Axial Spondyloarthritis in the Era of Precision Medicine

Pan American League of Associations for Rheumatology recommendations for the management of axial spondyloarthritis

Axial spondyloarthritis (axSpA) comprises a spectrum of chronic inflammatory manifestations affecting the axial skeleton and represents a challenge for diagnosis and treatment. Our objective was to generate a set of evidence-based recommendations for the management of axSpA for physicians, health professionals, rheumatologists and policy decision makers in Pan American League of Associations for Rheumatology (PANLAR) countries. Grading of Recommendations, Assessment, Development and Evaluation-ADOLOPMENT methodology was used to adapt existing recommendations after performing an independent systematic search and synthesis of the literature to update the evidence. A working group consisting of rheumatologists, epidemiologists and patient representatives from countries within the Americas prioritized 13 topics relevant to the context of these countries for the management of axSpA. This Evidence-Based Guideline article reports 13 recommendations addressing therapeutic targets, the use of NSAIDs and glucocorticoids, treatment with DMARDs (including conventional synthetic, biologic and targeted synthetic DMARDs), therapeutic failure, optimization of the use of biologic DMARDs, the use of drugs for extra-musculoskeletal manifestations of axSpA, non-pharmacological interventions and the follow-up of patients with axSpA.

The effect of uveitis and undiagnosed spondyloarthritis: a systematic review and meta-analysis

Delay diagnosis of spondyloarthritis (SpA) is associated with poor functional ability and quality of life. Uveitis is the most frequent extraarticular manifestation in SpA, and its prevalence increases with longer disease duration. This study examines the effect of uveitis on the disease activity and functional outcome of undiagnosed SpA. We reviewed published and unpublished studies. Data were pooled using the random-effects model; pooled means, and mean differences (MDs) were calculated. In the included 14 studies, disease activity, functional index, and inflammatory markers were measured in 2581 patients with SpA with uveitis and 13,972 without. The pooled mean delay in diagnosis of SpA with uveitis (6.08 years; 95% CI 4.77 to 7.38) was longer than those without (5.41 years; 95% CI 3.94 to 6.89). The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score was the highest for a delay of 2-5 years (5.60, 95% CI 5.47 to 5.73) and the Bath Ankylosing Spondylitis Functional Index (BASFI) score was the lowest for a delay of < 2 years (2.92, 95% CI 2.48 to 3.37) and gradually increased to delay of > 10 years (4.17, 95% CI 2.93 to 5.41). Patients with SpA with uveitis had higher trend of Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP and BASDAI. The delay to diagnosis was longer in SpA with uveitis, and disease activity was often higher than those without uveitis. Early diagnosis of SpA with timely initiation of an appropriate management plan may reduce the adverse effects of the disease and improve functional ability.

Patient-tailored dose reduction of tumor necrosis factor inhibitors in axial spondyloarthritis

Tumor necrosis factor inhibitors have been widely used in the field of axial spondyloarthritis, with current guidelines now recommending dose reduction instead of withdrawal of biologics. Systemic review and meta-analyses in literature have summarized present tapering strategies and principles in published heterogeneous studies. In this study, we reviewed and provided an update on present evidence based on prospective and retrospective studies from 2008 to 2022 by performing a literature review of related publications on remission or relapse from PubMed. We further stated the core issues concerning dose reduction, including the timing, optimization, intensity, maintenance, monitoring, factors associated with tapering and solutions to de-escalation failure. Remission/relapse should be the principal consideration in dose reduction implementation for individuals without comorbidities. As a treat-to-target scope of this multifaceted systemic disease, extra-articular manifestations such as uveitis, psoriasis, inflammatory bowel disease, cardiovascular complication, hip involvement and progressed structural damage influence patient-tailored dose reduction plans. Safety concerns and costs should be integrated into the decision-making schedule to optimize the individualized dose reduction paradigm.