Evaluation of the short-term efficacy of NSAIDs on patients with active ankylosing spondylitis in daily practice: a 3-month, longitudinal, observational study

Spondyloarthritis: How far are we from precision medicine?

Spondyloarthritis (SpA) is a family of heterogenous diseases consisting of different phenotypes. The exact disease mechanism remains unclear but evidence shows the complex pathophysiology with interplay between genome, microbiome, and immunome. Biologic DMARDs have markedly improved patients' disease control and quality of life. However, treatment response varies among patients. There is a growing need to identify biomarkers for the diagnosis, prognosis, prevention, and treatment of SpA. Genomic studies have been the research focus in the past two decades and have identified important genes involved in SpA. In recent years, emerging evidence supports the link between gut and joint inflammation in SpA, in which the role of gut microbiome in SpA is of great interest. Herein, potential genetic and gut microbial biomarkers for predicting treatment response are discussed. Novel strategies targeting dysbiosis in SpA are also summarized. These results represent a significant step toward precision medicine for patients with SpA.

Etanercept/celecoxib on improving MRI inflammation of active ankylosing spondylitis: A multicenter, open-label, randomized clinical trial

Objective

To investigate the efficacy and safety of clinical, magnetic resonance imaging (MRI) changes in active ankylosing spondylitis (AS) patients with etanercept and celecoxib alone/combined treatment.

Methods

A randomized controlled trial was conducted in three medical centers in China. Adult AS patients with BASDAI ≥4 or ASDAS ≥2.1, CRP >6 mg/L, or ESR 28 mm/1st hour were randomly assigned (1:1:1 ratio) to celecoxib 200 mg bid or etanercept 50 mg qw or combined therapy for 52 weeks. The primary outcomes were SPARCC change of the sacroiliac joint (SIJ) and spine and the proportion of patients achieving ASAS20 response at 52 weeks.

Results

Between September 2014 and January 2016, we randomly assigned 150 patients (mean age, 32.4 years; mean disease duration, 109 months), and 133 (88.6%) completed the study. SPARCC inflammation scores of the SIJ and spine decreased in the three groups, and significant differences were found between the combined group and the celecoxib group [between-group difference: −6.33, 95% CI (−10.56, −2.10) for SIJ; −9.53, 95% CI (−13.73, −5.33) for spine] and between the etanercept group and the celecoxib group [between-group difference: −5.02, 95% CI (−9.29, −0.76) for SIJ; −5.80, 95% CI (−10.04, −1.57) for spine]. The ASAS20 response rates were 44%, 58%, and 84% in the celecoxib, etanercept, and combined groups, respectively, and a significant difference was only found between the combined and the celecoxib groups.

Conclusion

Etanercept with or without celecoxib decreases inflammation detected by MRI at 1 year compared to celecoxib alone in active AS patients. The combination of etanercept and celecoxib was superior to celecoxib alone for the primary clinical response.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT01934933.

Disease activity guided stepwise tapering or discontinuation of rhTNFR:Fc, an etanercept biosimilar, in patients with ankylosing spondylitis: a prospective, randomized, open-label, multicentric study

Background

The aim of this study was to evaluate disease-activity-guided stepwise tapering or discontinuation of rhTNFR:Fc, an etanercept biosimilar, in patients with ankylosing spondylitis (AS) in a prospective, randomized, open-label, multicentric study.

Methods

Active AS patients with AS disease activity score (ASDAS) ⩾2.1 recruited from 10 hospitals were treated with rhTNFR:Fc 50 mg weekly for 12 weeks, and further randomized into different tapering or discontinuation groups according to ASDAS at week 12. Patients who achieved clinical remission (ASDAS < 1.3) were assigned randomly to stepwise tapering group or discontinuation group. Patients who achieved low disease activity (LDA, 1.3⩽ASDAS < 2.1) were assigned randomly to stepwise tapering, delayed tapering, or discontinuation group. All patients were evaluated every 12 weeks until week 48. The primary endpoint was cumulative flare rates in different groups at week 48.

Results

A total of 311 patients were enrolled with an average ASDAS of 3.6 ± 1.0, and 259 completed 12 weeks of rhTNFR:Fc induction therapy, with 148 patients (57.1%) achieved clinical remission, 100 (38.6%) achieved LDA, and 11 (4.3%) remained as high disease activity (ASDAS⩾2.1). In patients who achieved clinical remission at week 12, stepwise tapering of rhTNFR:Fc demonstrated significantly lower flare rates at each evaluation compared with discontinuation. In patients who achieved LDA, there was no significant difference of flare rates between stepwise tapering, delayed tapering, and discontinuation. With stepwise tapering of rhTNFR:Fc, flare rates were comparable in AS patients, irrespective of initial ASDAS before tapering.

Conclusion

Stepwise tapering of rhTNFR:Fc when patients achieved clinical remission was able to maintain favorable low flare rates in 48 weeks. LDA was an alternative therapeutic target, as well as an viable timing for initiation of rhTNFR:Fc tapering. rhTNFR:Fc 25 mg monthly maintained flare-free status in a considerable number of patients. However, abrupt discontinuation of rhTNFR:Fc even if patients achieved clinical remission should be avoided.

Trial registration

ClinicalTrials.gov: NCT03880968,URL: https://clinicaltrials.gov/ct2/show/NCT03880968.

Use of nonsteroidal anti-inflammatory drugs in early axial spondyloarthritis in daily practice: Data from the DESIR cohort

OBJECTIVES

Nonsteroidal anti-inflammatory drugs (NSAID) are the cornerstone of treatment in axial spondyloarthritis (axSpA). We aimed to describe the real life NSAID use in early axSpA according to the disease characteristics.

METHODS

The DESIR cohort is an observational study of patients presenting with inflammatory back pain suggestive of axSpA for less than 3 years. Patients who attended all 6 visits (every 6 months during the first 2 years and yearly at 3 years) were analysed. Data collected at every visit over 3 years was NSAID intake and the ASAS-NSAID score for the 6 months preceding the visit, where 100 reflects the full daily intake of an NSAID.

RESULTS

In all, 627 patients were assessed: 46.1% males, mean age: 33.7 (standard deviation: 8.7) years, mean symptom duration: 1.5 (0.9) year and mean BASDAI: 44.3 (25.3). Over the 6 months preceding inclusion, 92.8% had received NSAIDs; this proportion significantly decreased over time, to 73% patients after 3 years (P<0.001). This decrease was not different with regard to the fulfillment (or not) of the ASAS criteria at baseline, nor with regard to the "arm" of the ASAS criteria fulfilled (i.e. imaging vs. clinical). The median ASAS-NSAID score was 36 [interquartile range: 13-72] at inclusion, and substantially decreased to reach 7 [0-44] after 3 years (P<0.001), although BASDAI at 3 years was 33.8 (21.7).

CONCLUSION

NSAID prescription was very frequent in this early axSpA cohort, but the intake was low, and decreased significantly over time, even though symptoms remained present. Early axSpA patients may not be sufficiently treated with NSAIDs.

2014 Update of the Canadian Rheumatology Association/Spondyloarthritis Research Consortium of Canada Treatment Recommendations for the Management of Spondyloarthritis. Part II: Specific Management Recommendations

Objective.

The Canadian Rheumatology Association (CRA) and the Spondyloarthritis Research Consortium of Canada (SPARCC) have collaborated to update the recommendations for the management of spondyloarthritis (SpA).

Methods.

A working group was assembled and consisted of the SPARCC executive committee, rheumatologist leaders from SPARCC collaborating sites, Canadian rheumatologists from across the country with an interest in SpA (both academic and community), a rheumatology trainee with an interest in SpA, an epidemiologist/health services researcher, a member of the CRA executive, a member of the CRA therapeutics committee, and a patient representative from the Canadian Spondylitis Association. An extensive review was conducted of literature published from 2007 to 2014 involving the management of SpA. The working group created draft recommendations using multiple rounds of Web-based surveys and an in-person conference.

Results.

Recommendations for the management of SpA were created. Part II: Specific Management Recommendations addresses management with nonpharmacologic methods, nonsteroidal anti-inflammatories and analgesics, disease-modifying antirheumatic drugs, antibiotics, tumor necrosis factor inhibitors, other biologic agents, and surgery. Also included are 10 modifications for application to juvenile SpA.

Conclusion.

These recommendations were developed based on current literature and applied to a Canadian healthcare context. It is hoped that implementation of these recommendations will promote best practices in the treatment of SpA.

The effect of UGT1A and UGT2B polymorphisms on colorectal cancer risk: haplotype associations and gene–environment interactions

UDP-glucuronosyltransferases (UGTs) play an important role in the phase II metabolism of exogenous and endogenous compounds. As colorectal cancer (CRC) etiology is thought to involve the biotransformation of dietary factors, UGT polymorphisms may affect CRC risk by altering levels of exposure. Genotyping of over 1800 Caucasian subjects was completed to identify the role of genetic variation in nine UGT1A and five UGT2B genes on CRC risk. Unconditional logistic regression and haplotype analyses were conducted to identify associations with CRC risk and potential gene-environment interactions. UGT1A haplotype analysis found that the T-G haplotype in UGT1A10 exon 1 (block 2: rs17864678, rs10929251) decreased cancer risk for the colon [proximal (OR = 0.28, 95% CI = 0.11–0.69) and for the distal colon (OR = 0.32, 95% CI = 0.12–0.91)], and that the C-T-G haplotype in the 3′ region flanking the UGT1A shared exons (block 11: rs7578153, rs10203853, rs6728940) increased CRC risk in males (OR = 2.56, 95% CI = 1.10–5.95). A haplotype in UGT2B15 containing a functional variant (rs4148269, K523T) and an intronic SNP (rs6837575) was found to affect rectal cancer risk overall (OR = 2.57, 95% CI = 1.21–5.04) and in females (OR = 3.08, 95% CI = 1.08–8.74). An interaction was found between high NSAID use and the A-G-T haplotype (block 10: rs6717546, rs1500482, rs7586006) in the UGT1A shared exons that decreased CRC risk. This suggests that UGT genetic variation alters CRC risk differently by anatomical sub-site and gender and that polymorphisms in the UGT1A shared exons may have a regulatory effect on gene expression that allows for the protective effect of NSAIDs on CRC risk.

Treatment of ankylosing spondylitis: a critical appraisal of nonsteroidal anti-inflammatory drugs and corticosteroids

Treatment of ankylosing spondylitis and related disorders has been revolutionized by the advent of biological therapy, especially tumor necrosis factor-α inhibitors. Nonsteroidal anti-inflammatory drugs, however, remain the first line of treatment. Evidence has accumulated that nonsteroidal anti-inflammatory drug therapy of ankylosing spondylitis and related disorders is effective in controlling several of the clinical manifestations seen in these disorders, particularly pain, physical function and perhaps progressive spinal fusion. What needs to be proven, however, is the long-term safety profile of these drugs.