Uveitis in spondyloarthritis including psoriatic arthritis, ankylosing spondylitis, and inflammatory bowel disease

Causal associations between both psoriasis and psoriatic arthritis and multiple autoimmune diseases: a bidirectional two-sample Mendelian randomization study

Background

Numerous observational studies have identified associations between both psoriasis (PsO) and psoriatic arthritis (PsA), and autoimmune diseases (AIDs); however, the causality of these associations remains undetermined.

Methods

We conducted a bidirectional two-sample Mendelian Randomization study to identify causal associations and directions between both PsO and PsA and AIDs, such as systemic lupus erythematosus (SLE), Crohn's disease (CD), ulcerative colitis (UC), multiple sclerosis (MS), uveitis, bullous pemphigoid (BP), Hashimoto's thyroiditis (HT), rheumatoid arthritis (RA), vitiligo, and ankylosing spondylitis (AS). The causal inferences were drawn by integrating results from four regression models: Inverse Variance Weighting (IVW), MR-Egger, Weighted Median, and Maximum Likelihood. Furthermore, we performed sensitivity analyses to confirm the reliability of our findings.

Results

The results showed that CD [IVW odds ratio (ORIVW), 1.11; 95% confidence interval (CI), 1.06-1.17; P = 8.40E-06], vitiligo (ORIVW, 1.16; 95% CI, 1.05-1.28; P = 2.45E-03) were risk factors for PsO, while BP may reduce the incidence of PsO (ORIVW, 0.91; 95% CI, 0.87-0.96; P = 1.26E-04). CD (ORIVW, 1.07; 95% CI, 1.02-1.12; P = 0.01), HT (ORIVW, 1.23; 95% CI, 1.08-1.40; P = 1.43E-03), RA (ORIVW, 1.11; 95% CI, 1.02-1.21, P = 2.05E-02), AS (ORIVW, 2.18; 95% CI, 1.46-3.27; P = 1.55E-04), SLE (ORIVW, 1.04; 95% CI, 1.01-1.08; P = 1.07E-02) and vitiligo (ORIVW, 1.27; 95% CI, 1.14-1.42; P = 2.67E-05) were risk factors for PsA. Sensitivity analyses had validated the reliability of the results.

Conclusions

Our study provides evidence for potential causal relationships between certain AIDs and both PsO and PsA. Specifically, CD and vitiligo may increase the risk of developing PsO, while CD, HT, SLE, RA, AS, and vitiligo may elevate the risk for PsA. Additionally, it is crucial to closely monitor the condition of PsO patients with specific AIDs, as they have a higher likelihood of developing PsA than those without AIDs. Moving forward, greater attention should be paid to PsA and further exploration of other PsO subtypes is warranted.

Genetic variations of IL10 and IL6R genes in acute anterior uveitis in Han Chinese

BACKGROUND

Several autoimmune disorders have been linked to polymorphisms in IL10 and IL6R genes. This research aimed to study whether single nucleotide polymorphisms (SNPs) in the genes of IL10 and IL6R were associated with acute anterior uveitis (AAU) in Han Chinese.

METHODS

Genotyping was carried out by the iPLEX Gold Genotyping Assay. Our study comprised 420 patients with AAU and 918 healthy subjects from Han Chinese. Using the chi-square (χ2) test, alleles and genotypes were analyzed between AAU subjects and healthy controls.

RESULTS

All ten SNPs were successfully genotyped and four SNPs (IL10/rs1800871, IL10/rs3021094, IL10/rs2222202, IL6R/rs4845618) exhibited weak associations with AAU, as indicated by their Puncorr values. However, upon applying the Bonferroni correction, there was no significant association between AAU and the control subjects. Additionally, the haplotype analysis of the ten SNPs revealed no association with AAU.

CONCLUSION

Our findings suggested that polymorphisms of the tested ten SNPs on the IL10 and IL6R genes did not show any association with the risk of developing AAU among the Han Chinese population.

Unraveling the connection: Uveitis prevalence and risk factors in psoriasis patients - a population-based study

The association between uveitis and spondyloarthropathy (SpA)-related conditions is well-established. However, evidence describing the link between uveitis and psoriasis, and psoriasis without concomitant SpA-related conditions is scarce and conflicting. This large-scale population-based study sought to describe the prevalence and features of uveitis among psoriasis patients in Israel as well as investigating the risk for uveitis in different subgroups of psoriasis patients compared to the general population. We conducted a retrospective study utilizing the electronic database of the Meuhedet Health Maintenance Organization. The study included all patients diagnosed with psoriasis between 2000 and 2020, each patient was matched with four controls based on age, sex, place of residence, and index date. Logistic regression models were employed to assess the association between psoriasis and uveitis while adjusting for the presence of SpA-related conditions. A total of 61 003 psoriasis patients and 244 012 matched controls were included. The prevalence of uveitis was 1.3% versus 1.1% respectively (OR  1.12; 95% CI 1.10-1.30; p < 0.001). When adjusting to psoriasis severity, concurrent SpA, and psoriasis treatment no significant association was found. The rates of uveitis among psoriasis patients with concurrent SpA-related conditions was 3.2% compared to 1.4% in controls without psoriasis or SpA (OR 2.38; 95% CI 2.00-2.83; p < 0.001), while in psoriasis patients without SpA, the rate of uveitis was 1.0% and was similar to controls. Although crude rates of uveitis were higher in patients with severe psoriasis compared to mild psoriasis (2.1% vs. 1.1%), after adjustment, no significant association compared to controls was found in either group. Our findings suggest that the positive association between psoriasis and uveitis is primarily mediated by the coexistence of other SpA-related conditions. These findings imply the presence of a shared pathogenetic mechanism and set the direction for a phenotypic-targeted screening strategy.

Targeted therapies for uveitis in spondyloarthritis: A narrative review

Spondyloarthritis (SpA) encompasses a group of chronic inflammatory disorders of the joints frequently associated with uveitis in almost a quarter of cases. SpA-related uveitis typically affects the eye anterior chamber with sudden onset, causing pain, redness, photophobia, and blurred vision. Ophthalmologists will describe an acute anterior unilateral uveitis. Most patients present with episodic acute anterior non-granulomatous uveitis and retain excellent visual acuity. However, systemic treatments are recommended in the event of frequent relapses (2-3/year) or in rare cases of sight-threatening with ocular complications. The improved understanding of the pathogenesis of SpA has led to the management of this disease by biologics. Here, we review the main data regarding the opportunity to target specific components in inflammatory pathways for the treatment of SpA-related uveitis. These therapies are recommended for long-term control when uveitis relapses occur too frequently despite conventional systemic treatments. Significant benefits have been obtained with the tumor necrosis factor-α inhibitors (TNFis), particularly infliximab and adalimumab. Paradoxically, a high number of uveitis occurrences have been shown on etanercept. Mixed results have been demonstrated with interleukin-17 antagonists (secukinumab) and interleukin-12/interleukin-23 antagonists (ustekinumab) in cases of failure of TNFis. JAK inhibitors seem to be a valuable class of medications for these patients in the future. Although SpA-related uveitis is typically managed with conventional local and/or systemic treatments, these biological/targeted therapies may provide avenues to control both the underlying SpA and uveitis manifestations. Thus, a close collaboration between patients, rheumatologists, internists, and ophthalmologists is needed to optimally manage ocular inflammation in SpA.

Ocular involvement in rheumatic diseases

Rheumatic diseases are associated with a significant decline in quality of life, which is not only related to the progression of the underlying disease but also to the development of coexisting conditions. One of the possible complications in this group of diseases is ocular involvement. Impaired vision is strongly associated with a significant decline in quality of life and can also exacerbate problems related to physical functioning. Consequently, it can lead to serious complications in the treatment of the underlying disease. Additionally, from a clinical point of view, it is also important to note that ocular diseases may precede the occurrence of inflammatory joint and spinal diseases, as well as organ involvement in systemic connective tissue disorders. Therefore, paying attention to ocular symptoms can help in early diagnosis and thus improve patient prognosis. For the aforementioned reasons, ocular diseases should be carefully considered in routine rheumatologic practice.

Rheumatologist's Perspective on Non-Infectious Uveitis: Patterns from Tertiary Referral Rheumatologic Clinics in Italy

Non-infectious uveitis (NIU) can be an early or even the first extra-articular manifestation of systemic rheumatic diseases, or the first one; thus, rheumatologists are often involved in the diagnostic and therapeutic assessment of NIU. We evaluated 130 patients with a diagnosis of NIU who were admitted to two Italian rheumatologic clinics (Tor Vergata University Hospital in Rome, and Federico II University in Naples) from January 2018 to December 2021. Anterior uveitis (AU) occurred in 75.4% of patients, followed by posterior uveitis (PU, 21.5%); acute (54.6%) and recurrent (35.4%) NIU were more documented than chronic NIU (10%), and a bilateral involvement was observed in 38.7% of cases. Half of NIU cases were associated with spondyloarthritis (SpA); the remaining were affected by Behçet disease (BD)-related uveitis (13.9%) and idiopathic NIU (9.2%). HLA-B27⁺ patients (34.8%) had a higher prevalence of anterior and unilateral NIU (p = 0.005) with acute course (p = 0.04) than HLA-B27^- patients. On the contrary, HLA-B51⁺ patients (19.6%) had mostly PU and bilateral NIU (p < 0.0001) and recurrent course (p = 0.04) than HLA-B51^- patients. At the first rheumatologic referral, 117 patients (90%) received systemic treatments. Findings from this study demonstrate that rheumatologic referral has a pivotal role in the diagnostic work-up of NIU and may dramatically influence NIU-treatment strategies.

The Role of Neutrophils in Spondyloarthritis: A Journey across the Spectrum of Disease Manifestations

Spondyloarthritis (SpA) contemplates the inflammatory involvement of the musculoskeletal system, gut, skin, and eyes, delineating heterogeneous diseases with a common pathogenetic background. In the framework of innate and adaptive immune disruption in SpA, neutrophils are arising, across different clinical domains, as pivotal cells crucial in orchestrating the pro-inflammatory response, both at systemic and tissue levels. It has been suggested they act as key players along multiple stages of disease trajectory fueling type 3 immunity, with a significant impact in the initiation and amplification of inflammation as well as in structural damage occurrence, typical of long-standing disease. The aim of our review is to focus on neutrophils' role within the spectrum of SpA, dissecting their functions and abnormalities in each of the relevant disease domains to understand their rising appeal as potential biomarkers and therapeutic targets.

Uveitis in psoriatic arthritis: study of 406 patients in a single university center and literature review

BACKGROUND/PURPOSE

The manifestations of uveitis are well established in axial spondyloarthritis (ax-SpA), but not in psoriatic arthritis (PsA). We aimed to assess, in a large unselected series of PsA: (A) the frequency and clinical features of uveitis; (B) its association with PsA activity, the impact of disease and functional disability, and (C) its relationship with the biological treatment. In addition, a literature review was performed.

METHODS

Retrospective longitudinal study of PsA patients from a single referral hospital. PsA was classified according to the CASPAR criteria, and uveitis was diagnosed by experienced ophthalmologists.

RESULTS

We studied 406 patients with PsA (46.3±12.3 years). Uveitis was observed in 20 (4.9%). Uveitis was acute in all cases, anterior (80%), unilateral (80%) and recurrent (50%). Patients with uveitis had a higher prevalence of HLA-B27 (45% vs 7.5%, p<0.0001), sacroiliitis on MRI (25% vs 8.3% p=0.027), ocular surface pathology (10% vs 0.8%, p=0.021), and median PsA impact of Disease Score (5.9 (2.1-6.8) vs 1.25 (0.0-3.0), p=0.001) and Bath Ankylosing Spondylitis Functional Index (4 (1.6-5) vs 1.0 (0.0-3.5), p=0.01) than patients without uveitis.The exposure adjusted incidence rate (episodes/100 patients-year) of uveitis before versus after biological treatment decreased with anti-TNFα monoclonal antibodies (56.3 vs 9.4) and increased with etanercept (ETN) (6.03 vs 24.2) and secukinumab (SECU) (0 vs 50) (including only one patient treated in the last two cases).

CONCLUSION

The prevalence of uveitis in patients with PsA was about 5%. The pattern was similar to that observed in ax-SpA. Uveitis was associated with a worse quality of life and greater functional disability. The uveitis exposure adjusted incidence rate decreased with anti-TNFα monoclonal antibodies and increased with ETN and SECU.

Consensus statements for pharmacological management, monitoring of therapies, and comorbidity management of psoriatic arthritis in the United Arab Emirates

OBJECTIVE

Psoriatic arthritis (PsA), a chronic inflammatory disease characterized by heterogeneous clinical manifestations, substantially impacts the quality of life of affected individuals. This article aims at developing consensus recommendations for the management of PsA and associated comorbidities and screening and monitoring requirements of PsA therapies in the United Arab Emirates (UAE) population.

METHODS

An extensive review of present international and regional guidelines and publications on the pharmacological management, monitoring of therapies in the context of PsA was performed. Key findings from guidelines and literature were reviewed by a panel of experts from the UAE at several meetings to align with current clinical practices. Consensus statements were formulated based on collective agreement of the experts and members of Emirates Society for Rheumatology.

RESULTS

The consensus recommendations were developed to aid practitioners in clinical decision-making with respect to dosage recommendations for pharmacological therapies for PsA, including conventional drugs, non-biologic, and biologic therapies. Consensus recommendations for therapeutic options for the treatment of PsA domains, including peripheral arthritis, axial disease, enthesitis, dactylitis, psoriasis, and nail disease, were developed. The panel emphasized the importance of monitoring PsA therapies and arrived at a consensus on monitoring requirements for PsA therapies. The expert panel proposed recommendations for the management of common comorbidities associated with PsA.

CONCLUSION

These consensus recommendations can guide physicians and healthcare professionals in the UAE in making proper treatment decisions, as well as efficiently managing comorbidities and monitoring therapies in patients with PsA.

Uveitis and nail psoriasis in a patient without articular involvement: a case report

Background

This study aimed to report a case of bilateral anterior non-granulomatous chronic non-infectious uveitis associated with isolated nail psoriasis without articular involvement.

Case presentation

A 55-year-old man with a history of open-angle glaucoma was referred to our uveitis and ocular immunology center with intraocular inflammation concordant with chronic non-infectious bilateral anterior non-granulomatous uveitis. At presentation, he had moderate inflammation in the anterior chamber bilaterally and lesions characteristic of nail psoriasis. Nail psoriasis was later confirmed by nail ultrasonography performed by a radiologist who specialized in psoriasis. Appropriate clinical and paraclinical assessments were conducted, ruling out all other possible causes of uveitis. The patient required dual systemic immunomodulatory therapy with methotrexate and adalimumab, topical anti-inflammatory drugs (steroidal and non-steroidal), and anti-glaucoma therapy to achieve satisfactory inflammatory and ocular pressure control.

Discussion and conclusions

This is the first report of non-infectious uveitis associated with nail compromise in a patient without other manifestations of psoriasis. Despite reports on the relationship between psoriatic disease and uveitis, there is insufficient information on clinical phenotypes associated with uveitis that could lead to later diagnosis and treatment of associated intraocular inflammation. Clinicians should be aware of all subtypes of psoriasis that increases a risk of developing uveitis in these patients.

Risk of inflammatory bowel disease in uveitis patients: a population-based cohort study

OBJECTIVES

To investigate the potential association between uveitis and an increased risk of developing inflammatory bowel disease (IBD).

METHODS

We conducted a retrospective cohort study by interrogating data from the Taiwan National Health Insurance Research Database entered between January 1, 2001 and December 31, 2013 to identify uveitis patients and age- and gender-matched controls. The cumulative incidence rates of subsequent IBD in the two groups were compared. The adjusted hazard ratio (HR) of IBD related to uveitis was generated by a multivariate cox regression model after adjustment for hypertension, diabetes, hyperlipidaemia, obesity and smoking. Furthermore, the HRs of the Crohn's disease (CD) and ulcerative colitis (UC) IBD subtypes were calculated separately.

RESULTS

A total of 198,923 subjects with uveitis and 397,846 controls were enroled. The mean age of the cohort was 47.7 ± 18.9 years. A significantly higher cumulative incidence of IBD was found in the uveitis group than in controls (4.13% vs. 1.48%, p < 0.0001). Under univariate cox regression analysis, uveitis patients had a significantly higher risk of IBD (HR = 1.47; 95% confidence interval (CI): 1.43-1.52, p < 0.0001). The association remained significant in the multivariate regression model, with an adjusted HR of 1.44 (95% CI: 1.39-1.49, p < 0.0001). Moreover, in subgroup analysis, uveitis was significantly associated with an increased risk of Crohn's disease (adjusted HR = 1.49; 95% CI: 1.44-1.54), but not with ulcerative colitis (adjusted HR = 1.03; 95% CI: 0.92-1.15).

CONCLUSIONS

Patients with uveitis are at significantly greater risk of developing IBD than individuals without uveitis.

Searching for New Genetic Biomarkers of Axial Spondyloarthritis

Background: Axial spondyloarthritis (axSpA) is a chronic inflammatory condition of the spine. In addition to musculoskeletal symptoms, there are also extra-articular manifestations. The aim of this study was to search for new biomarkers associated with the clinical presentation and treatment response in axSpA patients. Methods: In this study, 106 axSpA patients and 110 healthy controls were enrolled. Six single-nucleotide polymorphisms (SNPs) were selected for genotyping: ERAP1 rs2287987, ERAP2 rs2549782, TNF rs1800629, TNFRSF1A rs767455, TNFRSF1B rs1061622, and FCGR2A rs1801274. Participants were examined at baseline and after 12 and 24 weeks of anti-TNF therapy. Results: SNPs associated with high axSpA initial activity were TNFRSF1A rs767455 and TNFRSF1B rs1061622 (p < 0.008). The ERAP1 rs2287987 AA genotype was more frequently observed in patients with enthesitis (AA vs. G+, p = 0.049), while the TNFRSF1B rs1061622 GG genotype was more common in participants with uveitis (GG vs. TT, p = 0.042). Potential in predicting anti-TNF treatment response was demonstrated by ERAP1 rs2287987, ERAP2 rs2549782, TNFRSF1B rs1061622, and FCGR2A rs1801274. Conclusions: SNPs can be used to identify patients at risk of severe disease to initiate treatment earlier. Genetic testing will allow clinicians to choose the right drug for the patient.

Single Cell Transcriptome and Surface Epitope Analysis of Ankylosing Spondylitis Facilitates Disease Classification by Machine Learning

Ankylosing spondylitis (AS) is an immune-mediated inflammatory disorder that primarily affects the axial skeleton, especially the sacroiliac joints and spine. This results in chronic back pain and, in extreme cases, ankylosis of the spine. Despite its debilitating effects, the pathogenesis of AS remains to be further elucidated. This study used single cell CITE-seq technology to analyze peripheral blood mononuclear cells (PBMCs) in AS and in healthy controls. We identified a number of molecular features associated with AS. CD52 was found to be overexpressed in both RNA and surface protein expression across several cell types in patients with AS. CD16+ monocytes overexpressed TNFSF10 and IL-18Rα in AS, while CD8+ TEM cells and natural killer cells overexpressed genes linked with cytotoxicity, including GZMH, GZMB, and NKG7. Tregs underexpressed CD39 in AS, suggesting reduced functionality. We identified an overrepresented NK cell subset in AS that overexpressed CD16, CD161, and CD38, as well as cytotoxic genes and pathways. Finally, we developed machine learning models derived from CITE-seq data for the classification of AS and achieved an Area Under the Receiver Operating Characteristic (AUROC) curve of > 0.95. In summary, CITE-seq identification of AS-associated genes and surface proteins in specific cell subsets informs our understanding of pathogenesis and potential new therapeutic targets, while providing new approaches for diagnosis via machine learning.

Psoriatic arthritis

Psoriatic arthritis (PsA) is a type of inflammatory arthritis that is included within the spondyloarthritis, a group of rheumatological diseases characterized by different clinical manifestations and associated comorbidities, that can compromise the quality of life of patients. The diagnosis of PsA is sometimes difficult due to an enormous clinical and radiological variability, including six different domains of involvement: peripheral joint, axial skeleton, skin psoriasis, nail psoriasis, enthesitis and dactylitis. Currently, there are no biomarkers that allow the detection of PsA in patients with psoriasis, so a high level of suspicion is important, mainly by dermatologists, but also by other specialists, such as family doctors. Advances in the knowledge of new immunological mechanisms and joint management by rheumatologists and dermatologists have made it possible to improve the therapeutic approach in patients with PsA.

Prevalence and risk factors for uveitis in spondyloarthritis

AIM

To determine the prevalence and risk factors for uveitis in spondyloarthritis (SpA) patients.

METHODS

A total of 225 patients who fulfilled Assessment of Spondyloarthritis International Society classification criteria for axial and peripheral SpA were enrolled. The diagnosis of uveitis was confirmed by an ophthalmologist. From medical records and from clinical evaluation associated information like disease duration, and human leukocyte antigen B27 was collected. Relevant laboratory tests were done and disease severity was assessed using Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score - erythrocyte sedimentation rate and C-reactive protein. Characteristics of uveitis positive and uveitis negative groups were compared. Multivariate logistic regression analysis was done for the risk factors, and P values <.05 were considered significant.

RESULTS

Prevalence of uveitis was 18.7%. The disease duration was 9.3 ± 7 years and 5.4 ± 4.5 years in uveitis and no uveitis groups respectively (P ≤ .001). Family history of SpA was positive in 45.2% in the uveitis group (P ≤ .001). The frequency of axial SpA was 92.9% and 73.8% in the uveitis and no uveitis groups respectively (P ≤ .008). The mean BASDAI was 2.4 ± 1.9 and 3.3 ± 2.8 in uveitis and no uveitis groups respectively (P = .050). In multivariate logistic regression analysis, among the selected variables, family history of SpA (odds ratio [OR] =3.697; 95% CI =1.616-8.457; P = .002) and duration of disease (OR =1.089; 95% CI =1.004-1.181; P = .039) were independently associated with the occurrence of uveitis.

CONCLUSIONS

The prevalence of uveitis was 18.7%. The family history and the disease duration of SpA were independently associated with uveitis.

A Road Map of the Axial Spondyloarthritis Continuum

Axial spondyloarthritis (axSpA) is a chronic, immune-mediated inflammatory disease characterized by inflammatory low back pain, inflammation in peripheral joints and entheses, and other extra-articular or systemic manifestations. Although our understanding of the natural history of axSpA has been limited by incomplete knowledge of disease pathogenesis, axSpA is increasingly understood as a spectrum of axial, peripheral, and extra-articular inflammatory conditions that includes nonradiographic axSpA and radiographic axSpA, also known as ankylosing spondylitis. In this narrative review, we present a road map of this axSpA continuum, highlighting genetic risk factors for the development of axSpA, triggers of disease, and reasons for and implications of diagnostic delay. We present a detailed overview of the spectrum of axSpA clinical manifestations and highlight factors known to influence the risk of disease progression. Finally, we provide some expert commentary on the practical use of this road map to assist health care providers in the identification of axSpA in clinical practice.

Intraocular dendritic cells characterize HLA-B27-associated acute anterior uveitis

Uveitis describes a heterogeneous group of inflammatory eye diseases characterized by infiltration of leukocytes into the uveal tissues. Uveitis associated with the HLA haplotype B27 (HLA-B27) is a common subtype of uveitis and a prototypical ocular immune-mediated disease. Local immune mechanisms driving human uveitis are poorly characterized mainly due to the limited available biomaterial and subsequent technical limitations. Here, we provide the first high-resolution characterization of intraocular leukocytes in HLA-B27-positive (n = 4) and -negative (n = 2) anterior uveitis and an infectious endophthalmitis control (n = 1) by combining single-cell RNA-sequencing with flow cytometry and protein analysis. Ocular cell infiltrates consisted primarily of lymphocytes in both subtypes of uveitis and of myeloid cells in infectious endophthalmitis. HLA-B27-positive uveitis exclusively featured a plasmacytoid and classical dendritic cell (cDC) infiltrate. Moreover, cDCs were central in predicted local cell-cell communication. This suggests a unique pattern of ocular leukocyte infiltration in HLA-B27-positive uveitis with relevance to DCs.

Ankylosing Spondylitis

The seronegative spondyloarthropathies are a group of autoimmune inflammatory diseases lacking rheumatoid factor or antinuclear antibody in their serum. They include ankylosing spondylitis (AS), reactive arthritis, psoriatic arthritis, spondylitis associated with Crohn's disease and ulcerative colitis, and undifferentiated spondyloarthropathies. Inflammation mostly affects the axial joints, entheses, and extra-articular structures such as uveal tract, gastrointestinal tract, mucocutaneous tissue, and heart. Uveitis is the most common extra-articular manifestation. Spondyloarthropathies, especially AS, have a strong association with the presence of Human Leukocyte Antigen (HLA)-B27 gene. AS happens earlier in HLA-B27 patients and men are more prone to the disease. Uveitis, typically unilateral non-granulomatous acute anterior uveitis, occurs in up to 50% of the patients with AS. HLA-B27 positivity correlates with more frequent flare-ups. Conjunctivitis and scleritis are rare ocular manifestations of AS. To establish the diagnosis of AS, at least one clinical and one radiologic parameter are required for definitive diagnosis. Magnetic resonance imaging (MRI) or bone scan can help early detection of the axial skeleton inflammation. The course of eye and joint involvement are not correlated. Short-term treatment with topical corticosteroids and cycloplegic agents control the uveitis attack. In resistant cases, local or systemic therapy with corticosteroids are recommended. NSAIDs, disease-modifying anti-rheumatic drugs (DMARDs), methotrexate, azathioprine, anti-IL-17A monoclonal antibodies, and TNF-α antagonists are effective treatments for ocular and systemic manifestations of AS. If not treated adequately, uveitis may become recalcitrant and extend posteriorly. Functional impairment due to joint destruction can also occur as a result of under-treatment.

Ixekizumab for the treatment of pediatric patients with moderate to severe plaque psoriasis

Introduction: Ixekizumab (IXE), a high affinity humanized monoclonal antibody that selectively targets interleukin-17A, is approved in the United States (US) and the European Union (EU) for pediatric patients with moderate to severe plaque psoriasis. This review summarizes ixekizumab use in the phase 3, randomized, double-blind, placebo-controlled study in pediatric patients with moderate to severe plaque psoriasis and provides some clinical pearls we have learned after using the drug in the pediatric population for the past 3 years.Areas covered: Review of IXORA-PEDS trial data, general literature review pertaining to the systemic treatment of pediatric psoriasis as well as our clinical experience with IXEExpert opinion: IXE is the only IL17 antagonist for pediatric psoriasis and is a welcome addition to our armamentarium.

Uveitis for the non-ophthalmologist

The uveitides are a heterogeneous group of diseases characterized by inflammation inside the eye. The uveitides are classified as infectious or non-infectious. The non-infectious uveitides, which are presumed to be immune mediated, can be further divided into those that are associated with a known systemic disease and those that are eye limited,-ie, not associated with a systemic disease. The ophthalmologist identifies the specific uveitic entity by medical history, clinical examination, and ocular imaging, as well as supplemental laboratory testing, if indicated. Treatment of the infectious uveitides is tailored to the particular infectious organism and may include regional and/or systemic medication. First line treatment for non-infectious uveitides is corticosteroids that can be administered topically, as regional injections or surgical implants, or systemically. Systemic immunosuppressive therapy is used in patients with severe disease who cannot tolerate corticosteroids, require chronic corticosteroids at >7.5 mg/day prednisone, or in whom the disease is known to respond better to immunosuppression. Management of many of these diseases is optimized by coordination between the ophthalmologist and rheumatologist or internist.

Uveitis as the first symptom in spondyloarthritis and its association with the evolution of the disease. Results from the REGISPONSER registry

OBJECTIVES

To describe the time of onset of acute anterior uveitis (AAU) relative to the appearance of rheumatic symptoms and to determine its association with the evolution of the spondyloarthritis (SpA) in terms of activity, structural damage, functional ability and treatment.

METHODS

This was a cross-sectional study with data extracted from the REGISPONSER (SpA Registry of the Spanish Rheumatology Society). Thirty-one centres participated, and patients with SpA according to the ESSG criteria were included from 2004 to 2007. Patients were classified according to the time of uveitis appearance with regard to rheumatic symptom onset (before, concomitant with, or after rheumatic symptom onset). We compared the clinical characteristics, disease activity, radiographic damage and functional ability between "AAU before or concomitant with rheumatic symptoms" and "AAU after rheumatic symptoms onset". Finally, we compared whether the time of appearance of AAU had an impact on the use of conventional and biological disease-modifying antirheumatic drugs (csDMARDs and bDMARDs, respectively).

RESULTS

A total of 2367 patients were included in REGISPONSER, with an AAU prevalence of 16.2% (379 patients). Patients with AAU before/concomitant with rheumatic symptom onset (n=59) exhibited better functional ability (BASFI, OR 0.85 [0.73-0.99]) and less structural damage (spinal BASRI, OR 0.88 [0.79-0.99]). Additionally, this group of patients was older at SpA symptom onset (OR 1.05 [1.02-1.09]) and had a shorter diagnosis delay (OR 0.90 [0.84-0.96]) compared patients with AAU after rheumatic symptom onset (n=229). No statistically significant differences in the use of DMARDs were noted (27.9% vs 23.2% for csDMARD use and 15.3% vs 20.3% for bDMARD use in patients with AAU before or concomitant with rheumatic symptom onset vs after rheumatic symptom onset, respectively).

CONCLUSION

Patients presenting with a first episode of AAU before/concomitant with the onset of rheumatic symptoms had less severe disease (better functional ability and less structural damage) and a shorter diagnosis delay; however, the time of AAU onset did not impact the treatments received.

Spondylitis-psoriasis-enthesitis-enterocolitis-dactylitis-uveitis-peripheral synovitis (SPEED-UP) treatment

Axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), psoriasis, inflammatory bowel disease (IBD), and noninfectious uveitis form a distinct group among the immune mediated inflammatory diseases. Thus, many patients suffer from more than one of these disease manifestations. Here, we will use the term spondylitis-psoriasis-enthesitis-enterocolitis-dactylitis-uveitis-peripheral synovitis (SPEED-UP) spectrum disease. The aim is to review the new targeted pharmacological treatment options for all these diseases. All biological or targeted synthetic drugs with U.S. Food and Drug Administration (FDA) or European Medicines Agency (EMA) approval for any of the diagnoses axSpA, PsA, psoriasis, IBD, or non-infectious uveitis were included. Some of the drugs have documented efficacy in more than one of the diseases, e.g. tumor necrosis factor (TNF) inhibitors. However, other drugs are particularly effective for a specific inflamed tissue and approved in only one or two of the disease entities, e.g. abatacept for peripheral arthritis and vedolizumab for inflammatory bowel disease. This contributes with bedside to bench understanding of the immunology underlying this disease spectrum and provides clinicians with an overview that can assist stratified treatment decisions. We hope that this review will help guide clinicians to speed up treatment of patients with this disease spectrum.

Long-term effectiveness and safety of infliximab and golimumab in ankylosing spondylitis patients from a Canadian prospective observational registry

BACKGROUND

The objectives of this study were to describe the profile of ankylosing spondylitis (AS) patients treated with either infliximab (IFX) or subcutaneous golimumab (GLM) treatment in Canadian routine care setting along with assessing long-term effectiveness and safety.

METHODS

AS patients who were eligible for treatment with IFX or subcutaneous GLM as per their respective Canadian product monographs were enrolled into the BioTRAC registry from 2005 to 2017. The study visits occurred at baseline and every 6 months thereafter. Effectiveness was assessed by changes in clinical outcomes and acute phase reactants. Safety was evaluated by assessing the incidence of adverse events (AEs) and drug survival rates.

RESULTS

A total of 389 IFX- and 421 GLM-treated patients were enrolled. A significant decrease in disease duration at baseline was observed in the IFX cohort, from a median of 8.0 in 2005-2008 to 1.0 years in 2009-2015 (p < 0.001). A reduction in baseline BASFI score (p = 0.011) and proportion of patients in ASDAS very high disease activity (p = 0.004) was also observed over time. Meanwhile, in the GLM cohort, most disease parameters remained similar from 2010 to 2017. Treatment with both agents significantly improved all disease parameters over time with similar efficacy between the two agents. The incidence of AEs and SAEs were 136 and 131 events/100 PYs and 10.5 and 8.45 events/100 PYs for IFX- and GLM-treated patients, respectively.

CONCLUSION

Both IFX and GLM treatment in AS significantly reduced disease activity in most outcome measures in a similar fashion and were well tolerated in Canadian routine care.

TRIAL REGISTRATION

NCT00741793 .

Recognizing Axial Spondyloarthritis: A Guide for Primary Care

Axial spondyloarthritis (axSpA) is an important cause of chronic low back pain and affects approximately 1% of the US population. The back pain associated with axSpA has a characteristic pattern referred to as inflammatory back pain (IBP). Features of IBP include insidious onset before age 45 years, association with morning stiffness, improvement with exercise but not rest, alternating buttock pain, and good response to treatment with nonsteroidal anti-inflammatory drugs. In patients with IBP, it is essential to look for other features associated with spondyloarthritis (SpA), such as enthesitis, dactylitis, peripheral arthritis, extra-articular manifestations (eg, psoriasis, uveitis, or inflammatory bowel disease), human leukocyte antigen B27 positivity, and a family history of SpA. Axial SpA is underrecognized, and a delay of several years between symptom onset and diagnosis is common. However, with new and effective therapies available for the treatment of active axSpA, early recognition and diagnosis are of critical importance. For this narrative review, we conducted a literature search of English-language articles using PubMed. Individual searches were performed to identify potential articles of interest related to axSpA (search terms: ["axSpA" OR "axial SpA" OR "axial spondyloarthritis" OR "ankylosing spondylitis"]) in combination with terms related to IBP ("inflammatory back pain" OR "IBP" OR "chronic back pain" OR "CBP" OR "lower back pain" OR "LBP"), diagnosis (["diagn∗" OR "classification"] AND ["criteria" OR "recommend∗" OR "guidelines"]), and referral ("refer∗"). No date range was formally selected, as we were interested in providing an overview of the evolution of these concepts in clinical practice. We supplemented the review with insights based on our clinical expertise. Patients with chronic back pain should be screened for IBP and other SpA features; suspicion for axSpA should trigger referral to a rheumatologist for further evaluation.

Uveitis in spondyloarthritis

Uveitis is the most frequent extra-articular manifestation of axial spondyloarthritis (SpA), occurring in up to one-third of the patients. In the majority of patients, uveitis is acute, anterior and unilateral and presents with photosensitivity, sudden onset of pain and blurred vision. Topical steroids are an effective treatment; however, recurrent or refractory cases may need conventional disease-modifying antirheumatic drugs or biological treatment with monoclonal tumor necrosis factor (TNF) inhibitors, thus also influencing treatment strategy of the underlying SpA. Though the exact pathogenesis of SpA and uveitis remains unknown, both seem to result from the interaction of a specific, mostly shared genetical background (among other HLA-B27 positivity), external influences such as microbiome, bacterial infection or mechanical stress and activation of the immune system resulting in inflammation. Up to 40% of patients presenting with acute anterior uveitis (AAU) have an undiagnosed SpA. Therefore, an effective referral strategy for AAU patients is needed to shorten the diagnostic delay of SpA and enable an early effective treatment. Further, the risk for ophthalmological manifestations increases with the disease duration in SpA; and patients presenting with ocular symptoms should be referred to an ophthalmologist. Thus, a close collaboration between patient, rheumatologist and ophthalmologist is needed to optimally manage ocular inflammation in SpA.

Rates of spondyloarthropathies vary with age and ethnicity in HLAB27 uveitis

BACKGROUND/AIMS

To determine associations between HLAB27-positive uveitis, ethnicity and seronegative spondyloarthropathies (SpAs) in a New Zealand population.

METHODS

Retrospective observational cohort study. Medical records of all subjects with uveitis at Auckland District Health Board from 2008 to 2018 were reviewed for HLAB27 status, age of presentation, ethnicity and SpA.

RESULTS

In 10 years, 2567 subjects with uveitis were seen and 492 (19.2%) were HLAB27-positive. Of the HLAB27-positive subjects, 301 were male (60.3%) and median age was 37.8 years (IQR 29.7-50.0). Ethnicities were Caucasian (n=298, 60.6%), Asian (n=111, 22.6%), Maori (n=41, 8.2%) and Pacific Islander (n=38, 7.7%). Uveitis classification was anterior (n=478, 97.2%), intermediate (n=40, 8.1%), panuveitis (n=9, 1.8%) and scleritis (n=2, 0.4%). Maori or Pacific Islander ethnicity was associated with intermediate or panuveitis (p=0.003). Ankylosing spondylitis occurred in 163 subjects (33.1%); 29 (17.8%) were Maori or Pacific Islander. Subjects were younger (OR 0.982, p=0.009) and male (OR 1.980, p=0.001). There was no association with ethnicity or uveitis classification. Psoriatic arthritis (PsA) occurred in 11 subjects (2.2%). Chronic anterior uveitis was more common with PsA (27.3% vs 7.1%, p=0.023). There was no association with gender or ethnicity. Inflammatory bowel disease occurred in 19 subjects (3.8%) and reactive arthritis occurred in 14 subjects (2.8%). None developed chronic anterior uveitis (p=0.246 and p=0.227, respectively). There was no association with age at presentation, gender, ethnicity or uveitis classification.

CONCLUSION

This cohort of New Zealand-based subjects with HLAB27-positive uveitis showed a difference in age and ethnicity in uveitis subtypes and SpAs.

New-Onset Uveitis Possibly Caused by Secukinumab in a 47-Year-Old Male Patient with Long-Standing Ankylosing Spondylitis

Secukinumab, “an IL-17 antagonist”, is one of the biological agents used to treat active ankylosing spondylitis (AS). Although it has been proven that certain agents are linked with a paradoxical increase in uveitis, there are limited data on whether secukinumab has this effect or not. We report a case of a new-onset anterior uveitis after 6 months of starting secukinumab in a 47-year-old male, HLA-B27 positive AS patient. He had a long-standing history with the disease over 25 years. He was treated in the past with methotrexate then adalimumab and later on with etanercept. He had no history of uveitis during all of this time. The uveitis was mild and treated conventionally with local measures while secukinumab was maintained. After a close follow-up, the uveitis had completely resolved. Is this part of the original disease or a possible side effect from secukinumab?

Incidence of Uveitis in Secukinumab-treated Patients With Ankylosing Spondylitis: Pooled Data Analysis From Three Phase 3 Studies

Objective

The objective of this study was to report the incidence of uveitis in secukinumab‐treated patients with ankylosing spondylitis (AS) in a pooled analysis of three phase 3 trials (MEASURE 1‐3 [ClinicalTrials.gov identifiers NCT01358175, NCT01649375, NCT02008916]).

Methods

Analysis included pooled patient‐level data from all patients (N = 794) who received any dose (one or more) of secukinumab up to the last patient attending the week 156 study visit in MEASURE 1 and up to the week 156 visit in MEASURE 2 and the week 104 visit in MEASURE 3 for each patient. Postmarketing data were from the periodic safety update report. Incidence of uveitis is reported as the exposure‐adjusted incidence rate (EAIR) per 100 patient‐years of secukinumab exposure.

Results

Overall, 135 (17%) patients reported preexisting (but not active or ongoing) uveitis at baseline, and 589 (74.2%) patients were HLA antigen B27 positive. The EAIR for uveitis was 1.4 per 100 patient‐years over the entire treatment period. Among all cases of uveitis (n = 26), 14 (54%) were flares. The exposure‐adjusted reporting rate of uveitis in the postmarketing data (which included patients across the three approved indications of psoriasis, psoriatic arthritis, and AS) was 0.03 per 100 patient‐years based on cumulative secukinumab exposure of 96 054 patient‐years.

Conclusion

The incidence rate of uveitis in secukinumab‐treated patients with active AS does not suggest an increased risk with secukinumab treatment.

Occurrence of anterior uveitis in patients with spondyloarthritis treated with tumor necrosis factor inhibitors: comparing the soluble receptor to monoclonal antibodies in a large observational cohort

Background

The objective of this study was to compare in real life the occurrence of anterior uveitis in patients with spondyloarthritis (SpA), including psoriatic arthritis (PsA), treated with the soluble-receptor etanercept (ETA) or monoclonal antibodies (mAbs).

Methods

This was an observational, retrolective study. Patients with SpA who were prescribed anti-TNF agents between 2000 and 2014 were included. The risk of uveitis was interpreted qualitatively (number of subjects with at least one uveitis) and quantitatively (number of uveitis flares for each individual). Models were adjusted for propensity score of receiving preferentially mAbs or ETA.

Results

Four hundred twenty-nine patients were included (302 with SpA and 127 with PsA); 203 received a mAb and 226 ETA as a first TNF-α inhibitor. Probability of uveitis occurring during the first year of treatment was lower with ETA than with mAbs but not significantly (odds ratio 0.94 [95% confidence interval 0.35; 2.54], p = 0.90, on qualitative analysis and relative risk 0.62 [0.26; 1.46], p = 0.27, on quantitative analysis) after adjustment for the propensity score. The over-time risk of uveitis was numerically higher with ETA than with mAbs, but the differences were not statistically significant.

Conclusion

In this observational study, the risk of uveitis in patients with SpA does not appear to be greater with ETA than with mAb treatment. The occurrence of uveitis in patients receiving an anti-TNF-α agent seems linked more to the history of uveitis than the prescribed molecule.

Comorbidities associated with psoriatic arthritis: Review and update

Psoriatic arthritis is an inflammatory arthropathy frequently associated with psoriasis and several other comorbidities. The goal of this review is to summarize the available evidence on the epidemiology, clinical implications, pathological mechanisms proposed, and screening and management recommendations for the comorbidities related with PsA. Reported comorbidities include cardiovascular disease, metabolic syndrome, obesity, diabetes mellitus, dyslipidemia, inflammatory bowel disease, fatty liver disease, uveitis, kidney disease, infections, osteoporosis, depression, central sensitization syndrome, and gout. Given that these comorbidities may affect both clinical outcomes and the management for these patients, their recognition and monitoring by all health-care providers caring for patients with psoriatic arthritis is of utmost importance.

Enthesitis-related Arthritis: Prevalence and Complications of Associated Uveitis in Children and Adolescents From a Population-based Nationwide Study in Germany

Objective.

Enthesitis-related arthritis (ERA) represents a subgroup of juvenile idiopathic arthritis (JIA) that is regularly accompanied by anterior uveitis. This study describes the prevalence and characteristics of ERA-related uveitis.

Methods.

Cross-sectional data from the National Pediatric Rheumatological Database (NPRD) were used to characterize ERA-related uveitis (ERA-U). In addition to sociodemographic variables, we documented the occurrence of uveitis and course of disease, including symptoms, visual acuity, and complications, as well as JIA characteristics such as disease activity (Juvenile Arthritis Disease Activity Score 10), functional ability (Childhood Health Assessment Questionnaire score), laboratory variables, and treatment.

Results.

In the years from 2002 to 2014, there were 3778 (15.2%) of a total of 24,841 JIA patients recorded in the NPRD who had ERA, and 280 (7.4%) of them had developed uveitis. Detailed ophthalmological documentation by a uveitis add-on module was available for 22.9% of these patients. Uveitis onset was acutely symptomatic in 63% of patients. Patients with uveitis were more frequently male, HLA-B27–positive, younger at ERA onset, and they had higher erythrocyte sedimentation rate values at first uveitis documentation than those without uveitis. Uveitis was diagnosed at a mean age of 11.5 (± 3.9) years (50% within 2 years after ERA onset). Systemic treatment with corticosteroids and synthetic and biologic disease-modifying antirheumatic drugs was associated with a (not significantly) lower risk of developing uveitis.

Conclusion.

The course of disease in ERA-U patients is frequently similar to HLA-B27–associated uveitis in adults; however, a subgroup of patients presents with asymptomatic uveitis.

Phenotype of Innate Immune Cells in Uveitis Associated with Axial Spondyloarthritis- and Juvenile Idiopathic Arthritis-associated Uveitis

Purpose: To analyze circulating immune cells in patients with anterior uveitis (AU) associated to axial spondyloarthritis (SpA), or juvenile idiopathic arthritis (JIA).Methods: Venous blood samples were collected from healthy controls (n = 16), and either SpA (n = 19) or JIA (n = 23) patients with associated anterior uveitis (AU) during active flare, or after ≥3 months of inactivity. Frequencies of CD56⁺, MHC-I⁺, and S100A9⁺ monocytes, CCR7⁺ dendritic cells, CD56^+dim natural killer (NK) cells and CD3⁺CD56^bright T-cells were analyzed via flow cytometry. Serum S100A8/A9 levels were determined via ELISA.Results: SpA patients showed a reduced frequency of CD56^+dim NK cells during uveitis activity, a constitutively activated monocyte phenotype, and elevated S100A8/A9 serum levels. In contrast, JIAU patients showed elevated frequencies of CD56⁺ monocytes and CCR7⁺ DC.Conclusion: Phenotype of peripheral immune cells differ between patients, probably contributing to different courses of acute onset AU in SpA and insidious onset AU in JIAU patients.Abbreviations: AU: anterior uveitis, AR: arthritis, JIA: juvenile idiopathic arthritis, SpA: axial spondyloarthritis.

Diagnostic dilemma: Unilateral panuveitis mimicking endophthalmitis in very severe HLA B27-associated uveitis

Purpose

To report a case of a 28-years-old male who presented with a worsening unilateral panuveitis after intensive topical steroid therapy which resulted in a diagnostic and treatment dilemma as to whether the patient should be treated as for infective endophthalmitis despite no immediate known infective risk factors.

Observations

A patient presented initially with unilateral non-granulomatous acute anterior uveitis which worsened after being started on intensive steroid therapy, developing fibrinous panuveitis. The rapid worsening of inflammation and vision deterioration despite being on intensive steroid therapy resulted in the patient subsequently being treated as for infective endophthalmitis. Anterior chamber and vitreous tap were done and intravitreal antibiotics were administered, along with topical antibiotics therapy. Vitrectomy was withheld due to the lack of conclusive evidence of infective etiology and risk factors. Full uveitis and infective workup were done. Investigations were largely unremarkable, and fluid and vitreous cultures were negative. HLA B27 was positive. The patient was subsequently started on systemic oral corticosteroids and improved in terms of his visual acuity, signs and symptoms.

Conclusions

HLA B27-associated uveitis can present in a range of clinical spectrum with the extreme being of unusual severity in the form of fibrinous panuveitis that can mimic infective endophthalmitis. This can lead to a dilemma in management and subject patients to unnecessary risks from diagnostic and therapeutic interventions. Patients under this subgroup may require long term systemic immunosuppression therapy for disease remission and will require long term follow up.

Iontophoretic Dexamethasone Phosphate Compared to Topical Prednisolone Acetate 1% for Noninfectious Anterior Segment Uveitis

PURPOSE

To evaluate the safety and efficacy of dexamethasone phosphate ophthalmic solution (EGP-437) delivered by a transscleral iontophoresis delivery system (EyeGate II) compared to that of topical prednisolone acetate 1% (PA 1%) in subjects with noninfectious anterior uveitis.

DESIGN

Prospective, randomized, double-masked, parallel group, noninferiority clinical trial.

METHODS

A total of 193 subjects with active noninfectious anterior uveitis (anterior chamber [AC] cell count ≥11 cells) were randomized to EGP-437 delivered by iontophoresis (days 0 and 7) or self-administered PA 1% daily (tapered schedule, days 0-28). Masking was maintained with placebo iontophoresis or eye drops. The primary efficacy endpoint was the proportion of subjects with an AC cell count of zero on day 14. Noninferiority of EGP-437 was defined if the lower limit of the confidence interval (CI) for the difference (EGP-437 minus PA 1%) was less than -10%.

RESULTS

At day 14, 32 of 96 EGP-437 subjects (33.3%) and 32 of 97 PA 1% subjects (33.0%) had an AC cell count of zero (difference, 0.34; 95% CI, -12.94 to 13.63; P = 0.064). Efficacy trended better with EGP-437 among patients with more severe baseline uveitis (AC cell count >25). Safety and tolerability were good with both treatments. EGP-437 subjects experienced fewer IOP elevations ≥6 mm Hg versus PA 1% subjects (13 vs 24 incidents, respectively, through day 28).

CONCLUSIONS

Despite clinically similar response rates, statistical noninferiority of EGP-437 versus a tapered regimen of PA 1% was not achieved. Numerical trends suggesting fewer IOP elevations with EGP-437, similar efficacy overall, and possibly better efficacy in more severe disease warrant further study.

Targeted synthetic pharmacotherapy for psoriatic arthritis: state of the art

INTRODUCTION

In recent years, different studies regarding psoriatic arthritis (PsA) have shown the pathogenetic role of dysfunction of signaling pathways involving the phosphodiesterase-4 enzyme and transcription factors or enzymes belonging to the kinase (JAK)-signal family pathway. These also represent the target of several drugs known as targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs).

AREAS COVERED

The authors performed a systematic literature search using the PubMed database, as well as through retrieving data from randomized controlled trials, their post-hoc analysis, and pooled data analysis on the efficacy and safety profile of the PDE4 inhibitor (PDE4i), apremilast, and the inhibitors of JAK (JAKis), tofacitinib, filgotinib, baricitinib, and upadacitinib, in PsA.

EXPERT OPINION

In PsA, the PDE4i, apremilast, and the JAKi, tofacitinib, are effective across multiple clinical domains and have an acceptable tolerability profile, thus expanding the treatment options available for PsA patients. Apremilast and tofacitinib show several advantages mainly represented by their oral administration, a fast onset of action, and a short half-life. Data on tsDMARDs in PsA are still limited, and randomized trials and real-life studies are advocated.

Certolizumab pegol for the treatment of psoriatic arthritis and plaque psoriasis

Introduction: Certolizumab pegol (CZP) is an Fc-free PEGylated TNF-α inhibitor approved for the treatment of psoriatic arthritis (PsA) and plaque psoriasis in many countries. It demonstrated favorable results in PsA in terms of improvement in peripheral arthritis, dactylitis, and enthesitis in a phase III trial (RAPID-PSA) and in real-life experiences. Recently, three phase III randomized clinical trials (CIMPASI-1, CIMPASI-2, CIMPACT) showed significant and sustained improvements in signs and symptoms of moderate-to-severe plaque psoriasis as well as in quality of life parameters as compared to placebo and etanercept.Areas covered: We reviewed the structure and the mechanism of action of CZP, and critically analyzed data from clinical trials and real-life, concerning its efficacy and safety in all aspects of the psoriatic disease. We designed a comprehensive literature search on this topic, by a review of published articles in indexed international journals up until 31 July 2019.Expert opinion: CZP demonstrated positive results in several domains of psoriatic disease, also in patients previously exposed to other TNF-α inhibitors and in patients receiving re-treatment after treatment interruption. The peculiar chemical structure, along with its well-established efficacy and safety, support CZP as the drug of choice in specific subgroups of patients with psoriatic disease, in particular patients with comorbidities and pregnant or breastfeeding female patients.

Insight into the Quality of Life of Patients with Ankylosing Spondylitis: Real-World Data from a US-Based Life Impact Survey

INTRODUCTION

We aim to assess the real-world, US patient-reported impact of ankylosing spondylitis (AS) on quality of life (QOL) across physical, discomfort, social, and emotional domains.

METHODS

Demographic and QOL data were collected from a random sample of patients associated with the Spondylitis Association of America (SAA) from July to December 2017. QOL measures were based on the Evaluation of Ankylosing Spondylitis Quality of Life (EASi-QoL) questionnaire. The survey evaluated AS impact on the physical domain on the day of survey participation and impact on the discomfort, social, and emotional domains within the week before participation. A 3:1 (male to female) weighting was performed to reflect the reported prevalence of AS in US adults.

RESULTS

Of 820 respondents who completed the survey, 716 self-reported receiving an AS diagnosis from their doctor and were included in this analysis (mean age, 55.5 years; 46.9% male). The mean total EASi-QoL score was 28.9 (weighted); overall, 33.7%, 31.7%, and 34.7% of respondents, respectively, reported a low (EASi-QoL score 0-17), a medium (18-35), and a high (≥ 36) impact of AS on QOL. The physical domain was most impacted; 41.9% of respondents had an EASi-QoL score ≥ 10 (weighted). Women were significantly more likely than men to report a high impact of AS on all QOL domains. Biologic users reported an impact on QOL comparable with the impact on QOL of nonsteroidal anti-inflammatory drug use. AS also impacted lifestyle characteristics, including career choice and sports participation.

CONCLUSION

AS negatively impacted all QOL domains analyzed. The incorporation of subjective measures of disease into disease evaluation should be considered.

FUNDING

Novartis Pharmaceuticals Corporation and UCB, Inc. Plain language summary available for this article.

Psoriasis and uveitis: links and risks

Uveitis, an inflammatory disorder of the mid-portion of the eye, is considered a relatively rare but very serious ocular complication of psoriasis. Data on the specific characteristics of uveitis in the background of psoriasis are extremely limited. The presence of uveitis in the context of psoriasis has been estimated to occur in 7-20% of the psoriasis cases. This incidence tends to be higher in patients suffering from psoriasis and psoriatic arthritis (PsA) or PSA alone. Psoriatic uveitis is usually bilateral, chronic, and severe. In term of pathogenesis, both psoriasis and uveitis are considered as paradigms of T-helper 1/T-helper 17 (Th1/Th17) inflammatory reactions. Certain cytokines such as tumor necrosis factor-α (TNF- α), Interleukin-17 (IL-17), IL-23, and IL-6 play a significant role in the pathogenesis of both psoriasis and uveitis. As uveitis shares common pathogenetic mechanisms with psoriasis in certain circumstances, both diseases may benefit from the same targeted biologic therapies. Undiagnosed and under-treated cases of psoriatic uveitis may cause significant morbidity and even vision loss. Larger prospective studies are needed in order to further investigate the association between these two entities.

Anterior uveitis in patients with spondyloarthropathies in a single US academic center: a retrospective study

Uveitis may represent an opportunity to diagnose spondyloarthropathies (SpA) earlier and influence treatment decisions. We describe the percentage of acute anterior uveitis (AAU) in a diverse group of SpA patients seen at one academic setting and compare demographic and clinical characteristics according to the presence of uveitis. We conducted a retrospective study of patients with SpA and AAU (January 2016-June 2017). Patients were identified using ICD-10 and administrative claim codes, diagnoses were confirmed through chart review. Extracted data included demographics, laboratory, clinical data, treatment and Routine Assessment of Patient Index Data 3 (RAPID3) scores based on Multidimensional Health Assessment Questionnaire (MDHAQ). Baseline description and comparison between the two groups were performed. We included 190 patients, mostly men (59.5%), with a mean age of 45.9 years: 48% with ankylosing spondylitis (AS), 26% with psoriatic arthritis (PsA), 22% with undifferentiated SpA, and 4% with SpA associated with inflammatory bowel disease (IBD). Uveitis was identified in 17% of patients, ranging from 25% in AS to 4% in PsA. Time from symptom onset to SpA diagnosis was longer in patients with uveitis (10.9 versus 5.9 years, p < 0.001). A higher percentage of patients with uveitis were HLA-B27 positive (85% versus 67%, p = 0.02). The prevalence of uveitis in our population was 17%, slightly lower than previously reported in the literature. There was a diagnostic delay of about 7 years, significantly longer in patients with uveitis. New screening strategies in collaboration with ophthalmology may lead to earlier diagnosis and better outcomes.

Transitions of care across hospital settings in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic, inflammatory disorder characterised by both intestinal and extra-intestinal pathology. Patients may receive both emergency and elective care from several providers, often in different hospital settings. Poorly managed transitions of care between providers can lead to inefficiencies in care and patient safety issues. To ensure that the sharing of patient information between providers is appropriate, timely, accurate and secure, effective data-sharing infrastructure needs to be developed. To optimise inter-hospital data-sharing for IBD patients, we need to better understand patterns of hospital encounters in this group.

AIM

To determine the type and location of hospital services accessed by IBD patients in England.

METHODS

This was a retrospective observational study using Hospital Episode Statistics, a large administrative patient data set from the National Health Service in England. Adult patients with a diagnosis of IBD following admission to hospital were followed over a 2-year period to determine the proportion of care accessed at the same hospital providing their outpatient IBD care, defined as their ‘home provider’. Secondary outcome measures included the geographic distribution of patient-sharing, regional and age-related differences in accessing services, and type and frequency of outpatient encounters.

RESULTS

95055 patients accessed hospital services on 1760156 occasions over a 2-year follow-up period. The proportion of these encounters with their identified IBD ‘home provider’ was 73.3%, 87.8% and 83.1% for accident and emergency, inpatient and outpatient encounters respectively. Patients living in metropolitan centres and younger patients were less likely to attend their ‘home provider’ for hospital services. The most commonly attended specialty services were gastroenterology, general surgery and ophthalmology.

CONCLUSION

Transitions of care between secondary care settings are common for patients with IBD. Effective systems of data-sharing and care integration are essential to providing safe and effective care for patients. Geographic and age-related patterns of care transitions identified in this study may be used to guide interventions aimed at improving continuity of care.

Prefoldin 5 and Anti-prefoldin 5 Antibodies as Biomarkers for Uveitis in Ankylosing Spondylitis

Objective: Uveitis is the most common extra-articular manifestation of ankylosing spondylitis (AS), for which no diagnostic biomarkers have been identified. This study was conducted to identify biomarker for uveitis in AS.

Methods: To identify autoantibodies associated with uveitis in AS, we performed human protein microarray analysis using sera derived from various autoimmune diseases and ELISA analysis of sera derived from AS and rheumatoid arthritis patients. In the curdlan-induced SKG mice model, ophthalmic examination was performed at week 8 post-immunization and histologic examination of the ocular lesions performed at week 16 post-immunization. Serum levels of target antibodies were assessed at various time-points. To evaluate the functional role of specific autoantibodies, an in vitro apoptosis assay using ARPE-19 cells was performed.

Results: Reactivity against prefoldin subunit 5 (PFDN5) was identified in AS with uveitis. Levels of anti-PFDN5 antibodies and PFDN5 in sera from AS with uveitis patients were significantly higher than those in AS without uveitis. At week 8, half of curdlan-treated SKG mice developed anterior uveitis, while all of them developed histologically confirmed uveitis at week 16. The levels of anti-PFDN5 antibodies increased over time in the sera of curdlan-treated SKG mice along with increased expression of PFDN5 and apoptosis in the ocular lesions. Knockdown of PFDN5 in ARPE19 cells resulted in increased apoptosis, suggesting a protective role of PFDN5 against cell death in uveitis.

Conclusion: AS patients with uveitis have increased levels of anti-PFDN5 antibodies, and our findings suggest that anti-PFDN5 antibodies could provide a biomarker for uveitis in AS.

Reclassifying Idiopathic Uveitis: Lessons From a Tertiary Uveitis Center

PURPOSE

Idiopathic uveitis is frequently the most common diagnosis in series from uveitis clinics. This study sought to determine the percentage of patients initially diagnosed as idiopathic, noninfectious uveitis referred to a tertiary uveitis center who were subsequently found to have an identifiable cause of uveitis.

DESIGN

Retrospective case series.

METHODS

We performed a computerized database analysis of 179 consecutive patients who were referred to our practice with the diagnosis of idiopathic, noninfectious uveitis between 2008 and 2016. Patients were evaluated by a thorough history and ophthalmic examination with selected laboratory testing targeted by clues from the history and examination. Standardization of Uveitis Nomenclature (SUN) criteria were used to better assess different types of uveitis.

RESULTS

Fifty-two out of 179 (29.0%) patients initially diagnosed with idiopathic uveitis were subsequently diagnosed with an underlying condition. Among patients referred with a diagnosis of idiopathic disease, female patients were most commonly affected (121/179; 67.6%). Among subsequent diagnoses, sarcoidosis was the most common (19/52 or 36.5%), followed by HLA-B27-associated uveitis (11/52, 21.1%), infectious uveitis (6/52, 11.5%), tubulointerstitial nephritis with uveitis (6/52, 11.5%), and juvenile idiopathic uveitis (4/52, 7.7%). Other diagnosable conditions included Behçet disease, multifocal choroiditis, panuveitis, Crohn disease, multiple sclerosis, and relapsing polychondritis. An underlying condition was not found in 127 of 179 (70.9%) patients.

CONCLUSIONS

We report that 29% of patients referred to our tertiary uveitis center diagnosed as "idiopathic" had an associated identifiable cause. Identifying an underlying condition associated with uveitis could be potentially lifesaving for some illnesses (eg, sarcoidosis with cardiac involvement) and is critical to management (eg, infection). Although we were able to use limited testing to classify many patients who had been previously incorrectly labeled with idiopathic uveitis, idiopathic uveitis remains the most common diagnosis in our uveitis clinic.

The role of neutrophils in the pathogenesis of Crohn's disease

Crohn's disease (CD) is caused by a trigger, almost certainly enteric infection by one of a multitude of organisms that allows faeces access to the tissues, at which stage the response of individuals predisposed to CD is abnormal. In CD the failure of acute inflammation results in the failure to recruit neutrophils to the inflammatory site, as a consequence of which the clearance of bacteria from the tissues is defective. The retained faecal products result in the characteristic chronic granulomatous inflammation and adaptive immune response. Impaired of digestion of bacteria and fungi by CGD neutrophils can result in a similar pathological and clinical picture. The neutrophils in CD are normal and their inadequate accumulation at sites of inflammation generally results from diminished secretion of proinflammatory cytokines by macrophages consequent upon disordered vesicle trafficking.

Use of Laplacian Heat Diffusion Algorithm to Infer Novel Genes With Functions Related to Uveitis

Uveitis is the inflammation of the uvea and is a serious eye disease that can cause blindness for middle-aged and young people. However, the pathogenesis of this disease has not been fully uncovered and thus renders difficulties in designing effective treatments. Completely identifying the genes related to this disease can help improve and accelerate the comprehension of uveitis. In this study, a new computational method was developed to infer potential related genes based on validated ones. We employed a large protein–protein interaction network reported in STRING, in which Laplacian heat diffusion algorithm was applied using validated genes as seed nodes. Except for the validated ones, all genes in the network were filtered by three tests, namely, permutation, association, and function tests, which evaluated the genes based on their specialties and associations to uveitis. Results indicated that 59 inferred genes were accessed, several of which were confirmed to be highly related to uveitis by literature review. In addition, the inferred genes were compared with those reported in a previous study, indicating that our reported genes are necessary supplements.

Distinguishing rheumatoid arthritis from psoriatic arthritis

Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) have key differences in clinical presentation, radiographic findings, comorbidities and pathogenesis to distinguish between these common forms of chronic inflammatory arthritis. Joint involvement is typically, but not always, asymmetric in PsA, while it is predominantly symmetric in RA. Bone erosions, without new bone growth, and cervical spine involvement are distinctive of RA, while axial spine involvement, psoriasis and nail dystrophy are distinctive of PsA. Patients with PsA typically have seronegative test findings for rheumatoid factor (RF) and cyclic citrullinated peptide (CCP) antibodies, while approximately 80% of patients with RA have positive findings for RF and CCP antibodies. Although there is overlap in the pathogenesis of PsA and RA, differences are also present that affect the efficacy of treatment. In PsA, levels of interleukin (IL)-1β, IL-6, IL-17, IL-22, IL-23, interferon-γ and tumour necrosis factor-α (TNF-α) are elevated, and in RA, levels of IL-1, IL-6, IL-22, IL-33, TNF-α, chemokine ligand 11 and chemokine C-X-C motif ligand 13 are elevated. Differences in the pathogenesis of RA and PsA translate into some variances in the specificity and efficacy of therapies.