Evaluation and Management of the Patient With Suspected Inflammatory Spine Disease

Inflammatory activity evaluation in patients with axial spondyloarthritis using MRI relaxometry and mucosal-associated invariant T cells

Background

Currently, there is a lack of an objective quantitative measure to comprehensively evaluate the inflammatory activity of axSpA, which poses certain challenges in accurately assessing the disease activity.

Objective

To explore the value of combined-parameter models of sacroiliac joints (SIJs) MRI relaxometry and peripheral blood Mucosal-associated invariant T (MAIT) cells in evaluating the inflammatory activity of axial spondyloarthritis (axSpA).

Methods

This retrospective clinical study included 88 axSpA patients (median age 31.0 (22.0, 41.8) years, 21.6% females) and 20 controls (median age 28.0 (20.5, 49.5) years, 40.0% females). The axSpA group was classified into active subgroup (n=50) and inactive subgroup (n=38) based on ASDAS-CRP. All participants underwent SIJs MRI examination including T1 and T2* mapping, and peripheral blood flow cytometry analysis of MAIT cells (defined as CD3+Vα7.2+CD161+) and their activation markers (CD69). The T1 and T2* values, as were the percentages of MAIT cells and CD69+MAIT cells were compared between different groups. Combined-parameter models were established using logistic regression, and ROC curves were employed to evaluate the diagnostic efficacy.

Results

The T1 values of SIJs and %CD69+MAIT cells in the axSpA group and its subgroup were higher than the control group (p<0.05), while %MAIT cells were lower than the control group (p<0.05). The T1 values and %CD69+MAIT cells correlated positively, while %MAIT cells correlated negatively, with the ASDAS-CRP (r=0.555, 0.524, -0.357, p<0.001). Between the control and axSpA groups, and between the inactive and active subgroups, the combined-parameter model T1 mapping+%CD69+MAIT cells has the best efficacy (AUC=0.959, 0.879, sensibility=88.6, 70%, specificity=95.0, 94.7%, respectively).

Conclusion

The combined-parameter model T1 mapping+%CD69+MAIT cells allows a more accurate evaluation of the level of inflammatory activity.

A UK survey evaluation of First Contact Practitioners' and musculoskeletal physiotherapists' confidence, recognition, and referral of suspected axial spondyloarthritis

BACKGROUND

Axial Spondyloarthritis is an inflammatory disease associated with significant diagnostic delays. Steen et al. (2021) found inadequate consideration of axial Spondyloarthritis (axSpA) in physiotherapists back pain assessments. Since the previous survey, increased professional education on axSpA has occurred and First Contact Practitioners (FCPs), now widely established in General Practice, are key in supporting earlier recognition.

OBJECTIVES

(1) To re-evaluate physiotherapists' and evaluate FCPs' awareness, knowledge, and confidence in screening for and recognising features of axSpA and criteria prompting referral to rheumatology. (2) To compare these results to previous research (Steen et al., 2021).

DESIGN

As per Steen et al. (2021), an online survey was undertaken combining back pain vignettes (reflecting axSpA, non-specific low back pain [NSLBP] and radicular syndrome) and questioning on features of suspected axSpA.

RESULTS

165 surveys were analysed. Only 73% (n = 120/165) of respondents recognised the axSpA vignette compared to NSLBP 91% (n = 80/88) and radicular syndrome 88% (n = 68/77). An improvement in axSpA recognition was demonstrated compared with previous data. FCPs performed slightly better with 77% (n = 67/87) of respondents recognising the axSpA vignette. Adequate awareness of national referral guidance was evident in only 55% of 'clinical reasoning' and 6% of 'further subjective screening' responses. There was still misplaced confidence in recognising clinical features of axSpA compared to knowledge levels shown, including high importance given to inflammatory markers.

CONCLUSION(S)

Musculoskeletal physiotherapists demonstrate some improved knowledge and awareness of axSpA compared with previous study findings. Consideration of axSpA is still not universal in musculoskeletal physiotherapists' or FCPs' approaches to persistent back pain assessments and awareness of national referral guidance remains limited. This study highlights the continued need for professional education. Enhanced knowledge of screening and referral criteria in musculoskeletal clinical practice would support earlier diagnosis and better outcomes.

Role of advanced MRI techniques for sacroiliitis assessment and quantification

The introduction of MRI was supposed to be a qualitative leap for the evaluation of Sacroiliac Joint (SIJ) in patients with Axial Spondyloarthropathies (AS). In fact, MRI findings such as bone marrow edema around the SIJ has been incorporated into the Assessment in SpondyloArthritis International Society (ASAS criteria). However, in the era of functional imaging, a qualitative approach to SIJ by means of conventional MRI seems insufficient. Advanced MRI sequences, which have successfully been applied in other anatomical areas, are demonstrating their potential utility for a more precise assessment of SIJ. Dixon sequences, T2-mapping, Diffusion Weighted Imaging or DCE-MRI can be properly acquired in the SIJ with promising and robust results. The main advantage of these sequences resides in their capability to provide quantifiable parameters that can be used for diagnosis of AS, surveillance or treatment follow-up. Further studies are needed to determine if these parameters can also be integrated into ASAS criteria for reaching a more precise classification of AS based not only on visual assessment of SIJ but also on measurable data.

Awareness and knowledge of the common features of inflammatory back pain among primary care physicians in the western region of Saudi Arabia

Often, there is a delay in the diagnosis of inflammatory back pain (IBP) in the primary care setting. This may be attributed to the inability of healthcare providers to distinguish between inflammatory and mechanical back pain. This study aimed to evaluate primary care physicians' current practices for assessing patients with IBP using clinical, radiographic, and laboratory tests. A questionnaire-based survey was emailed to all primary care physicians in the western region of Saudi Arabia by the Saudi Commission of Health Specialists from February to May 2021. The questionnaire included data about axial spondyloarthropathy based on the Calin, Berlin, and European Spondyloarthropathy Study Group criteria. A total of 103 primary care physicians responded who represented around 24% of primary care physicians at primary healthcare. The most often perceived IBP symptoms include a response to NSAIDs, morning stiffness lasting >30 minutes, age of onset <45 years old, duration of back pain >3 months, and improvement with exercise. The most frequently questioned patient or family history conditions were peripheral arthritis (92.2%), family history of spondyloarthritis (83.5%), and inflammatory bowel disease (97.6%). The most-reported investigations were CRP/ESR (86.4%) and spinal radiography (66%). For treatment of IBP, NSAIDs were most prescribed (48.6%), followed by physiotherapy (45.6%) and disease-modifying anti-rheumatic drugs (41.7%). Primary care physicians were more confident in management of mechanical back pain than IBP (P < .001). Primary care physicians have good knowledge of IBP symptoms but not of disease-specific features and modest confidence in evaluating patients with IBP, indicating the need for educational programs and a more effective, feasible referral strategy.

The Journey to Diagnose Spondyloarthritis in Patients From Riyadh: A Cross-Sectional Study

Introduction  Ankylosing spondylitis, now frequently referred to as spondyloarthritis (SpA), is a chronic inflammatory disease causing axial arthritis and inflammatory lower back pain resulting in the eventual impairment of spinal mobility. Moreover, its systemic complications include stiffness and inflexibility, restriction of lung capacity and function, eye inflammation, compression spinal fractures, and heart problems. Hence, early diagnosis and intervention play a key role in preventing acute complications and improving the quality of life. Objective  We aimed to estimate the average duration of diagnosis, the average number of doctors visited, and the association between the specialty of the first physician and the length of SpA diagnosis delay. Methods A cross-sectional retrospective study was conducted from November 2019 to April 2020 with patients from King Khalid University Hospital, Riyadh, Saudi Arabia. The patients were 18 years and older and diagnosed with SpA. Call interviews were conducted and patients' medical charts were reviewed. The data were analyzed using the Statistical Package for Social Sciences statistical software, version 23 (IBM Corp., Armonk, NY). Result  The total sample was 101 patients: 59 (58.4%) males and 42 (41.6%) females. The average duration from the onset of symptoms until seeking medical advice (lag 1) and from seeking medical advice until the definite diagnosis (lag 2) was 24.74 ± 48.13 and 16.16 ± 34.62 months, respectively. The average number of doctors visited between the first medical encounter and the final diagnosis was 3.56 ± 5.3. Patients who consulted rheumatologists as the first medical encounter showed less delay in diagnosis compared to patients who sought non-rheumatologists, such as orthopedists, emergency physicians, and general physicians (11.81 ± 33.35 months vs. 26.63 ± 44.28, 26.96 ± 44.88, and 44.33 ± 65.75 months, respectively). Conclusion  Patients with SpA who were not seen by rheumatologists took a longer period till the final diagnosis than those who visited rheumatologists earlier in the course of the disease. Therefore, more studies are required to define the exact factors leading to the delay.

Does Gender Impact a Diagnosis of Ankylosing Spondylitis?

Objective

The study objective was to explore differences in ankylosing spondylitis (AS) diagnosis experiences between men and women by examining the coding of health events over the 2 years preceding AS diagnosis.

Methods

Claims data (January 2006–April 2019) from the MarketScan databases were examined. Patients who had received two or more AS diagnoses at least 30 days apart and had at least 2 years of insurance enrollment before their first AS diagnosis were analyzed. Men were matched 1:1 to women by age, diagnosis date, insurance type, and enrollment duration. Health events (diagnosis and provider codes) were examined over 2 years before AS diagnosis and stratified by gender. Data were analyzed using univariate χ² tests.

Results

Among 7744 patients, 274 of 1906 AS‐related codes showed statistically significant differences between men and women. Women received more diagnosis codes than men across diagnoses and providers; the largest difference in diagnosis codes among women versus men was in peripheral symptom coding (57.7% vs. 43.9%, respectively). More women than men received diagnosis codes for depression (21.2% vs. 9.8%) and other musculoskeletal symptoms (52.8% vs. 40.0%); only gout was more common in men (6.5%) than in women (2.2%). Among men, backache codes gradually increased 12 months before AS diagnosis, whereas axial and sacroiliitis coding increased sharply immediately before diagnosis. The greatest difference in physician types visited was for rheumatologists: 64.2% of women had visits compared with 45.1% of men.

Conclusion

Further investigation into the dissimilarities in diagnostic experiences between men and women is needed to determine whether differences are due to disease phenotype or potential cognitive bias influencing diagnostic decision‐making.

Axial Spondyloarthritis in the Chiropractic Care Setting: A Systematic Literature Review

ABSTRACT

Diagnosis of axial spondyloarthritis (axSpA), an immune-mediated inflammatory disease, is commonly associated with chronic inflammatory back pain (IBP) and often occurs years after initial onset of clinical symptoms. Recognition of IBP is important for timely referral of patients with suspected axSpA to a rheumatologist. Patients with all types of back pain are treated in chiropractic care, but the proportion of patients with undiagnosed axSpA is unknown. This systematic literature review investigated the presence of axSpA in patients treated by chiropractors and identified the chiropractor's role in axSpA diagnosis, referral, and management. A PubMed search was conducted using the following search strings: "chiropract*" AND ("sacroiliac" OR "back pain" OR "spondyloarthritis" OR "ankylosing spondylitis"); English language, since 2009; and (chiropractic OR chiropractor) AND (ankylosing spondylitis OR axial spondyloarthritis), with no date limits. Of 652 articles identified in the searches, 27 met the inclusion criteria. Although back pain was identified as a common reason for patients seeking chiropractic care, there was no mention of axSpA, ankylosing spondylitis, or the distinction between mechanical and IBP. Data from relevant articles suggested that the majority of patients seeking chiropractic care have lower back pain, whereas no articles reported axSpA in this patient population. The near absence of any identified articles on axSpA in chiropractic care may be due to underrecognition of axSpA, resulting in delayed rheumatology referral and appropriate management. Better awareness and increased use of validated screening tools could reduce diagnostic delay of axSpA in chiropractic care.

Improved Performance of Compartments in Detecting the Activity of Axial Spondyloarthritis Based on IVIM DWI with Optimized Threshold b Value

Purpose

To explore the diagnostic performance of the optimized threshold b values on IVIM to detect the activity in axial spondyloarthritis (axSpA) patients.

Method

40 axSpA patients in the active group, 144 axSpA patients in the inactive group, and 20 healthy volunteers were used to evaluate the tissue diffusion coefficient (D_slow), perfusion fraction (f), and pseudodiffusion coefficient (D_fast) with b thresholds of 10, 20, and 30 s/mm². The Kruskal-Wallis test and one way ANOVA test was used to compare the different activity among the three groups in axSpA patients, and receiver operating characteristic (ROC) curve analysis was applied to evaluate the performance for D_slow, f, and D_fast to detect the activity in axSpA patients, respectively.

Results

D_slow demonstrated a statistical difference between two groups (P < 0.05) with all threshold b values. With the threshold b value of 30 s/mm², f could discriminate the active from control groups (P < 0.05). D_slow had similar performance between the active and the inactive groups with threshold b values of 10, 20, and 30 s/mm² (AUC: 0.877, 0.882, and 0.881, respectively, all P < 0.017). Using the optimized threshold b value of 30 s/mm², f showed the best performance to separate the active from the inactive and the control groups with AUC of 0.613 and 0.738 (both P < 0.017) among all threshold b values.

Conclusion

D_slow and f exhibited increased diagnostic performance using the optimized threshold b value of 30 s/mm² compared with 10 and 20 s/mm², whereas D_fast did not.

Expert recommendations on early diagnosis and referral of axial spondyloarthritis in the Kingdom of Saudi Arabia

Axial spondyloarthritis is a chronic inflammatory disorder that primarily involves the axial skeleton (sacroiliac joints and spine), causing stiffness, severe pain and fatigue. In some patients, definitive structural damage of sacroiliac joints is visible on imaging and is known as radiographic axial spondyloarthritis. Some patients do not have a clear radiographic damage of the sacroiliac joints, and this subtype is known as non-radiographic axial spondyloarthritis. Early diagnosis is important for reducing the risk of irreversible structural damage and disability. Management of axial spondyloarthritis is challenging in Saudi Arabia because of inadequate disease knowledge and the unavailability of local guidelines. Therefore, this expert consensus is intended to provide recommendations, including the referral pathway, the definition of remission and the treat-to-target approach, to all healthcare professionals for the management of patients with axial spondyloarthritis. A Delphi technique of consensus was developed by involving an expert panel of 10 rheumatologists, 1 dermatologist and 1 general physician. The experts offered consensus-based recommendations based on a review of available scientific evidence and clinical experience for the referral, screening and management of patients with axial spondyloarthritis.

A Road Map of the Axial Spondyloarthritis Continuum

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

Patient Perspectives on Biologics for Axial Spondyloarthritis in a Cross-sectional Study in a Predominantly Female Population: Treatment Satisfaction, Wear-off Between Doses, and Use of Supplemental Medication

Introduction

There is limited information regarding treatment experience of patients with axial spondyloarthritis/ankylosing spondylitis (axSpA/AS) receiving biological disease-modifying antirheumatic drugs (bDMARDs). Here we characterize patient experiences and perspectives, including satisfaction among those currently treated with bDMARD therapy for axSpA/AS. We also assess the use of supplemental medication during perceived wear-off between doses.

Methods

Adult participants from the United States within the ArthritisPower registry with physician-diagnosed axSpA/AS were invited to complete electronic patient-reported outcome measures and an online survey about their perspectives of treatment. Analysis compared patient characteristics and treatment satisfaction by whether wear-off in axSpA/AS between bDMARD doses was reported.

Results

Of 128 patients currently taking a DMARD, the mean age was 46.9 (10.3) years, 82.0% were female, and 93.8% were White. A total of 78 (60.9%) perceived wear-off with their current bDMARD before the next dose, 19 (14.8%) did not experience wear-off and 31 (24.2%) were unsure about wear-off. Mean (standard deviation [SD]) Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score indicated poor disease control in all patients receiving bDMARDs (6.4 [1.8]); worse for those perceiving wear-off between doses versus those who did not perceive wear-off or were unsure (6.8 [1.6] vs. 5.9 [2.0], p = 0.011). Patients experiencing wear-off reported being ‘very satisfied’ or ‘somewhat satisfied’ with their treatment less frequently than patients without wear-off (73.1 vs. 89.5%, respectively). Of patients reporting wear-off, 82.1% (n = 64) used supplemental medications during wear-off (non-steroidal anti-inflammatory drugs [68.8%, n = 44], muscle relaxants [42.2%, n = 27], and/or opioids [37.5%, n = 24]).

Conclusions

In a predominantly female sample of bDMARD-treated patients with axSpA/AS and high disease activity, the majority expressed treatment satisfaction. However, most experienced wear-off between doses and relied on supplemental medications, including opioids, to manage symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00417-6.

Patient perspectives on health care provider practices leading to an axial spondyloarthritis diagnosis: an exploratory qualitative research study

BACKGROUND

The average time to a diagnosis for people with axial spondyloarthritis (axSpA) is 7-10 years. Delayed diagnosis may result in increased structural damage, worse physical function, and worse quality of life relative to patients with a timely axSpA diagnosis. Understanding patient experiences may provide insights for how to reduce diagnostic delays.

OBJECTIVE

To provide foundational knowledge about patient experiences with healthcare providers leading to an axSpA diagnosis.

METHODS

We conducted an exploratory qualitative research study with six focus groups interviews with participants recruited from three rheumatology clinics within the United States (MA (n = 3); CO (n = 2); PA (n = 1)) that included a total of 26 adults (10 females, 16 males) with rheumatologist confirmed diagnosis of axSpA in 2019. Focus groups were ~ 2 h, audio recorded, transcribed, and subject to dual coding. The codes reviewed were in relation to the patients' diagnostic experiences.

RESULTS

Patients described frustrating and lengthy diagnostic journeys. They recognized that the causes of diagnostic delays in axSpA are multifactorial (e.g., no definitive diagnostic test, disease characteristics, lack of primary care provider's awareness about axSpA, trust). Patients described how doctors minimized or dismissed complaints about symptoms or told them that their issues were psychosomatic. Patients believed the healthcare system contributed to diagnostic delays (e.g., lack of time in clinical visits, difficulty accessing rheumatologists, health insurance challenges). Advice to physicians to reduce the diagnostic delay included allowing time for patients to give a complete picture of their illness experience, listening to, and believing patients, earlier referral to rheumatology, provision of HLA-B27 gene testing, and that physicians need to partner with their patients.

CONCLUSIONS

Patients desire a definitive test that could be administered earlier in the course of axSpA. Until such a test is available, patients want clinicians who listen to, believe, and partner with them, and who will follow them until a diagnosis is reached. Educating primary care clinicians about guidelines and referral for diagnosis of axSpA could reduce diagnostic delay.

Physiotherapists' awareness, knowledge and confidence in screening and referral of suspected axial spondyloarthritis: A survey of UK clinical practice

BACKGROUND

Axial spondyloarthritis (axSpA) is an inflammatory disease associated with significant diagnostic delays and is commonly missed in assessments of persistent back pain.

OBJECTIVE

To explore musculoskeletal physiotherapists' awareness, knowledge and confidence in screening for signs, symptoms and risk factors of suspected axSpA and criteria for rheumatology referral.

DESIGN

An online UK survey was undertaken combining back pain vignettes (reflecting axSpA, non-specific back pain and radicular syndrome) and questioning on features of suspected axSpA. Recruitment utilised online professional forums and social media. Data analysis included descriptive statistics and conceptual content analysis for free text responses.

RESULTS

132 survey responses were analysed. Only 67% (88/132) of respondents identified inflammatory pathologies as a possible cause of persistent back pain. Only 60% (79/132) recognised the axSpA vignette compared to non-specific low back pain (94%) and radicular syndrome (80%). Most suspecting axSpA would refer for specialist assessment (77/79; 92%). Awareness of national referral guidance was evident in only 50% of 'clinical reasoning' and 20% of 'further subjective screening' responses. There was misplaced confidence in recognising clinical features of axSpA (≥7/10) compared to knowledge levels shown, including high importance given to inflammatory markers and human leucocyte antigen B27 (median = 8/10).

CONCLUSIONS

Musculoskeletal physiotherapists may not be giving adequate consideration to axSpA in back pain assessments. Awareness of national referral guidance was also limited. Professional education on screening and referral for suspected axSpA is needed to make axSpA screening and referral criteria core knowledge in musculoskeletal clinical practice, supporting earlier diagnosis and better outcomes.

Exploring the Prevalence and Factors Associated With Fatigue in Axial Spondyloarthritis in an Asian Cohort in Singapore

Aim: To evaluate the prevalence of fatigue and the factors associated with fatigue among patients with axial spondyloarthritis (axSpA) within an Asian population.

Method: We used the baseline data from a clinic registry in a tertiary referral center. All patients fulfilled the 2009 Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axSpA. Severe fatigue was defined as Bath Ankylosing Spondylitis Disease Activity Index-fatigue (BASDAI-fatigue) ≥5/10 and vitality domain of Short Form-36 Health Survey (SF-36 VT) ≤10th percentile of the general population.

Results: We included 262 consecutive patients with axSpA (79% men, 82.4% Chinese). The mean (standard deviation, SD) age and duration of disease were 41.7 (13.7) and 10.1 (8.3) years, respectively. 145 (55.3%) and 52 (31.1%) patients reported severe fatigue by the BASDAI-fatigue and SF-36 VT criteria, respectively. Patients with severe fatigue had worse scores across all disease activity assessments and disease impact measures compared to those without severe fatigue. Using principal component analyses, disease activity and impact were associated with BASDAI-fatigue, while disease activity and impact, and disease chronicity were associated with SF-36 VT. In the univariable analyses, all disease activity assessments and disease impact measures correlated with both BASDAI-fatigue and SF-36 VT. In the multivariable analyses, BASDAI-axial pain, BASFI, BAS-G, and ethnicity were associated with BASDAI-fatigue, while ASQoL and BASDAI-morning stiffness were associated with SF-36 VT.

Conclusion: Fatigue is prevalent amongst patients with axSpA in Asia and is associated with disease activity, disease impact as well as patient related factors.

Recognizing Axial Spondyloarthritis: A Guide for Primary Care

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

Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review

INTRODUCTION

Few studies have evaluated the impact of delayed diagnosis of axial spondyloarthritis (axSpA) on the overall burden of disease. The objective of this review was to evaluate the available literature on the clinical, economic, and humanistic burden of delayed diagnosis in patients with axSpA.

METHODS

This systematic literature review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the MEDLINE and Embase databases for English-language publications of original research articles (up to July 12, 2018) and conference abstracts (January 1, 2014, to July 12, 2018) reporting studies of adult patients with delayed diagnosis of axSpA associated with clinical, economic, or humanistic burden. Retrieved publications were screened for eligibility by two independent reviewers; discrepancies were resolved by a third independent reviewer. Data were extracted by one reviewer and validated by a second independent reviewer.

RESULTS

A total of 1391 publications were retrieved, of which 21 met the inclusion criteria and were included in the analysis. Of these, 15 reported data on clinical burden, nine on economic burden, and six on humanistic burden, with eight studies reporting a combination of clinical, economic, and/or humanistic burden. Patients with a delayed diagnosis of axSpA generally had higher disease activity, worse physical function, and more structural damage than those who received an earlier diagnosis. Patients with a delayed diagnosis also had a greater likelihood of work disability and higher direct and indirect healthcare costs than those who received an earlier diagnosis. Delayed diagnosis was associated with a greater likelihood for depression, negative psychological impacts, and worse quality of life.

CONCLUSIONS

Delayed axSpA diagnosis was associated with more functional impairment, higher healthcare costs, and worse quality of life, highlighting the importance of early recognition of axSpA to reduce extensive burden on patients and society. Plain language summary available for this article.

Clinical practice recommendations for the use of imaging in the diagnosis and management of axial spondyloarthritis in Taiwan

OBJECTIVE

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease bearing challenges in early diagnosis. To improve clinical diagnosis and management of axSpA, recommendations were developed with current axSpA classification criteria and recent advances in medical imaging applications.

METHODS

A systematic literature review was conducted by 10 rheumatologists and radiologists in Taiwan to retrieve research evidence on the utilization of imaging modalities, including conventional radiography (CR), magnetic resonance imaging (MRI), computed tomography (CT), ultrasound (US), quantitative sacroiliac scintigraphy (QSS), and dual-energy X-ray absorptiometry (DXA). The panel of experts proposed six key issues on the role of imaging in early diagnosis of axSpA, monitoring of disease activity and structural changes, predicting treatment effects, and assessing complications such as osteoporosis and spinal fracture. The consensus was established on the basis of research evidence, clinical experiences and expert opinions. For each recommendation statement, the level of evidence was evaluated, the strength of recommendation was graded and the final level of agreement was determined through voting.

RESULTS

In total, four overarching principles and 13 recommendations were formulated. These recommendations outlined different imaging approaches in the diagnosis and management of axSpA disease progression. Considering CT is easy to perform when MRI is less available in Taiwan, the expert panel proposed a concise and practical diagnostic scheme to strengthen the valuable role of MRI and CT in the diagnostic evaluation of axSpA without evident radiographic features.

CONCLUSION

These modified recommendations provide guidance for rheumatologists, radiologists and healthcare professionals on timely diagnosis of axSpA and disease management with appropriate imaging modalities.

Clinical and patient reported outcomes of the multidisciplinary management in patients with inflammatory bowel disease-associated spondyloarthritis

OBJECTIVE

Arthritis is the most frequent extra-intestinal manifestation in patients with inflammatory bowel diseases (IBD). The coexistence of intestinal and articular inflammation advocates the need for a multidisciplinary management of patients with IBD-associated spondyloarthritis.

METHODS

Consecutive IBD patients were evaluated jointly by the gastroenterologist and the rheumatologist in a combined clinic. All the patients were assessed and screened for articular involvement, disease activity and health related quality of life. After the prescription of a shared treatment, patients with spondyloarthritis were followed up for 24 months.

RESULTS

Two hundred sixty-two IBD patients, including 80 who were classified as affected by spondyloarthritis according to the ASAS criteria, were included in the study. At baseline, patients with both IBD and spondyloarthritis showed worse quality of life in both the physical and mental domains. The multidisciplinary management provided a significant improvement of gastrointestinal and articular manifestations, as well as the health-related quality of life. Moreover, global and gastrointestinal-specific quality of life significantly correlated with articular disease activity.

CONCLUSION

The multidisciplinary management significantly improves both articular and gastrointestinal disease activities and the quality of life of patients with IBD-associated spondyloarthritis. An appropriate screening strategy and the integrated management of these patients should be encouraged and employed in clinical practice.

Psoriatic arthritis for dermatologists

Psoriatic arthritis (PsA) affects up to one-third of patients with psoriasis. It is the major comorbidity of psoriasis because of the likelihood that loss of function and permanent disability will develop if initiation of treatment is delayed. Dermatologists are uniquely positioned to recognize early signs of PsA and be the first-line healthcare practitioners to detect PsA in patients with psoriasis. PsA can affect six clinical domains: peripheral arthritis, dactylitis, enthesitis, psoriasis, psoriatic nail disease, and axial disease. However, not every patient will have involvement of all domains and the domains affected can change over time. Complicating the diagnosis is the condition's similarity with other arthritic diseases and potential heterogeneity. In this article, we provide practical guidance for dermatologists for detecting PsA in patients with psoriasis. We also review the available treatment options by each clinical domain of PsA and give advice on how to interpret the results of PsA clinical trials. Through early recognition of PsA in patients with psoriasis and initiation of proper treatment, dermatologists can help to prevent PsA disease progression, irreversible joint damage, and resultant permanent disability, and improve quality of life.

Nonradiographic axial spondyloarthritis: clinical and therapeutic relevance

Current classification criteria for axial spondyloarthritis (axSpA) provide for the inclusion of patients with a wide range of presentations and manifestations. While not considered a formal subclassification, patients are often divided into radiographic or nonradiographic axSpA based on the presence or absence of radiographic sacroiliitis. This review will focus on nonradiographic axSpA and will discuss clinical manifestations of disease that distinguish, or in many cases do not distinguish, this entity from other individuals with axSpA. This review will also cover treatment paradigms for nonradiographic axSpA, particularly the use of biologic therapies, where current data suggest that nonradiographic disease should be managed largely the same as radiographic disease, or classical ankylosing spondylitis.