Description of the registry of patients with ankylosing spondylitis in Turkey: TRASD-IP

Biological treatment in elderly and young patients with ankylosing spondylitis: TURKBIO real-life data results

Objectives

This study aims to investigate the effect of age on disease activity and biological treatment in patients with ankylosing spondylitis (AS).

Patients and methods

A total of 811 AS patients registered in the TURKBIO registry database between 2011 and 2019 were categorized according to their age at the time of entry into the registry and assigned to one of two groups: young patients, defined as <60 years of age (n=610), and those aged ≥60 years (n=201) were recorded as elderly patients. Demographic, clinical, and laboratory characteristics, along with disease activity markers and other follow-up parameters, as well as current and prior treatments, were electronically recorded during each visit using open-source software.

Results

The mean age of the elderly patients was 67±5.8 years, while the mean age of the younger patients was 49.2±10.9 years. Male predominance was lower in the older AS group compared to the younger AS group (p=0.002). During follow-up period, 397 patients (comprising 318 young and 79 elderly individuals) had a history of using at least one biological disease-modifying agent (bDMARD). There was no significant difference between the groups in terms of DMARD and bDMARD-use distributions. First tumor necrosis factor inhibitor (TNFi) retention rates were found to be similar in both groups over 10 years of follow-up. Adverse events were found to be similar in young (19.9%) and elderly (26.8%) AS patients.

Conclusion

Research in the TURKBIO cohort reveals that both older and younger patients with AS exhibited similar disease activity levels with comparable treatment approaches. Moreover, the results of TNFi treatments in elderly patients were the same as those observed in younger patients, with no notable increase in safety concerns.

Sex Bias in Diagnostic Delay: Are Axial Spondyloarthritis and Ankylosing Spondylitis Still Phantom Diseases in Women? A Systematic Review and Meta-Analysis

Diagnostic delay (DD) is associated with poor radiological and quality of life outcomes in axial spondyloarthritis (ax-SpA) and ankylosing spondylitis (AS). The female (F) population is often misdiagnosed, as classification criteria were previously studied mostly in males (M). We conducted a systematic review to investigate (i) the difference in DD between the sexes, the impact of HLA*B27 and clinical and social factors (work and education) on this gap, and (ii) the possible influence of the year of publication (before and after the 2009 ASAS classification criteria), geographical region (Europe and Israel vs. extra-European countries), sample sources (mono-center vs. multi-center studies), and world bank (WB) economic class on DD in both sexes. We searched, in PubMed and Embase, studies that reported the mean or median DD or the statistical difference in DD between sexes, adding a manual search. Starting from 399 publications, we selected 26 studies (17 from PubMed and Embase, 9 from manual search) that were successively evaluated with the modified Newcastle-Ottawa Scale (m-NOS). The mean DD of 16 high-quality (m-NOS > 4/8) studies, pooled with random-effects meta-analysis, produces results higher in F (1.48, 95% CI 0.83-2.14, p < 0.0001) but with significant results at the second analysis only in articles published before the 2009 ASAS classification criteria (0.95, 95% CI 0.05-1.85, p < 0.0001) and in extra-European countries (3.16, 95% CI 2.11-4.22, p < 0.05). With limited evidence, some studies suggest that DD in F might be positively influenced by HLA*B27 positivity, peripheral involvement, and social factors.

Prevalence of HLA B27 in Patients Diagnosed with Ankylosing Spondylitis (AS) in Diyarbakır, Southeastern Region of Turkey

AIM

The research to be conducted on human leukocyte antigen (HLA)-B27 in patients diagnosed with ankylosing spondylitis (AS) in Diyarbakır between 2019-2021 is to contribute to the understanding of the prevalence and effect of this genetic marker in the local population. As a researcher working on HLA-B27 and AS, our focus is to research the following. HLA-B27 Prevalence: To determine the prevalence of HLA-B27 in patients diagnosed with AS during the specified period in Diyarbakır. This information can provide insight into the genetic factors associated with the disease in the local population. Disease Severity: Investigate the relationship between HLA-B27 positivity and severity of AS symptoms. To examine factors such as disease progression, pain levels, functional impairment, and quality of life in HLA-B27 positive patients compared to HLA-B27 negative patients. By Genetic Associations: To enable the discovery of potential genetic relationships between HLA-B27 and other genetic markers known to be associated with AS. To investigate whether there are any specific genetic variants associated with HLA-B27 that contribute to disease susceptibility or severity. Researchers: We recommend considering the following approaches to generate knowledge on this topic globally: Literature Review: Conducting a comprehensive review of the available scientific literature on HLA-B27 and AS. It is to describe relevant studies conducted globally and summarize their findings to provide a broader understanding of the subject. Collaboration and Data Sharing: To encourage cooperation with researchers from other regions or countries doing similar studies on HLA-B27 and ASs. By sharing our data and collaborating on analysis, we can improve the global perspective and generalizability of your findings. International Conferences and Journals: Presenting our research findings at international conferences focusing on rheumatology, genetics or related fields. To disseminate our findings globally is to submit your research articles to reputable journals specializing in AS or genetic studies. Online Platforms: Using online platforms such as Researchgate.net, academia.edu or social media networks to share our research findings, connect with other researchers in the field and participate in discussions on a global scale. By using these fields, it is possible to contribute to the global knowledge and understanding of the relationship between HLA-B27 and AS. It is also to obtain insights from studies carried out in other regions.

MATERIALS AND METHODS

198 (104 male and 94 female) patients who applied to Dicle University Faculty of Medicine Physical Therapy and Rehabilitation Clinic with AS symptoms between 2019-2021 and were referred to Dicle University Medical Biology and Genetics Department for evaluation. HLA-B27 positivity was included in our study as a case group. As the control group, 50 people (25 males, 25 females) were selected among the unrelated people who applied to our laboratory to be a bone marrow donor. In both groups, DNA isolation was performed from peripheral blood using the salt precipitation method. Rotar Gene Q device was used for real-time PCR analysis. As a statistical method in analysis; The prevalences of the variables of interest were calculated. The lower and upper limits of 95% were determined as the confidence interval. According to the presence of HLA 27 positivity, the mean of ESR, CRP, and age variables were compared. Mann-Whitney U test was used due to the small number of subjects. Also, correlations between ESR and CRP were calculated. Spearman rho correlation statistics were used as a statistical method. Analyzed.

RESULT

Radiological examinations and laboratory tests were performed on 198 patients with suspicion AS and 50 healthy control group of 248 subjects. The prevalence of those with a definite diagnosis of AS was calculated as statistical analysis recalculated 20.16 (95% CI: 0.76-0.9552). The prevalence of HLA-B27 in 50 patients diagnosed with AS as a result of radiological examinations and laboratory tests was calculated as 92%.

CONCLUSION

Our study is the first study covering the province of Diyarbakır in the Southeastern Anatolia Region, which we think will contribute to the literature in the evaluation of HLA-B27 positivity in AS patients. The prevalence of HLA-B27 in our region is higher than the prevalence in Turkey.

Genetically predicted ankylosing spondylitis is causally associated with psoriasis

Background

Previous observational studies have reported the striking association between ankylosing spondylitis (AS) and psoriasis, but the causal relationship between the two diseases remains unclear.

Methods

Two-sample Mendelian randomization (MR) analysis with methods of inverse-variance weighted, MR-Egger regression, weighted median, and weighted mode was conducted to evaluate the bidirectional causal associations between AS and psoriasis. Effective single-nucleotide polymorphisms (SNPs) from genome-wide association studies (GWAS) were selected as instrumental variables (IVs). Sensitivity analyses were also applied to verify whether heterogeneity and pleiotropy can bias the results.

Result

We found positive causal effects of genetically increased AS risk on psoriasis (IVW: OR = 1.009, 95% CI = 1.005-1.012, p = 8.07E-07). Comparable outcomes were acquired by MR-Egger regression, weighted median, and weighted mode approaches. Nevertheless, we did not find significant causal effects of psoriasis on AS (IVW: OR = 1.183, 95% CI = 0.137-10.199, p = 0.879). The sensitivity analyses showed that the horizontal pleiotropy was unlikely to skew the causality. The leave-one-out analysis demonstrated that no single SNP can drive the MR estimates. No evidence of heterogeneity was found between the selected IVs.

Conclusion

Our findings provide evidence that AS has positive causal effects on the risk of psoriasis in the European population.

A review of patient-reported outcome measures used in uveitis

We review patient-reported outcome measures (PROMs) used to evaluate the quality of life (QoL) in uveitis and provide a quality assessment of the psychometric properties of the PROMs, making it easier to choose the best questionnaire for uveitis. Our review included 158 articles. A total of 98 PROMs were used to measure QoL in uveitis and the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ -25) was the most frequently used PROM in these studies. There were 5 uveitis-specific PROMs, but they were meant for either birdshot choroidopathy or cytomegalovirus retinitis or paediatric uveitis. There are no PROMs developed explicitly for the more common, anterior uveitis, intermediate uveitis, panuveitis, and chronic uveitis. The uveitis-specific PROMs performed better in our quality assessment criteria compared to other PROMs. However, these PROMs were constructed using traditional classical test theory and have not been assessed using the modern family of psychometric assessment methods such as Rasch analysis. As new therapeutic modalities for uveitis such as the new biological agents and steroid implants, continue to evolve, a comprehensive PROM will be increasingly valued in clinical trial settings to compare the effects of treatments from the patient's perspective.

Diagnostic delay in axial spondyloarthritis: a systematic review

Identification of axial spondyloarthritis (axSpA) remains challenging, frequently resulting in a diagnostic delay for patients. Current benchmarks of delay are usually reported as mean data, which are typically skewed and therefore may be overestimating delay. Our aim was to determine the extent of median delay patients’ experience in receiving a diagnosis of axSpA and examine whether specific factors are associated with the presence of such delay. We conducted a systematic review across five literature databases (from inception to November 2021), with studies reporting the average time period of diagnostic delay in patients with axSpA being included. Any additional information examining associations between specific factors and delay were also extracted. A narrative synthesis was used to report the median range of diagnostic delay experienced by patients with axSpA and summarise which factors have a role in the delay. From an initial 11,995 articles, 69 reported an average time period of diagnostic delay, with 25 of these providing a median delay from symptom onset to diagnosis. Across these studies, delay ranged from 0.67 to 8 years, with over three-quarters reporting a median of between 2 years and 6 years. A third of all studies reported median delay data ranging from just 2 to 2.3 years. Of seven variables reported with sufficient frequency to evaluate, only ‘gender’ and ‘family history of axSpA’ had sufficient concordant data to draw any conclusion on their role, neither influenced the extent of the delay. Despite improvements in recent decades, patients with axSpA frequently experience years of diagnostic delay and this remains an extensive worldwide problem. This is further compounded by a mixed picture of the disease, patient and healthcare-related factors influencing delay.

Key points • Despite improvements in recent decades, patients with axSpA frequently experience years of diagnostic delay. • Median diagnostic delay typically ranges from 2 to 6 years globally. • Neither ‘gender’ nor ‘family history of axSpA’ influenced the extent of diagnostic delay experienced. • Diagnostic delay based on mean, rather than median, data influences the interpretation of the delay time period and consistently reports a longer delay period.

Reviewing Disease Activity Indices in Spondyloarthritis From the Sex Perspective: A Systematic Review and Metaanalysis

OBJECTIVE

To determine whether the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Ankylosing Spondylitis Disease Activity Score (ASDAS) exhibited differences between women and men.

METHODS

We systematically searched MEDLINE, Embase, Web of Science, and other sources in English or Spanish from January 1, 1995, to July 31, 2020, to assess the differences according to sex in BASDAI and ASDAS. We performed a comparative analysis by sex using t test and mean difference by sex metaanalyses for BASDAI and ASDAS, as well as a random-effects model using the inverse-variance method.

RESULTS

Forty-one studies included BASDAI (6785 women, 12,929 men) and 16 of them included ASDAS (2046 women, 4403 men). Disease activity detected using BASDAI was significantly higher in women than in men (mean 4.9 vs 4.2, P = 0.02), whereas ASDAS did not detect differences between sexes (mean 2.8 women vs 2.8 men). In the metaanalyses, BASDAI detected significant differences between women and men (mean difference = 0.55 [95% CI 0.46-0.65], P < 0.00001), but ASDAS did not identify significant mean difference between sexes (0.04, 95% CI -0.05 to 0.12], P = 0.38).

CONCLUSION

The 2 most widely used indices of disease activity in spondyloarthritis (SpA) discriminate differently according to sex by their different evaluations of peripheral disease. The different components and weights in BASDAI and ASDAS influence their values. BASDAI may be affected by fatigue, and in predominantly peripheral manifestations such as enthesitis, ASDAS may not be sensitive enough to detect activity. This may represent a sex bias unfavorable to women, because peripheral SpA is more common in women than in men.

Evaluation of the early cervical structural change in patients with non-radiographic axial spondyloarthropathy

In this double-blind, controlled, cross-sectional study, we compared structural changes in the cervical vertebrae of patients with nonradiographic axial spondyloarthropathy (nr-axSpA), patients with ankylosing spondylitis (AS), and a control group. We used the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) to determine whether the involvement of the cervical spine occurs earlier and is more severe than that of the lumbar spine in axial spondyloarthropathy (axSpA). A statistically significant difference was found in the total mSASSS between the AS and nr-axSpA groups (p = 0.038), but not in the cervical and lumbar mSASSS. Although the duration of the symptoms was shorter in the nr-axSpA group than in the AS group, no statistically significant difference was found in the cervical mSASSS between the AS and nr-axSpA groups. In both the AS and nr-axSpA groups, the cervical mSASSS values were found to be higher than the lumbar mSASSS values for the majority of the patients (82.8 and 89.5%, respectively). This may indicate that structural changes in the cervical spine occur during an early period of axSpA.

Conventional disease-modifying antirheumatic drugs therapy may not slow spinal radiographic progression in ankylosing spondylitis: results from an 18-year longitudinal dataset

Objectives:

The clinical benefit of conventional disease-modifying antirheumatic drugs (cDMARDs) for treating ankylosing spondylitis (AS) is generally limited to improvements in peripheral arthritis. However, cDMARDs could be conditionally considered as alternatives to established drugs for improving axial manifestations in exceptional circumstances. However, there are few studies of the impact of cDMARDs on radiographic progression outcomes. Therefore, we investigated the effectiveness of cDMARDs on radiographic progression in AS.

Methods:

Among 1280 AS patients at a single hospital from 2000 to 2018, 301 who had been treated with sulfasalazine (SSZ) or methotrexate (MTX) were enrolled. For each patient, the entire follow-up period was split into 1-year intervals. Each interval was classified as either an “on-cDMARD” interval, which was a period of treatment with SSZ alone, MTX alone, or a combination of SSZ and MTX, or an “off-cDMARD” interval, which was a period without cDMARD treatment. Radiographic progression was scored using the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). The relationship between cDMARD use and radiographic progression within the intervals, defined as the rate of mSASSS progression, was investigated using linear models with adjustment for potential confounding covariates and for clustering among observations from the same patient.

Results:

The 732 on-cDMARD intervals and 1027 off-cDMARD intervals were obtained from enrolled patients. In multivariable regression analysis, there was no significant association between cDMARDs and the rate of mSASSS progression (β = −0.081, p = 0.418). The mean adjusted mSASSS change per year was 0.610 from on-cDMARD intervals and 0.691 from off-cDMARD intervals.

Conclusion:

Treatment with cDMARDs may not reduce radiographic progression in AS patients.

The relationship of ischemia-modified albumin levels to disease activity scores and HLA-B27 in patients with ankylosing spondylitis

OBJECTIVE:

Recent studies have implicated increased oxidative stress in the pathogenesis of Ankylosing spondylitis (AS). Ischemia-modified albumin (IMA), an altered form of albumin, increases oxidative stress. This study aimed to investigate the relationship between IMA levels and other indicators of disease severity in AS.

METHODS:

This study included 63 AS patients and 48 healthy controls. Patients were examined for serum lipid profile, C-reactive protein (CRP), complete blood count, Bath Ankylosing Spondylitis Disease Activity Index, human leukocyte antigen (HLA) B27, and treatment regimen. They were categorized based on disease activity, HLA-B27 status, and the drug treatment and compared for IMA levels.

RESULTS:

The patients had significantly higher IMA levels than controls (p=0.020); among patients, the levels were higher in those with active disease (p=0.001) and positively correlated with the CRP levels. No significant difference was found between the IMA levels of the patients with different HLA-B27 status or treatment method.

CONCLUSION:

The IMA levels were higher in patients than controls and further increased in patients with active AS. IMA was associated with disease activity and can be used as an inflammatory marker in AS. More comprehensive future studies with a larger sample size may help understand the relationship in greater detail.

Prevalence and impact of comorbidities in axial spondyloarthritis: systematic review and meta-analysis

OBJECTIVES

Comorbidities are common in people with axial spondyloarthritis (axSpA). In this systematic review and meta-analysis, we aimed to: (i) describe the prevalence of commonly reported comorbidities, (ii) compare comorbidities between axSpA and control populations, and (iii) examine the impact of comorbidity burden on axSpA outcomes.

METHODS

We systematically searched Medline, PubMed, Scopus and Web of Science using a predefined protocol in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We excluded studies of only one comorbid condition or a few closely related diseases within one organ system. Where possible, meta-analysis was performed using random-effects models.

RESULTS

A total of 40 studies were included for analysis. 36 studies reported prevalence of comorbidities, amounting to a combined sample size of 119 427 patients. The number of comorbidities studied ranged from 3 to 43. The most prevalent individual comorbidities were hypertension (pooled prevalence 23%), hyperlipidaemia (17%) and obesity (14%). Eleven studies consistently showed higher prevalence of comorbidities in axSpA than controls, particularly large differences were seen for depression [pooled odds ratio (OR) 1.80] and heart failure (OR 1.84). Comorbidities (total number of and individual conditions) were also associated with axSpA disease activity, functional impairment, quality of life, work productivity and mortality.

CONCLUSIONS

Comorbidities are common in axSpA, particularly cardiovascular diseases and risk factors. Most comorbidities were more prevalent in axSpA patients than in control populations. Overall comorbidity burden, and many individual conditions, were associated with axSpA outcomes including worse disease severity, work productivity and mortality.

The rs6427384 and rs6692977 Single Nucleotide Polymorphisms of the Fc Receptor-Like 5 (FCRL5) Gene and the Risk of Ankylosing Spondylitis: A Case Control Study in a Single Center in China

BACKGROUND The study aimed to explore the genetic association of Fc receptor-like 5 (FCRL5) gene variants (rs6427384 and rs6692977) with ankylosing spondylitis risk in Chinese Han population. MATERIAL AND METHODS Genotyping for FCRL5 gene variations rs6427384 and rs6692977 was implemented among 130 ankylosing spondylitis cases and 135 healthy persons, through polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) method. Frequency dissimilarity for 2 polymorphisms was compared between 2 groups using chi-square test. The association strength of FCRL5 gene polymorphism with ankylosing spondylitis risk was estimated by odds ratios with 95% confidence intervals. RESULTS The frequencies of rs6427384 CC genotype and C allele were significantly lower in the case group than that in the control group (P<0.05), which suggested that C allele of rs6427384 polymorphism might offer protection against ankylosing spondylitis onset. Whereas only 2 genotypes of rs6692977 were detected in the control group, and no significant association was found with ankylosing spondylitis susceptibility. CONCLUSIONS FCRL5 gene polymorphism rs6427384 was correlated to ankylosing spondylitis occurrence among Chinese Han population, while rs6692977 was not.

Add-On Effects of Conventional Synthetic Disease-Modifying Anti-Rheumatic Drugs in Ankylosing Spondylitis: Data from a Real-World Registered Study in China

Background

The aim of this study was to investigate the effects of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) on patients with ankylosing spondylitis (AS) using real-world data, and to analyze patients’ choices of csDMARDs and reasons for discontinuation.

Material/Methods

This observational study included 320 patients satisfying the modified New York criteria for AS. Patients were grouped according to medication: Group 1: 122 patients receiving non-steroidal anti-inflammatory drug (NSAID) monotherapy; Group 2: 198 patients receiving csDMARDs and NSAIDs. Patients were followed for 18 months at 6-month intervals. The change in AS Disease Activity Score and C-reactive protein (ASDAS-CRP) at each visit was the primary outcome. Secondary outcomes were based on validated disease activity questionnaires, clinical assessment, and acute-phase biomarkers (CRP and erythrocyte sedimentation rate [ESR]). Inter-group relationships were assessed across the 18-month follow-up period using generalized additive mixed models.

Results

Sulfasalazine and thalidomide were the most commonly used csDMARDs, with cumulative use times of 8.9±4.1 months and 9.1±4.7 months, respectively. In Group 2, 56 patients discontinued or switched csDMARDs during the follow-up period, with lack of efficacy being the primary reason. The ASDAS-CRP was found to decrease significantly in both groups; however, improvements in many parameters (including ASDAS-CRP, disease activity questionnaires and ESR) were greater in Group 2.

Conclusions

Use of csDMARDs can improve disease activity in terms of ASDAS-CRP. The addition of csDMARDs may provide increased benefits compared with NSAID monotherapy, particularly in the reduction of AS disease activity, in the Chinese population.

Is ultrasonographic enthesitis evaluation helpful for diagnosis of non-radiographic axial spondyloarthritis?

The aim of this study is to evaluate the diagnostic utility of ultrasonographic enthesitis assessment in patients with non-radiographic axial spondyloarthritis (nr-axSpA) and to compare different sonographic scoring methods. Patients with nr-axSpA (n = 30) and mechanical back pain (MBP) (n = 30) were enrolled in the study with standardized clinical criteria. For both of the groups, a total of 18 entheses were evaluated in each patient with B mode ultrasound and power Doppler by a sonographer who is blinded to initial clinical and radiological assessments. Glasgow Ultrasound Enthesitis Scoring System (GUESS), Madrid Sonographic Enthesitis Index (MASEI) and D'Agostino grading system were performed. Intra-rater and inter-rater reliability analyses were evaluated with the intraclass correlation coefficient (ICC). There was at least one enthesitis in 96.7% of patients with nr-axSpA. Median values of the number of enthesitis were 5 in nr-axSpA and 0 in MBP. Mean GUESS total scores were 0.9 in MBP and 4.5 in nr-axSpA. Mean MASEI total scores were 2.3 and 10.5, respectively. The sensitivities were 96.7% and 93.3% for GUESS and MASEI while the detected specificities were 80% for both methods. For Intra-rater reliability analysis, ICC was calculated as 0.981 for GUESS and 0.975 for MASEI, while it was calculated as 0.964 and 0.962 for inter-rater reliability analysis. Thus, evaluation of enthesitis with ultrasound is a reliable, helpful tool for the distinction of patients with nr-axSpA from patients with MBP. We favored the use of MASEI because of assessing upper extremity, using power Doppler and having a correlation with disease activity.

Harmonization, data management, and statistical issues related to prospective multicenter studies in Ankylosing spondylitis (AS): Experience from the Prospective Study Of Ankylosing Spondylitis (PSOAS) cohort

Ankylosing spondylitis (AS) is characterized by inflammation of the spine and sacroiliac joints causing pain and stiffness and, in some patients, ultimately new bone formation, and progressive joint ankyloses. The classical definition of AS is based on the modified New York (mNY) criteria. Limited data have been reported regarding data quality assurance procedure for multicenter or multisite prospective cohort of patients with AS. Since 2002, 1272 qualified AS patients have been enrolled from five sites (4 US sites and 1 Australian site) in the Prospective Study Of Ankylosing Spondylitis (PSOAS). In 2012, a Data Management and Statistical Core (DMSC) was added to the PSOAS team to assist in study design, establish a systematic approach to data management and data quality, and develop and apply appropriate statistical analysis of data. With assistance from the PSOAS investigators, DMSC modified Case Report Forms and developed database in Research Electronic Data Capture (REDCap). DMSC also developed additional data quality assurance procedure to assure data quality. The error rate for various forms in PSOAS databases ranged from 0.07% for medications data to 1.1% for arthritis activity questionnaire-Global pain. Furthermore, based on data from a sub study of 48 patients with AS, we showed a strong level (90.0%) of agreement between the two readers of X-rays with respect to modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). This paper not only could serve as reference for future publications from PSOAS cohort but also could serve as a basic guide to ensuring data quality for multicenter clinical studies.

Gender Differences in Axial Spondyloarthritis: Women Are Not So Lucky

PURPOSE OF REVIEW

Ankylosing spondylitis (AS) was historically seen as a predominantly male disease. However, more recent data showed a more homogenous sex prevalence. Unfortunately, in many studies in axial spondyloarthritis (axSpA), the number of women included is low and the analyses are often not stratified for gender distribution. The purpose of this review is to aggregate the existing data on gender differences in axSpA in order to increase the awareness that female axSpA patients are still under-recognized.

RECENT FINDINGS

Several studies considering gender differences revealed that female axSpA patients had different disease manifestations due to different immunological, hormonal, and genetic responses. For instance, allelic frequencies of the AHNK-gene and tissue non-specific alkaline phosphatase (TNAP) haplotypes differed between men and women with ankylosing spondylitis (AS). In addition, different levels of tumor necrosis factor (TNF), interleukins IL-6, IL-17, and IL-18, were found between the two sexes. Furthermore, female patients show a higher diagnostic delay compared to males. Several studies indicate a higher frequency of extra-articular manifestations (EAM) in female axSpA patients, such as enthesitis, psoriasis, and inflammatory bowel disease (IBD), whereas acute anterior uveitis is more prevalent in male patients. Male AS patients more frequently show a higher Bath Ankylosing Spondylitis Radiology Index (BASRI) scores and modified Stoke Ankylosing Spondylitis Spine Scores (mSASSS) than females, which indicates that males have higher radiological damage and radiographic progression. However, disease activity (BASDAI) and quality of life (AsQol) scores are significantly higher in women, and more importantly, they have significantly lower response rates to treatment with TNF inhibitors (TNFi) and a significantly lower drug adherence. Despite the fact that men with axial SpA have a worse radiologic prognosis, women have a high disease burden, in part because they have a longer delay in diagnosis, higher disease activity, and significantly less responsiveness to treatment with TNFi.

Understanding How the Diagnostic Delay of Spondyloarthritis Differs Between Women and Men: A Systematic Review and Metaanalysis

OBJECTIVE

To identify empirical evidence of diagnostic delay in spondyloarthritis (SpA), determine whether sex-related differences persist, and conduct an analysis from that perspective of the possible causes, including the influence of quality research, in this group of inflammatory rheumatic diseases.

METHODS

A systematic review was done of delay in diagnosis of SpA in MEDLINE and EMBASE and other sources. Study quality was determined in line with the Strengthening The Reporting of OBservational studies in Epidemiology (STROBE) statement. A metaanalysis of 13 papers reporting sex-disaggregated data was performed to evaluate sex-related differences in diagnostic delay. The global effect of diagnostic delay by sex was calculated using means difference (D) through a fixed effects model.

RESULTS

The review included 23,883 patients (32.3% women) from 42 papers. No significant differences between the sexes were detected for symptoms at disease onset or during evolution. However, the mean for delay in diagnosis of SpA showed sex-related differences, being 8.8 years (7.4-10.1) for women and 6.5 (5.6-7.4) for men (p = 0.01). Only 40% of papers had high quality. A metaanalysis included 12,073 participants (31.2% women). The mean global effect was D = 0.6 years (0.31-0.89), indicating that men were diagnosed 0.6 year (7 months) before women.

CONCLUSION

Delay in diagnosis of SpA persists, and is longer in women than in men. There are no significant sex-related differences in symptoms that could explain sex-related differences in diagnostic delay. Methodological and possible publication bias could result in sex-biased medical practice.

Relationship between articular and nonarticular manifestations in inflammatory bowel diseases

Background:

Musculoskeletal manifestations (MSM) of inflammatory bowel diseases (IBDs) are usually the most frequent extraintestinal manifestations. However, they are not paid enough attention during regular office visits. This cross-sectional study aimed to draw a clinical picture of MSM and their relationships with other findings in patients with IBD.

Materials and Methods:

Patients of our IBD cohort between March 2012 and September 2013 were consecutively evaluated. Those with current or past history of any MSM were examined by a rheumatologist. The outcome of interest was different MSMs. Distribution of IBD manifestations between the two groups of patients with (n = 20) and without (n = 253) MSM was compared. Logistic regression analysis was employed to find the relationships of demographic, clinical, and laboratory findings with MSM.

Results:

Two hundred and seventy-three patients were enrolled. Forty-two patients (15.4%) had extraintestinal manifestations of which twenty patients (7.5%) had at least one MSM. 7/20 patients (35%) versus 22/253 (8.7%) had other extraintestinal manifestations (P = 0.0001). 12/20 patients (57%) had arthritis (polyarthritis, 33% and oligoarthritis, 67%). The most frequent involved joints were knee and ankle observed in 8 (40%) and 7 (35%) patients, respectively. The inflammatory back pain was recorded in 5/20 patients (25%) whereas two patients (10%) had ankylosing spondylitis. In regression analysis, oral aphthous (odds ratio [OR] =8.8 [95% confidence intervals (CI), 1.7–45], P = 0.009) and other extraintestinal manifestations (OR = 5.2 [95% CI, 1.3–20], P = 0.02) were significantly related with arthritis.

Conclusion:

The most frequent extraintestinal manifestations in patients with IBD were MSM. Knee and ankle were the most frequent involved joints. Extraintestinal manifestations were determinant variables of arthritis.

Association of rs11209032 and rs1004819 Polymorphisms in Interleukin-23 Receptor Gene With Ankylosing Spondylitis

Objectives

This study aims to investigate the distribution of human leukocyte antigen B27 (HLA-B27) alleles (+/-) and interleukin-23 receptor (IL-23R) gene rs11209032 and rs1004819 polymorphisms among ankylosing spondylitis (AS) patients in a Turkish cohort.

Patients and methods

The study sample comprised 106 AS patients (89 males, 18 females; mean age 38.9±10 years; range 19 to 65 years) and 82 healthy controls (70 males, 12 females; mean age 32.15±7.07 years; range 19 to 51 years). Distribution of HLA-B27 alleles (+)/(-) in AS patients were observed by reverse hybridization technique. Genotyping of IL-23R rs11209032 and rs1004819 polymorphisms of AS patients and healthy controls were performed by real time polymerase chain reaction.

Results

Of the AS patients, 69 (65.1%) were HLA-B27 positive. Distribution of rs11209032 genotype frequencies in AS group were 31.1% for GG, 50.9% for GA, and 17.9% for AA; while in control group, it was 34.1% for GG, 53.7% for GA, and 12.2% for AA. Distribution of rs1004819 genotype frequencies in AS group were 30.2% for CC, 52.8% for CT, and 17.0% for TT; while in control group, it was 42.7% for CC, 46.3% for CT, and 11.0% for TT. There was no significant difference between AS patients and controls in terms of genotype frequencies of IL-23R gene rs11209032 and rs1004819 polymorphisms.

Conclusion

No association was found between AS and IL23R rs11209032 and rs1004819 polymorphisms in this Turkish AS cohort.

Biologic Treatment Registry Across Canada (BioTRAC): a multicentre, prospective, observational study of patients treated with infliximab for ankylosing spondylitis

OBJECTIVES

To describe the profile of patients with ankylosing spondylitis (AS) treated with infliximab in Canadian routine care and to assess the effectiveness and safety of infliximab in real world.

SETTING

46 primary care rheumatology practices across Canada.

PARTICIPANTS

303 biological-naïve patients with AS or patients previously treated with a biological for <6 months and who were eligible for infliximab treatment as per routine care within the Biologic Treatment Registry Across Canada (BioTRAC).

INTERVENTION

Not applicable (non-interventional study).

PRIMARY AND SECONDARY OUTCOMES

Effectiveness was assessed with changes in disease parameters (AS Disease Activity Score (ASDAS), Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), Health Assessment Questionnaire Disease Index (HAQ-DI), physician global assessment of disease activity (MDGA), patient global disease activity (PtGA), back pain, C-reactive protein, erythrocyte sedimentation rate (ESR), morning stiffness). Safety was assessed with the incidence of adverse events (AEs).

RESULTS

Of the 303 patients included, 44.6% were enrolled in 2005-2007 and 55.4% in 2008-2013. Patients enrolled in 2005-2007 had significantly higher MDGA and ESR at baseline while all other disease parameters examined were numerically higher with the exception of PtGA. Treatment with infliximab significantly (p<0.001) improved all disease parameters over time in both groups. At 6 months, 56% and 31% of patients achieved clinically important (change≥1.1) and major (change≥2.0) improvement in ASDAS, respectively; at 48 months, these proportions increased to 75% and 50%, respectively. Among patients unemployed due to disability at baseline, 12.1% returned to work (mean Kaplan-Meier (KM)-based time=38.8 months). The estimated retention rate at 12 and 24 months was 78.3% and 60.1%, respectively. The profile and incidence of AEs were comparable to data previously reported for tumour necrosis factor-α inhibitors.

CONCLUSIONS

Characteristics of patients with AS at infliximab initiation changed over time towards lower disease activity and shorter disease duration. Infliximab treatment significantly reduced disease activity independent of treatment initiation year, although patients enrolled in recent years achieved lower disease activity over 48 months.

TRIAL REGISTRATION NUMBER

NCT00741793.

The effect of IL-4 and MTHFR gene variants in ankylosing spondylitis

PURPOSE

Ankylosing Spondylitis (AS) is a chronic inflammatory rheumatic disease that characteristically affects the sacroiliac joints and the spine. The exact pathogenesis of AS remains poorly understood, but genetic factors play a key role in disease development. Several genes have been consistently associated with susceptibility to AS. This study was conducted in Turkish AS patients to determine the frequency of the methylenetetrahydrofolate reductase (MTHFR) gene C677T and interleukin-4 (IL-4) gene 70 bp variable number of tandem repeats (VNTR) variants, as well as their association with clinical characteristics.

METHODS

Genomic DNA obtained from 272 persons (122 AS patients and 150 healthy controls) was used in this study. Genomic DNA was isolated and genotyped using a polymerase chain reaction (PCR)-based restriction fragment length polymorphism (RFLP) assay for the MTHFR C677T and IL-4 70 bp VNTR gene variants, which were determined using specific PCR primers.

RESULTS

There was statistically significant difference between the groups with respect to MTHFR genotype distribution (p = 0.02) and allele frequencies (p < 0.001). When we examined MTHFR and IL-4 genotype frequencies according to clinical characteristics, we found an association between the homozygous MTHFR TT genotype and ocular involvement, although this did not reach statistical significance (p = 0.02). However, we did not find any difference between the groups with respect to IL-4 genotype distribution or allele frequencies and clinical characteristics (p > 0.05).

CONCLUSION

Our findings suggest that there is an association of the MTHFR gene C677T polymorphism with the susceptibility of a person for development of AS. However, the IL-4 gene is not associated with AS within the same population.

Predictors of response and drug survival in ankylosing spondylitis patients treated with infliximab

Background

The advent of anti-tumor necrosis factor-α (TNFα) drugs has changed the course of ankylosing spondylitis (AS). While data are available concerning the long term effectiveness of single anti-TNF agents, little has been published about predictors of treatment response in AS. The aim of this retrospective study was to evaluate the survival, effectiveness, and safety of infliximab over a 5-year period and to identify predictors of disease outcome.

Methods

Seventy AS patients attending the Rheumatology Clinic of the University of Padua who were treated with intravenous infliximab at 0, 2, 4 weeks and then every 6, 8, or up to 16 weeks were studied retrospectively. Demographic information, laboratory inflammatory and disease indices (BASDAI, BASFI, BASMI) were collected (at baseline, 3, 6, 12 months and once a year thereafter). Clinical improvement, drug tolerability, adverse events/side effects and causes leading to discontinuation were recorded.

Results

Infliximab caused a rapid, persistent improvement at all the assessment times in the BASDAI 50 (71.4 %) and ASDAS scores (97.1 % in ASAS20, 80 % in ASAS40, 80 % in ASAS5/6), and already within 6 months of beginning treatment in 50 % percent of the patients. The other 50 % withdrew because of: adverse events (12 = 34.3 %), side effects (5 = 14.3 %), drug inefficacy (12 = 34.3 %), spontaneously (4 = 11.4 %). Those who did not respond were prevalently females (34.3 % vs 17.1 %).

Conclusion

Factors such as female sex, use of steroids, persistently high inflammatory levels, BASFI and BASDAI indices were found to be negative predictors of treatment response. Infliximab was found to be safe, effective and well-tolerated; it elicited satisfactory long term response and drug survival rates.

Elevated serum levels of calprotectin (myeloid-related protein 8/14) in patients with ankylosing spondylitis and its association with disease activity and quality of life

BACKGROUND

Calprotectin is one of the major leukocyte S100 proteins showing both calcium binding and antimicrobial characteristics. The serum level of calprotectin is markedly elevated in patients with inflammatory bowel disease, rheumatoid arthritis, as well as systemic lupus erythematosus and has been suggested to play a prominent role in both progression and pathogenesis of these diseases.

AIM

The purpose of this study was to investigate the serum level of calprotectin in patients with ankylosing spondylitis (AS) and its association with disease activity and other clinical characteristics of AS.

MATERIALS AND METHODS

Thirty-one patients who met the modified New York criteria for AS and 45 healthy controls were included in this study. Both Bath AS disease activity index and AS disease activity score were applied on the patients with AS for the assessment of disease activity; Bath AS functional index, for the assessment of functional activity; Bath AS radiology index, for the assessment of radiological damage; and the AS quality of life questionnaire for the assessment of disease-related life status. Spinal and hip measurements were performed using Bath AS metrology index. The serum level of calprotectin was determined using enzyme-linked immunosorbent assay kit.

RESULTS

Mean serum level of calprotectin was significantly higher in the patients with AS compared with healthy controls (P = 0.003). Serum levels of calprotectin did not correlate with Bath AS disease activity index, AS disease activity score, Bath AS functional index, Bath AS radiology index, Bath AS metrology index, modified Schober, chest expansion, AS quality of life questionnaire, erythrocyte sedimentation rate, and C-reactive protein values (P > 0.05).

CONCLUSIONS

Our results suggest that calprotectin might play an important role in the pathogenetic mechanisms of AS; however, the calprotectin levels did not correlate with the measurements of disease activity, functional abilities, radiological damage, and the quality of life in these patients. Further insight into this area of research might provide opportunities to develop novel treatment strategies, which take into account the role of these peptides in the pathogenetic mechanisms of AS.

Evaluation of choroidal thickness in ankylosing spondylitis using optical coherence tomography

Abstract Purpose: To investigate posterior segment (PS) findings in the eye in patients with ankylosing spondylitis (AS).

METHODS

Eighty-four patients with AS and 63 healthy controls were enrolled. PS evaluations were performed using optical coherence tomography (OCT). Foveal thickness, peripapillary retinal nerve fiber layer thickness, macular volume, ganglion cell complex, and choroidal thickness (CT) values were compared between the groups.

RESULTS

Mean CT was higher in patients with AS (326.5 ± 71.5 µm) than in the healthy controls (286.2 ± 59.5 µm) (p = 0.001). There was no significant difference between patients with AS and the healthy control group in terms of other OCT parameters. There was also no significant correlation between CT, AS activity index, and disease duration.

CONCLUSIONS

This is the first study to evaluate effects of AS on CT. CT was high in patients with AS compared to healthy controls.

Gender differences in Iranian patients with ankylosing spondylitis

Inequalities in features and severity of ankylosing spondylitis (AS) have been noticed between men and women, suggesting a possible influence of gender on disease phenotypes. Comparing disease features and characterization of gender differences in clinical features and medications could help elucidate the potential influence of gender on the severity of AS in patients. This study aims to assess the influence of gender on disease patterns in Iranian patients with AS. Three hundred and twenty patients diagnosed with primary AS were assessed for demographic variables, clinical manifestations, HLA status, disease severity, functional capacities, quality of life, and treatment status. Sixty-seven women and 253 men were included corresponding to a male to female ratio of 3.78:1. Both groups were similar regarding ethnicity, positive family history, and juvenile onset AS. HLA-B27 was more frequent among males (78.3 vs. 55.2%; p < 0.001). There was a higher proportion of female patients with overall enthesitis (p < 0.05). Extra-articular manifestations and treatment modalities presented similar frequencies in both genders. No difference in gender-associated diagnostic delays was observed. Female disease was at least as severe as male disease, and in some aspects, females presented with more severe disease. Despite a relatively similar disease profile, we observed a higher rate of enthesitis among women. Together with the equally high rate of disease activity indices in both genders, these findings indicate an overall longer delay to diagnosis in our country. Early detection and specialized care would be of great practical importance.