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García-Vicuña R, Juanola X, Navarro-Compán V, Moreno-Ramos MJ, Castillo-Gallego C, Moreno M, Galíndez E, Montoro M, Gómez I, Rebollo-Laserna FJ, Loza E. Management of Specific Clinical Profiles in Axial Spondyloarthritis: An Expert's Document Based on a Systematic Literature Review and Extended Delphi Process. Rheumatol Ther 2023; 10:1215-1240. [PMID: 37450194 PMCID: PMC10468481 DOI: 10.1007/s40744-023-00575-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION The management of specific clinical scenarios is not adequately addressed in national and international guidelines for axial spondyloarthritis (axSpA). Expert opinions could serve as a valuable complement to these documents. METHODS Seven expert rheumatologists identified controversial areas or gaps of current recommendations for the management of patients with axSpA. A systematic literature review (SLR) was performed to analyze the efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, conventional synthetic, biologic and targeted synthetic disease-modifying antirheumatic drugs (csDMARDs, b/tsDMARDs) in axSpA regarding controversial areas or gaps. In a nominal group meeting, the results of the SLR were discussed and a set of statements were proposed. A Delphi process inviting 150 rheumatologists was followed to define the final statements. Agreement was defined as if at least 70% of the participants voted ≥ 7 (from 1, totally disagree, to 10, totally agree). RESULTS Three overarching principles and 17 recommendations were generated. All reached agreement. According to them, axSpA care should be holistic and individualized, taking into account objective findings, comorbidities, and patients' opinions and preferences. Integrating imaging and clinical assessment with biomarker analysis could also help in decision-making. Connected to treatments, in refractory enthesitis, b/tsDMARDs are recommended. If active peripheral arthritis, csDMARD might be considered before b/tsDMARDs. The presence of significant structural damage, long disease duration, or HLA-B27-negative status do not contraindicate for the use of b/tsDMARDs. CONCLUSIONS These recommendations are intended to complement guidelines by helping health professionals address and manage specific groups of patients, particular clinical scenarios, and gaps in axSpA.
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Affiliation(s)
- Rosario García-Vicuña
- Servicio de Reumatología, Hospital Universitario La Princesa, IIS-Princesa, Madrid, Spain
| | - Xavier Juanola
- Servicio de Reumatología, Hospital Universitario de Bellvitge, Universidad de Barcelona, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | | | - Manuel José Moreno-Ramos
- Servicio de Reumatología, Hospital Clínico Universitario Virgen de La Arrixaca, El Palmar, Murcia, Spain
| | | | - Mireia Moreno
- Servicio de Reumatología, Universitari Parc Taulí Hospital, Institut d’Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain
| | - Eva Galíndez
- Servicio de Reumatología, Hospital Universitario de Basurto, Bilbao, Spain
| | - María Montoro
- Pfizer Medical Department, Alcobendas, Madrid, Spain
| | - Ismael Gómez
- Pfizer Medical Department, Alcobendas, Madrid, Spain
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Li B, Guo Z, Qu J, Zhan Y, Shen Z, Lei X. The value of different involvement patterns of the knee "synovio-entheseal complex" in the differential diagnosis of spondyloarthritis, rheumatoid arthritis, and osteoarthritis: an MRI-based study. Eur Radiol 2023; 33:3178-3187. [PMID: 36892646 DOI: 10.1007/s00330-023-09485-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/25/2022] [Accepted: 01/25/2023] [Indexed: 03/10/2023]
Abstract
OBJECTIVES To explore the different involvement patterns of the knee "synovio-entheseal complex (SEC)" on MRI in patients with spondyloarthritis (SPA), rheumatoid arthritis (RA), and osteoarthritis (OA). METHODS This study retrospectively included 120 patients (male:female, 55:65) with a mean age of 39.20 years diagnosed with SPA (n = 40), RA (n = 40), and OA (n = 40) at the First Central Hospital of Tianjin between January 2020 and May 2022. Six knee entheses were assessed by two musculoskeletal radiologists according to the SEC definition. Bone marrow lesions associated with entheses include bone marrow edema (BME) and bone erosion (BE), which were classified as entheseal or peri-entheseal based on their relationship to the entheses. Three groups (OA, RA, and SPA) were established to characterize the location of enthesitis and the different SEC involvement patterns. Inter-group and intra-group differences were analyzed using the ANOVA or chi-square tests, and the inter-class correlation coefficient (ICC) test was used to determine inter-reader agreement. RESULTS The study contained a total of 720 entheses. The SEC-based analysis revealed different involvement patterns in three groups. The OA group had the most abnormal signals in tendons/ligaments (p = 0.002). The RA group had considerably greater synovitis (p = 0.002). The majority of peri-entheseal BE was identified in the OA and RA groups (p = 0.003). Furthermore, entheseal BME in the SPA group was significantly different from those in the other two groups (p < 0.001). CONCLUSIONS SEC involvement patterns differed in SPA, RA, and OA, which is important for differential diagnosis. SEC should be used as a whole evaluation method in clinical practice. KEY POINTS • The "synovio-entheseal complex (SEC)" explained differences and characteristic alterations in the knee joint in patients with spondyloarthritis (SPA), rheumatoid arthritis (RA), and osteoarthritis (OA). • The various SEC involvement patterns are crucial for differentiating SPA, RA, and OA. • When "knee pain" is the only symptom, a detailed identification of characteristic alterations in the knee joint of SPA patients may help timely treatment and delay the structural damage.
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Affiliation(s)
- Boya Li
- First Central Clinical College, Tianjin Medical University, Tianjin, China
| | - Zikang Guo
- First Central Clinical College, Tianjin Medical University, Tianjin, China
| | - Jin Qu
- Department of Radiology, Tianjin First Central Hospital, Tianjin Institute of Imaging Medicine, Tianjin, China
| | - Ying Zhan
- Department of Radiology, Tianjin First Central Hospital, Tianjin Institute of Imaging Medicine, Tianjin, China
| | - Zhiwei Shen
- Clinical Science, Philips Healthcare, Beijing, China
| | - Xinwei Lei
- Department of Radiology, Tianjin First Central Hospital, Tianjin Institute of Imaging Medicine, Tianjin, China. .,Department of radiology, Tianjin First Central Hospital, Tianjin Institute of Imaging Medicine, NO. 24 Fukang Road, Nankai District, Tianjin, 300192, China.
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Xiong Y, Cai M, Xu Y, Dong P, Chen H, He W, Zhang J. Joint together: The etiology and pathogenesis of ankylosing spondylitis. Front Immunol 2022; 13:996103. [PMID: 36325352 PMCID: PMC9619093 DOI: 10.3389/fimmu.2022.996103] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/28/2022] [Indexed: 08/16/2023] Open
Abstract
Spondyloarthritis (SpA) refers to a group of diseases with inflammation in joints and spines. In this family, ankylosing spondylitis (AS) is a rare but classic form that mainly involves the spine and sacroiliac joint, leading to the loss of flexibility and fusion of the spine. Compared to other diseases in SpA, AS has a very distinct hereditary disposition and pattern of involvement, and several hypotheses about its etiopathogenesis have been proposed. In spite of significant advances made in Th17 dynamics and AS treatment, the underlying mechanism remains concealed. To this end, we covered several topics, including the nature of the immune response, the microenvironment in the articulation that is behind the disease's progression, and the split between the hypotheses and the evidence on how the intestine affects arthritis. In this review, we describe the current findings of AS and SpA, with the aim of providing an integrated view of the initiation of inflammation and the development of the disease.
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Affiliation(s)
- Yuehan Xiong
- Department of Immunology, Chinese Academy of Medical Sciences (CAMS) Key Laboratory of T Cell and Cancer Immunotherapy, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences (CAMS) and School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Menghua Cai
- Department of Immunology, Chinese Academy of Medical Sciences (CAMS) Key Laboratory of T Cell and Cancer Immunotherapy, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences (CAMS) and School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Yi Xu
- Department of Immunology, Chinese Academy of Medical Sciences (CAMS) Key Laboratory of T Cell and Cancer Immunotherapy, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences (CAMS) and School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Peng Dong
- Changzhou Xitaihu Institute for Frontier Technology of Cell Therapy, Changzhou, China
| | - Hui Chen
- Department of Immunology, Chinese Academy of Medical Sciences (CAMS) Key Laboratory of T Cell and Cancer Immunotherapy, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences (CAMS) and School of Basic Medicine, Peking Union Medical College, Beijing, China
- Changzhou Xitaihu Institute for Frontier Technology of Cell Therapy, Changzhou, China
| | - Wei He
- Department of Immunology, Chinese Academy of Medical Sciences (CAMS) Key Laboratory of T Cell and Cancer Immunotherapy, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences (CAMS) and School of Basic Medicine, Peking Union Medical College, Beijing, China
- Changzhou Xitaihu Institute for Frontier Technology of Cell Therapy, Changzhou, China
| | - Jianmin Zhang
- Department of Immunology, Chinese Academy of Medical Sciences (CAMS) Key Laboratory of T Cell and Cancer Immunotherapy, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences (CAMS) and School of Basic Medicine, Peking Union Medical College, Beijing, China
- Changzhou Xitaihu Institute for Frontier Technology of Cell Therapy, Changzhou, China
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Wu X, Liu D, Li Y, Xie Y, Tu L, Zhang Y, Zhang X, Fang L, Luo X, Lin Z, Liao Z, Rong L, Ren J, Zhou Y, Yang N, Xu J, Zhang H, Xu B, Wu Z, Zhan F, Li Z, Xiao W, Liu S, Zhou Y, Ye S, Lv Q, Zhang L, Zhao D, He S, Zhao L, Wu L, Lin H, Zhu Y, Guo D, Yang Z, Liu B, Yang K, Gu J. A clinical practice guideline for the screening and assessment of enthesitis in patients with spondyloarthritis. Front Immunol 2022; 13:978504. [PMID: 36172360 PMCID: PMC9510351 DOI: 10.3389/fimmu.2022.978504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The aim of this review is to provide guidance on the selection of approaches to the screening and assessment of enthesitis in patients with spondyloarthritis (SpA). Methods Twenty-four questions regarding the approaches to the screening and assessment of enthesitis and the implementation details were devised, followed by a systemic literature review. The Grading of Recommendations Assessment, Development, and Evaluation methodology was employed in the development of this guideline, with modifications to evaluate non-interventional approaches under comprehensive consideration of costs, accessibility, and evidence strength. A consensus from the voting panel was required for the inclusion of the final recommendations and the strength of each recommendation. Results Seventeen recommendations (including five strong recommendations) were included in this guideline. The voting panel expressed unequivocal support for the necessity of screening and assessment of enthesitis in patients with SpA. It was agreed unanimously that symptom evaluation and physical examination should serve as the initial steps to the recognition of enthesitis, whereas Maastricht Ankylosing Spondylitis Enthesitis Score is a reliable tool in both clinical trials and daily medical practice. Ultrasound examination is another reliable tool, with power Doppler ultrasound as an informative addition. Notwithstanding its high resolution, MRI is limited by the costs and relatively low accessibility, whereas radiographs had low sensitivity and therefore should be rendered obsolete in the assessment of enthesitis. PET/CT was strongly opposed in the detection of enthesitis. Conclusion This guideline provides clinicians with information regarding the screening and assessment of enthesitis in patients with SpA. However, this guideline does not intend on dictating choices, and the ultimate decisions should be made in light of the actual circumstances of the facilities.
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Affiliation(s)
- Xinyu Wu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dong Liu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yanfei Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Ya Xie
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liudan Tu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yanli Zhang
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xi Zhang
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Linkai Fang
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiqing Luo
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhiming Lin
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zetao Liao
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Limin Rong
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jie Ren
- Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuqi Zhou
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou>, China
| | - Niansheng Yang
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian Xu
- Department of Internal Medicine, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hua Zhang
- Department of Rheumatology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Baijie Xu
- Department of Rheumatology, Jieyang People's Hospital, Jieyang, China
| | - Zhenbiao Wu
- Department of Rheumatology, Tangdu Hospital of Air Force Military Medical University, Xian, China
| | - Feng Zhan
- Department of Rheumatology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Zhenbin Li
- Department of Rheumatology, Bethune International Peace Hospital, People's Liberation Army, Shijiazhuang, China
| | - Weiguo Xiao
- Department of Rheumatology, The First Hospital of China Medical University, Shenyang, China
| | - Shengyun Liu
- Department of Rheumatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yi Zhou
- Department of Rheumatology and Immunology, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shanhui Ye
- Department of Rheumatology and Immunology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qing Lv
- Department of Rheumatology, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Lijun Zhang
- Department of Rheumatology, Shenzhen Hospital, The University of Hong Kong, Shenzhen, China
| | - Dongbao Zhao
- Department of Rheumatology and Immunology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Shanzhi He
- Department of Rheumatology, Zhongshan People's Hospital, Zhongshan, China
| | - Like Zhao
- Department of Rheumatology and Immunology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Lijun Wu
- Department of Rheumatology and Immunology, The People's Hospital of the Xinjiang Uygur Autonomous Region, Urumqi, China
| | - He Lin
- Department of Rheumatology, Fujian Provincial Hospital, Fuzhou, China
| | - Yunxiao Zhu
- Department of Medical Ultrasonics, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Donggeng Guo
- Department of Rheumatology and Immunology, Ningxia Clinical Institute of Bone and Joint Research, The Affiliated People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, China
| | - Zehong Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Budian Liu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Jieruo Gu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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