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Abstract
PURPOSE OF REVIEW Flares correspond to fluctuations in disease activity or symptoms. They should be avoided in chronic inflammatory diseases. In axial spondyloarthritis (axSpA), work is ongoing to better conceptualise and treat flares. This review highlights recent data on the definition and management of flares in axSpA. RECENT FINDINGS Many definitions of flares have been used in clinical trials, limiting the interpretation and comparison of studies. The expert group Assessment of SpondyloArthritis International Society (ASAS) developed a data-driven definition of flares/disease worsening: an increase in Ankylosing Spondylitis Disease Activity Score-C-reactive protein (ASDAS-CRP) of at least 0.9 points, for use in axSpA clinical trials. Flares are more challenging to define in clinical practice because of their multifaceted nature. Qualitative studies have shown that flares from the patient's perspective are related not only to disease activity, but also to fatigue, mood, sleep and general well-being. The management of axSpA relies on a treat-to-target (T2T) strategy and aims at reaching clinical remission while monitoring closely disease activity to prevent and shorten flares. SUMMARY The concept of flares has been clarified, and definitions have been developed for use in trials. The T2T approach aims at minimising flares in axSpA. The early recognition of flares and their severity may lead to better management.
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Affiliation(s)
- Krystel Aouad
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
- Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
| | - Laure Gossec
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
- Pitié-Salpêtrière hospital, AP-HP, Rheumatology Department, Paris, France
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Jacquemin C, Maksymowych WP, Boonen A, Gossec L. Patient-reported Flares in Ankylosing Spondylitis: A Cross-sectional Analysis of 234 Patients. J Rheumatol 2016; 44:425-430. [PMID: 27980007 DOI: 10.3899/jrheum.160838] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Ankylosing spondylitis (AS) is characterized by periodic flares. The objective of this study was to assess the frequency of patient-reported flares and their related factors. METHODS This cross-sectional study analyzed the 2004 data of a Canadian cohort. Participants had AS according to the modified New York criteria. Current flare status ("Are you experiencing a current flare"?), number of flares over the past 3 months, their average duration, the Bath Ankylosing Spondylitis Disease Activity and Functional Index (BASDAI and BASFI, respectively), and the AS Quality of Life questionnaire were assessed by self-report. Univariate and multivariate regressions analyzed the factors associated with current flare. RESULTS Among 234 analyzed patients, 169 (73.5%) were men, mean age was 45.5 (± 11.8) years, mean disease duration of 21.7 (± 11.7) years, and mean BASDAI and BASFI (0-10) of 4.4 (± 2.3) and 3.4 (± 2.6), respectively; 18 (7.7%) received antitumor necrosis factor (anti-TNF). Overall, 175 patients (74.8%) reported flares and 117 (50%) were currently in flare. Patients reporting flares had a median of 3 flares in 3 months, with a median duration of 2 weeks. Overall, the 234 patients spent a median of 25% of their time in flare. In multivariate analyses, current flare was significantly associated with higher BASDAI (OR 2.01, p = 0.01), worse quality of life (OR 1.37, p = 0.004), shorter AS duration (OR 1.19, p = 0.04), and less anti-TNF (OR 7.14, p = 0.03). CONCLUSION In this population, before the wide use of biologics, flares were frequent and long. As expected, flare was associated with higher disease activity, suggesting the validity of the concept of patient-reported flares.
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Affiliation(s)
- Charlotte Jacquemin
- From the UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS); APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology, Paris, France; University of Alberta, Department of Medicine, Edmonton, Alberta, Canada; Maastricht University Medical Center, Department of Rheumatology, Maastricht, the Netherlands.,Dr. W.P. Maksymowych received research grants from Abbvie, Janssen, and Pfizer, and honoraria from Abbvie, Eli-Lilly, and Pfizer. Dr. L. Gossec received research grants from Pfizer France and Lilly France.,C. Jacquemin, MD, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS), and APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology; W.P. Maksymowych, FRCP(C), University of Alberta, Department of Medicine; A. Boonen, MD, PhD, Maastricht University Medical Center, Department of Rheumatology; L. Gossec, MD, PhD, Professor, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS), and APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology
| | - Walter P Maksymowych
- From the UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS); APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology, Paris, France; University of Alberta, Department of Medicine, Edmonton, Alberta, Canada; Maastricht University Medical Center, Department of Rheumatology, Maastricht, the Netherlands.,Dr. W.P. Maksymowych received research grants from Abbvie, Janssen, and Pfizer, and honoraria from Abbvie, Eli-Lilly, and Pfizer. Dr. L. Gossec received research grants from Pfizer France and Lilly France.,C. Jacquemin, MD, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS), and APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology; W.P. Maksymowych, FRCP(C), University of Alberta, Department of Medicine; A. Boonen, MD, PhD, Maastricht University Medical Center, Department of Rheumatology; L. Gossec, MD, PhD, Professor, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS), and APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology
| | - Annelies Boonen
- From the UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS); APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology, Paris, France; University of Alberta, Department of Medicine, Edmonton, Alberta, Canada; Maastricht University Medical Center, Department of Rheumatology, Maastricht, the Netherlands.,Dr. W.P. Maksymowych received research grants from Abbvie, Janssen, and Pfizer, and honoraria from Abbvie, Eli-Lilly, and Pfizer. Dr. L. Gossec received research grants from Pfizer France and Lilly France.,C. Jacquemin, MD, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS), and APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology; W.P. Maksymowych, FRCP(C), University of Alberta, Department of Medicine; A. Boonen, MD, PhD, Maastricht University Medical Center, Department of Rheumatology; L. Gossec, MD, PhD, Professor, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS), and APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology
| | - Laure Gossec
- From the UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS); APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology, Paris, France; University of Alberta, Department of Medicine, Edmonton, Alberta, Canada; Maastricht University Medical Center, Department of Rheumatology, Maastricht, the Netherlands. .,Dr. W.P. Maksymowych received research grants from Abbvie, Janssen, and Pfizer, and honoraria from Abbvie, Eli-Lilly, and Pfizer. Dr. L. Gossec received research grants from Pfizer France and Lilly France. .,C. Jacquemin, MD, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS), and APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology; W.P. Maksymowych, FRCP(C), University of Alberta, Department of Medicine; A. Boonen, MD, PhD, Maastricht University Medical Center, Department of Rheumatology; L. Gossec, MD, PhD, Professor, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS), and APHP, Pitié-Salpêtrière Hospital, Department of Rheumatology.
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Lubrano E, Massimo Perrotta F, Manara M, D’Angelo S, Addimanda O, Ramonda R, Punzi L, Olivieri I, Salvarani C, Marchesoni A. Predictors of Loss of Remission and Disease Flares in Patients with Axial Spondyloarthritis Receiving Antitumor Necrosis Factor Treatment: A Retrospective Study. J Rheumatol 2016; 43:1541-6. [DOI: 10.3899/jrheum.160363] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2016] [Indexed: 01/22/2023]
Abstract
Objective.The aim of this study was to evaluate rate and predictive factors of loss of remission and disease flare in patients with axial spondyloarthritis (axSpA) receiving antitumor necrosis factor (anti-TNF) treatment.Methods.In this retrospective multicenter study, patients with axSpA, according to the Assessment of Spondyloarthritis international Society (ASAS) criteria, treated with adalimumab, etanercept, or infliximab with a minimum followup of 12 months and satisfying the ASAS partial remission criteria and/or Ankylosing Spondylitis Disease Activity Score (ASDAS) inactive disease were studied. Disease flare was defined as a Bath Ankylosing Spondylitis Disease Activity Index score > 4.5 or ASDAS score > 2.5 on at least 1 occasion.Results.One hundred seventy-four patients with axSpA were studied. After a median [interquartile range (IQR)] followup of 4 years (2–6), 37 patients (21.2%) experienced a loss of remission and 28 (16.1% of the whole study group) a disease flare. Median (IQR) duration of remission in patients who lost this status was 1 year (0.625–2). Higher median erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values, continuous nonsteroidal antiinflammatory drug (NSAID) use, and an ASDAS-CRP ≥ 0.8 during the remission period were significantly associated with both loss of remission and disease flare. At the multivariate analysis, continuous NSAID intake (OR 4.05, 95% CI 1.4–11.74, p = 0.010) and ESR > 15 (OR 2.90, 95% CI 1.23–6.82, p = 0.015) were the only factors predictive of disease reactivation.Conclusion.In this study, loss of remission and disease flares occurred, respectively, in about 21% and 16% of the patients with axSpA who achieved a state of remission while receiving anti-TNF therapy. Residual disease activity was associated with disease reactivation.
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Gossec L, Portier A, Landewé R, Etcheto A, Navarro-Compán V, Kroon F, van der Heijde D, Dougados M. Preliminary definitions of 'flare' in axial spondyloarthritis, based on pain, BASDAI and ASDAS-CRP: an ASAS initiative. Ann Rheum Dis 2016; 75:991-6. [PMID: 26847821 DOI: 10.1136/annrheumdis-2015-208593] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 01/16/2016] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Flares may be used as outcomes in axial spondyloarthritis (axSpA) trials or observational studies. The objective was to develop a definition for 'flare' (or worsening) in axSpA, based on validated composite indices, to be used in the context of clinical trial design. METHODS (1) Systematic literature review of definitions of 'flare' in published randomised controlled trials in axSpA. (2) Vignette exercise: 140 scenarios were constructed for a typical patient with axSpA seen at two consecutive visits. Each scenario included a change in one of the following outcomes: pain, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), BASDAI plus C-reactive protein (CRP) or Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP. Each Assessment of Spondyloarthritis (ASAS) expert determined if every scenario from a random sample of 46 scenarios was considered a flare (yes/no). Receiver-operating characteristic (ROC) analyses were applied to derive optimal cut-off values. (3) ASAS consensus was reached. RESULTS (1) The literature review yielded 38 studies using some definition of 'flare', with 27 different definitions indicating important heterogeneity. The most frequent definitions were based on BASDAI changes or pain changes. (2) 121 ASAS experts completed 4999 flare assessments. The areas under the ROC curves were high (range: 0.88-0.89). Preliminary cut-offs for pain (N=3), BASDAI (N=5) and ASDAS-CRP (N=4) were chosen, with a range of sensitivity 0.60-0.99 and range of specificity 0.40-0.94 against the expert's opinions. CONCLUSIONS This data-driven ASAS consensus process has led to 12 preliminary draft definitions of 'flare' in axSpA, based on widely used indices. These preliminary definitions will need validation in real patient data.
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Affiliation(s)
- Laure Gossec
- Sorbonne Universités, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS), Paris, France Department of Rheumatology, AP-HP, Pitié Salpêtrière Hospital, Paris, France
| | - Agnès Portier
- Sorbonne Universités, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique, GRC-UPMC 08 (EEMOIS), Paris, France Medicine Faculty, Paris Descartes University, Paris, France Rheumatology B Department, APHP, Cochin Hospital, Paris, France
| | - Robert Landewé
- Department of Clinical Immunology & Rheumatology, Amsterdam Rheumatology Center, Amsterdam and Atrium Medical Center, Heerlen, The Netherlands
| | - Adrien Etcheto
- Medicine Faculty, Paris Descartes University, Paris, France Rheumatology B Department, APHP, Cochin Hospital, Paris, France
| | - Victoria Navarro-Compán
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands Rheumatology Department, University Hospital La Paz, Madrid, Spain
| | - Féline Kroon
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Maxime Dougados
- Medicine Faculty, Paris Descartes University, Paris, France Rheumatology B Department, APHP, Cochin Hospital, Paris, France
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