune cell composition between pSpA and RA patients. •Based on immune profiles of combined PB and SF data, we could correctly predict the formal clinical pSpA diagnosis of an undifferentiated arthritis (UA) patient received later. •This pilot study gives an example of how MC might contribute to faster clinical diagnosis of pSpA patients in the absence of biomarkers.

Dose reduction and discontinuation of biologic and targeted synthetic disease-modifying anti-rheumatic drugs (DMARDs) for people with psoriatic arthritis in remission or low disease activity

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To determine the benefits and harms of dose reduction or discontinuation of biologic disease-modifying anti-rheumatic drugs or targeted synthetic disease-modifying anti-rheumatic drugs in adults with psoriatic arthritis who are in remission or a low disease activity state.

The worldwide prevalence of psoriatic arthritis-a systematic review and meta-analysis

OBJECTIVES

Previous attempts to pool prevalence studies in PsA have failed to take account of important methodological differences between studies that may have created biased estimates. The aim of this review is to estimate the prevalence of PsA within the adult general population worldwide, considering potential differences between population-based and health administrative studies separately.

METHODS

Four electronic databases were systematically searched for articles reporting the prevalence of PsA. Data were pooled to generate worldwide prevalence estimates. Where sufficient data were available, results were summarized by continent.

RESULTS

Thirty studies were identified, with half from Europe (n = 15). Thirteen population-based studies were identified comprising >92 000 adults, plus 17 studies (>180 million adults) based on health administrative data. The worldwide prevalence of PsA was 112 per 100 000 adults. The prevalence of PsA estimated using population-based studies was 113 per 100 000 with continent-specific estimates of 207 (Europe), 64 (North America) and 37 (Asia) per 100 000. Health administrative studies gave a global prevalence of 109 per 100 000 with continent-specific prevalence of 175 (Europe), 147 (North America), 78 (Asia) and 17 (South America).

CONCLUSION

This review compiles currently available estimates of PsA prevalence in the general population into global and continent-based estimates and considers important study design characteristics. There is wide variability between continents, and data in some geographical areas are sparse, but available evidence suggests that PsA is more common in Europe and North America compared with Asia and South America, and current best estimates suggest a global prevalence of 112 per 100 000 adults.

Patient-initiated follow-up supported by asynchronous telemedicine versus usual care in spondyloarthritis (TeleSpA-study): a randomised controlled trial of clinical and cost-effectiveness

BACKGROUND

With rising health-care expenditures and workforce shortages, sustainable alternatives to traditional outpatient follow-up strategies are required to optimise care efficiency. We aimed to investigate the cost-effectiveness and clinical effectiveness of patient-initiated follow-up (PIFU) supported by asynchronous telemedicine for patients with spondyloarthritis compared with usual care in daily practice.

METHODS

TeleSpA was a multicentre, pragmatic, open-label, randomised controlled trial. Patients with spondyloarthritis and stable disease were randomly assigned (1:1) to either the PIFU and asynchronous telemedicine group or usual care group. All patients received a scheduled outpatient visit at baseline and after 1 year. Patients were monitored remotely at 6 months (PIFU and asynchronous telemedicine) or at the discretion of the treating rheumatologist (usual care). The primary outcome was the number of rheumatology visits within a 1-year period. A trial-based 1-year health-economic evaluation from a Dutch health-care perspective (only including health-care costs) and societal perspective (also including travel costs and work productivity losses), per the Dutch guidelines was used to estimate cost-effectiveness. The safety analysis was done in the intention-to-treat population and was based on spontaneous reports of adverse events and serious adverse events or as observed by the research team. The primary analysis was in the intention-to-treat population. Individuals with relevant lived experience were involved in the study design. This trial was registered with the Dutch National Trial Register (NL71041.068.19) and ClinicalTrials.gov (NCT04673825) and is completed.

FINDINGS

Between Dec 2, 2020, and June 20, 2022, 200 patients were randomly assigned to PIFU and asynchronous telemedicine (n=100) or usual care (n=100). 79 (40%) of 200 participants were women, 121 (60%) were men, and the mean age was 55·0 years (SD 11·9). After 1 year, the mean number of rheumatology visits was 1·9 (SD 1·5) for the PIFU and asynchronous telemedicine group and 2·6 (1·3) in the usual care group (mean difference -0·7 [95% CI -1·0 to -0·3]; 25·4% reduction; p<0·0001). PIFU and asynchronous telemedicine was cost-effective from a health-care perspective, saving health-care costs (-€180 [95% CI -921 to 560]) without a loss in quality-adjusted life-years (0·004 [95 % CI -0·022 to 0·030]). Seven non-trial-related adverse events occurred in the PIFU and asynchronous telemedicine group and eight in usual care group (including one death).

INTERPRETATION

PIFU and asynchronous telemedicine resulted in significant and clinically meaningful reductions in rheumatology visits. This was not at the expense of health outcomes and saved health-care costs.

FUNDING

Dutch Arthritis Society.

Epidemiologic Trends and Socioeconomic Disparities of Ankylosing Spondylitis in South Korea: A Nationwide Population-Based Study, 2010-2021

PURPOSE

To investigate the epidemiological trends and socioeconomic disparities associated with ankylosing spondylitis (AS) in South Korea over a decade (2010-2021) using National Health Insurance Service (NHIS) claims data.

MATERIALS AND METHODS

Employing data from the NHIS database, this study identified 31753 incident AS patients in 2010-2021. We calculated the annual age-standardized prevalence and incidence rates and analyzed crude incidence rates and diagnostic patterns across age groups. Additionally, we compared the mean annual proportions of medical aid recipients between AS patients and the general population, utilizing p for trend analysis to assess the differences between the two groups across increasing age groups.

RESULTS

The study period saw a steady increase in age-standardized prevalence (from 34.6 to 91.0 per 100000) and incidence rates (from 4.41 to 8.33 per 100000 person-years), with the most substantial rise of incidence found in younger demographics. Diagnostic trends revealed a shift from internal medicine (IM) to other specialties including orthopedics with increasing patient age groups (p for trend=0.008), indicating old-age diagnosis in non-IM departments. A 1.4-fold higher proportion of medical aid recipients in AS patients (p<0.001) and the widening gap of dependency on medical aid in older age groups (p for trend=0.012) compared to the general population highlight socioeconomic disparities.

CONCLUSION

This comprehensive analysis reveals the growing epidemiological burden of AS, especially in younger populations, and the socioeconomic disparities regarding the disease in South Korea. It underscores the need for early diagnosis and effective treatment strategies, paving the way for health interventions and policies aimed at improving patient outcomes and addressing socioeconomic disparities.

Effectiveness of N-3 fatty acids supplementation on spondyloarthritis: A systematic review and meta-analysis

BACKGROUND & AIMS

The study aims to systematically review and meta-analyze randomized controlled trials (RCTs) assessing the effects of n-3 fatty acids (FA) supplementation on spondyloarthritis (SpA) disease activity, inflammatory markers, and imaging.

METHODS

The study protocol was developed and registered online in advance. The PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases were systematically searched for RCTs up to April 2024. Two independent reviewers screened, assessed for eligibility, and extracted data from the eligible RCTs. The revised Cochrane Risk of Bias tool was used to assess the quality of trials. The random-effects model was used to calculate the pooled estimates.

RESULTS

We included four RCTs, involving 245 patients with SpA. Supplementation with n-3 FA did not improve physician-reported outcomes [number of tender joints (four trials, standardized mean difference (SMD): -0.22; 95 % confidence interval (CI): -0.74 to 0.29; I2 = 61 %), number of swollen joints (two trials, SMD: -0.13; 95 % CI: -0.42 to 0.15; I2 = 0 %)], and patient-reported outcomes [pain (three trials, SMD: -0.16; 95 % CI: -1.03 to 0.70; I2 = 74 %), Health Assessment Questionnaire (three trials, SMD: -0.04; 95 % CI: -0.78 to 0.70; I2 = 71 %). The other nine pre-specified outcomes were not analyzed due to lack of information from the original RCTs which were evaluated as «some concerns» or «high risk» of bias.

CONCLUSIONS

In the present systematic review and meta-analysis including placebo-controlled RCTs, n-3 FA supplementation did not show improvement in the reported outcomes. Future RCTs should be conducted with homogenous intervention, placebo, and outcomes to re-examine possible beneficial effects.

Testing the efficacy of WORK-ON: vocational rehabilitation for people with chronic inflammatory arthritis in Denmark-protocol for a randomised controlled trial

INTRODUCTION

Among people with chronic inflammatory arthritis (IA), up to 40% lose their job in the first few years after diagnosis of this condition and are hence at high risk of being permanently excluded from the labour market. Therefore, we developed a new context-specific vocational rehabilitation (VR) for people with IA. This 6 month VR (WORK-ON) includes the following: (1) an initial assessment and goal setting by a coordinating occupational therapist, who supports cooperation and coordination between relevant partners and navigation across primary and secondary care, (2) four group sessions with peers and (3) individual sessions with a social worker, nurse or physiotherapist. The objective of this trial is to test the overall efficacy of WORK-ON as an add-on to usual care and compare it with usual care provided to a control group.

METHODS AND ANALYSIS

A randomised controlled trial has been planned. Patients with IA, aged at least 18 years and experiencing job insecurity will be randomised to one of two groups: (1) the intervention group receiving WORK-ON VR as an add-on to usual care and (2) the control group receiving usual care. The primary outcome is the difference in work ability 12 months after baseline, which will be measured using the Work Ability Index single item. The key secondary outcome measures are absenteeism, presenteeism, overall work impairment, activity impairment and job loss measured at baseline and at 6, 12, 18 and 30 month follow-up. Secondary outcome measures are quality of life, mental well-being, fatigue, sleep, physical activity, occupational balance and pain, which will be measured at baseline and at 6 and 12 month follow-up.

ETHICS AND DISSEMINATION

The Regional Committees on Health Research Ethics in Southern Denmark waived the requirement for a formal approval (Journal number S-20232000-3). The participants will provide informed consent prior to participating in the trial.

TRIAL REGISTRATION NUMBER

NCT06299917.

Novel DNA Aptamers to Dickkopf-1 Protein and Their Application in Colorimetric Sandwich Assays for Target Detection in Patients with Axial Spondyloarthritis

Chronic immunoinflammatory rheumatic diseases, such as axial spondyloarthritis (AxSpA), are accompanied by a dysregulation of bone remodeling. Among potential biomarkers of bone metabolism, the Wnt pathway antagonist, Dickkopf-1 (DKK-1), is of particular interest because of its potential to reflect a shift towards joint ossification or osteoporosis, but its diagnostic value needs validation. There is still a lack of stable and efficient methods of measuring serum DKK-1 levels suitable for longitude studies. The use of aptamer-based diagnostic assays could be very promising for this purpose. We generated novel anti-DKK-1 DNA aptamers from a combinatorial library with a pre-defined sequence pattern in the randomized region. This approach showed high efficacy, as only four SELEX rounds of selection produced high-affinity aptamers with dissociation constants ranging from 1.3 to 3.7 nM. A family of their truncated versions was also developed by rational design. Novel DNA aptamers functioned as capture components in a microplate ELISA-like assay with HRP-conjugated anti-DKK-1 antibody as a reporter component. We succeeded in revealing the aptamer/aptamer sandwich pairs that provided an aptamer-only sandwich colorimetric assay. The aptamer/antibody colorimetric test systems were also examined in the analyses of blood serum from AxSpA patients and shown sufficient workability. However, in a number of cases we registered significant differences between assays based on TD10 and DK4 aptamers and made some suggestions about the origin of this effect.

Axial Imaging in Spondyloarthritis

Imaging plays a crucial role in diagnosing and forecasting treatment outcomes in axial spondyloarthritis. Conventional radiography may overlook patients in the initial stages of the disease, while MRI is sensitive in identifying inflammation early on. Computed tomography reliably detects structural abnormalities. Practicing rheumatologists must possess a fundamental understanding of interpreting both active inflammatory and structural lesions in axial spondyloarthritis.

Psoriatic arthritis with psychological comorbidities: an overview of systematic reviews on incidence, prevalence, and geographic disparities

Systematic reviews and meta-analysis evaluating the prevalence, incidence, and psychological comorbidities of psoriatic arthritis (PsA) are increasing, so it's time to perform an overview of systematic reviews. To summarize the pooled prevalence, incidence, and psychological comorbidities rates of PsA, and to explore possible continent disparities. In this overview of systematic reviews the CINAHL, EMBASE, PsycINFO, and PubMed were searched to October 25, 2023. This overview included systematic reviews with meta-analysis of people with PsA, providing the pooled prevalence or incidence rates of PsA in general, or clinical populations and/or psychological comorbidities. The Preferred Reporting Items for Overviews of Reviews (PRIOR) statement was followed. AMSTAR-2 assessed the quality of reviews. The degree of overlap was calculated using the corrected covered area (CCA). Maps were developed using the location of where primary studies were conducted using DataWrapper App. The protocol was prospectively registered with Open Science Framework registry. Pooled prevalence and incidence rates of PsA or its associated psychological comorbidities in general or specific populations. We also collected locations from the primary studies of the included meta-analyses. Only the assessment of prevalence rates of PsA in people with psoriasis showed slight overlap (CCA = 3.3%). Items 2, 3, 4, 7, 8, 10, 12, and 13 were poorly reported in AMSTAR-2. The pooled prevalence of PsA ranged from 0.13 to 0.15% in the general population, and 15.5% to 19.7% in people with psoriasis. The pooled incidence of PsA ranged from 8.26 to 9.27 cases per 100,000 inhabitants to 0.87 cases in individuals with hidradenitis suppurativa. The pooled prevalence of psychological comorbidities was 11.9-20% for depression, 19-33% anxiety, 38% alexithymia, and 72.9% in poor sleep quality. Only the pooled incidence of depression was assessed with 21.3 per 1000-person year. PsA seems to be prevalent and incident not only in people with psoriasis, but also in general population. Depression and anxiety symptoms may be present in some patients with PsA. Finally, continent disparities exist, and methodological and clinical issues were found, which could be helpful in the future agenda of the epidemiology of PsA.

Is vitamin D associated with disease activity in patients with axial or peripheral spondyloarthritis? A real-life study

Vitamin D plays important role in inflammatory rheumatic diseases, which in turn rose an interest for investigating association of its deficiency with disease activity. In this research we aimed to evaluate this matter in the context of spondyloarthritis (SpA), together with treatment modalities and bone density in people diagnosed with axial or peripheral SpA in real-life setting. In our study we enrolled 99 patients with diagnosis of SpA treated at the tertiary level rheumatology department. Serum 25(OH)D levels, treatment modality (NSAIR or DMARDs), disease activity, tobacco smoking habits, mineral density of bone, supplementation and seasonal variations were assessed. We used standardized questionnaires such as ASDAS-CRP, BASFI and joint count, among many others, to evaluate some of the mentioned parameters. Sixty-five percent of patients had vitamin D deficiency. We found marginaly higher activity of disease in subjects with low vitamin D. In cases of peripheral SpA, there was a significant association of higher number of swollen joints and lower vitamin D levels. Additionally, the significant correlation was seen between normal serum vitamin D and supplementation. In our real-life study of patients with SpA we found a significant percentage of vitamin D deficit, with a tendency of slightly higher disease activity in those patients.In order to clarify the impact of the vitamin on disease activity in SpA and the supplementation recommendations for patients with these conditions, the conduction of further studies is required.

Prevalence and Predictors of Inflammatory Arthritis in Hidradenitis Suppurativa

Hidradenitis Suppurativa (HS) is a chronic, debilitating, auto-inflammatory condition often associated with inflammatory arthritis, significantly impacting patients' quality of life. Early diagnosis of both conditions is crucial for optimal management. The objective of this study was to determine the prevalence and factors associated with the development of inflammatory arthritis among HS patients. A cross-sectional study was conducted between November 2021 and February 2023 at an academic dermatology centre in Canada. Adult patients with HS were consecutively sampled, and 52 patients consented to participate and completed assessments. Variables examined included age, sex, HS severity, treatment, ethnicity, family history, lifestyle factors and comorbidities. The main outcomes were rheumatologist-confirmed inflammatory arthritis diagnosis and associated risk factors. Among 52 patients (24 males, 28 females; mean age: 37.4 years), 12 had inflammatory arthritis. Multivariate analysis revealed that Blacks (OR = 0.10, p < 0.001, CI: 0.026-0.343) and Asians (OR = 0.02, p < 0.001, CI: 0.005-0.109) had lower inflammatory arthritis odds compared to Whites. Every 1-year increase in age at HS onset correlated with a 1.17-fold increase in the odds of developing inflammatory arthritis (OR: 1.17, p < 0.001, CI: 1.12-1.24). Smoking (OR = 0.01, p < 0.001, CI: 0.002-0.49), hypertension (OR: 0.23, p = 0.04, CI: 0.057-0.930) and depression (OR: 0.12, p < 0.001, CI: 0.041-0.330) reduced inflammatory arthritis odds. White ethnicity and older age at HS onset were positively associated with inflammatory arthritis, while smoking, hypertension and depression were negatively associated. These findings suggest a distinct subset of HS patients with inflammatory arthritis that warrant further prospective studies. This study contributes to the understanding of inflammatory arthritis in HS patients and emphasises the importance of rheumatology referral during dermatologic clinic visits.

Regional variations in psoriatic arthritis: Insights from a nationwide multicenter analysis in Türkiye

Objectives

The study aimed to investigate and compare clinical features, disease activity, and the overall disease burden among psoriatic arthritis (PsA) patients across seven distinct geographic regions in Türkiye.

Patients and methods

A multicenter cross-sectional study involving 1,134 PsA patients from 25 referral centers across seven regions was conducted. Demographic and clinical characteristics, comorbidities, joint involvement, extra-articular manifestations, and disease activity measures were evaluated across regions.

Results

A total of 1134 PsA patients from seven different geographic regions in Türkiye participated in this study. The highest number of participants was from the Marmara region (n=409), with subsequent representation from Central Anatolia (n=370), Aegean (n=139), Mediterranean (n=60), Black Sea (n=60), Eastern Anatolia (n=60), and Southeastern Anatolia (n=36) regions. There were significant variations in demographic profile, including age, body mass index, age of disease onset, educational status, comorbidities, and family history of both psoriasis and PsA. Clinical features, such as enthesitis, dactylitis, uveitis, and joint involvement, demonstrated significant variation across regions. Additionally, disease activity measures, including pain, patient and physician global assessments, acute phase reactants, disease activity indices, quality of life, and functional status, displayed considerable regional differences.

Conclusion

This nationwide study revealed substantial regional diversity in demographic data, clinical characteristics, disease activity, and quality of life among PsA patients in Türkiye. These findings stress the need to customize treatment approaches to address regional needs and to conduct further research to uncover reasons for disparities. It is crucial to enhance region-specific approaches to improve patient care and outcomes for PsA.

The time of equipoise on the use of biological DMARDs in for inflammatory arthritis during pregnancy is finally over: a reappraisal of evidence to optimise pregnancy management

Active inflammatory arthritis in pregnancy is associated with an increased risk of adverse pregnancy outcomes. Treatment of active inflammation and maintenance of low disease activity with medication reduces these risks. Therapeutic decisions on disease-modifying antirheumatic drugs (DMARDs) in pregnancy are complicated by safety concerns, which have led to inappropriate withdrawal of treatment and consequential harm to mother and fetus. Studies of inflammatory arthritis in pregnancy have consistently shown minimal safety concerns with the use of biological DMARDs and an increased risk of disease flare with discontinuation of biological DMARDs. It is our opinion that during pregnancy, the benefits of disease control with biological DMARDs, when required in addition to conventional synthetic DMARDs, outweigh the risks. In this Series paper, we review the reasons for reconsideration of equipoise and propose an agenda for future research to optimise the use of biological DMARDs in inflammatory arthritis during pregnancy.

Identification of necroptosis-related genes in ankylosing spondylitis by bioinformatics and experimental validation

The pathogenesis of ankylosing spondylitis (AS) remains unclear, and while recent studies have implicated necroptosis in various autoimmune diseases, an investigation of its relationship with AS has not been reported. In this study, we utilized the Gene Expression Omnibus database to compare gene expressions between AS patients and healthy controls, identifying 18 differentially expressed necroptosis-related genes (DENRGs), with 8 upregulated and 10 downregulated. Through the application of three machine learning algorithms-least absolute shrinkage and selection operation, support vector machine-recursive feature elimination and random forest-two hub genes, FASLG and TARDBP, were pinpointed. These genes demonstrated high specificity and sensitivity for AS diagnosis, as evidenced by receiver operating characteristic curve analysis. These findings were further supported by external datasets and cellular experiments, which confirmed the downregulation of FASLG and upregulation of TARDBP in AS patients. Immune cell infiltration analysis suggested that CD4+ T cells, CD8+ T cells, NK cells and neutrophils may be associated with the development of AS. Notably, in the group with high FASLG expression, there was a significant infiltration of CD8+ T cells, memory-activated CD4+ T cells and resting NK cells, with relatively less infiltration of memory-resting CD4+ T cells and neutrophils. Conversely, in the group with high TARDBP expression, there was enhanced infiltration of naïve CD4+ T cells and M0 macrophages, with a reduced presence of memory-resting CD4+ T cells. In summary, FASLG and TARDBP may contribute to AS pathogenesis by regulating the immune microenvironment and immune-related signalling pathways. These findings offer new insights into the molecular mechanisms of AS and suggest potential new targets for therapeutic strategies.

Cost of lost productivity in inflammatory arthritis and osteoarthritis in the year before and after diagnosis: An inception cohort study

AIM

Existing studies on the cost of inflammatory arthritis (IA) and osteoarthritis (OA) are often cross-sectional and/or involve patients with various disease durations, thus not providing a comprehensive perspective on the cost of illness from the time of diagnosis. In this study, we therefore assessed the cost of lost productivity in an inception cohort of patients with IA and OA in the year before and after diagnosis.

METHODS

Employment status, monthly income, days absent from work, and presenteeism were collected at diagnosis and 1 year later to estimate the annual costs of unemployment, absenteeism, and presenteeism using human capital approach. Non-parametric bootstrapping was performed to account for the uncertainty of the estimated costs.

RESULTS

Compared to patients with OA (n = 64), patients with IA (n = 102, including 48 rheumatoid arthritis, 19 spondyloarthritis, 23 psoriatic arthritis, and 12 seronegative IA patients) were younger (mean age: 52.3 vs. 59.5 years) with a greater proportion receiving treatment (99.0% vs. 67.2%) and a greater decrease in presenteeism score (median: 15% vs 10%) 1 year after diagnosis. Annual costs of absenteeism and presenteeism were lower in patients with IA than those with OA both in the year before (USD566 vs. USD733 and USD8,472 vs. USD10,684, respectively) and after diagnosis (USD636 vs. USD1,035 and USD6,866 vs. USD9,362, respectively).

CONCLUSION

Both IA and OA impose substantial cost of lost productivity in the year before and after diagnosis. The greater improvement in productivity seen in patients with IA suggests that treatment for IA improves work productivity.

Raftlin - a potential biomarker for axial spondyloarthritis and psoriatic arthritis: An observational study

Our aim is to evaluate serum Raftlin levels as a biomarker for diagnosing and monitoring disease activity in patients with axial spondyloarthritis (axSpA) and Psoriatic arthritis (PsA). This trial included 40 axSpA patients, 40 PsA patients, and 40 healthy participants as the control group. Disease activity was assessed with Ankylosing Spondylitis Disease Activity Score for axSpA patients and The Disease Activity Index for Psoriatic Arthritis for PsA patients. The Spondyloarthritis Research Consortium of Canada index, health assessment questionnaire-disability index, and numeric rating scale were used to evaluate the enthesitis severity, disability, and pain status of all patients. Serum Raftlin levels were determined using the ELISA method. The 3 groups had no statistical differences regarding gender, age, weight, height, BMI, educational status, and exercise habits. The axSpA group had higher Raftlin levels than the PsA and control groups, and Raftlin levels were statistically significant in predicting the likelihood of axSpA. We found no statistically significant differences between the PsA and control groups. We found no statistically significant difference in Raftlin levels in HLA-B27 positive versus HLA-B27 negative patients in both axSpA and PsA groups. Our results also did not detect any correlation of Raftlin levels with Ankylosing Spondylitis Disease Activity Score, C-reactive protein, erythrocyte sedimentation rate, health assessment questionnaire-disability index, numeric rating scale, and Spondyloarthritis Research Consortium of Canada index in axSpA patients. Receiver operating characteristic analysis determined that Raftlin level ≥ 6.31 ng/mL discriminates axSpA from normal individuals with 92.5% sensitivity, 59% specificity, and an area under the curve of 0.738. Our results demonstrate that although serum Raftlin levels are elevated in axSpA patients, Raftlin cannot be used as an alone diagnostic marker for axSpA. Furthermore, it was not found to be related to the monitoring of disease activity, the level of pain, disability, or severity of enthesitis. This study is prospectively registered at www.clinicaltrials.gov (ID: NCT05771389).

Sex dimorphism of IL-17-secreting peripheral blood mononuclear cells in ankylosing spondylitis based on bioinformatics analysis and machine learning

BACKGROUND

Ankylosing spondylitis (AS) with radiographic damage is more prevalent in men than in women. IL-17, which is mainly secreted from peripheral blood mononuclear cells (PBMCs), plays an important role in the development of AS. Its expression is different between male and female. However, it is still unclear whether sex dimorphism of IL-17 contribute to sex differences in AS.

METHODS

GSE221786, GSE73754, GSE25101, GSE181364 and GSE205812 datasets were collected from the Gene Expression Omnibus (GEO) database. Differential expressed genes (DEGs) were analyzed with the Gene Set Enrichment Analysis (GSEA), Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) methods. CIBERSORTx and EcoTyper algorithms were used for immune infiltration analyses. Machine learning based on the XGBoost algorithm model was used to identify the impact of DEGs. The Connectivity Map (CMAP) database was used as a drug discovery tool for exploring potential drugs based on the DEGs.

RESULTS

According to immune infiltration analyses, T cells accounted for the largest proportion of IL-17-secreting PBMCs, and KEGG analyses suggested an enhanced activation of mast cells among male AS patients, whereas the expression of TNF was higher in female AS patients. Other signaling pathways, including those involving metastasis-associated 1 family member 3 (MAT3) or proteasome, were found to be more activated in male AS patients. Regarding metabolic patterns, oxidative phosphorylation pathways and lipid oxidation were significantly upregulated in male AS patients. In XGBoost algorithm model, DEGs including METRN and TMC4 played important roles in the disease process. we integrated the CMAP database for systematic analyses of polypharmacology and drug repurposing, which indicated that atorvastatin, famciclocir, ATN-161 and taselisib may be applicable to the treatment of AS.

CONCLUSIONS

We analyzed the sex dimorphism of IL-17-secreting PBMCs in AS. The results showed that mast cell activation was stronger in males, while the expression of TNF was higher in females. In addition, through machine learning and the CMAP database, we found that genes such as METRN and TMC4 may promote the development of AS, and drugs such as atorvastatin potentially could be used for AS treatment.

Molecular maps of synovial cells in inflammatory arthritis using an optimized synovial tissue dissociation protocol

In this study, we optimized the dissociation of synovial tissue biopsies for single-cell omics studies and created a single-cell atlas of human synovium in inflammatory arthritis. The optimized protocol allowed consistent isolation of highly viable cells from tiny fresh synovial biopsies, minimizing the synovial biopsy drop-out rate. The synovium scRNA-seq atlas contained over 100,000 unsorted synovial cells from 25 synovial tissues affected by inflammatory arthritis, including 16 structural, 11 lymphoid, and 15 myeloid cell clusters. This synovial cell map expanded the diversity of synovial cell types/states, detected synovial neutrophils, and broadened synovial endothelial cell classification. We revealed tissue-resident macrophage subsets with proposed matrix-sensing (FOLR2+COLEC12high) and iron-recycling (LYVE1+SLC40A1+) activities and identified fibroblast subsets with proposed functions in cartilage breakdown (SOD2highSAA1+SAA2+SDC4+) and extracellular matrix remodeling (SERPINE1+COL5A3+LOXL2+). Our study offers an efficient synovium dissociation method and a reference scRNA-seq resource, that advances the current understanding of synovial cell heterogeneity in inflammatory arthritis.

Risk of disease flare in spondyloarthritis patients after tapering tumor necrosis factor inhibitors: A meta-analysis and literature review

BACKGROUND

Tumor necrosis factor inhibitors (TNFis) have shown dramatic benefit in patients with spondyloarthritis (SpA). Tapering of TNFi medication may be considered in patients with sustained low disease activity because continued use of TNFis at standard doses may increase the risk of side effects including infections and impose an economic burden. However, the optimal TNFi tapering strategy for SpA patients with inactive disease has not been established. In the present study, we investigated whether tapering TNFi doses is associated with similar risk of disease flare to maintaining SpA patients on TNFis at the standard dosage.

METHODS

The MEDLINE, Embase, and Cochrane databases were systemically searched to retrieve randomized control trials (RCTs) and observational studies published prior to August 2023, that compared disease flare in SpA (including axial SpA [axSpA], psoriatic arthritis [PsA], and SpA with IBD) patients who received standard TNFi doses and those who received a tapered dose of TNFi. Odds ratios (ORs) and 95% confidence intervals (CIs) were directly retrieved or calculated, and meta-analyses were performed. Bias was assessed using funnel plots with Begg and Mazumdar rank correlation / Egger's regression method.

RESULTS

Among 2,237 SpA patients in the 12 studies (9 RCTs and 3 observational studies) retrieved, 1,301 received the standard TNFi dose, while 936 SpA patients underwent TNFi tapering. Of these, 216 (16.6%) standard-dose TNFi and 217 (23.2%) TNF-tapering patients experienced disease flares. The pooled OR for disease flare in TNFi-tapering patients was 1.601 (95% CI 1.276 - 2.008) compared with the standard-dose patients. The funnel plot showed no publication bias.

CONCLUSIONS

The strategy of TNFi tapering was associated with a significantly increased risk of disease flare compared to maintaining SpA patients at the standard TNF dose. Further studies are needed to determine which patients can safely undergo tapering of TNFi and to develop safe tapering strategies.

Pro-inflammatory cytokines in spondyloarthritis: a case-control study

OBJECTIVES

We aimed to determine the discriminative values of pro-inflammatory cytokines to distinguish spondyloarthritis patients from healthy subjects and to assess the association between these cytokines and spondyloarthritis characteristics.

METHODS

We conducted a case-control study, including 144 subjects matched for age and sex: 72 spondyloarthritis patients(G1) and 72 controls (G2). The disease activity was assessed using ASDAS-CRP and BASDAI. Structural damage was assessed using BASRI. The levels of interleukin (IL) IL-1, IL-6, IL-8, IL-17, IL-23, and tumor necrosis factor α(TNFα) were measured.

RESULTS

Each group included 57 men. The mean age was 44.84 ± 13.42 years. Except for IL-8, all cytokine levels were significantly higher in patients compared to controls (IL-1: p = 0.05, IL-6: p = 0.021, TNFα: p = 0.039, IL-17 and IL-23: p < 0.001). Cutoff values of IL-17 and IL-23 distinguishing patients in G1 from those in G2 were 17.6 and 7.96 pg/mL, respectively. TNFα level correlated to BASDAI (p = 0.029) and BASRI (p = 0.002). Multivariate analysis showed that structural damage was associated with the male gender (p = 0.017), longer disease duration (p = 0.038), and high disease activity (p = 0.044). Disease activity was associated with longer disease duration (p = 0.012) and increased IL-6 levels (p = 0.05).

CONCLUSION

Our study showed that IL-17 was the ablest to distinguish between spondyloarthritis patients and controls, suggesting that IL-17 may be helpful for the diagnosis of spondyloarthritis.

Exploring the Pathogenesis of Spondylarthritis beyond HLA-B27: A Descriptive Review

Spondylarthritis (SpA) is a chronic inflammatory condition that encompasses damage to the axial or peripheral skeleton, accompanied by specific extra-articular symptoms. Within this group, Ankylosing Spondylitis stands out as the hallmark member. Although the heritability of Ankylosing Spondylitis is estimated to be over 95%, only a portion of the heritability has been explained, with HLA-B27 accounting for 20.1% of it; therefore, ongoing research endeavors are currently concentrated on investigating the potential participation of different entities in the development of the disease. Genome-wide association studies have led to significant advances in our understanding of the genetics of SpA. In this descriptive review, we delve into the pathogenesis of Spondylarthritis beyond HLA-B27. We summarize the latest research on the potential participation of various entities in the development of the disease, including other genetic loci, immune dysregulation, microbiota, and environmental factors. The multifactorial nature of SpA and the complex interplay of genetic, immunological, and environmental factors are being increasingly recognized; therefore, it is of paramount importance to consider a holistic approach to comprehend the pathogenesis of SpA in order to identify novel therapeutic targets.

Increased interleukin-26 in the peripheral joints of patients with axial spondyloarthritis and psoriatic arthritis, co-localizing with CD68-positive synoviocytes

Objectives

IL26 levels are elevated in the blood and synovial fluid of patients with inflammatory arthritis. IL26 can be produced by Th17 cells and locally within joints by tissue-resident cells. IL26 induces osteoblast mineralization in vitro. As osteoproliferation and Th17 cells are important factors in the pathogenesis of axial spondyloarthritis (axSpA), we aimed to clarify the cellular sources of IL26 in spondyloarthritis.

Methods

Serum, peripheral blood mononuclear cells (n = 15-35) and synovial tissue (n = 3-9) of adult patients with axSpA, psoriatic arthritis (PsA) and rheumatoid arthritis (RA) and healthy controls (HCs, n = 5) were evaluated by ELISA, flow cytometry including PrimeFlow assay, immunohistochemistry and immunofluorescence and quantitative PCR.

Results

Synovial tissue of axSpA patients shows significantly more IL26-positive cells than that of HCs (p < 0.01), but numbers are also elevated in PsA and RA patients. Immunofluorescence shows co-localization of IL26 with CD68, but not with CD3, SMA, CD163, cadherin-11, or CD90. IL26 is elevated in the serum of RA and PsA (but not axSpA) patients compared with HCs (p < 0.001 and p < 0.01). However, peripheral blood CD4+ T cells from axSpA and PsA patients show higher positivity for IL26 in the PrimeFlow assay compared with HCs. CD4+ memory T cells from axSpA patients produce more IL26 under Th17-favoring conditions (IL-1β and IL-23) than cells from PsA and RA patients or HCs.

Conclusion

IL26 production is increased in the synovial tissue of SpA and can be localized to CD68+ macrophage-like synoviocytes, whereas circulating IL26+ Th17 cells are only modestly enriched. Considering the osteoproliferative properties of IL26, this offers new therapeutic options independent of Th17 pathways.

Prevalences of Other Non-Thyroid Autoimmune Diseases and Factor Associated with Their Presence in Ocular Myasthenia Gravis

Purpose

To report the prevalences of other non-thyroid autoimmune diseases and identify factors associated with their presence in ocular myasthenia gravis (OMG) subjects.

Subjects and Methods

A total of 208 subjects with OMG diagnosis were included. Demographic data, clinical characteristics, the ice-pack test, the acetylcholine receptor (AChR) antibody test, electrophysiology tests (single-fiber electromyography and repetitive nerve stimulation), the presence of thymoma, generalized myasthenia gravis conversion, and the presence of other non-thyroid autoimmune diseases (defined as the presence of at least one other non-thyroid autoimmune disease) were retrospectively reviewed. Factors associated with the presence of other non-thyroid autoimmune diseases were analyzed by univariate and multivariate logistic regression.

Results

Of the total 208 subjects, 21 (10.10%) exhibited the presence of other non-thyroid autoimmune diseases (19 subjects (9.14%) and 2 subjects (0.96%) had one and two other non-thyroid autoimmune diseases, respectively), and systemic lupus erythematosus (SLE) was diagnosed in 9 subjects, followed by Sjogren's syndrome (7 subjects), rheumatoid arthritis (6 subjects), and ankylosing spondylitis (1 subject). Therefore, the prevalences of SLE, Sjogren's syndrome, rheumatoid arthritis, and ankylosing spondylitis in OMG subjects were estimated to be 4.33% (95% confidence interval (CI): 2.29-8.02%), 3.37% (95% CI: 1.64-6.79%), 2.88% (95% CI: 1.33-6.14%), and 0.48% (95% CI: 0.08-2.67%), respectively. Positivity of the AChR antibody was the only significant factor associated with the presence of other non-thyroid autoimmune diseases (odds ratio 4.10, 95% CI: 1.11-15.21, p = 0.035).

Conclusions

The presence of other non-thyroid autoimmune diseases was found in approximately 10% of OMG patients, with SLE displaying the highest prevalence. We recommend screening and monitoring for other non-thyroid autoimmune diseases in OMG patients, particularly those with positivity of the AChR antibody.

Leukocytoclastic vasculitis in a patient with ankylosing spondylitis: A case report

Key Clinical Message

Although the concurrent occurrence of vasculitis with AS is uncommon, when patients diagnosed with AS exhibit symptoms including skin petechiae, purpura, abdominal discomfort, malaise, elevated ESR, and reduced complement levels, vigilant monitoring for vasculitis is advisable following the exclusion of secondary vasculitis triggers such as malignancies, infections, and pharmaceutical agents.

Abstract

The primary characteristic of ankylosing spondylitis (AS) involves inflammation occurring within the sacroiliac joint and the spine, leading to destruction and eventual ankylosis. A notably infrequent complication associated with AS is vasculitis, with limited reports linking AS to vasculitis. This case study documents a 48-year-old male, diagnosed with HLA-B27-positive AS for the past 15 years, who developed abdominal pain and skin lesions following the cessation of his medication on his own. Subsequent clinical evaluations identified leukocytoclastic vasculitis (LCV) related to AS after excluding all other potential causes of LCV, including drug-related sources, cancer, hepatitis B and C viruses, Henoch-Schönlein purpura (HSP), and IgA nephropathy.

Effect of dietary interventions on nutritional status in patients with rheumatoid arthritis and spondyloarthritis - A systematic review and meta-analysis

BACKGROUND & AIM

Patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) have an increased risk of developing altered body composition, such as low muscle mass, and an increased risk of developing cardiovascular diseases (CVD). Thus, investigating how to improve body composition and CVD risk factors is a relevant topic to improve management of RA and SpA. The aim of this study was to identify dietary interventions that can improve body composition, as well as reduce CVD risk factors in RA and SpA.

METHODS

We searched the databases Medline, Embase and Cochrane. Duplicates were removed using Endnote and records were screened through Rayyan. The primary outcomes were muscle mass (kg) and fat mass (kg). Secondary outcomes were body weight (kg), body mass index (BMI: kg/m2), waist circumference (cm) and lipid profile (total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides, mmol/L).

RESULTS

A total of 4965 articles were identified, and 17 articles were included in this review, of which 15 were suitable for meta-analysis. We found a reduction in TC and LDL-C, (Mean difference, [95%CI]: -0.36, [-0.63, -0.10], I2 = 43%, and -0.20, [-0.35, -0.05], I2 = 0% respectively). Otherwise, no other significant effect was seen in either primary or secondary outcomes. The evidence was graded as moderate for TC and low for LDL-C.

CONCLUSION

Dietary interventions might reduce the levels of blood lipids, and consequently, the risk of cardiovascular diseases. However, body composition did not change significantly after a 2-4 month dietary intervention. Both short intervention period and lack of reliable methods to assess body composition are possible explanations for this finding. Further studies of longer duration are needed.

The effect of anti-TNF drugs on the intestinal microbiota in patients with spondyloarthritis, rheumatoid arthritis, and inflammatory bowel diseases

Spondyloarthritis (SpA), rheumatoid arthritis (RA), and inflammatory bowel diseases (IBD) are chronic inflammatory autoimmune diseases that are associated with alterations in the composition of the intestinal microbiota (i.e., dysbiosis). For SpA and RA, a gut-joint-enthesis axis is hypothesized and recent data suggests that dysbiosis may contribute directly to initiating and perpetuating joint and spine inflammation. Biologic drugs targeting tumor necrosis factor (TNF) are effective in treating these diseases and have been shown to partially restore the disrupted microbiome. Hence, drugs that affect both the intestinal and joint components of these diseases, such as anti-TNF drugs, may act on the intestinal microbiome. However, despite the remarkable efficacy of anti-TNF-α treatments, non-responders are frequent, and predictors of patient outcomes have not been identified. In this narrative review, we summarize recent research on the downstream effects of anti-TNF drugs on the intestinal microbiota in SpA, RA, and IBD. We also discuss whether these changes could have a role as predictive biomarkers of anti-TNF response.

Upadacitinib for the treatment of adults with active non-radiographic axial spondyloarthritis (nr-axSpA)

INTRODUCTION

Non-radiographic axial spondyloarthritis (nr-axSpA) is a chronic inflammatory condition with axial and peripheral musculoskeletal involvement, fulfilling criteria of axSpA in the absence of advanced radiographic sacroiliitis. While appropriate treatment is required for chronic pain and disability resulting from disease progression, the limited availability of treatment options becomes evident. Upadacitinib, an oral selective Janus kinase 1 inhibitor, was approved in Europe, the United States, and other countries for management of nr-axSpA with inadequate response to existing therapies.

AREA COVERED

This review summarizes essential drug profiles, efficacy, and safety of upadacitinib for nr-axSpA in conjunction with data pertaining to radiographic axSpA.

EXPERT OPINION

In a phase 3 trial, upadacitinib exhibited efficacy for patients with nr-axSpA, irrespective of prior exposures to biological disease-modifying antirheumatic drugs (bDMARDs). The safety profiles of upadacitinib in nr-axSpA mirrored those in other indications, underscoring its potential as a promising treatment option for nr-axSpA. Concurrently, physicians should be aware of the absence of real-world data, longitudinal efficacy and safety, direct comparative studies between upadacitinib and bDMARDs in nr-axSpA, and evidence for precision medicine to identify patients who may optimally benefit from upadacitinib over bDMARDs. Future research is imperative to facilitate the effective utilization of upadacitinib in daily clinical practice.

Burden of Disease in Psoriatic Arthritis in Latin America: a Systematic Literature Review

INTRODUCTION

Psoriatic arthritis is a chronic inflammatory pathology that generates a substantial and progressive deterioration of functionality and quality of life. It is associated with comorbidities (cardiovascular and metabolic) and involvement of mental health. In Latin America, information regarding the disease is limited. This study reviews the burden of disease (disease activity, functional involvement, clinical manifestations, comorbidities, patient-reported outcomes, quality of life, and use of health resources) in PsA patients in Latin America.

METHODS

Systematic literature review of publications in PUBMED, EMBASE, Cochrane Database of Systematic Reviews-CDSR/Database of Abstracts of Reviews of Effects, LILACS, Scielo, Redalyc, conference abstracts, and grey literature. Two independent assessors selected studies and extracted information. Quality was assessed according to the type of study.

RESULTS

We identified 692 references, selecting 50 studies: 41 cross-sectional, four economic-studies, four cohort studies and one systematic review. The information comes mainly from Brazil, Argentina, and Mexico. The estimated disease prevalence for Latin America ranges from 0.004 to 0.08% (95% CI 0.02-0.20). Measurements with validated instruments suggest suboptimal assessment of disease domains, significant functional compromise, loss of productivity, and high frequency of comorbidities, including mental health. Methodological and population considerations limit the generalizability of the findings.

CONCLUSIONS

The available information reports a considerable burden of disease in patients with PsA in Latin America, with involvement of quality of life associated with disability in relation to disease activity and its various manifestations. Future research and funding efforts should be aimed at generating more standardized information about the impact of PsA in the region. Key Points •The functional involvement related to disease activity, the impact on the quality of life, and the frequency of cardiometabolic and psychological comorbidities are remarkable in Latin American patients with PsA. •The current synthesis offers an overview of the burden of disease (disease activity, functional involvement, clinical manifestations, comorbidities, patient-reported outcomes, quality of life, and use of health resources) in PsA patients in Latin America. •Future research efforts and clinical strategies are required in order to generate standardized data on the patients and better estimate the burden of disease in the region.

Development of a complex Interdisciplinary Nurse-coordinated SELf-MAnagement (INSELMA) intervention for patients with inflammatory arthritis

BACKGROUND

Apart from a consistent focus on treating inflammation, patients with inflammatory arthritis (IA) report a range of unmet needs. Many experience not only residual symptoms but also various other physical, psychological, and social effects. Therefore, this study aimed to develop a complex Interdisciplinary Nurse-coordinated self-management (INSELMA) intervention for patients with IA, as an add-on treatment to usual outpatient care for those with substantial disease impact.

METHODS

This study followed the British Medical Research Council's updated framework for developing complex interventions. The process encompassed the following steps: (1) The evidence base was identified; (2) workshops were held, involving 38 relevant stakeholders (managers, physicians, nurses, physiotherapists, occupational therapists, social workers, psychologists from hospitals and municipalities, and two patient research partners), to discuss and further develop the preliminary ideas; (3) relevant theories were identified (i.e., self-efficacy, acceptance and commitment therapy, and health literacy); (4) the intervention was modeled and remodeled and (5) the results, describing the final INSELMA intervention and outcomes.

RESULTS

The INSELMA intervention encompasses an initial biopsychosocial assessment, which is performed by a rheumatology nurse. Then, activities that the participant wishes to improve are identified and goals are set. The nurse refers the participant to a multidisciplinary team and coordinates their support and relevant services in the participant's municipality. In addition, the health professionals have the opportunity to hold two interdisciplinary conferences during the intervention period. The participant and the health professionals work to achieve the set goals during a 6-month period, which ends with a status assessment and a discussion of further needs. The INSELMA intervention aims to increase self-management, reduce the impact of IA (e.g., pain, fatigue, sleep problems, and absenteeism), and increase self-efficacy, quality of life, mental well-being, work ability, and physical activity.

CONCLUSIONS

The development of the INSELMA intervention involved stakeholders from two Danish rheumatology outpatient clinics, patient research partners and municipalities. We believe that we have identified important mechanisms to increase the self-management and quality of life of people with IA and to decrease the disease impact in those who are substantially affected. The health professionals involved have developed competences in delivering the intervention and it is ready to be tested in a feasibility study.

Validation of diagnosis algorithms for ankylosing spondylitis in claim-based database

BACKGROUND

Claims-based algorithms using International Classification of Diseases (ICD) codes have become a common approach for researchers to define ankylosing spondylitis (AS) in studies. To address potential misclassification bias caused by the claim-based algorithms, we conducted the current study to validate whether these algorithms of medical claims could accurately represent AS diagnoses.

METHODS

Patients diagnosed with AS based on ICD codes were retrieved from the electronic medical records database at a Taiwanese medical center (Chung Shan University Hospital, Taiwan). After random sampling and stratification based on age and sex, the medical information of participants was appraised based on the 2009 ASAS guideline to evaluate the actual status of ICD codes claim-based AS patients. Positive predict values (PPV) of different algorithms of ICD codes were also calculated.

RESULTS

Within the 4160 patients with claim-based AS diagnosis, 387 eligible patients were finally included in the study design after random sampling. The PPV of the diagnostic algorithm of having at least 4 outpatient or 1 inpatient ICD record was 72.77 (95% CI, 66.79-78.75), whereas the PPV increased to 85.64 when the diagnoses were restricted to be made by rheumatologists (95% CI, 80.53-90.74).

CONCLUSIONS

While performing database studies, researchers should be aware of the low PPV of specific algorithms when defining AS. Algorithms with higher PPV were recommended to be adopted to avoid misclassification biases.

Prevalence of axial spondyloarthritis in Colombia: data from the National Health Registry 2017-2021

INTRODUCTION

Registries allow ascertaining the epidemiology of chronic diseases such as axial spondyloarthritis (axSpA). The Colombian Ministry of Health has implemented a National Health Registry (SISPRO) that collects data from each medical contact in the system, which provides close to universal coverage (around 98%).

OBJECTIVE

To establish the 5-year prevalence of axSpA in Colombia, and to describe its demographics, using data from January 1st, 2017, to December 31st, 2021.

METHODS

We performed an observational, cross-sectional study using the International Statistical Classification of Diseases and Related Health Problems as search terms related to ax-SpA, based on SISPRO data. We estimated the prevalence using three approaches: (1) ankylosing spondylitis (AS) diagnoses; (2) diagnoses compatible with axSpA; and (3) diagnoses compatible with axSpA, including sacroiliitis. We calculated prevalence per 100,000 inhabitants.

RESULTS

Based on our three approaches, patients with a primary diagnosis compatible with ax-SpA ranged between 12,684 and 117,648, with an estimated 5-year adjusted prevalence between 26.3 and 244 cases per 100,000 inhabitants (0.03-0.2%). The male-to-female ratio ranged between 1.2:1 and 0.4:1, which was markedly skewed towards a higher prevalence in women when we included the code for sacroiliitis. We found the highest frequency of cases in the 50-54 years group. A differential prevalence was observed between different regions in our country, particularly in regions known to have European ancestors.

CONCLUSION

This is the first study that describes demographic characteristics of ax-SpA in Colombia and offers valuable information for stakeholders. Key Points • Using the official country-level health database, the prevalence of axSpA in Colombia ranges between 26.3 and 244 cases per 100,000 inhabitants (0.03% - 0.2%) • The prevalence of axSpA peaked among the 50-54 years patient group, suggesting an increased survival • Nations with a substantial admixture, such as Colombia, may present a differential prevalence of axSpA among regions within the country • Including the ICD-10 code for sacroiliitis (M46.1) in epidemiological studies probably overestimates the frequency of axSpA.

Ankylosing spondylitis status and risk of secondary systemic amyloidosis: A two-sample mendelian randomization study

OBJECTIVES

There is still controversy regarding the causal relationship between ankylosing spondylitis (AS) and secondary systemic amyloidosis (SSA). This study utilized aggregated data from genome-wide association studies (GWAS) on population cohorts to investigate whether a causal relationship exists between AS and SSA.

METHODS

The genetic causal relationship between AS status and SSA was analyzed utilizing a two-sample Mendelian randomization (TSMR). The analyses were conducted using the weighted mode method (WM2), inverse variance weighted method (IVW), simple mode (SM), weighted median method (WM1), and Mendelian randomization Egger regression (MR-Egger). Among these methods, the primary results were based on the IVW approach. The association was evaluated using the odds ratio (OR) along with a 95% confidence interval (95% CI).

RESULTS

The IVW analysis revealed a positive causal relationship between AS status and SSA (OR = 1.411, 95 % CI = 1.069, 1.862, P = 0.015). Meanwhile, the WM1 (OR = 1.394, 95 % CI = 1.115, 1.742, P = 0.004) and WM2 (OR = 1.393, 95 % CI = 1.112, 1.743, P = 0.045) methods also identified a positive causal relationship between AS status and SSA. The MR-Egger method did not identify a causal relationship between AS and SSA (OR = 1.175, 95 % CI = 0.888, 1.555, P = 0.342). The SM results demonstrated that the observed genotypes did not exhibit statistically significant differences between AS and SSA (OR = 1.184, 95 % CI = 0.416, 3.366, P = 0.767). The results of the MR-Egger regression suggested that the results were unaffected by bias caused by genetic pleiotropy (Intercept = 0.283, SE = 0.134, P = 0.126). Cochran's Q test did not reveal any significant heterogeneity (Q = 1.759, P = 0.624). The "leave-one-out" analysis further confirmed that the absence of any single SNP did not impact the robustness of our results.

CONCLUSION

This study revealed a positive causal relationship between AS status and the occurrence of SSA, providing new insights into the genetic analysis of SSA.

Ixekizumab for Active Radiographic Axial Spondyloarthritis in Chinese Patients: 16- and 52-Week Results from a Phase III, Randomized, Double-Blind, Placebo-Controlled Study

INTRODUCTION

Ixekizumab, an interleukin-17A inhibitor, was efficacious and well tolerated for the treatment of active radiographic axial spondyloarthritis (r-axSpA) in international clinical studies. This phase III study aimed to determine the efficacy and safety of ixekizumab for treating Chinese patients with active r-axSpA.

METHODS

Adults with active r-axSpA naïve to biologic disease-modifying antirheumatic drugs (bDMARDs), or with an inadequate response/intolerance to one tumor necrosis factor inhibitor, were randomized (1:1), double-blind, to receive ixekizumab 80 mg every 4 weeks (IXEQ4W; starting dose 160 mg), or placebo, for 16 weeks. Patients receiving placebo were then switched to IXEQ4W, and those receiving IXEQ4W continued, until week 52. The primary endpoint was the proportion of bDMARD-naïve patients achieving an Assessment of SpondyloArthritis International Society 40 (ASAS40) response at week 16.

RESULTS

In total, 147 patients were randomized to receive placebo (n = 73) or IXEQ4W (n = 74). At week 16, more bDMARD-naive patients achieved ASAS40 in the IXEQ4W group (n = 66; 40.9%) than the placebo group (n = 64, 7.8%; p < 0.001). In the overall study population, ASAS40 was also achieved by more patients in the IXEQ4W group (37.8%) than the placebo group (8.2%; p < 0.001) at week 16, with a significant difference observed as early as week 1. There were significant improvements in all key secondary endpoints at week 16 with IXEQ4W versus placebo. Efficacy was sustained at week 52 in patients who continued IXEQ4W and there were also clinical improvements from weeks 16 to 52 in patients switched to IXEQ4W. The safety profile of ixekizumab was consistent with that described previously. Infections and injection-site reactions were the most frequently reported events of special interest.

CONCLUSIONS

IXEQ4W was associated with rapid and significant improvements in the signs and symptoms of active r-axSpA in Chinese patients at week 16 that were sustained at week 52, with no new safety signals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT04285229.

Clinical features and outcomes of spine surgery in patients with ankylosing spondylitis

OBJECTIVES

The study aimed to comprehend the clinical features and outcomes of surgical treatments for spinal disorders in patients with ankylosing spondylitis (AS).

METHODS

This retrospective study enrolled patients with AS who underwent spine surgery between 2000 and 2019 in our facility.

RESULTS

Thirteen patients with AS underwent spine surgeries. The mean age was 56.2 years, and the mean disease duration was 25.1 years at the time of surgery. Nine patients had vertebral fracture, two had kyphotic deformity, and two had myelopathy due to the spinal ligament ossification. Fracture cases included five patients with secondary pseudarthrosis/delayed palsy due to conservative treatment failure. Spinal fixation was performed in all patients. Pedicle subtraction osteotomy for kyphosis and laminectomy for myelopathy were also conducted. All patients improved after surgeries. One patient with kyphotic deformity underwent additional surgery of bilateral hip prosthesis, which resulted in better spine alignment. Four cases of perioperative complications were observed.

CONCLUSION

Myelopathy was newly found as the aetiology requiring surgery in patients with AS. This summarized case series could help physicians to identify patients with surgically treatable spinal disorders among patients with AS.

HLA-B27, axial spondyloarthritis and survival

INTRODUCTION

Ankylosing spondylitis (AS), and carriage of HLA-B27 gene in otherwise healthy individuals, are reportedly associated with increased mortality. We evaluated this hypothesis, using data from both a 35-year AS follow-up study and UK Biobank data.

METHODS

In 1985, 363 members of the Swiss AS Patient Society and 806 relatives were screened clinically and then radiographically for AS/axial spondyloarthritis (axSpA). Life expectancy was analysed in 377 axSpA patients having available pelvic radiographs and HLA-B27 status, comparing with matched Swiss population data. Survival in relation to HLA-B27 status in the general population was studied in UK Biobank European-ancestry participants (n=407 480, n=30 419 deaths).

RESULTS

AS patients have increased standardised mortality rate (SMR) compared with the general population (1.37, 95% CI 1.11 to 1.62). This increase was significant for HLA-B27-positive AS (SMR 1.38, 95% CI 1.11 to 1.65). Shortened life expectancy was observed among both HLA-B27-positive AS women (SMR 1.77, 95% CI 1.09 to 2.70) and men (SMR 1.31, 95% CI 1.02 to 1.59). Patients with non-radiographic axSpA (nr-axSpA) had significantly lower SMR: 0.44 (95% CI 0.23 to 0.77), compared with the general population. In the UK Biobank European-ancestry population cohort, HLA-B27 carriage was not significantly associated with any change in mortality (HR 1, 95% CI 0.97 to 1.1, p=0.349, adjusted by sex), in either males (HR 1, 95% CI 0.98 to 1.1, p=0.281) or females (HR 0.96, 95% CI 0.9 to 1, p=0.232), and no increase in vascular disease mortality was observed.

DISCUSSION

AS patients, but not nr-axSpA patients, have a significantly shortened life expectancy. Increased mortality is particularly significant among women with HLA-B27-positive AS. HLA-B27 carriage in the European-ancestry general population does not influence survival, or the risk of death due to vascular disease.

Pan American League of Associations for Rheumatology recommendations for the management of axial spondyloarthritis

Axial spondyloarthritis (axSpA) comprises a spectrum of chronic inflammatory manifestations affecting the axial skeleton and represents a challenge for diagnosis and treatment. Our objective was to generate a set of evidence-based recommendations for the management of axSpA for physicians, health professionals, rheumatologists and policy decision makers in Pan American League of Associations for Rheumatology (PANLAR) countries. Grading of Recommendations, Assessment, Development and Evaluation-ADOLOPMENT methodology was used to adapt existing recommendations after performing an independent systematic search and synthesis of the literature to update the evidence. A working group consisting of rheumatologists, epidemiologists and patient representatives from countries within the Americas prioritized 13 topics relevant to the context of these countries for the management of axSpA. This Evidence-Based Guideline article reports 13 recommendations addressing therapeutic targets, the use of NSAIDs and glucocorticoids, treatment with DMARDs (including conventional synthetic, biologic and targeted synthetic DMARDs), therapeutic failure, optimization of the use of biologic DMARDs, the use of drugs for extra-musculoskeletal manifestations of axSpA, non-pharmacological interventions and the follow-up of patients with axSpA.

Altered sleep in axial spondyloarthritis and psoriatic arthritis: Post hoc comparative study based on a sleep-specific question from the ASAS health index

BACKGROUND AND AIMS

Sleep problems are common in spondyloarthritis (SpA), but the factors associated with them are only partially known. In this study, responses to item #16 from the Assessment of SpondyloArthritis international Society-Health Index (ASAS HI) that explores the sleep category according to the International Classification of Functioning, Disability and Health (ICF) were compared between psoriatic arthritis (PsA) and axial SpA (axSpA).

METHODS

Post hoc analysis of a multicentre cross-sectional study included a total of 201 consecutive patients. The prevalence, correlations, and disease factors associated with a positive response to item #16 were analyzed in both SpA populations.

RESULTS

Forty-eight/111 (43.2%) patients with axSpA and 42/90 (46.7%) with PsA reported sleep problems. There was a moderate-high correlation between item #16 and the ASAS HI sum score in both populations (r≥.59). In axSpA, poor sleep was associated with disease activity (OR 8.45, p<.001), biological therapy use (OR .24, p<.05) and CRP levels (OR .16, p<.05). In PsA, disturbed sleep was independently associated with disease activity showing a dose-response effect (OR 1.16, p<.001). Taking both populations together, disease severity (OR 6.33, p<.001) and axSpA (OR .50, p<.05) were independently associated with a positive response to item #16. Correlations between the different components of the ASAS HI and item #16 were markedly different in both populations.

CONCLUSIONS

A positive response to item #16 was common in both SpA phenotypes. However, the link between inflammatory burden and disturbed sleep was higher in axSpA than in PsA.

The effectiveness of exercise and physical activity programs on fatigue and sleep in people with arthritis - A systematic review with meta-analysis

This systematic review aimed to systematically investigate the literature on the effectiveness of exercise and physical activity programs on fatigue and sleep in people with arthritis. For that, seven databases were searched for relevant randomized controlled trials. After the searches, 36 studies investigating 2281 participants were included. Risk of bias assessments were done by two independent reviewers using the Cochrane Risk of Bias tool 2. Random-effects meta-analyses were performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to judge the certainty of evidence. The evidence on benefits of exercise and physical activity programs on fatigue and sleep parameters in people with osteoarthritis and psoriatic arthritis was either lacking or inconclusive. There was very low to low certainty evidence for a slight benefit of exercise and physical activity programs on fatigue at short-term in people with ankylosing spondylitis and rheumatoid arthritis. However, the evidence was very uncertain for the medium- and long-term as well as for any sleep parameters. The results indicate that exercise and physical activity programs may offer some benefits on fatigue for people with arthritis in the short-term, although the best type of exercise remains uncertain. The available evidence on improvements in sleep was insufficient to draw strong conclusions.