Second-line treatment in seronegative spondylarthropathies

Tapering of Biological Agents in Juvenile ERA Patients in Daily Clinical Practice

Objectives: We aim to evaluate the proportion and characteristics of enthesitis-related arthritis (ERA) patients in whom medications can be withdrawn in daily practice and to analyze the factors associated with flare-ups during medication tapering of these patients.

Methods: We retrospectively reviewed records of patients under 16 years old diagnosed with ERA from April 2001 to March 2020 in one tertiary medical center in Taiwan. Patients were categorized by different medication uses: conventional disease modifying anti-rheumatic drugs (cDMARDs) only and cDMARDs plus biologics. Demographics, laboratory data, presence of uveitis, and medication withdrawal rate were analyzed. Subgroup analysis was performed in the patients with cDMARDs plus biologics to identify factors associated with flare-ups during medication tapering of these patients. Statistical analysis was performed using R (v3.6.0).

Results: There were 75 juvenile ERA patients with a median onset age of 10.28 years old. Nineteen (25.3%) patients used cDMARDs for disease control; 56 (74.7%) patients depended on cDMARDs plus biologics. Poly-articular involvement was noted in 29 (38.7%) patients, and it occurred more frequently in the cDMARDs plus biologics subgroup (cDMARDs only, 5.3%; cDMARDs plus biologics, 53.6%; P = 0.0001). ANA positivity was observed in 18 (24.0%) patients, and it occurred more frequently in the cDMARDs plus biologics subgroup (cDMARDs, 0%; cDMARDs plus biologics, 32.1%; P = 0.0038). The overall medication withdrawal rate was 34.7%, and it occurred more frequently in patients with cDMARDs only (cDMARDs only, 84.2%; cDMARDs plus biologics, 17.9%; P < 0.001). In the subgroup analysis of patients with cDMARDs plus biologics, patients on biologics tapering with flare-up had a significantly longer time interval between disease onset and initiation of cDMARDs (biologics tapering without flare-up: 0.27 (0.11–0.73) years; biologics tapering with flare-up: 1.14 (0.39–2.02) years; ever withdrawing biologics: 0.26 (0.18–0.42) years, P = 0.0104).

Conclusion: Juvenile ERA patients with polyarticular involvement had a higher risk of developing cDMARDs refractory and progressing to biologics use. Patients with a long time interval between disease onset and initiation of cDMARDs were prone to experience flare-up during tapering of biologics.

Late-Onset Ankylosing Spondylitis and Related Spondylarthropathies

Ankylosing spondylitis is the prototype of related diseases commonly called spondylarthropathies which include reactive arthritis, psoriatic arthritis, arthritis associated with inflammatory bowel diseases (enteropathic arthritis) and undifferentiated spondylarthropathies. Ankylosing spondylitis and spondylarthropathies are generally observed in young patients but can be observed later in life or in persons >50 years of age. All the spondylarthropathy subgroups are represented in the elderly with some features particular to this age group. Indeed, radiological aspects of ankylosing spondylitis may be difficult to interpret because of the radiological changes induced by aging. Late-onset peripheral spondylarthropathies are characterised by severe disease, marked elevation of laboratory parameters of inflammation, oligoarthritis involving the lower limbs and oedema of the extremities. Psoriatic arthritis is more severe in the elderly and is associated with worse outcomes than in young patients. The clinical presentation of undifferentiated spondylarthropathy is as varied in the elderly as in young and middle-aged adults. Reactive arthritis and enteropathic arthritis are observed in the elderly more rarely. The effects of aging on drug metabolism and pharmacokinetics, together with the existence of co-morbidities and polypharmacy, are responsible for difficulties in the therapeutic management of late-onset ankylosing spondylitis or spondylarthropathies. Indeed, NSAIDs should be used with caution in older patients because of the high risk of serious gastrointestinal complications. Sulfasalazine and methotrexate have been used as disease-controlling drugs but did not prove very effective. Pamidronate and tumour necrosis factor (TNF)-alpha antagonists offer a therapeutic alternative but have not been specifically tested in the elderly. Pamidronate has been tested in young-onset ankylosing spondylitis and spondylarthropathies with conflicting results but can be used in older patients without risk of major adverse effects. TNFalpha antagonists have been adequately evaluated in ankylosing spondylitis and spondylarthropathies and are associated with dramatic improvement in clinical and biological parameters of disease activity. However, the safety profile of these agents in the elderly is not currently known and careful surveillance, in particular for the risk of infection such as tuberculosis, and/or exacerbation of chronic heart failure, is thus required when using these drugs in this age group.

[Reiter's syndrome after Salmonella infection]

Two patients with Reiter's syndrome, after Salmonella infection were treated on the Infections disease ward at Clinical hospital center in Kragujevac. In the first patient, ten days after the onset of Salmonella infection, signs of edema and pain in the right ankle occurred, accompanied by expressed conjunctivitis. Within next two months consecutive metatarsophalanges changes joint of the right foot have appeared. In the second patient, two weeks after the onset of Salmonella infection, edema of the left hand joints and a week later edema of the right hand and right ankle joints appeared. In both patients inflammatory syndrome was expressed (high erythrocyte sedimentation rates, fibrinogen, C-reactive protein) along with negative rheumatoid factors and positive antigen HLA-B27. Outcome of the disease in both cases was favourable upon receiving nonsteroid antirheumatic therapy. Signs of arthritis disappeared after three months. No signs of recurrent arthritis have been seen during the next four years in the first and next two years in the second patient.

HLA-B27-associated reactive arthritis: pathogenetic and clinical considerations

Current evidence supports the concept that reactive arthritis (ReA) is an immune-mediated synovitis resulting from slow bacterial infections and showing intra-articular persistence of viable, non-culturable bacteria and/or immunogenetic bacterial antigens synthesized by metabolically active bacteria residing in the joint and/or elsewhere in the body. The mechanisms that lead to the development of ReA are complex and basically involve an interaction between an arthritogenic agent and a predisposed host. The way in which a host accommodates to invasive facultative intracellular bacteria is the key to the development of ReA. The details of the molecular pathways that explain the articular and extra-articular manifestations of the disease are still under investigation. Several studies have been done to gain a better understanding of the pathogenesis of ReA; these constitute the basis for a more rational therapeutic approach to this disease.

Reactive arthritis: newer developments

Reactive arthritis (ReA) is characterized by an aseptic inflammatory articular involvement occurring in a genetically predisposed individual secondary to an infectious process localized outside the joint. ReA usually refers to an acute or insidious oligoarthritis process after enteric (enteroarthritis) or urogenital (uroarthritis) infection. Conventional antirheumatic therapeutic modalities based on nonsteroid anti-inflammatory drugs, sulfasalazine, and steroids are effective in the majority of patients. In more refractory cases, the use of second-line agents including methotrexate and more recently biological agents such as etanercept and infliximab has been found highly effective. The role of antibiotics remains not well established, although they appear to be effective in acute ReA of urogenital origin.

Recent progress in ankylosing spondylitis treatment

Ankylosing spondylitis (AS) is a systemic inflammatory rheumatic disease responsible for back pain, stiffness and loss of functional capacity. The therapeutic management of AS includes regular physical exercise together with the use of NSAIDs. Second-line treatments, such as sulfasalazine, are required in cases of NSAID-refractory AS. Some patients have severe and inadequately controlled disease, explaining the need for the development of new treatments. This therapeutic development in AS involves the assessment of new NSAIDs, namely COX2 selective agents and new second-line treatments, such as methotrexate (MTX), pamidronate and anti-TNFalpha agents. Controlled studies are lacking for MTX. Pamidronate showed to be effective in NSAID refractory AS patients in open and controlled trials. Anti-TNFalpha agents (infliximab and etanercept) gave promising results with dramatic improvement of AS symptoms in open and preliminary controlled trials, but further studies are required to evaluate the real long-term effects and tolerability of these drugs.

Medication toxicity among patients with ankylosing spondylitis

OBJECTIVE

To determine the role of medication toxicity in the discontinuation of antirheumatic treatment among patients with ankylosing spondylitis (AS), and to compare the toxicity of different medications.

METHODS

In a prospective longitudinal study of 241 patients with AS, we examined the duration of treatment and discontinuations due to side effects of new courses of sulfasalazine, methotrexate, ibuprofen, naproxen, indomethacin, diclofenac, piroxicam, nabumetone, and celecoxib.

RESULTS

Of the 241 patients, 167 reported having a new treatment course of either sulfasalazine (n = 49), methotrexate (n = 19), ibuprofen (n = 105), naproxen (n = 57), indomethacin (n = 50), diclofenac (n = 38), piroxicam (n = 34), nabumetone (n = 27), or celecoxib (n = 25), for a total of 404 new treatment courses. Side effects were reported in 6.7% (ibuprofen) to 47.3% (methotrexate) of the courses. Between 2% (ibuprofen) and 23.5% (piroxicam) of courses were discontinued due to toxicity. For each medication, the duration of treatment was most often limited by factors other than toxicity. The time to drug discontinuation for any reason and the time to discontinuation due to toxicity did not differ between sulfasalazine and methotrexate. The time to drug discontinuation for any reason did not differ among nonsteroidal antiinflammatory drugs (NSAIDs), but discontinuations due to toxicity occurred earlier with piroxicam than with other NSAIDs.

CONCLUSION

Although medication toxicity is common among patients with AS, it is an uncommon cause of discontinuation of antirheumatic treatment.

Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor alpha

BACKGROUND

There are few effective treatments for ankylosing spondylitis, which causes substantial morbidity. Because of the central role of tumor necrosis factor alpha in the spondyloarthritides, we performed a randomized, double-blind, placebo-controlled trial of etanercept, a recombinant human tumor necrosis factor receptor (p75):Fc fusion protein, in patients with ankylosing spondylitis.

METHODS

Forty patients with active, inflammatory ankylosing spondylitis were randomly assigned to receive twice-weekly subcutaneous injections of etanercept (25 mg) or placebo for four months. The primary end point was a composite of improvements in measures of morning stiffness, spinal pain, functioning, the patient's global assessment of disease activity, and joint swelling. Patients were allowed to continue taking nonsteroidal antiinflammatory drugs, oral corticosteriods (< or =10 mg per day), and disease-modifying antirheumatic drugs at stable doses during the trial.

RESULTS

Treatment with etanercept resulted in significant and sustained improvement. At four months, 80 percent of the patients in the etanercept group had a treatment response, as compared with 30 percent of those in the placebo group (P=0.004). Improvements over base-line values for various measures of disease activity, including morning stiffness, spinal pain, functioning, quality of life, enthesitis, chest expansion, erythrocyte sedimentation rate, and C-reactive protein, were significantly greater in the etanercept group. Longitudinal analysis showed that the treatment response was rapid and did not diminish over time. Etanercept was well tolerated, with no significant differences in rates of adverse events between the two groups.

CONCLUSIONS

Treatment with etanercept for four months resulted in rapid, significant, and sustained improvement in patients with ankylosing spondylitis.

Methotrexate in the treatment of ankylosing spondylitis

There have been few well-conducted studies into the efficacy of methotrexate in Ankylosing spondylitis. The results of a new prospective study in 51 patients are presented in this issue but the clinical response was poor. A recurring theme, however, is the promising effect noted on peripheral joints compared with that on the axial skeleton. Recent histological and magnetic resonance imaging evidence suggests that synovitis and subchondral bone marrow changes offer a more rational explanation for widespread joint destruction than does enthesitis alone. Furthermore, enthesis lesions close to synovial joints occur frequently and may be intimately linked with peripheral joint synovitis. At the moment there is no hard evidence of efficacy in axial disease, but these observations raise the possibility that suppression of synovitis might help in the spine, and that enthesitis might respond wherever it is anatomically. Thus further long-term, placebo-controlled studies are needed to address specifically the issues of enthesitis. spinal symptom relief and the suppression of long-term ankylosis.

Therapeutic advances in ankylosing spondylitis

Ankylosing spondylitis (AS) is a systemic inflammatory rheumatic disease involving spinal and sacroiliac joints. This condition is responsible for back pain, stiffness, but also loss of functional capacity with socio-economic consequences. The management of AS includes patient education, rest, a programme of regular physical exercise, together with the use of NSAIDs. Second-line treatments are required in cases of severe or refractory AS, however only sulfasalazine has proven to benefit AS patients with peripheral arthritis. In spite of this management, the disease may not be adequately controlled, mainly for patients with refractory axial disease, enthesopathy or extra-articular features. Thus, new innovative treatments are needed for AS. It is likely that the new NSAIDs or COX-2 specific inhibitors will certainly take the place of the conventional NSAIDs, with regard to their superior tolerability. Methotrexate is a therapeutic option for AS treatment, but its usefulness in this disease remains to be established in adequate controlled studies. Finally, the TNF-alpha targeting drugs, namely thalidomide and the anti-TNF-alpha mAb, infliximab, have given promising results in the treatment of severe and/or refractory AS patients, however further controlled studies are required. In addition, the long-term use (efficacy and tolerability) of these two agents deserves attention.

Bones and Crohn's: problems and solutions

Inflammatory bowel disease may manifest in various extra intestinal manifestations. Osteopenia and various arthropathies may be debilitating. These may be related to the disease itself, patient genetics, lifestyle, or disease treatment. Calcium and vitamin D malabsorption, vitamin K deficiency, malnutrition, corticosteroid and other immunosuppressive medications, smoking, lack of exercise and postmenopausal state may all play important roles. Treatment may be undertaken to correct nutrient deficiencies, inhibit bone resorption and increase bone formation.

Renal diseases in ankylosing spondylitis: review of the literature illustrated by case reports

Ankylosing spondylitis (AS) can be accompanied by extraarticular manifestations in the cardiovascular, pulmonary, neurologic and renal organs. Secondary renal amyloidosis is the most common cause of renal involvement in AS (62%) followed by IgA nephropathy (30%), mesangioproliferative glomerulonephritis (5%) as well as rarely membranous nephropathy (1%), focal segmental glomerulosclerosis (1%) and focal proliferative glomeruleonephritis (1%). Treatment associated nephrotoxicity may result from non-steroidal anti-inflammatory drugs or disease modifying agents. The purpose of this paper was to alert for the possibility of renal damage in AS and to analyse the frequencies of different etiologies of renal involvement. Two typical case reports of renal involvement in AS are presented to illustrate the clinical course of such patients. Renal side effects and possible pre-existing renal diseases should be taken into account while choosing the appropriate medication for patients with AS.

Spondylarthropathy treatment: progress in medical treatment, physical therapy and rehabilitation

The monitoring and treatment of the diseases belonging to the concept of spondylarthropathy are related more to their clinical presentation, for example axial versus peripheral involvement, than to the precise diagnosis, for example, ankylosing spondylitis versus psorìatic arthritis. For each clinical presentation the treatment comprises local and systemic routes of administration but also drug and non-drug therapies.

Bowel inflammation and the spondyloarthropathies

The concept of spondyloarthropathies gathers together a group of chronic diseases in which not only the locomotor system is involved but also other organs, especially the gastrointestinal tract. In humans, ileocolonoscopic studies demonstrated the presence of inflammatory gut lesions in all the diseases in the spondyloarthropathy group; their presence varied in the different diseases between 20% and 70%. The inflammation could be related to specific disease features in the spondyloarthropathies. Further research supports the hypothesis of subclinical inflammatory bowel disease in some patients with spondyloarthropathy, in which the locomotor inflammation was the only clinical manifestation. The link between gut inflammation and arthropathy has also been demonstrated in animal models, notably the human leukocyte antigen B27 transgenic rats. The temporal relationship between activity and severity of colonic involvement and flares of peripheral arthritis directs treatment of choice. For all forms of enterogenic arthropathies, nonsteroidal anti-inflammatory drugs remain the acute treatment form. Caution is in order, however, because of their possible harmful effects on intestinal integrity, permeability, and even on gut inflammation.

Prognosis, course of disease, and treatment of the spondyloarthropathies

Prognosis in the majority of patients with acute reactive arthritis is usually good, with most patients recovering in a few months. In about 15% to 30% of such patients, the disease progresses, and spondyloarthropathy and even ankylosing spondylitis develop in the following 10 to 20 years. A recurrent attack of reactive arthritis is common in patients with chlamydia-triggered arthritis, but it is rare in patients who have had enteroarthritis. In patients with chronic spondyloarthropathy without evidence of preceding infection, the disease can progress slowly into ankylosing spondylitis. When reactive chlamydia arthritis is indicated, a prolonged course of antibiotics is needed. For other forms of reactive arthritis, solid evidence in favor of antibiotic therapy is still lacking. Presence of hip pain, decreased mobility of thoracic cervical or thoracic spine, heel pain, inflammatory gut lesions, high erythrocyte sedimentation rate, positive family history, and presence of human leukocyte antigen B27 are indicators for chronicity. Sulfasalazine might be of use in chronic arthritis and ankylosing spondylitis, especially if the patient has peripheral arthritis.

Review article: bone and joint diseases in inflammatory bowel disease

The intestinal and articular systems are closely linked in inflammatory bowel disease. Clinical and immunological studies support an important aetio-pathogenetic link between intestinal and articular inflammation. There is increasing evidence for a negative link between bone mass density and intestinal inflammation. This paper will focus on the prevalence, aetio-pathogenesis and treatment of arthritis (peripheral, sacroiliitis and spondylitis) and osteoporosis in inflammatory bowel disease.