A Road Map of the Axial Spondyloarthritis Continuum

The association of cervical and lumbar mobility with functional ability in axial spondyloarthritis: Insights from the CASTRO registry using Inertial Measurement Unit system

OBJECTIVE

This study aimed to evaluate the association of cervical and lumbar mobility with functional ability in patients with axial spondyloarthritis (axSpA) using an inertial measurement unit (IMU) sensor system, as well as the influence of disease duration on this association.

METHODS

This cross-sectional study included 156 patients with axSpA from the Córdoba axSpA Task Force Registry and Outcomes (CASTRO) registry. Spinal mobility was assessed with the IMU system and functional ability was measured using the Bath Ankylosing Spondylitis Functional Index (BASFI). Patients were categorized into non-longstanding (≤23 years) and longstanding (>23 years) groups based on the median disease duration. Univariable and multivariable linear regressions were conducted to evaluate the variability of BASFI explained by each spinal movement (coefficient of determination [R²]).

RESULTS

Multivariable linear regression analysis showed that cervical movements collectively explained 19.9 % (R2 = 0.199) of BASFI variability, while lumbar mobility accounted for 11.3 %. Among longstanding axSpA patients, cervical rotation (unstandardized regression coefficient [B] = -0.68, 95 % CI1.13 to -0.24) and lumbar flexion (B = 0.65, 95 % CI 0.05 to 1.24), were independently associated with the BASFI scores. In non-longstanding patients, lumbar mobility, particularly lumbar rotation (B = -0.51, 95 % CI0.97 to -0.05), showed a stronger association with functional ability.

CONCLUSIONS

This study suggests that cervical mobility is more strongly associated with functional ability than lumbar mobility in axSpA patients. However, the impact of cervical and lumbar mobility on functional ability varies with disease duration.

Efficacy and Safety of Intravenous Secukinumab in Patients With Active Axial Spondyloarthritis: Results From a Randomized, Placebo-Controlled, Phase 3 Study

OBJECTIVE

Our goal was to assess the efficacy and safety of intravenous (IV) secukinumab for the treatment of adults with active axial spondyloarthritis (axSpA) in INVIGORATE-1.

METHODS

INVIGORATE-1 (NCT04156620) was a randomized, double-blind, parallel-group, phase 3 trial in patients with active axSpA (either radiographic or nonradiographic). Patients were randomized one to one to receive IV secukinumab (6 mg/kg at baseline followed by 3 mg/kg every four weeks) or IV placebo for 16 weeks. After week 16, patients randomized to placebo were switched to IV secukinumab (3 mg/kg every four weeks), and patients randomized to secukinumab continued treatment through week 52. The primary endpoint was the Assessment of SpondyloArthritis International Society (ASAS40) response at week 16. Safety was evaluated through week 60.

RESULTS

Among patients initially randomized to IV secukinumab (n = 264) or placebo (n = 262), 86.0% and 88.9% completed the entire 60-week study period, respectively. A higher proportion of patients receiving secukinumab versus placebo met the primary endpoint (ASAS40 response) at week 16 (40.9% vs 22.9%; P < 0.0001). By week 24, patients who switched from placebo to secukinumab at week 16 achieved ASAS40 response rates comparable to those in patients originally randomized to secukinumab. All secondary efficacy endpoints were met at week 16, and responses were sustained through week 52. No new or unexpected safety signals were observed with IV secukinumab.

CONCLUSION

IV secukinumab was effective for the treatment of adults with active axSpA over 52 weeks. The safety profile was consistent with that in previous reports on subcutaneous secukinumab.

Effects of Exercise Therapy in Axial Spondyloarthritis: A Systematic Review, Meta-analysis, and Meta-regression of Randomized Trials

OBJECTIVE

This study aimed to assess the effectiveness of exercise therapy for patients with axial spondyloarthritis (axSpA).

DATA SOURCES

We searched MEDLINE (via PubMed), Cochrane Library, Embase, Web of Science, Scopus, and SPORTDiscus for all relevant publications from database inception to March 2024, without language restriction.

STUDY SELECTION

We included randomized controlled trials (RCTs) of patients with axSpA in which ≥1 group received exercise therapy.

DATA EXTRACTION

Two independent reviewers assessed the quality of the literature using the Cochrane Collaboration Risk of Bias Tool 2.0. The outcomes were ankylosing spondylitis (AS) disease activity score (ASDAS), Bath AS disease activity index (BASDAI), Bath AS functional index (BASFI), Bath AS metrology index (BASMI), 6-minute walk test (6MWT), chest expansion capacity, peak oxygen consumption (VO2peak), pain, fatigue, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR).

DATA SYNTHESIS

A total of 20 RCTs, including 1670 patients, were included in this study. Compared with the control group, exercise therapy improved BASFI (weighted mean difference [WMD], -0.49; 95% confidence interval [CI], -0.65 to -0.32; I2=3.4%; P=.414), BASMI (WMD, -0.49; 95% CI, -0.87 to -0.11; I2=71.9%; P=.679), BASDAI (WMD, -0.78; 95% CI, -1.08 to -0.47; I2=55.9%; P=.021), ASDAS (WMD, -0.44; 95% CI, -0.64 to -0.24; I2=0.0%; P=.424), VO2peak (WMD, 3.16; 95% CI, 1.37-4.94; I2=0.0%; P=.873), 6MWT (WMD, 27.64; 95% CI, 12.04-43.24; I2=0.0%, P=.922), pain (standardized mean difference [SMD], -0.47; 95% CI, -0.74 to -0.21; I2=66.0%, P=.046), and fatigue (SMD, -0.49; 95% CI, -0.71 to -0.27; I2=0.0%; P=.446). However, no significant benefit was found in chest expansion, CRP, and ESR outcomes.

CONCLUSIONS

Exercise therapy is an effective strategy for improving disease control and symptom relief in patients with axSpA.

Unmet needs in axial spondyloarthritis. Proceedings of the French spondyloarthritis taskforce workshop

The progress observed over the last 30 years in the field of axial spondyloarthritis (axSpA) has not made it possible to answer all the current questions. This manuscript represents the proceedings of the meeting of the French spondyloArthitiS Task force (FAST) in Besançon on September 28 and 29, 2023. Different points of discussion were thus individualized as unmet needs: biomarkers for early diagnosis and disease activity, a common electronic file dedicated to SpA nationwide, a better comprehension of dysbiosis in the disease, a check-list for addressing to the rheumatologist, adapt patient reported outcomes thresholds for female gender, implementation of comorbidities screening programs, new imaging tools, in research cellular and multi omics approaches, grouping, at a nationwide level, different cohorts and registries, therapeutic strategy studies, consensual definition of difficult to treat disease and management, preclinical stage of the disease, mastering AI as a tool in the various aspects of research. These elements may represent a framework for the research agenda in axSpA for the years to come.

An update on the management of axial spondyloarthritis for sports medicine professionals

BACKGROUND

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease which mainly affects the spine and sacroiliac joints, causing longstanding back pain, stiffness, and limited mobility. AxSpA is an underrecognized disease in non-rheumatology practices because of its heterogeneous clinical features that may be difficult to identify.

MAIN BODY

Sports medicine practitioners are well positioned to suspect and recognize axSpA among their patients with chronic back pain and refer them to a rheumatologist. Early referral to a rheumatologist is important for timely diagnosis, prompt treatment, and improved long-term outcomes for patients with axSpA. Physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) remain the first-line treatment for and the cornerstone of axSpA management. For patients with inadequate response to or intolerance of NSAIDs, biologic disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic (ts) DMARDs are indicated. These drugs can reduce pain, inflammation, fatigue, and disability and can improve health-related quality of life. The goal of this review is to improve awareness of axSpA among sports medicine practitioners and other non-rheumatologists so that these providers ensure timely referral of patients with suspected axSpA to rheumatologists for appropriate treatment and better outcomes. We also provide an update on current treatment possibilities for axSpA and describe how rheumatologists use treatment guidelines and disease activity measures to identify and optimally treat patients with active axSpA.

CONCLUSION

Sports medicine practitioners have an excellent opportunity to identify patients with suspected axSpA and refer them to rheumatologists in a timely manner, as well as monitor symptoms among patients diagnosed with axSpA to identify inadequately controlled disease.

Exploratory analysis of the potential disconnect between objective inflammatory response and clinical response following certolizumab pegol treatment in patients with active axial spondyloarthritis

INTRODUCTION

This post hoc analysis evaluated the relationship between objective measures of inflammation and clinical outcomes following 12 weeks of certolizumab pegol (CZP) treatment in patients with active axial spondyloarthritis (axSpA).

METHODS

We report the proportion of patients achieving ≥50% and ≥75% improvements in clinical composite outcome measures of disease activity (Axial Spondyloarthritis Disease Activity Score [ASDAS], Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]) and objective measures of inflammation (C reactive protein [CRP], Ankylosing Spondylitis spine MRI score [ASspiMRI-a] Berlin score and Spondyloarthritis Research Consortium of Canada [SPARCC] MRI Sacroiliac Joints [SIJ] score) following 12 weeks of CZP treatment. Data from two independent readers over four MRI reading campaigns were pooled using a mixed model with repeated measures for each variable.

RESULTS

136 patients (radiographic axSpA [r-axSpA]: 76; non-radiographic axSpA [nr-axSpA]: 60) were included. Following CZP treatment, CRP, ASspiMRI-a Berlin score and SPARCC SIJ score were reduced by ≥50% in most patients (CRP: 136/136 [100.0%]; Berlin: 73/136 [53.7%]; SPARCC SIJ: 71/136 [52.2%]), and often by ≥75%. Less than half of patients with r-axSpA and nr-axSpA showed ≥50% reduction in clinical responses (BASDAI: 64/136 [47.1%]; ASDAS: 66/136 [48.5%]). These results were also observed at the individual patient level; ≥50% improvements in MRI/CRP inflammatory measures did not translate into similar improvements in clinical responses for most patients.

CONCLUSION

There is a potential disconnect between objective measures of inflammation and clinical outcome responses in patients with axSpA. The use of only clinical response measures as trial endpoints may underestimate anti-inflammatory treatment effects.

TRIAL REGISTRATION NUMBER

NCT01087762.

Secondary fibromyalgia: An entity to be remembered-A case series with axial spondyloarthritis

Fibromyalgia (FM) is a clinical syndrome characterised by chronic widespread musculoskeletal pain, stiffness, and tenderness in addition to a variety of physical and mental symptoms such as fatigue, sleep disturbances, depression, anxiety, cognitive dysfunction, headaches, and digestive problems. FM can be associated with or coexist with other inflammatory rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, and spondyloarthritis. This phenomenon is called secondary FM. Although FM cannot be considered an autoimmune disease, it may in some cases be an early sign of an autoimmune disease. Therefore, clinicians should be cautious in these situations. This case series presents three patients diagnosed with axial spondyloarthritis coexisted with FM symptoms.

Achievement of higher thresholds of clinical responses and lower levels of disease activity is associated with improvements in workplace and household productivity in patients with axial spondyloarthritis

Background

Patients with active axial spondyloarthritis (axSpA) exhibit more absences and lower levels of productivity in the workplace and household than the general population, which can improve upon treatment.

Objectives

The objective of this study is to determine the long-term impact of achieving different levels of clinical response or disease activity on workplace and household productivity in patients with axSpA.

Design

RAPID-axSpA (NCT01087762) was a 204-week phase III trial evaluating the safety and efficacy of certolizumab pegol (CZP) in adult patients with active axSpA.

Methods

The impact of axSpA on workplace and household productivity was evaluated using the validated arthritis-specific Work Productivity Survey. Outcomes included the percentage of patients achieving Assessment of SpondyloArthritis International Society (ASAS) response and Ankylosing Spondylitis Disease Activity Score (ASDAS) thresholds. This post hoc study used a generalised estimating equations model to determine the association between the threshold of clinical response achieved and patient productivity.

Results

Of 218 CZP-randomised patients, 65.1% completed week 204. At baseline, 72.0% were employed outside the home. Of the patients who were unemployed, 42.6% were unable to work due to arthritis. Achievement of higher treatment response thresholds, such as clinical remission, was associated with fewer days affected by workplace absenteeism (ASAS-partial remission: 4.0 days, ASAS40: 8.6 days, ASAS20 but not reaching ASAS40 response: 29.4 days, ASAS20 non-response: 69.2 days; ASDAS-inactive disease: 5.0 days, ASDAS-low disease activity: 15.6 days, ASDAS-high disease activity: 32.7 days, ASDAS-very high disease activity: 93.4 days). Similar associations were found for workplace presenteeism, and household absenteeism and presenteeism.

Conclusions

Over 4 years, achievement of higher clinical response thresholds and lower levels of disease activity was associated with fewer cumulative days affected by absenteeism or presenteeism, with clinical remission associated with the greatest improvements in productivity. This highlights the importance of targeting these thresholds to limit the burden of axSpA on society and on patients' daily lives.

Axial Spondyloarthritis: Reshape the Future-From the "2022 GISEA International Symposium"

The term "axial spondyloarthritis" (axSpA) refers to a group of chronic rheumatic diseases that predominantly involve the axial skeleton and consist of ankylosing spondylitis, reactive arthritis, arthritis/spondylitis associated with psoriasis (PsA) and arthritis/spondylitis associated with inflammatory bowel diseases (IBD). Moreover, pain is an important and common symptom of axSpA. It may progress to chronic pain, a more complicated bio-psychosocial phenomena, leading to a significant worsening of quality of life. The development of the axSpA inflammatory process is grounded in the complex interaction between genetic (such as HLA B27), epigenetic, and environmental factors associated with a dysregulated immune response. Considering the pivotal contribution of IL-23 and IL-17 in axSpA inflammation, the inhibition of these cytokines has been evaluated as a potential therapeutic strategy. With this context, here we discuss the main pathogenetic mechanisms, therapeutic approaches and the role of pain in axSpA from the 2022 International GISEA/OEG Symposium.