Clinical presentation of patients suffering from recent onset chronic inflammatory back pain suggestive of spondyloarthritis: The DESIR cohort

Diagnosis, monitoring, and management of axial spondyloarthritis

Axial spondyloarthritis (axSpA) is a chronic condition predominantly affecting the spine and sacroiliac joints. This article provides an in-depth overview of the current approaches to diagnosing, monitoring, and managing axSpA, including insights into developing terminology and diagnostic difficulties. A substantial portion of the debate focuses on the challenging diagnostic procedure, noting the difficulty of detecting axSpA early, particularly before the appearance of radiologic structural changes. Despite normal laboratory parameters, more than half of axSpA patients experience symptoms. X-ray and magnetic resonance imaging (MRI) are essential for evaluating structural damage and inflammation. MRI can be beneficial when there is no visible structural damage on X-ray as it can help unravel bone marrow edema (BME) as a sign of ongoing inflammation. The management covers both non-pharmacological and pharmacological approaches. Lifestyle modifications, physical activity, and patient education are essential components of the management. Pharmacological therapy, including nonsteroidal anti-inflammatory drugs (NSAIDs) and biologic disease-modifying anti-rheumatic drugs (bDMARDs), are explored, emphasizing individualized treatment. To effectively manage axSpA, a comprehensive and well-coordinated approach is necessary, emphasizing the significance of a multidisciplinary team. Telehealth applications play a growing role in axSpA management, notably in reducing diagnostic delays and facilitating remote monitoring. In conclusion, this article underlines diagnostic complexities and emphasizes the changing strategy of axSpA treatment. The nuanced understanding offered here is designed to guide clinicians, researchers, and healthcare providers toward a more comprehensive approach to axSpA diagnosis and care.

Disease activity and widespread pain are main contributors to patient-reported global health in axial spondyloarthritis: an analysis of 6064 patients

Global health (GH) and health-related quality of life are patient priorities in axial spondyloarthritis (axSpA). Our objective was to assess the relative importance of disease-related factors including disease activity, and patient-related factors including comorbidities, to explain GH in axSpA. Post hoc cross-sectional analyses of 4 sets (COMOSPA, PERSPA, COMEDSPA, and DESIR) of patients fulfilling ASAS criteria for axSpA. GH was assessed through the ASAS Health Index (ASAS-HI) or the EuroQoL-5D-3L (EQ-5D). Disease-related factors included disease activity (ASDAS, psoriasis, arthritis, enthesitis, and CRP), disease duration, diagnostic delay, bamboo spine, and treatment. Non-disease-related factors included sociodemographic characteristics, comorbidities and chronic widespread pain. Multivariable logistic and linear regressions and partial variances (R2) were applied to identify independent determinants of GH. In 6064 patients (range 284-2756 across datasets), mean age ranged 38.9-45.8 years, 51-68% were male. GH was generally moderate: median ASAS-HI ranged 5.0-7.0. GH was explained by ASDAS (range of odds ratios, OR, 2.60-4.48) and chronic widespread pain (range of OR 2.19-8.39); other determinants included comorbidities and sociodemographic characteristics. Only 47-57% of the total variance in GH could be explained by the models; disease activity (partial variance, 16-26%) and chronic widespread pain (partial variance 12-15%) were the key contributing variables. A wide range of disease and non-disease-related variables usually collected in studies could only explain 47-57% of the variability in GH. Among these, disease activity and chronic widespread pain were most relevant and of similar magnitude of importance. These findings will be helpful for shared decision-making.

Diagnosis challenges in inception cohorts in axial spondyloarthritis: the case of the French national DESIR cohort

BACKGROUND

Inception cohorts aim to describe chronic diseases from diagnosis and over years of follow-up. Axial spondyloarthritis (axSpA) diagnosis might be challenging during the first years of the disease. Thus, identifying the features that will be associated with a confirmed diagnosis over time is key.

OBJECTIVES

To assess the frequency and the predisposing factors for a change of an initial diagnosis in an inception axSpA cohort.

METHODS

DESIR is an ongoing national multicentre inception axSpA cohort with currently 12.5 years of follow-up. At the entry visit and confirmed at each visit, the diagnosis of axSpA was based on the opinion of the treating rheumatologist. Follow-up was interrupted in case of a change in this initial diagnosis. Multiple imputation was used to estimate the probability of a change in the initial diagnosis of axSpA for each patient lost to follow-up. Factors predisposing to an unchanged diagnosis of axSpA were then assessed using a multivariate logistic regression model on the imputed data sets.

RESULTS

Of the 708 patients included, over 10 years of follow-up, 45 (6.4%) were excluded due to a diagnosis change and 300 (42.4%) patients were lost to follow-up. Based on the imputation of these 300 patients, a change in their initial axSpA diagnosis was estimated in 42 (14.0%). Factors predisposing to an unchanged initial axSpA diagnosis during follow-up were (ORs (95% CIs)): radiographic sacroiliitis: 17.0 (4.1 to 71.0); psoriasis: 5.3 (2.0 to 14.3); CRP≥6 mg/L: 2.7 (1.3 to 5.3); good NSAID response: 2.5 (1.5 to 4.2); HLA B27+: 2.0 (1.3 to 3.3); anterior chest wall pain: 2.0 (1.2 to 3.3) and female sex: 1.9 (1.2 to 3.0).

CONCLUSION

These data suggest that a change in diagnosis in recent onset axSpA exists, but is not frequent, and is less likely to occur in the presence of objective features at baseline.

Sacroiliac radiographic progression over 10 years in axSpA: data from the DESIR inception cohort

OBJECTIVES

To evaluate sacroiliac radiographic progression over a 10-year follow-up and determine the baseline factors associated with such progression in patients with recent-onset axial spondyloarthritis (axSpA, <3 years).

METHODS

This analysis was performed in the DESIR cohort (NCT01648907). The radiographic status of the patients (radiographic axSpA (r-axSpA) vs non-radiographic axSpA (nr-axSpA)) was based on the modified New York (mNY) criteria. Information on mNY criteria on the pelvic radiographs was obtained in four reading waves over a 10-year period. Images were blinded and centrally read by 3 trained readers. The % of mNY net progressors (ie, number of 'progressors' minus number of 'regressors' divided by the total number of patients) was assessed in completers (ie, pelvic radiographs at baseline and 10 years). The yearly likelihood of mNY+ was estimated using an integrated analysis (ie, including all patients with at least one available mNY score ('intention-to-follow' population) using a generalised estimating equations model and time-varying tumour necrosis factor (TNF) use as a confounder. Baseline predictors of mNY+ during 10 years were evaluated.

RESULTS

Completers included 294 patients, while intention-to-follow included 659 participants. In the completers, the net % progression (from nr-axSpA to r-axSpA) was 5.8%. In the intention-to-follow population, the probability of being mNY+ was estimated to increase 0.87% (95% CI 0.56 to 1.19) per year (ie, 8.7% after 10 years) while when introducing TNF inhibitors (TNFi) as a time-varying covariate, the probability was 0.45% (95% CI 0.09 to 0.81) (ie, 4.5% after 10 years). Baseline bone marrow oedema (BME) on MRI of the sacroiliac joints (SIJ) was associated with being mNY+ over time OR 6.2 (95% CI 5.3 to 7.2) and OR 3.1 (95% CI 2.4 to 3.9) in HLA-B27+ and HLA-B27-, respectively). Male sex, symptom duration >1.5 years, Axial Spondyloarthritis Disease Activity Score ≥2.1 and smoking (only in HLA-B27 positives) were also associated with being mNY+ over 10 years. BME was not found to be a mediator of the HLA-B27 effect on mNY+ at 10 years.

CONCLUSIONS

The yearly likelihood of switching from nr-axSpA to r-axSpA in patients after 10 years of follow-up was low, and even lower when considering TNFi use.

Ten-year clinical outcome of recent-onset axial spondyloarthritis: Results from the DESIR inception Cohort

OBJECTIVES

This study aimed to evaluate the 10-year clinical outcome of patients with recent-onset axial spondyloarthritis (axSpA).

METHODS STUDY DESIGN

The DESIR cohort is an inception cohort of axSpA patients.

METHODS DIAGNOSIS AND MANAGEMENT

The diagnosis and management of patients were based on the decision of the treating rheumatologist.

METHODS STATISTICAL ANALYSIS

Both complete cases and imputed data analyses were conducted.

RESULTS

Of the 708 enrolled patients, 45 were excluded due to a change in the baseline diagnosis, 3 patients died, and 300 were lost to follow-up over the 10years. In the completer population, one patient required bilateral total hip replacement, and 56 patients received a pension due to invalidity. The prevalence of main extra-musculoskeletal features increased from baseline to year 10: psoriasis from 18% to 30%, acute anterior uveitis from 10% to 18%, and inflammatory bowel disease from 5% to 10%. The most frequent comorbidity was hypertension, with an increase from 5% to 15% from baseline to year 10. In the imputed data analysis the estimated proportions of patients with an acceptable status at year 10 were 70% [95% CI: 63; 77] for acceptable PASS, 43% [95% CI: 37; 49] for BASDAI<3, and 48% [95% CI: 41; 56] for ASDAS<2.1.

CONCLUSION

These findings suggest that despite a quite favorable 10-year outcome exists for severe outcomes, a large proportion of patients present with an important disease burden reflected by patient-reported outcomes. This information can be valuable for providing patients with information at the time of diagnosis.

Erosions on T1-Weighted Magnetic Resonance Imaging Versus Radiography of Sacroiliac Joints in Recent-Onset Axial Spondyloarthritis: 2-Year Data (EMBARK Trial and DESIR Cohort)

OBJECTIVE

(1) To compare the capacity to detect sacroiliac joint (SIJ) erosions and baseline-to-week 104 change in erosions between magnetic resonance imaging (MRI) and radiographs in recent-onset axial spondyloarthritis (axSpA); and (2) to compare treatment-discriminatory capacities of MRI and radiographic scores for erosion detection in patients receiving etanercept in the Effect of Etanercept on Symptoms and Objective Inflammation in Nonradiographic axSpA (EMBARK) trial vs controls in the DESIR (Devenir des Spondylarthropathies Indifférenciées Récentes) cohort.

METHODS

Anonymized SIJ MRI and radiographs were assessed at patient and joint surface levels. Three readers evaluated MRI; 3 different readers evaluated radiographs. Final scores for comparison of radiographs and MRI for detection of erosions were assigned based on agreement of ≥ 2 of 3 readers' assessments.

RESULTS

At baseline, discordance in erosion detection between imaging methods was more frequent for MRI erosions in the absence of radiographic erosions (48/224 [21.4%] patients) than for radiographic erosions in the absence of MRI erosions (14/224 [6.3%] patients; P < 0.001). After 104 weeks, a decrease in erosions was observed on MRI but not radiographs in 49/221 (22.2%) patients, and on radiographs but not MRI in 6/221 (2.7%) patients (P < 0.001). In the treatment-discriminant capacity analysis, the largest standardized differences between etanercept and control cohorts at week 104 were changes in Spondyloarthritis Research Consortium of Canada MRI erosion discrete score, changes in erosion average score, and meeting the modified New York criteria on radiographs, with unadjusted/adjusted Hedges G effect sizes of 0.40/0.50, 0.40/0.56, and 0.40/0.43, respectively.

CONCLUSION

In recent-onset axSpA, SIJ erosions and erosion change were observed more frequently on MRI than radiography. The significance of interval improvement of MRI erosions warrants further research. [ClinicalTrials.gov: NCT01258738, NCT01648907].

Factors Associated With Treatment Pathways in Early Axial Spondyloarthritis: A Multistate Analysis of the 10-Year Follow-Up of the DESIR Cohort

OBJECTIVE

Current recommendations for the management of patients with axial spondyloarthritis (axSpA) emphasize the need of an individualized strategy in therapeutic decision-making. The study objectives were to describe therapeutic strategies observed in axSpA, and to assess the factors associated with treatment intensification over time.

METHODS

We included patients with axSpA from the French prospective cohort DESIR (Devenir des Spondylarthropathies Indifférenciées Récentes), with a scheduled 10-year follow-up. A multistate model with 4 ordered treatment states (no treatment, nonsteroidal antiinflammatory drugs [NSAIDs], conventional synthetic disease-modifying antirheumatic drugs [csDMARDs], and tumor necrosis factor inhibitors [TNFi]) was defined, with 6 possible transitions. Restricted mean sojourn times in each state were estimated. Then, predictors of those transitions were assessed by multivariable Cox models.

RESULTS

A total of 686/708 (96.9%) patients who had > 1 visit were analyzed. At cohort entry, 199 (29%) were untreated, 427 (62.2%) were receiving NSAIDs, 60 (8.7%) csDMARDs, and none were receiving TNFi. Over the follow-up period, patients mostly (46.4% of the time) received NSAIDs, followed by TNFi (24.4% of the time). The presence of sacroiliitis on radiographs, inflammatory bowel disease, and articular index were jointly associated with the transition to NSAIDs. Longer duration in the previous state often decreased the hazard of the transition to csDMARDs or TNFi. Worse disease activity outcomes increased the hazard of most transitions.

CONCLUSION

To our knowledge, this was the first study using a multistate model to easily represent different treatment states, detailing the transitions across them and their associated factors. Different time profiles for the management of patients with axSpA were identified, including in those abstaining from treatment up to a significant proportion of patients treated with csDMARDs.

The ethanol extract of Scutellaria baicalensis Georgi attenuates complete Freund's adjuvant (CFA)-induced inflammatory pain by suppression of P2X3 receptor

ETHNOPHARMACOLOGICAL RELEVANCE

Scutellaria baicalensis Georgi (SBG) is a perennial herb with anti-inflammatory, antibacterial, and antioxidant activities, which is traditionally used to treat inflammation of respiratory tract and gastrointestinal tract, abdominal cramps, bacterial and viral infections. Clinically, it is often used to treat inflammatory-related diseases. Research has shown that the ethanol extract of Scutellaria baicalensis Georgi (SGE) has anti-inflammatory effect, and its main components baicalin and baicalein have analgesic effects. However, the mechanism of SGE in relieving inflammatory pain has not been deeply studied.

AIM OF THE STUDY

This study aimed to evaluate the analgesic effect of SGE on complete Freund's adjuvant (CFA)-induced inflammatory pain rats, and to investigate whether its effect on relieving inflammatory pain is associated with regulation of P2X3 receptor.

MATERIALS AND METHODS

The analgesic effects of SGE on CFA-induced inflammatory pain rats were evaluated by measuring mechanical pain threshold, thermal pain threshold, and motor coordination ability. The mechanisms of SGE in relieving inflammatory pain were explored by detecting inflammatory factors levels, NF-κB, COX-2 and P2X3 expression, and were further verified by addition of P2X3 receptor agonist (α, β me-ATP).

RESULTS

Our results revealed that SGE can notably increase the mechanical pain threshold and thermal pain threshold of CFA-induced inflammatory pain rats, and markedly alleviate the pathological damage in DRG. SGE could suppress the release of inflammatory factors including IL-1β, IL-6, TNF-α and restrain the expression of NF-κB, COX-2 and P2X3. Moreover, α, β me-ATP further exacerbated the inflammatory pain of CFA-induced rats, while SGE could markedly raise the pain thresholds and relieve inflammatory pain. SGE could attenuate the pathological damage, inhibit P2X3 expression, inhibit the elevation of inflammatory factors caused by α, β me-ATP. SGE can also inhibit NF-κB and ERK1/2 activation caused by α, β me-ATP, and inhibit the mRNA expression of P2X3, COX-2, NF-κB, IL-1β, IL-6 and TNF-α in DRG of rats induced by CFA coupled with α, β me-ATP.

CONCLUSIONS

In summary, our research indicated that SGE could alleviate CFA-induced inflammatory pain by suppression of P2X3 receptor.

Looking through the window of opportunity in axial spondyloarthritis?

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that affects the spine and sacroiliac joints, that can lead to irreversible structural damage. Early detection and timely intervention are crucial for preventing long-term structural damage, improving quality of life, and reducing the burden of the disease. The concept of a window of opportunity suggests that an early intervention in the reversible stage of the disease can lead to improved long-term outcomes. However, it is unclear whether this concept applies in axSpA. Recent advances in axSpA management, including the use of diagnostic techniques such as magnetic resonance imaging as well as the use of advanced therapies, have shown promise in improving outcomes. However, studies investigating the potential window of opportunity in axSpA by assessing the impact of an early treatment on clinical outcomes have yielded inconclusive results. One of the reasons behind this is the lack of a standardized definition of early axSpA. The Assessment of Spondyloarthritis International Society (ASAS)-SPEAR (SPondyloarthritis EARly) project has set the ground for it by working on a consensus definition of early axSpA. Randomized controlled trials specifically focused on the comparison between treating axSpA in the early and late stages of the disease and using the standardised definition of early axSpA are essential to understand better the potential benefits of an early treatment on clinical outcomes. Additionally, it would be relevant to assess the long-term outcomes of early axSpA treatment, especially regarding structural damage, to better grasp the concept of the window of opportunity in axSpA.

HCN2 Channels in the Ventral Hippocampal CA1 Regulate Nociceptive Hypersensitivity in Mice

Chronic pain is a significant health problem worldwide. Recent evidence has suggested that the ventral hippocampus is dysfunctional in humans and rodents, with decreased neuronal excitability and connectivity with other brain regions, parallel pain chronicity, and persistent nociceptive hypersensitivity. But the molecular mechanisms underlying hippocampal modulation of pain remain poorly elucidated. In this study, we used ex vivo whole-cell patch-clamp recording, immunofluorescence staining, and behavioral tests to examine whether hyperpolarization-activated cyclic nucleotide-gated channels 2 (HCN2) in the ventral hippocampal CA1 (vCA1) were involved in regulating nociceptive perception and CFA-induced inflammatory pain in mice. Reduced sag potential and firing rate of action potentials were observed in vCA1 pyramidal neurons from CFA-injected mice. Moreover, the expression of HCN2, but not HCN1, in vCA1 decreased in mice injected with CFA. HCN2 knockdown in vCA1 pyramidal neurons induced thermal hypersensitivity, whereas overexpression of HCN2 alleviated thermal hyperalgesia induced by intraplantar injection of CFA in mice. Our findings suggest that HCN2 in the vCA1 plays an active role in pain modulation and could be a promising target for the treatment of chronic pain.

Bone marrow edema in the sacroiliac joints is associated with the development of structural lesions at the same anatomical location over time in patients with axial spondyloarthritis

OBJECTIVE

To assess whether the presence of bone marrow edema (BME) leads to the development of structural lesions at the same anatomical location of the sacroiliac joints (SIJ), and to investigate the association between BME patterns over time and structural lesions in patients with early axial spondyloarthritis (axSpA).

METHODS

Patients with axSpA from the DESIR cohort with ≥2 consecutive magnetic resonance imaging (MRI)-SIJ were assessed at baseline, 2 and 5 years. MRI-SIJ images were divided into 8 quadrants. The association between BME and subsequent structural lesions (sclerosis, erosions, fatty lesions, and ankylosis) on MRI in the same quadrant was tested longitudinally. Additionally, patients were grouped according to the pattern of BME evolution across quadrants over time (no BME, sporadic, fluctuating, and persistent). The association between these patterns and 5-year imaging outcomes (eg: ≥5 erosions and/or fatty lesions on MRI-SIJ) was tested.

RESULTS

In total, 196 patients were included. BME in each quadrant was associated with sclerosis (OR:1.9 (95%CI: 1.1;3.4)), erosions (1.9 (1.5;2.5)) and fatty lesions (1.9 (1.4;2.6)). Ankylosis was uncommon. There was a gradient between increased level of inflammation and subsequent damage: compared to the 'no BME' pattern, the sporadic (OR (95% CI): 2.1 (1.0;4.5)), fluctuating (OR:5.6(2.2;14.4)) and persistent (OR:7.5(2.8;19.6)) patterns were associated with higher structural damage on MRI-SIJ at 5-years.

CONCLUSIONS

In early axSpA, inflammation on MRI-SIJ leads to damage at the quadrant level. The higher the exposure to inflammation across quadrants in the SIJs over time the higher the likelihood of subsequent structural damage, suggesting a cumulative effect.

Increase in axial spondyloarthritis diagnoses after the introduction of the ASAS criteria: a systematic review

To explore the proportion of axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) diagnoses within all newly referred patients visiting rheumatology outpatient clinics. And more specifically, to analyze whether there is an effect of the introduction of the ASAS and CASPAR classification criteria for axSpA and PsA. We systematically searched Embase, Medline Ovid, Cochrane Central and Web of Science from database inception to November 2022. Articles that investigated new onsets of axSpA and PsA in adults from rheumatology clinics were included. In total, 170 out of 7139 studies were found eligible for full-text review, after which 33 unique studies were included. Seventeen studies reported new onsets of axSpA, and 20 studies of PsA. The pooled proportion of axSpA within all newly referred patients was 19% (95% CI 15-23%) and 18% (95% CI 14-22%) for PsA. The proportion of axSpA before 2009 was 3% (95% CI 0-6%) and increased up to 21% (95% CI 14-28%) after 2009. For PsA, limited data were available in order to analyze the proportions of PsA before 2006. Overall, heterogeneity was high (I² > 95%, p < 0.001) that was most likely caused by geographical area, study design, setting and use of different referral strategies. The pooled proportion of axSpA and PsA among patients referred to the rheumatology outpatient clinic was 19 and 18%, respectively. Although the proportion of diagnosed axSpA patients seemed to increase after the introduction of the ASAS criteria, due to the large heterogeneity our findings should be interpreted with caution.

Validation of the ASDAS with a quick quantitative CRP assay (ASDAS-Q) in patients with axial SpA: a prospective multicentre cross-sectional study

Objectives:

The objective of the study was to validate the Ankylosing Spondylitis Disease Activity Score (ASDAS) based on a quick quantitative C-reactive protein (qCRP) assay (ASDAS-Q) in a multicentre, prospective, cross-sectional study in patients with axial spondyloarthritis (axial SpA).

Methods:

Disease activity assessment was performed in prospectively recruited patients with axial SpA. Routine laboratory CRP was determined in the central laboratory of each study centre, while quick qCRP and erythrocyte sedimentation rate (ESR) were measured locally. Consequently, ASDAS-CRP, ASDAS-Q using the qCRP and ASDAS-ESR were calculated. The absolute agreement on the disease activity category ascertainment was analysed with cross-tabulations and weighted Cohen’s kappa. Bland–Altman plots and intraclass correlation coefficients (ICCs) were used to analyse the criterion validity.

Results:

Overall, 251 axial SpA patients were included in the analysis. The mean qCRP value (6.34 ± 11.13 mg/l) was higher than that of routine laboratory CRP (5.26 ± 9.35 mg/l). The ICC for routine laboratory CRP versus qCRP was 0.985 [95% confidence interval (CI): 0.972–0.991]. Comparing ASDAS-Q with ASDAS-CRP, 242 of 251 (96.4%) patients were assigned to the same disease activity categories with a weighted Cohen’s kappa of 0.966 (95% CI: 0.943–0.988) and ICC of 0.997 (95% CI: 0.994–0.999).

Conclusions:

ASDAS-Q showed an almost perfect agreement with ASDAS-CRP in the assignment to specific disease activity categories. Consequently, ASDAS-Q using the qCRP value can be applied as an accurate and quickly available alternative to ASDAS-CRP, thus facilitating the implementation of the treat-to-target concept in clinical trials and clinical routine.

Gut dysbiosis associated with worse disease activity and physical function in axial spondyloarthritis

Background

Based on clinical and genetic associations, axial spondyloarthritis (axSpA) and inflammatory bowel disease (IBD) are suspected to have a linked pathogenesis. Gut dysbiosis, intrinsic to IBD, has also been observed in axSpA. It is, however, not established to what degree gut dysbiosis is associated with axSpA disease severity.

The objective of this study was to compare gut dysbiosis frequency between controls, non-radiographic axial spondyloarthritis (nr-axSpA), and ankylosing spondylitis (AS) patients and investigate whether gut dysbiosis is cross-sectionally associated with axSpA disease activity, physical function, mobility, or pain.

Methods

Gut dysbiosis was assessed by 16SrRNA analysis of feces from 44/88 nr-axSpA/AS patients (ASAS/mNY criteria) without inflammatory bowel disease (IBD) and 46 controls without IBD or rheumatic disease. The GA-map™ Dysbiosis Test was used, grading gut microbiota aberrations on a 1-5 scale, where ≥3 denotes dysbiosis. Proportions with dysbiosis were compared between the groups. Furthermore, standard axSpA measures of disease activity, function, mobility, and pain were compared between patients (nr-axSpA and AS combined) with and without dysbiosis, univariately, and adjusted for relevant confounders (ANCOVA).

Results

Gut dysbiosis was more frequent in AS than controls (36% versus 17%, p=0.023), while nr-axSpA (25% dysbiosis) did not differ significantly from either AS or controls. Univariately, most axSpA measures were significantly worse in patients with dysbiosis versus those without: ASDAS-CRP between-group difference 0.6 (95% CI 0.2–0.9); BASDAI 1.6 (0.8–2.4); evaluator’s global disease activity assessment (Likert scale 0–4) 0.3 (0.1–0.5), BASFI 1.5 (0.6–2.4), and VAS pain (cm) 1.3 (0.4–2.2). Differences remained significant after adjustment for demographics, lifestyle factors, treatments, gut inflammation (fecal calprotectin ≥50 mg/kg), and gut symptoms, except for VAS pain. BASMI and CRP were not associated with dysbiosis.

Conclusion

Gut dysbiosis, more frequent in AS patients than controls, is associated with worse axSpA disease activity and physical function, seemingly irrespective of both gut inflammation and treatments. This provides further evidence for an important link between disturbances in gastrointestinal homeostasis and axSpA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02733-w.

Prevalence and consequences of psoriasis in recent axial spondyloarthritis: an analysis of the DESIR cohort over 6 years

OBJECTIVES

The consequences of psoriasis associated to axial spondyloarthritis (axSpA) are unclear. The objectives were to determine the prevalence and the consequences of psoriasis in recent axSpA over 6 years of follow-up.

METHODS

The multicentric prospective cohort DESIR (NCT01648907) of adult patients with recent inflammatory back pain suggestive of axSpA was analysed over 6 years. Psoriasis was recorded at each visit and cumulative prevalence and incidence were calculated. Patients with vs without psoriasis at any time point were compared. Outcomes included disease activity (Ankylosing Spondylitis Disease Activity Score-C reactive protein (ASDAS-CRP), joint and enthesitis count, CRP), patient-reported outcomes for function (Health Assessment Questionnaire for axSpA, HAQ-AS) and quality of life, and treatment use over 6 years. Outcomes were compared through univariable and multivariable analyses, as well as linear mixed effect models.

RESULTS

In 589 patients, mean age 40.5±8.7 years, 45.8% men and baseline mean symptom duration 1.5±0.9 years, the cumulative prevalence of psoriasis increased from 16.8% (99/589) at baseline to 26.8% (158/589) at 6 years, leading to an incidence of 2.1/100 patient-years. Over 6 years of follow-up, patients with psoriasis developed more synovitis (p=0.008), and received more methotrexate (cumulative use, 25.5% vs 11.8%, p<0.001) and biological disease-modifying drugs (55.7% vs 38.5%, p<0.001). There were no significant consequences of psoriasis on other outcomes, including disease activity (ASDAS-CRP), functional capacity (HAQ-AS) and quality of life.

CONCLUSION

Psoriasis is frequent in early axSpA. AxSpA patients with psoriasis had more swollen joints over time and received more biologics; they did not have worse outcomes related to axSpA in terms of activity and severity.

TRIAL REGISTRATION NUMBER

NCT01648907.

Evaluation of long-term TNFi effectiveness after a first switch in early axial spondyloarthritis considering time-varying prescription bias: an inverse-probability weighting analysis of the DESIR cohort

Objective

To evaluate long-term effectiveness of tumour necrosis factor inhibitor (TNFi) after a first switch, and their associated factors in an early axial spondyloarthritis (axSpA) population, considering time-varying prescription bias.

Methods

Observational prospective cohort (DEvenir des Spondylarthropathies Indifférenciées Récentes) with 5 years of follow-up, including 708 TNFi-naïve patients with early axSpA. Long-term effectiveness of TNFi after a first switch (ASAS40 response after at least 2 visits under treatment) were estimated using marginal structural models (implementing inverse-probability weighting and iterative propensity scores). Factors associated with the outcome were explored by multivariate Cox regression models.

Results

The hazard to present an ASAS40 response after a first TNFi switch was increased (HR=2.4 (95% CI 1.9 to 3.0)); this response ratio was slightly lower compared with the response in TNFi naïve patients after a first TNFi (HR=3.3 (95% CI 2.9 to 3.8)). HLA-B27 positive was the only factor independently associated with ASAS40 response after a first TNFi switch.

Conclusion

After application of innovative methods to overcome time-varying prescription bias, the magnitude of the TNFi response after a first switch was found to be numerically lower but clinically relevant from the response in TNFi-naïve patients.

Australian Consensus Statements for the Assessment and Management of Non-radiographic Axial Spondyloarthritis

Background

The understanding of non-radiographic axial spondyloarthritis (nr-axSpA) has accelerated over the last decade, producing a number of practice-changing developments. Diagnosis is challenging. No diagnostic criteria exist, no single finding is diagnostic, and other causes of back pain may act as confounders.

Aim

To update and expand the 2014 consensus statement on the investigation and management of non‐radiographic axial spondyloarthritis (nr-axSpA).

Methods

We created search questions based on our previous statements and four new topics then searched the MEDLINE and Cochrane databases. We assessed relevant publications by full-text review and rated their level of evidence using the GRADE system. We compiled a GRADE evidence summary then produced and voted on consensus statements.

Results

We identified 5145 relevant publications, full-text reviewed 504, and included 176 in the evidence summary. We developed and voted on 22 consensus statements. All had high agreement. Diagnosis of nr-axSpA should be made by experienced clinicians, considering clinical features of spondyloarthritis, blood tests, and imaging. History and examination should also assess alternative causes of back pain and related conditions including non-specific back pain and fibromyalgia. Initial investigations should include CRP, HLA-B27, and AP pelvic radiography. Further imaging by T1 and STIR MRI of the sacroiliac joints is useful if radiography does not show definite changes. MRI provides moderate-to-high sensitivity and high specificity for nr-axSpA. Acute signs of sacroiliitis on MRI are not specific and have been observed in the absence of spondyloarthritis. Initial management should involve NSAIDs and a regular exercise program, while TNF and IL-17 inhibitors can be used for high disease activity unresponsive to these interventions. Goals of treatment include improving the frequent impairment of social and occupational function that occurs in nr-axSpA.

Conclusions

We provide 22 evidence-based consensus statements to provide practical guidance in the assessment and management of nr-axSpA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00416-7.

Paeoniflorin alleviates CFA-induced inflammatory pain by inhibiting TRPV1 and succinate/SUCNR1-HIF-1α/NLPR3 pathway

BACKGROUND

Treatment of chronic inflammatory pain remains a major goal in the clinic. It is thus of prime importance to characterize inherent pathophysiological pathways to design new therapeutic strategies and analgesics for pain management. Paeoniflorin (PF), a monoterpenoid glycoside from Paeonia lactiflora Pallas plants, possesses promising anti-nociceptive property. However, therapeutic effect and underlying mechanism of action of PF on inflammatory pain have not yet been fully elucidated. In this study, we aim to investigate the analgesic effect further and clarify its mechanism of action of PF on complete freund's adjuvant (CFA)-evoked inflammatory pain.

METHODS

Twenty-four male mice were divided into 3 groups: sham, CFA, and CFA + PF groups (n = 8/group). Mice were treated with normal saline or PF (30 mg/kg) for 11 days. Footpad swelling (n = 8/group), mechanical (n = 8/group) and thermal hypersensitivity (n = 8/group) were measured to evaluate the analgesic effect of PF on CFA-injected mice. At the end of the animal experiment, blood and L4-L6 dorsal root ganglion neurons were collected to assess the therapeutic effect of PF on CFA-induced inflammatory pain. Next, hematoxylin and eosin, quantitative realtime PCR, ELISA, capsaicin and dimethyl succinate induced pain test (n = 8/group), motor coordination test (n = 8/group), tail flicking test (n = 8/group), pyruvate and succinate dehydrogenase assay (n = 6/group), immunohistochemical staining, were performed to clarify the action mechanism of PF on CFA-evoked inflammatory pain. Besides, the effect of PF on TRPV1 was evaluated by whole-cell patch clamp recording on primary neurons (n = 7). Finally, molecular docking further performed to evaluate the binding ability of PF to TRPV1.

RESULTS

PF significantly relieved inflammatory pain (P < 0.001) and paw edema (P < 0.001) on a complete Freund adjuvant (CFA)-induced peripheral inflammatory pain model. Furthermore, PF inhibited neutrophil infiltration (P < 0.01), IL-1β increase (P < 0.01), and pain-related peptide substance P release (P < 0.001). Intriguingly, CFA-induced succinate aggregation was notably reversed by PF via modulating pyruvate and SDH activity (P < 0.01). In addition, PF dampened the high expression of subsequent succinate receptor SUCNR1 (P < 0.01), HIF-1α (P < 0.05), as well as the activation of NLPR3 inflammasome (P < 0.05) and TRPV1 (P < 0.05). More importantly, both capsaicin and dimethyl succinate supplementation obviously counteracted the pain-relieving effect of PF and TRPV1 (P < 0.01 or P < 0.001).

CONCLUSION

Our findings suggest that PF can significantly relieve CFA-induced paw swelling, as well as mechanical and thermal hyperalgesia. PF alleviated inflammatory pain partly through inhibiting the activation of TRPV1 and succinate/SUCNR1-HIF-1α/NLPR3 pathway. Furthermore, we found that PF exerted its analgesic effect without affecting motor coordination and pain-related cold ion-channels. In summary, this study may provide valuable evidence for the potential application of PF as therapeutic strategy for inflammatory pain treatment.

Clinical application of mesenchymal stem cells in rheumatic diseases

Mesenchymal stem cells (MSCs) are pluripotent stem cells derived from mesoderm during early development that are characterized by high self-renewal ability and multidirectional differentiation potential. These cells are present various tissues in the human body and can be cultured in vitro. Under specific conditions, MSCs can differentiate into osteoblasts, neuron-like cells, adipocytes and muscle cells and so on, therefore, have a great application value in cell replacement therapy and tissue repair. In recent years, the application of MSCs in rheumatic diseases has received increasing attention. On the one hand, MSCs have the ability to differentiate into bone and cartilage cells; on the other hand, these stem cells are also involved in immune regulation, resulting in the alleviation of inflammation and anti-fibrotic properties and the promotion of vascular repair, thus bringing new hope for the treatment of rheumatic diseases. This article reviews the clinical progress in MSC application for the treatment of rheumatic diseases.

Determining factors related to impaired spinal and hip mobility in patients with axial spondyloarthritis: longitudinal results from the DESIR cohort

Objective

To investigate the determinants of impaired spinal and hip mobility in patients with early axial spondyloarthritis (axSpA).

Methods

Five-year longitudinal data from the DEvenir des Spondyloarthrites Indifférenciées Récentes (DESIR) cohort were analysed. Associations were investigated using generalised estimating equations, using Bath Ankylosing Spondylitis Metrology Index (BASMI) linear or each of the five components of BASMI as dependent variables, and clinical and demographic variables as independent variables in univariable models. Multivariable analyses were performed, adjusting for potential confounders.

Results

Data from 644 patients and 5152 visits were analysed. Higher BASMI values were independently and positively associated with Ankylosing Spondylitis Disease Activity Score C reactive protein (ASDAS-CRP) (adjusted B (adjB)=0.21; 95% CI=0.15 to 0.28), MRI spinal inflammation score (adjB=0.11; 95% CI=0.04 to 0.19), enthesitis score (adjB=0.02; 95% CI=0.01 to 0.04) and age (adjB=0.02; 95% CI=0.01 to 0.03). All BASMI components were independently associated with ASDAS-CRP and MRI spinal inflammation, except for maximal intermalleolar distance (reflecting hip mobility), which was not associated with MRI spinal inflammation.

Conclusion

In early axSpA, spinal mobility impairment is independently determined by clinical disease activity, MRI spinal inflammation, enthesitis and age. The influence of spinal inflammation prevails in early axSpA, as opposed to spinal structural damage, which may become more relevant in later disease stages.

Sociodemographic determinants in the evolution of pain in inflammatory rheumatic diseases: results from ESPOIR and DESIR cohorts

Objective

To determine whether socio-demographic factors are associated with heterogeneity in pain evolution in inflammatory rheumatic diseases (IRDs) after accounting for disease-specific characteristics in a system with universal health care.

Methods

This analysis included the data from two prospective observational cohorts of early IRDs (ESPOIR for early RA and DESIR for early SpA). Data on pain was measured, respectively, on 13 and 9 occasions spanning 10 and 6 years of follow-up using the Short-Form 36 bodily pain score for 810 participants of ESPOIR, and 679 participants of DESIR. Linear mixed models were used to characterize differences in pain evolution as a function of age (tertiles), sex, ethnicity, education, marital, and professional status, after accounting for disease-related, treatment, lifestyle, and health factors.

Results

While transitioning from early (disease duration ≤6 months for RA and ≤3 years for SpA) to long-standing disease, differences in pain evolution emerged as a function of age (P < 0.001), sex (P = 0.050), and ethnicity (P = 0.001) in RA, and as a function of age (P = 0.048) in SpA; younger age, males, and Caucasians exhibited lower pain in the latter phases of both diseases. Highly educated participants (RA, β = −3.8, P = 0.007; SpA, β = −6.0, P < 0.001) for both diseases, and Caucasians (β = −5.6, P = 0.021) for SpA presented with low pain early in the disease, with no changes throughout disease course.

Conclusion

Being older, female, non-Caucasian and having lower education was found to be associated with worse pain in early and/or long-standing IRDs, despite universally accessible health-care. Early identification of at-risk populations and implementation of multidisciplinary strategies may reduce patient-reported health outcome disparities.

Trial registration registrations

ESPOIR: ClinicalTrials.gov, www.clinicaltrials.gov, NCT03666091. DESIR: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01648907.

Factors associated with remission at 5-year follow-up in recent onset axial spondyloarthritis: results from the DESIR cohort

Objective

The factors contributing to long-term remission in axial SpA (axSpA) are unclear. We aimed to characterize individuals with axSpA at the 5-year follow-up to identify baseline factors associated with remission.

Methods

We included all patients from the DESIR cohort (with recent-onset axSpA) with an available Ankylosing Spondylitis Disease Activity Score–CRP (ASDAS-CRP) at 5-year follow-up. Patients in remission (ASDAS-CRP < 1.3) were compared with those with active disease by demographic, clinical, biological and imaging characteristics. A logistic model stratified on TNF inhibitor (TNFi) exposure was used.

Results

Overall, 111/449 patients (25%) were in remission after 5 years. Among those never exposed to TNFi, 31% (77/247) were in remission compared with 17% (34/202) of those exposed to TNFi. Patients in remission after 5 years were more likely to be male, HLA-B27+, have a lower BMI, and a higher education level. Baseline factors associated with 5-year remission in patients never exposed to TNFi included lower BASDAI [adjusted odds ratio (OR_a) 0.9, 95% CI: 0.8, 0.9) and history of peripheral arthritis (OR_a 2.1, 95% CI: 1.2, 5.3). In those exposed to TNFi, remission was associated with higher education level (OR_a 2.9, 95% CI: 1.6, 5.1), lower enthesitis index (OR_a 0.8, 95% CI: 0.7, 0.9), lower BASDAI (OR_a 0.9, 95% CI: 0.9, 0.9) and lower BMI (OR_a 0.8, 95% CI: 0.7, 0.9).

Conclusion

This study highlights the difficulty in achieving 5-year remission in those with recent-onset axSpA, especially for the more active cases, despite the use of TNFi. Socio-economic factors and BMI are implicated in the outcome at 5 years.

Diagnosing axial spondyloarthritis by multidiciplinary team conference at 3.5 years' follow-up in a cohort of patients with disease features according to the ASAS criteria

OBJECTIVES

During the past two decades, magnetic resonance imaging (MRI) has increasingly been used diagnostically in axial spondyloarthritis (axSpA), and in 2009 MRI was introduced in the Assessment of SpondyloArthritis Society (ASAS) classification criteria. In clinical practice, there is a risk of overdiagnosis if MRI findings are not related to clinical and biochemical findings. The aim of this study was to provide an estimate of the prevalence of axSpA in a cohort of clinical patients with low back pain and findings suggestive of axSpA according to ASAS through consensus diagnosis at a multi-disciplinary team (MDT) conference, and to describe the performance of the features included in the ASAS criteria.

METHOD

Consensus diagnoses of axSpA at MDT conferences were retrospectively established at 3.5 years' follow-up in a cohort of 84 patients, initially referred with disease features according to the ASAS criteria. Patients were examined clinically regarding spondyloarthritis features, and biochemical tests and MRI of the sacroiliac joints and entire spine were performed at baseline and after a mean of 3.5 years.

RESULTS

According to the MDT consensus, 25 patients (30%) of the total cohort had axSpA at follow-up; 40% of individuals who fulfilled the ASAS criteria at baseline had axSpA, and 37% at follow-up; 96% of axSpA patients according to the MDT consensus met the ASAS criteria at baseline and 92% at follow-up.

CONCLUSION

Approximately one-third of the included patients had axSpA when evaluated at the MDT conference. The ASAS criteria had low predictive value, but high sensitivity at both baseline and follow-up.

Predictors of extra-articular manifestations in axial spondyloarthritis and their influence on TNF-inhibitor prescribing patterns: results from the British Society for Rheumatology Biologics Register in Ankylosing Spondylitis

OBJECTIVES

Extra-articular manifestations (EAMs) are important systemic features of axial spondyloarthritis (axSpA), which may influence the choice of tumour necrosis factor-inhibitor (TNFi). We examined the cumulative incidence and predictors of EAMs and the influence of these on first TNFi choice in a 'real-world' cohort of patients with axSpA.

METHODS

Clinical and patient-reported outcomes of 2420 patients with axSpA from 83 centres were collected by the British Society for Rheumatology Biologics Register in Ankylosing Spondylitis. Lifestyle factors for EAMs (acute anterior uveitis (AAU), inflammatory bowel diseases (IBD), psoriasis) were compared with those without EAMs. Also, the association between pretreatment EAMs and choice of first TNFi (adalimumab, etanercept, certolizumab) was analysed.

RESULTS

AAU was directly associated with human leukocyte antigen (HLA)-B27 (incidence rate ratio (IRR) 1.95, 95% CI 1.40 to 2.73) and inversely associated with ever-smoking (IRR=0.71, 95% CI 0.55 to 0.92). For both psoriasis and IBD, there was an inverse relationship with HLA-B27 (IRR 0.54, 95% CI 0.36 to 0.79 and IRR 0.63, 95% CI 0.43 to 0.91, respectively). A diagnosis of either AAU (OR 3.79, 95% CI 2.11 to 6.80) or IBD (OR 5.50, 95% CI 2.09 to 14.46) was associated with preference for adalimumab versus others. In contrast, a diagnosis of either AAU (OR 0.14, 95% CI 0.06 to 0.33) or IBD (OR 0.17, 95% CI 0.05 to 0.57) was associated with less preference for etanercept over other TNFi.

CONCLUSION

The higher occurrence of AAU and lower occurrence of psoriasis and IBD in HLA-B27-positive patients with axSpA are consistent with current pathophysiology. Patients with previous AAU and IBD are more likely to be prescribed adalimumab and less likely to receive etanercept, consistent with the superior efficacy of monoclonal TNFi for these indications. Future work will determine whether EAMs influence TNFi survival, or effectiveness, and whether this varies between agents.

5-year follow-up of spinal and sacroiliac MRI abnormalities in early axial spondyloarthritis: data from the DESIR cohort

Objective

To study changes on MRI of the spine and sacroiliac joint (SIJ) in early axial spondyloarthritis (axSpA) over time.

Methods

In the Devenir des Spondyloarthropathies Indifférenciées Récentes cohort, MRI-spine and MRI-SIJ at baseline and 2 and 5 years were scored by central readers for bone marrow oedema (BME), fatty lesions, erosions, sclerosis, ankylosis and spinal bone spurs. The average mean number of lesions was reported or the agreement of ≥2 out of 3 readers for binary outcomes. Net progression was calculated by subtracting the patients that ‘improved’ from those that ‘worsened’ divided by the total number of patients.

Results

Over 5 years, in 155 patients with axSpA (mean age 33.5 (SD 8.9) years, symptom duration 1.4 (0.8) years, 63% human leucocyte antigen+, 14% modified New York+), BME on MRI-SIJ decreased by a mean Spondyloarthritis Research Consortium of Canada score of 1.4 (SD 6.5) (p=0.009). The largest BME decrease was observed in patients using biological disease-modifying antirheumatic drugs at 5 years. Spinal BME increased by 0.3 (4.6) (p=0.41). Fatty lesions and/or erosions on MRI-SIJ increased by a mean of 1.0 (SD 2.6) (p<0.001). Spinal fatty lesions and/or erosions increased by 0.2 (SD 0.5) (p<0.001). Compared with baseline, at 5 years, 7.3% less patients had BME on MRI-SIJ according to the Assessment of Spondyloarthritis International Society definition, while 6.6% more patients had ≥5 fatty lesions and/or erosions. At 5 years, 0.7% less patients had ≥5 spinal BME lesions and 0.7% less patients had ≥5 spinal fatty lesions.

Conclusion

Over 5 years, BME on MRI-SIJ decreased and spinal BME remained similar, but numerically, little progression of structural lesions on MRI of the SIJ and spine was seen.

Peripheral arthritis and higher disease activity lead to more functional impairment in axial spondyloarthritis: Longitudinal analysis from ESPAXIA

OBJETIVE

The aim of this study was to investigate whether peripheral arthritis together with disease activity independently contribute to functional impairment over time in patients with axSpA and to evaluate if there are contextual factors modifying this relationship.

MATERIAL AND METHODS

Patients with axial spondyloarthritis from the ESPAXIA cohort were followed-up annually over a mean of 3.7 years. Physical function was assessed by the self-reported questionnaire BASFI, disease activity by ASDAS and peripheral arthritis was also recorded. Generalized estimating equations (GEE) were used to investigate longitudinal association between peripheral arthritis, ASDAS and BASFI as the outcome. Autoregressive models (adjusted for BASFI 1 year earlier) were run to allow for a truly longitudinal interpretation. Interactions between each of ASDAS and peripheral arthritis with contextual factors (age, gender, educational level, smoking, job type) were tested.

RESULTS

185 patients (77 % male, mean (SD) age 42 (13) years old and mean disease duration (SD) of 9.4 (9.6) years) were included. ASDAS and peripheral arthritis independently contributed to explaning BASFI over time. Contextual factors did not modify either of the relationships. A true longitudinal relation was proven with the autoregressive GEE model, showing that, adjusted for age, gender, spinal mobility and use of NSAIDs, an increase of one ASDAS unit led to a BASFI 0.48 units higher (ß 0.48 [95%CI 0.39, 0.57]), and the presence of peripheral arthritis, to a BASFI 0.44 units higher (ß 0.44 [95%CI 0.08, 0.8]).

CONCLUSION

Peripheral arthritis and higher disease activity independently lead to more functional impairment in axSpA over time. Contextual factors do not modify these relationships.

Changes in bone formation regulator biomarkers in early axial spondyloarthritis

OBJECTIVE

The hallmark of advanced axial SpA (axSpA) is spine ankylosis due to excessive ectopic bone formation. This prospective study aimed to describe the changes in serum levels of different regulators [sclerostin, dickkopf-1 (DKK-1)] and markers of bone formation [bone morphogenetic protein 7 (BMP-7)] over 5 years in early axSpA patients and to assess determinants of such changes.

METHODS

The DEvenir des Spondyloarthropathies Indifférenciées Récentes cohort is a prospective, multicentre French study of 708 patients with early (>3 months-<3 years) inflammatory back pain suggestive of axSpA. Serum levels of BMP-7, sclerostin and DKK-1 were assessed at baseline and after 2 and 5 years. Changes in bone formation regulators over time were analysed using mixed linear models.

RESULTS

Serum BMP-7 significantly increased over time, with a median relative change of 223.7% [interquartile range (IQR) 0-10 700 (0.17 pg/ml/month), P < 0.001]. Serum sclerostin significantly increased over time, with a median relative change of 14.8% [IQR -7.9-41.4% (0.001 ng/ml/month), P < 0.001]. Serum DKK-1 did not significantly change over time. Serum BMP-7 increased over time in active disease (Ankylosing Spondylitis Disease Activity Score with CRP ≥1.3, P = 0.01), but the increase was less pronounced with TNF inhibitor (TNFi) use (P < 0.001). No determinant was associated with serum sclerostin change.

CONCLUSION

Serum BMP-7 change over 5 years was related with inflammation; it was increased in active disease, but the increase was low with TNFi use. Serum sclerostin levels significantly increased over time, but to a lesser degree than for serum BMP-7.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/, NCT01648907.

Structural changes in the sacroiliac joint on MRI and relationship to ASDAS inactive disease in axial spondyloarthritis: a 2-year study comparing treatment with etanercept in EMBARK to a contemporary control cohort in DESIR

Background

Limited information is available on the impact of treatment with a tumor necrosis factor inhibitor (TNFi) on structural lesions in patients with recent-onset axial spondyloarthritis (axSpA). We compared 2-year structural lesion changes on magnetic resonance imaging (MRI) in the sacroiliac joints (SIJ) of patients with recent-onset axSpA receiving etanercept in a clinical trial (EMBARK) to similar patients not receiving biologics in a cohort study (DESIR). We also evaluated the relationship between the Ankylosing Spondylitis Disease Activity Score (ASDAS) and change in MRI structural parameters.

Methods

The difference between etanercept (EMBARK) and control (DESIR) in the net percentage of patients with structural lesion change was determined using the SpondyloArthritis Research Consortium of Canada SIJ Structural Score, with and without adjustment for baseline covariates. The relationship between sustained ASDAS inactive disease, defined as the presence of ASDAS < 1.3 for at least 2 consecutive time points 6 months apart, and structural lesion change was evaluated.

Results

This study included 163 patients from the EMBARK trial and 76 from DESIR. The net percentage of patients with erosion decrease was significantly greater for etanercept vs control: unadjusted: 23.9% vs 5.3%; P = 0.01, adjusted: 23.1% vs 2.9%; P = 0.01. For the patients attaining sustained ASDAS inactive disease on etanercept, erosion decrease was evident in significantly more than erosion increase: 34/104 (32.7%) vs 5/104 (4.8%); P < 0.001. A higher proportion had erosion decrease and backfill increase than patients in other ASDAS status categories. However, the trend across ASDAS categories was not significant and decrease in erosion was observed even in patients without a sustained ASDAS response.

Conclusions

These data show that a greater proportion of patients achieved regression of erosion with versus without etanercept. However, the link between achieving sustained ASDAS inactive disease and structural lesion change on MRI could not be clearly established.

Trial registration

EMBARK: ClinicalTrials.gov identifier: NCT01258738, Registered 13 December 2010; DESIR: ClinicalTrials.gov identifier: NCT01648907, Registered 24 July 2012.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02428-8.

Electroacupuncture Attenuates CFA-Induced Inflammatory Pain by Regulating CaMKII

Ca²⁺/calmodulin-dependent protein kinase II (CaMKII) is a multifunctional serine/threonine kinase that is ubiquitously distributed in the central and peripheral nervous systems. Moreover, its phosphorylated protein (P-CaMKII) is involved in memory, mood, and pain regulation in the anterior cingulate cortex (ACC). Electroacupuncture (EA) is a traditional Chinese therapeutic technique that can effectively treat chronic inflammatory pain. However, the CaMKII-GluA1 role in EA analgesia in the ACC remains unclear. This study investigated the role of P-CaMKII and P-GluA1 in a mouse model of inflammatory pain induced by complete Freund's adjuvant (CFA). There were increased P-CaMKII and P-GluA1 levels in the ACC. We found that intracerebroventricular injection of KN93, a CaMKII inhibitor, as well as EA stimulation, attenuated complete Freund's adjuvant-induced pain behavior. Further, EA increased pCaMKII-PICK1 complex (abbreviated as C-P complex) levels. Our findings demonstrate that EA inhibits inflammatory pain by inhibiting CaMKII-GluA1 phosphorylation. P-CaMKII is involved in EA analgesia as the pCaMKII-PICK1 complex.

Long-term association between disease activity and disability in early axial spondyloarthritis: results from the DESIR cohort

OBJECTIVES

Our primary objective was to study the long-term association between disease activity and disability in axial spondyloarthritis (axSpA). Our secondary objective was to define patient profiles according to their level of disability.

METHODS

We analysed data collected during the first five years of follow-up of a large early axSpA cohort - the Devenir des Spondylarthropathies Indifferénciées Récentes (DESIR) cohort. Multivariable models were built to study the association between Ankylosing Spondylitis Health Assessment Questionnaire (HAQ-AS) and Ankylosing Spondylitis Disease Activity Score C-reactive protein (ASDAS-CRP), adjusting for potential confounders. Hierarchical multivariable analysis was conducted using the Chi-square Automatic Interaction Detector (CHAID) method, to help determine how variables best cluster to explain HAQ-AS.

RESULTS

Data from 644 patients and 5152 visits were analysed. HAQ-AS was longitudinally, independently and positively associated with ASDAS-CRP [adjusted (adj) B=0.205, (95% confidence interval (CI)= 0.187 to 0.222], enthesitis score (adjB=0.011, CI=0.008 to 0.015), Bath Ankylosing Spondylitis Metrology Index (BASMI) (adjB=0.087, CI=0.069 to 0.105) and female gender (adjB=0.172, CI=0.120 to 0.225). The CHAID decision tree revealed ASDAS-CRP as the first variable with discriminative power on HAQ-AS. The cut-offs that separated different patient disability profiles were obtained.

CONCLUSION

Disease activity contributes longitudinally to disability and is hierarchically superior to any other variable in explaining this health domain. Enthesitis and spinal mobility are also key drivers of disability in early axSpA. ASDAS-CRP cut-offs that separated different patient disability profiles largely mimicked the cut-offs previously defined for ASDAS-CRP disease activity states.

Uveitis occurrence in early inflammatory back pain. Five years data from the prospective French nationwide DESIR cohort

OBJECTIVE

Uveitis is a frequent extra rheumatological manifestation in axial Spondyloarthritis (SpA). The aim of study was to evaluate the prevalence and incidence of uveitis over the first five years of a prospective nationwide cohort of patients with high suspicion of early axial SpA, and to evaluate its associated factors.

METHODS

DESIR is a prospective observational cohort of patients with recent onset inflammatory back pain (more than 3 months, less than 3 years), suggestive of axial SpA, All available factors in the database were compared between patients with and without uveitis at 5 years, by uni and then multivariate analysis. Baseline factors associated with new cases of uveitis occurrence over the 5 years were also analyzed.

SIGNIFICANCE

P less than 0.05.

RESULTS

After 5 years, 91 patients (out of 480 with complete follow-up) had at least one uveitis episode, giving an estimated prevalence of 18.9% [95% CI: 15.4-22.4]. In multivariate analysis, uveitis was significantly associated with dactylitis, and elevated ESR. New incident uveitis occurred in 31 cases over 5 years, giving an estimated incidence rate of 1.29 [0.84-1.74]/100 patient-years. Incidence of new uveitis was associated in multivariate analysis with baseline factors: diagnosis of SpA, sacro iliac MRI inflammatory SPARCC score, dactylitis, syndesmophyte score. No significant association was found with HLA-B27, DMARDs, BASDAI, ASDAS, BASFI.

CONCLUSION

Five-years data of the DESIR cohort allowed an estimation of incidence rate of uveitis of 1.3/100p-y; over five years, uveitis was associated with dactylitis, biologic and sacro iliac MRI inflammation.

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.

Inflammation of the Sacroiliac Joints and Spine and Structural Changes on Magnetic Resonance Imaging in Axial Spondyloarthritis: Five-year Data From the DESIR Cohort

OBJECTIVE

To test the impact of inflammation on structural changes occurring in the sacroiliac (SI) joints and the spine detected on magnetic resonance imaging (MRI).

METHODS

Patients with early axial spondyloarthritis (SpA) from the Devenir des Spondylarthropathies Indifferérenciées Récentes (DESIR) cohort were included. MRIs of the SI joints (MRI-SI joints) and spine (MRI-spine), obtained at baseline, 2 years, and 5 years, were scored by 3 central readers. Inflammation and structural damage on MRI-SI joints and MRI-spine were defined by the agreement of ≥2 of 3 readers (binary outcomes) and by the average of 3 readers (continuous outcomes). The effect of inflammation (MRI-SI joints/MRI-spine) on damage (MRI-SI joints/MRI-spine, respectively) was evaluated in 2 models: 1) a baseline prediction model (the effect of baseline inflammation on damage assessed at 5 years); and 2) a longitudinal model (the effect of inflammation on structural damage assessed during a 5-year period).

RESULTS

A total of 202 patients were included. Both the presence of bone marrow edema on MRI-SI joints and on MRI-spine at baseline were predictive of 5-year damage (≥3 fatty lesions) on MRI-SI joints (odds ratio [OR] 4.2 [95% confidence interval (95% CI) 2.4, 7.3]) and MRI-spine (OR 10.7 [95% CI 2.4, 49.0]), respectively, when adjusted for C-reactive protein level. The association was also confirmed in longitudinal models (when adjusted for Ankylosing Spondylitis Disease Activity Score) both in the SI joints (OR 5.1 [95% CI 2.7, 9.6]) and spine (OR 15.6 [95% CI 4.8, 50.3]). Analysis of other structural outcomes (i.e., erosions) on MRI-SI joints yielded similar results. In the spine, a significant association was found for fatty lesions but not for erosions and bone spurs, which occurred infrequently over time.

CONCLUSION

We found a predictive and longitudinal association between inflammation detected on MRI and several types of structural damage detected on MRI in patients with early axial SpA, which adds to the evidence for a causal relationship.

Pregnancy rates and outcomes in early axial spondyloarthritis: An analysis of the DESIR cohort

OBJECTIVES

Only scarce data is available regarding pregnancy outcomes in early axSpA, particularly little is known about the impact of disease activity. The objective is to identify (a) the factors associated with the occurrence of a clinical pregnancy during follow-up and (b) the risk factors for an unfavorable pregnancy outcome (e.g. miscarriage, medical termination or pre-term delivery) in an early axSpA population.

METHODS

Observational prospective French cohort (DESIR) with 6 years of follow-up including 381 TNFi-naïve women with early axSpA. Factors associated with a clinical pregnancy occurring over follow-up and risk factors for an unfavorable pregnancy outcome were estimated by multivariable multilevel models (i.e. Frailty Shared Models and Mixed Models).

RESULTS

During follow-up, 124 pregnancies occurred. Patients who got pregnant during follow-up were more likely to have discontinued their TNFi treatment in the 6 months preceding the pregnancy (HR=2.0 [95% CI 1.1-3.3], P=0.01) and to have an increased CRP at the previous visit (HR=1.7 [95% CI 1.2-2.5], P=0.01). Full-term delivery was by far the most frequent pregnancy outcome (75% of all pregnancies), and only NSAID use in the 6 months prior to the outcome was associated with an unfavorable outcome (OR=2.5 [95% CI 1.1-5.0], P=0.02). No association was found between TNFi use and an unfavorable pregnancy outcome.

CONCLUSION

Full-term delivery was the most frequent pregnancy outcome. NSAID use within 6 months of outcome, but not TNFi use, was associated with an unfavorable pregnancy outcome in this early axSpA cohort.

Measuring spinal mobility in early axial spondyloarthritis: does it matter?

OBJECTIVES

To investigate the frequency and order of impairment of spinal mobility measures (SMMs) and their cross-sectional and longitudinal usefulness in early axial spondyloarthritis.

METHODS

SMMs measurements of patients from the DESIR (5-year data) and SPACE (2.6 (1.9) years of follow-up) cohorts were analysed. Cross-sectional (group level) and longitudinal (individual level) analyses were performed comparing SMMs to pre-defined cut-offs derived from healthy individuals. Subgroup analyses were used to study patient and disease characteristics potentially influencing spinal mobility. Reliability was analysed using intraclass correlation coefficients and the smallest detectable change.

RESULTS

In 328 DESIR and 148 SPACE patients, lateral spinal flexion (LSF) and mSchober were the most impaired SMMs. If both (LSF and mSchober) were measured, 84% (DESIR) and 74% (SPACE) of the patients with impairment in ≥1 SMM would be captured. LSF and Bath AS Metrology Index best discriminated between subgroups of patients (higher impairment in patients ever treated with biologics, with higher disease activity and presence of baseline syndesmophytes): e.g. 31% of LSF impairment in patients with Ankylosing Spondylitis Disease Activity Score (ASDAS) < 2.1 in ≥2/3 visits vs 49% in those with ASDS ≥ 2.1. A high variability in SMMs within the same patient over time was observed, even when restricting the analysis to patients with low disease activity. Reliability of SMMs was 'fair' to 'good' (inter-reader intraclass correlation coefficients (2, 1): 0.55-0.84; intrareader intraclass correlation coefficients (2, 1): 0.49-0.72). Smallest detectable changes were in general high, e.g. 5.1 cm for LSF.

CONCLUSION

Cross-sectional use of SMMs, at the group level, is informative in patients with early axial spondyloarthritis. However, the high variation of SMMs over time impairs their use, at the individual patient level.

Clinical manifestations, disease activity and disease burden of radiographic versus non-radiographic axial spondyloarthritis over 5 years of follow-up in the DESIR cohort

Objectives

To compare the clinical manifestations, disease activity and disease burden between patients with radiographic (r-axSpA) and non-radiographic axial spondyloarthritis (nr-axSpA) over a 5-year follow-up period in the Devenir des Spondylarthropathies Indifferénciées Récentes (DESIR) cohort.

Methods

Patients from the DESIR cohort who had X-ray images of the sacroiliac joints available at baseline and did not leave the study during the 5-year follow-up period because of a diagnosis other than axSpA were included. A unilateral rating of ‘obvious sacroiliitis’ by the local reader was considered sufficient for classification as r-axSpA. The incidence of first episodes of peripheral and extra-rheumatic manifestations was compared between the two groups using the incidence rate ratio and Cox regressions adjusted for sex, age and tumour necrosis factor blocker (TNFb) intake. Mean values of patient-reported outcomes (PROs) and days of sick leave over 5 years of follow-up were compared using mixed models adjusted for sex, age, TNFb intake and baseline values.

Results

In total, 669 patients were included, of whom 185 (27.7%) and 484 (72.3%) were classified as r-axSpA and nr-axSpA, respectively. At baseline, the r-axSpA patients showed a significantly higher prevalence of males. After adjusting for age, sex and TNFb intake, Cox regressions for peripheral and extra-rheumatic manifestations did not show any significant differences between groups. Mixed models also showed similar mean levels in PROs and days of sick leave between groups over time.

Conclusion

The incidence of peripheral and extra-rheumatic manifestations as well as the disease burden over time remained similar between r-axSpA and nr-axSpA groups after adjusting for intermediate variables.

Trial registration number

NCT01648907

Spinal Radiographic Progression in Early Axial Spondyloarthritis: Five-Year Results From the DESIR Cohort

OBJECTIVE

To analyze the progression of spinal radiographic damage in patients with early axial spondyloarthritis (SpA).

METHODS

Axial SpA patients from the DESIR (Devenir des Spondylarthropathies Indifférenciées Récentes) cohort with 5-year spinal (cervical and lumbar) radiographs available (n = 549) were included. Two- and 5-year modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) progression and development of new syndesmophytes (net change: the number of patients with positive change minus the number of patients with negative change divided by the total number of patients) were assessed in subgroups defined at baseline according to the Assessment of SpondyloArthritis international Society axial SpA criteria and its arms, modified New York criteria (mNYC) and the presence of syndesmophytes.

RESULTS

Mean ± SD mSASSS progression was 0.2 ± 0.9 at 2 years and 0.4 ± 1.8 at 5 years. Five-year progression was higher in the imaging arm (mean ± SD 0.6 ± 2.3), magnetic resonance imaging (MRI)+/mNYC+ (mean ± SD 1.3 ± 4.0), than in the clinical arm only (mean ± SD 0.1 ± 0.7), and highest in patients with syndesmophytes (mean ± SD 2.7 ± 5.0). At 5 years, 7% of all patients had a net change of any new syndesmophyte; this value was 10% for the imaging arm (mNYC+/MRI+ with 18%), 17% for mNYC+ patients, and 42% for patients with syndesmophytes.

CONCLUSION

Spinal radiographic progression, although limited in early axial SpA, can be captured after 2 years. Inflammation and damage in the sacroiliac joint are associated with higher radiographic progression. The presence of baseline syndesmophytes already strongly predicts the development of further structural damage early in the disease.

Baseline MRI inflammation is not a determinant of 5-year bone mineral density loss in patients with early spondyloarthritis

OBJECTIVE

The aim of this study was to assess the effect of baseline inflammation on Magnetic Resonance Imaging (MRI) on the change in Bone Mineral Density (BMD) over 5 years in patients with early spondyloarthritis (SpA).

METHODS

From the patients of the DESIR cohort (an early axial SpA cohort), patients with BMD data at both baseline and 5 years, and baseline spine and sacroiliac joints MRI were included. Inflammation was assessed with the SpondyloArthritis Research Consortium of Canada (SPARCC) spine score. Significant BMD loss was defined by a change of >0.03g/cm². No patients had received TNF blockers before inclusion in the cohort. Univariate and multivariable prognostic analyses were performed. An inverse propensity score weighting method was used to handle confounders.

RESULTS

One hundred and eighty-three patients were included (mean age 33.9±8.7 years, 58.5% men). A significant bone loss was reported in 51% (n=92) of patients at either lumbar spine or hip. Fourteen (7%) patients had low BMD (Z-score <-2) at the end of the follow-up vs. 28 (15%) at baseline. In multivariable analysis, age was a protective factor of 5 year-BMD loss at any site (OR=0.96, 95% CI [0.93-0.99]). Baseline MRI inflammation has no significant effect on BMD change at any site (OR=0.84, 95% CI [0.46-1.53]).

CONCLUSION

Half of patients with early SpA have a significant bone loss at either lumbar spine or hip over 5 years. Baseline MRI inflammation is not a determinant of this bone loss.

Treat to Target in Axial Spondyloarthritis

This article discusses treat-to-target strategies in axial spondyloarthritis and current status. Treatment ranging from nonsteroidal anti-inflammatory drugs to biologic and other disease-modifying drugs is discussed in the context of treat-to-target. The article explores evidence from landmark randomized, controlled trials and observational studies focusing on both radiographic and nonradiographic axial spondyloarthritis. The feasibility of treat-to-target, as well as predictors of remission are addressed in line with existing evidence. Finally, issues around management principles and challenges, as well as unmet need in the field, are highlighted.

Associations of lumbar scoliosis with presentation of suspected early axial spondyloarthritis

OBJECTIVE

Scoliosis may impact the mechanical loading and cause secondary changes of the sacroiliac joints and lumbar spine. Our goal was to look how lumbar scoliosis modify the clinical and imaging-study in patients with recent-onset inflammatory back pain (IBP) suggesting axial spondyloarthritis (axSpA).

METHODS

Baseline weight-bearing lumbar-spine radiographs obtained in the DESIR cohort of patients aged 18-50 years and having IBP for at least 3 months but less than 3 years suggesting axSpA were studied. After training on scoliosis detection based on Cobb's angle>10° plus Nash-Moe grade≥1, readers blinded to patient data measured spine lumbar scoliosis, sacral horizontal angle, lumbosacral angle and lumbar lordosis on the radiograph of the lumbar and scored sacroiliitis on the radiograph of the pelvis. Baseline MRIs T1 and STIR of the lumbar spine and sacroiliac joints were evaluated for respectively degenerative changes and signs of axSpA.

RESULTS

Of the 360 patients (50.8% females) 88.7% had lumbar pain and 69.3% met ASAS criteria for axSpA. Mean Cobb's angle was 3.2°±5.0° and 28 (7.7%) patients had lumbar scoliosis. No statistical differences were observed for radiographic sacroiliitis, MRI sacroiliitis, modified Stoke Ankylosing Spondylitis Spinal Score, Pfirmmann score, high-intensity zone, protrusion, extrusion, MODIC score between patients with and without scoliosis. In both groups, degenerative changes by MRI were rare and predominated at L4-L5 and L5-S1.

CONCLUSION

In patients with early IBP suggesting axSpA, lumbar scoliosis was not associated with inflammatory or degenerative changes.

Evaluation of concomitant peripheral arthritis in patients with recent onset axial spondyloarthritis: 5-year results from the DESIR cohort

BACKGROUND

(a) To describe the prevalence and incidence of peripheral arthritis during 5 years of follow-up in recent axial spondyloarthritis (axSpA), (b) to evaluate factors associated with their appearance and (c) to assess their impact on treatment, patient-reported outcomes and sick leave after follow-up.

METHODS

Data from the early axSpA patients from the DESIR cohort (first 5 years of follow-up) were analysed. Prevalence and incidence of peripheral arthritis at each study visit were calculated. A multivariate analysis was performed to evaluate baseline factors associated with the development of the arthritis. The use of drugs, the impact on patient-reported outcomes and days of sick leave were compared in both groups over time.

RESULTS

Out of the 708 patients included in DESIR, 255 (36.0%) showed at least one episode of arthritis (151 before the inclusion visit and 104 during the follow-up), with an incidence of 3.7 cases per 100 person-years. Patients with peripheral arthritis were more likely (OR, 95%CI) to be aged ≥ 33 years (1.60, 1.12-2.27), non-smokers (1.58, 1.10-2.27) and HLAB27 negative (1.47, 1.04-2.08) and have presented with at least one episode of dactylitis (8.50, 4.96-14.60) and enthesitis (2.00, 1.41-2.84). Patients with peripheral arthritis showed a significant greater use of TNFb, csDMARDs and corticosteroids over follow-up; higher levels on BASDAI (40.46 vs. 34.28) and BASFI (27.89 vs. 22.52); poorer quality of life; and higher number of days of sick leave (17.97 vs. 12.78) over time.

CONCLUSION

In recent axSpA, 36% of patients reported peripheral arthritis at any time of the disease, being associated with negative HLAB27, non-smokers and with other peripheral manifestations. Patients with arthritis showed a higher burden of disease.

Effect of Gut Involvement in Patients with High Probability of Early Spondyloarthritis: Data from the DESIR Cohort

OBJECTIVE

Inflammatory bowel disease (IBD) is a well-known extraarticular feature of spondyloarthritis (SpA). The aims of this study were to evaluate factors associated with IBD and incidence over 5 years of followup in the DESIR cohort.

METHODS

DESIR is a prospective observational cohort of patients with recent-onset inflammatory back pain suggestive of axial SpA. All available variables in the database were compared between patients with and without IBD at baseline and 5 years, and occurrence over 5 years of followup, with uni- and then multivariable analysis.

RESULTS

At baseline, of 708 patients, 35 had IBD (prevalence 4.94%, CI 95% 3.3-6.5). IBD was associated (multivariable) with history of uveitis, levels of Dickkopf-1, and tumor necrosis factor, but not with phenotypic presentation (peripheral arthritis, enthesitis, dactylitis, uveitis) or baseline serum levels of other cytokines. At 5 years, 480 patients were analyzed, 58 with IBD. IBD was associated (multivariable) with fulfillment of modified New York criteria, sick leave, Bath Ankylosing Spondylitis Disease Activity Index, and smoking. There was no association with magnetic resonance imaging scores, enthesitis, psoriasis, and bone mineral density. Twenty-three incident cases of IBD were recorded: estimated occurrence rate of 0.95/100 (95% CI 0.57-1.35) patient-years (PY). Incidence of IBD is associated (multivariable) with HLA-B27 (OR 0.36, 95% CI 0.22-0.59), fulfillment of modified New York criteria (OR 3.35, 95% CI 1.85-6.08), and familial history of IBD (OR 3.31, 95% CI 1.62-6.77).

CONCLUSION

In early SpA, IBD occurs with an incidence of 1/100 PY, and is associated with poor outcome, familial history of IBD, absence of HLA-B27, and fulfillment of modified New York criteria.

Evaluation of the performances of 'typical' imaging abnormalities of axial spondyloarthritis: results of the cross-sectional ILOS-DESIR study

Objective

To evaluate the prevalence and performance as axial Spondyloarthritis (axSpA) diagnostic feature of radiographic and MRI lesions 'typical' of axSpA of the sacroiliac joint (SIJ) and spine in a mechanical chronic back pain (CBP) population and in an axSpA cohort.

Methods

Cross-sectional multicentre study. Patients: (1) recent onset axSpA (DESIR cohort) and (2) mechanical non-axSpA CBP matched for age and gender (ILOS study). Imaging: radiographs and MR scans were performed identically in both groups. All images were centrally read, blinded for diagnosis and for other imaging findings in the same patient. Statistical analysis: prevalence of lesions 'typical of axSpA' were compared in both groups. Sensitivity, specificity and positive likelihood ratios (LR+) of each lesion (and combination of lesions) were calculated.

Results

A total of 98 patients with CBP were included, and compared with 100 patients with recent onset axSpA. SIJ lesions were consistently more frequent in the axSpA group (35.0% vs 11.8% p<0.001, 35.0% vs 8.4% p<0.001% and 32.0% vs 10.0%. p<0.001 for modified New York criteria, MRI sacroiliitis and ≥3 erosions of the SIJ on MRI, respectively), and performed well (LR+ for ≥3 erosions 3.0 (95% CI 1.6 to 5.8)). Spine lesions were comparable across groups: radiographic lesions were rare, while all MRI lesions were frequent.

Conclusion

Our study confirms that 'typical' lesions can also be observed in patients with non-axSpA CBP but that SIJ lesions by all modalities remain the most valuable for diagnosis, including structural lesions of the SIJ. This suggests the potential interest of adding MRI SIJ structural lesions in the definition of MRI abnormalities for axSpA classification.

Which scoring method depicts spinal radiographic damage in early axial spondyloarthritis best? Five-year results from the DESIR cohort

Objective

To compare the performance of different spinal radiographic damage scoring methods in patients with early axial spondyloarthritis (axSpA).

Methods

Five-year spinal radiographs from the DESIR cohort were scored by three readers (averaged) for the calculation of the Stoke AS Spine Score (SASSS), modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), Radiographic AS Spinal Score (RASSS), BASRI-spine and BASRI-total, and following the OMERACT filter, scores were compared according to truth, discrimination (reliability and sensitivity to change) and feasibility. The proportion of patients with a net change > smallest detectable change and >1 was calculated. The proportion of total variance explained by the patient (true variance) was calculated for the change scores as a measure of reliability, using analysis of variance.

Results

In total 699 patients were included. Five-year net changes > smallest detectable change (>1) were: RASSS 17% (17%), mSASSS 12% (12%), BASRI-spine and BASRI-total 12% (9%), SASSS 11% (11%). The mSASSS and the RASSS performed the best in terms of capturing the signal (positive change) related to noise (negative change). The proportion of variance explained by the patient was highest for the mSASSS and RASSS (85% for both 5-year progression scores vs 50-55% for other methods). The proportion of patient variance in the thoracic segment of the RASSS was unsatisfactory (46% for progression).

Conclusion

The existing scoring methods to assess spinal radiographic damage performed well in early phases of axSpA. The mSASSS and RASSS captured most change. There was no clear gain in additionally scoring the thoracic spine for the RASSS. The mSASSS remains the most sensitive and valid scoring method in axSpA, including early phases of the disease.

A Review on the Effect of Tumor Necrosis Factor Inhibitors on Structural Progression in Early Axial Spondyloarthritis Using Magnetic Resonance Imaging

INTRODUCTION

Considering the progressive nature of axial spondyloarthritis (axSpA), it is important to determine whether tumor necrosis factor alpha (TNFα) inhibitors have an effect on early inflammatory and structural lesions detected using magnetic resonance imaging (MRI).

METHODS

A search of MEDLINE/PubMed for full-text, English-language articles on randomized controlled trials (RCTs) of adalimumab, certolizumab, etanercept, golimumab, or infliximab published since January 2007 was conducted in February 2018 and again in December 2018. The collected articles reported on inflammatory or fatty lesion progression in the spine or sacroiliac joint (SIJ), determined using MRI, in a population that included at least 40% of patients with early axSpA, defined as non-radiographic axSpA.

RESULTS

Of the 105 articles retrieved, 19 were included in this review, of which the majority were on etanercept (n = 11). A majority of selected articles included information on inflammatory lesions (SIJ 15/19; spine 12/19). All five TNFα inhibitors showed benefits on inflammation, assessed by MRI, in patients with early axSpA for up to 204 weeks of treatment. Structural progression in SIJ and the spine was assessed in 6/19 and 3/19 articles, respectively, with mixed evidence on benefits of TNF-inhibitor treatment.

CONCLUSIONS

In conclusion, treatment with TNFα inhibitors reduces MRI-evident inflammatory lesions in the SIJ and spine of patients with early axSpA for up to 4 years. There is less evidence of benefits on structural lesions. Additional studies are required to determine whether TNFα-inhibitor therapy can limit or delay radiological progression in patients with early axSpA.

FUNDING

Pfizer.