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Nakamura A, Towheed T. Pathogenesis, assessment, and management of bone loss in axial spondyloarthritis. Semin Arthritis Rheum 2024; 64:152345. [PMID: 38103486 DOI: 10.1016/j.semarthrit.2023.152345] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Axial spondyloarthritis (axSpA) presents a complex scenario where both new bone formation in entheseal tissues and significant trabecular bone loss coexist, emphasizing the intricate nature of bone dynamics in this context. METHODS A search of the literature was conducted to compose a narrative review exploring the pathogenesis, possible assessment methods, and potential management options for axSpA. RESULTS While chronic systemic and local inflammation contribute to bone loss, the mechanisms behind axSpA-associated bone loss exhibit distinct characteristics influenced by factors like mechanical stress and the gut microbiome. These factors directly or indirectly stimulate osteoclast differentiation and activation through the RANK-RANKL axis, while simultaneously impeding osteoblast differentiation via negative regulation of bone anabolic pathways, including the Wnt signaling pathway. This disruption in the balance between bone-resorbing osteoclasts and bone-forming osteoblasts contributes to overall bone loss in axSpA. Early evaluation at diagnosis is prudent for detecting bone changes. While traditional dual x-ray absorptiometry (DXA) has limitations due to potential overestimation from spinal new bone formation, alternative methods like trabecular bone score (TBS), quantitative CT (QCT), and quantitative ultrasound (QUS) show promise. However, their integration into routine clinical practice remains limited. In addition to approved anti-inflammatory drugs, lifestyle adjustments like regular exercise play a key role in preserving bone health. Tailoring interventions based on individual risk profiles holds potential for mitigating bone loss progression. CONCLUSION Recognizing the pivotal role of bone loss in axSpA underscores the importance of integrating regular assessments and effective management strategies into clinical practice. Given the multifaceted contributors to bone loss in axSpA, a multidisciplinary approach is essential.
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Affiliation(s)
- Akihiro Nakamura
- Department of Medicine, Division of Rheumatology, Queen's University, Kingston, Ontario, Canada; Translational Institute of Medicine, School of Medicine, Queen's University, Ontario, Canada; Kingston Health Science Centre, Kingston, Ontario, Canada.
| | - Tanveer Towheed
- Department of Medicine, Division of Rheumatology, Queen's University, Kingston, Ontario, Canada; Translational Institute of Medicine, School of Medicine, Queen's University, Ontario, Canada; Kingston Health Science Centre, Kingston, Ontario, Canada.
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Venetsanopoulou AI, Anagnostou NE, Tziortzioti Z, Zikou A, Astrakas L, Argyropoulou MI, Voulgari PV. "Long-term MRI findings in Ankylosing spondylitis patients treated with TNF inhibitors for a decade". Rheumatol Int 2024:10.1007/s00296-023-05530-z. [PMID: 38294543 DOI: 10.1007/s00296-023-05530-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/26/2023] [Indexed: 02/01/2024]
Abstract
OBJECTIVE This study aims to evaluate the active and chronic lesions in sacroiliac joints and lumbar spine over a decade of TNFi therapy in patients with AS. METHODS The study enrolled patients with AS under treatment with a TNFi for over a decade. The patients underwent a new MRI scan of their lumbar spine and sacroiliac joint (SIJ). Two readers evaluated all images. Inflammation of SIJ (SIS), SIJ structural damage (SSS) including Fat Metaplasia, Erosions, Backfill and Ankylosis, and Spondyloarthritis Research Consortium of Canada Bone marrow edema (SPARCC) spine score were recorded. RESULTS In the study, 15 patients were included, with 80% being male. The mean age during their first MRI was 38.1 (± 11.9) years old, and the majority (86.7%) tested positive for HLA-B27. While TNFi improved both BASDAI and BASFI scores, there was a noticeable increase in MRI acute lesions in the SIJ over time, where the median score increased from 0 (0-4) to 3 (0-10) after ten years (p = 0.028). After a decade of treatment, the median SPARCC spine score also increased from 0 (0-9) to 5 (0-16), p = 0.093. Finally, it was observed that there was a significant positive correlation between ESR and SIS erosions in cases of chronic lesions (r = 0.819, p < 0.001). CONCLUSIONS While TNFi have significantly improved the treatment of AS, this study shows that acute lesions can still develop despite treatment. A personalized approach that adapts MRI assessment to each patient's specific requirements may help detect changes early and enable doctors to intervene promptly to prevent further damage.
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Affiliation(s)
- Aliki I Venetsanopoulou
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, 45500, Greece
| | | | - Zoi Tziortzioti
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, 45500, Greece
| | - Anastasia Zikou
- Department of Radiology, Medical School, University of Ioannina, Ioannina, Greece
| | - Loukas Astrakas
- Department of Medical Physics, Medical School, University of Ioannina, Ioannina, Greece
| | - Maria I Argyropoulou
- Department of Radiology, Medical School, University of Ioannina, Ioannina, Greece
| | - Paraskevi V Voulgari
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, 45500, Greece.
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Drosos AA, Venetsanopoulou AI, Voulgari PV. Axial Spondyloarthritis: Evolving concepts regarding the disease's diagnosis and treatment. Eur J Intern Med 2023; 117:21-27. [PMID: 37414646 DOI: 10.1016/j.ejim.2023.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/08/2023]
Abstract
Spondyloarthritis (SpA) is a chronic inflammatory disease that affects the axial skeleton (axSpA) and/or the peripheral joints (p-SpA) and entheses. The natural history of SpA in the decades of the 80 and 90 s involved a progressive disease with pain, spinal stiffness, ankylosis of the axial skeleton, structural damage of peripheral joints, and a poor prognosis. In the last 20 years, enormous advances in understanding and managing SpA have occurred. With the introduction of the ASAS classification criteria and MRI, early disease recognition is now possible. The ASAS criteria widened the spectrum of SpA to include all the disease phenotypes, such as radiographic (r-axSpA), non-radiographic (nr-axSpA), and p-SpA and extraskeletal manifestations. Nowadays, the treatment of SpA is based on a shared decision between patients and rheumatologists and includes non-pharmacological and pharmacological therapies. Moreover, the discovery of TNFα, IL-17, which play a pivotal role in disease pathophysiology, has revolutionized disease management. Thus, new targeted therapies and many biological agents are now available and used in SpA patients. TNFα inhibitors (TNFi), IL-17, and JAK inhibitors were proven to be efficacious, with an acceptable toxicity profile. Overall, their efficacy and safety are comparable with some differences. Sustained clinical disease remission, low disease activity, improvement of patient's quality of life, and prevention of progression of structural damage, are the results of the above interventions. The concept of SpA has changed in the last 20 years. The disease burden can be ameliorated by early and accurate diagnosis and targeting therapies.
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Affiliation(s)
- Alexandros A Drosos
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina 45110, Greece.
| | - Aliki I Venetsanopoulou
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina 45110, Greece
| | - Paraskevi V Voulgari
- Department of Rheumatology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina 45110, Greece
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Sabeghi P, Katal S, Chen M, Taravat F, Werner TJ, Saboury B, Gholamrezanezhad A, Alavi A. Update on Positron Emission Tomography/Magnetic Resonance Imaging: Cancer and Inflammation Imaging in the Clinic. Magn Reson Imaging Clin N Am 2023; 31:517-538. [PMID: 37741639 DOI: 10.1016/j.mric.2023.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
Abstract
Hybrid PET/MRI is highly valuable, having made significant strides in overcoming technical challenges and offering unique advantages such as reduced radiation, precise data coregistration, and motion correction. Growing evidence highlights the value of PET/MRI in broad clinical aspects, including inflammatory and oncological imaging in adults, pregnant women, and pediatrics, potentially surpassing PET/CT. This newly integrated solution may be preferred over PET/CT in many clinical conditions. However, further technological advancements are required to facilitate its broader adoption as a routine diagnostic modality.
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Affiliation(s)
- Paniz Sabeghi
- Department of Radiology, Keck School of Medicine of University of Southern California, Health Science Campus, 1500 San Pablo Street, Los Angeles, CA 90033, USA
| | - Sanaz Katal
- Medical Imaging Department of St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Michelle Chen
- Department of Radiology, Keck School of Medicine of University of Southern California, Health Science Campus, 1500 San Pablo Street, Los Angeles, CA 90033, USA
| | - Farzaneh Taravat
- Department of Radiology, Keck School of Medicine of University of Southern California, Health Science Campus, 1500 San Pablo Street, Los Angeles, CA 90033, USA
| | - Thomas J Werner
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Babak Saboury
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine of University of Southern California, Health Science Campus, 1500 San Pablo Street, Los Angeles, CA 90033, USA
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Simon D, Kemenes S, Minopoulou I, Kleyer A. [From conventional to cutting edge imaging in rheumatology]. Z Rheumatol 2023; 82:666-671. [PMID: 37606726 DOI: 10.1007/s00393-023-01406-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 08/23/2023]
Abstract
Imaging instruments, such as conventional X‑ray, ultrasound and magnetic resonance imaging (MRI) are now fully established and highly valued in the care of rheumatology patients. However, the information provided by these imaging modalities in their current form is of limited utility for the prognostic prediction of individual patient outcomes. This article illuminates an important part of the development of imaging and shows that the vision of personalized medicine is becoming increasingly more tangible due to the further development of high-resolution imaging techniques, molecular imaging and artificial intelligence.
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Affiliation(s)
- David Simon
- Medizinische Klinik 3 - Rheumatologie und Immunologie, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität Erlangen-Nürnberg und Universitätsklinikum Erlangen, Erlangen, Deutschland.
| | - Stephan Kemenes
- Medizinische Klinik 3 - Rheumatologie und Immunologie, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität Erlangen-Nürnberg und Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Ioanna Minopoulou
- Medizinische Klinik 3 - Rheumatologie und Immunologie, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität Erlangen-Nürnberg und Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Arnd Kleyer
- Medizinische Klinik 3 - Rheumatologie und Immunologie, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität Erlangen-Nürnberg und Universitätsklinikum Erlangen, Erlangen, Deutschland.
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de Jongh J, Zwezerijnen GJC, Yaqub M, van der Laken CJ. Positron emission tomography/magnetic resonance imaging of the sacroiliac joints and spine to monitor effects of anti-tumor necrosis factor therapy in axial spondyloarthritis: comment on the article by Bruckmann et al. Arthritis Rheumatol 2022; 75:864. [PMID: 36382969 DOI: 10.1002/art.42400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022]
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