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Choufani M, Kay J, Ermann J. Axial spondyloarthritis guidelines - aiming for maximum impact. Curr Opin Rheumatol 2024; 36:251-260. [PMID: 38661436 DOI: 10.1097/bor.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW This review discusses international clinical practice guidelines (CPGs) for axial spondyloarthritis (axSpA) focusing on methodology, guideline quality, and implementation. RECENT FINDINGS The Assessment of SpondyloArthritis International Society/European Alliance of Associations for Rheumatology (ASAS/EULAR) and Pan-American League of Associations for Rheumatology (PANLAR) recently published axSpA CPGs and updates of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network (ACR/SAA/SPARTAN) and Asia-Pacific League of Associations for Rheumatology (APLAR) CPGs are expected. GRADE has emerged as the dominant framework for CPG development and has been used by three of the four international axSpA guidelines. Notable differences exist among these guidelines in the way that the recommendations are presented. Two of the four acknowledge the need for implementation strategies, but little detail about this is provided. The few studies that have evaluated the implementation of axSpA CPGs have identified poor adherence to recommendations on physical therapy/exercise and disease activity monitoring. Implementation science has identified many barriers and facilitators affecting guideline uptake, including those related to healthcare professionals and to the guidelines themselves. Creation of a tailored implementation plan simultaneously with the CPG is recommended. SUMMARY While methodological rigor in the creation of evidence-based recommendations is the focus of CPG development, recommendations must be presented in a user-friendly format that makes them easy to apply. 'Living guidelines' could facilitate keeping content up to date. Implementation is critical for the success of a CPG and should be emphasized in future axSpA guideline updates. Further research is needed to better understand the factors impacting the successful implementation of axSpA CPGs.
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Affiliation(s)
| | - Jonathan Kay
- UMass Chan Medical School and UMass Memorial Medical Center, Worcester
| | - Joerg Ermann
- Brigham and Women's Hospital, Boston
- Harvard Medical School, Boston, Massachusetts, USA
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Ciurea A, Kissling S, Bürki K, Baraliakos X, de Hooge M, Hebeisen M, Papagiannoulis E, Exer P, Bräm R, Nissen MJ, Möller B, Kyburz D, Andor M, Distler O, Scherer A, Micheroli R. Current differentiation between radiographic and non-radiographic axial spondyloarthritis is of limited benefit for prediction of important clinical outcomes: data from a large, prospective, observational cohort. RMD Open 2022; 8:rmdopen-2021-002067. [PMID: 35110365 PMCID: PMC8811599 DOI: 10.1136/rmdopen-2021-002067] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/17/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To compare disease characteristics and outcomes between patients with axial spondyloarthritis with non-radiographic disease (nr-axSpA), bilateral grade 2 sacroiliitis (r22axSpA) and unilateral/bilateral grade 3-4 sacroiliitis (r3+axSpA) according to the modified New York criteria. METHODS We included patients with axial spondyloarthritis with available pelvic radiographs from the Swiss Clinical Quality Management Cohort. Retention of a first tumour necrosis factor inhibitor (TNFi) was investigated with multiple adjusted Cox proportional hazards models. The proportion of patients reaching 50% reduction in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI50) at 1 year was assessed with multiple adjusted logistic regression analyses. Spinal radiographic progression, defined as an increase in ≥2 mSASSS units in 2 years, was assessed in generalised estimating equation models. RESULTS From 2080 patients, those with nr-axSpA (n=485) and r22axSpA (n=443) presented with lower C reactive protein levels and less severe clinical spinal involvement compared with patients with r3+axSpA (n=1152). While TNFi retention was similar in r22axSpA and nr-axSpA, the risk of discontinuation was significantly lower in r3+axSpA (HR 0.60, 95% CI 0.44 to 0.82 vs nr-axSpA). BASDAI50 responses at 1 year were comparable in r22axSpA and nr-axSpA, with a better response associated with r3+axSpA (OR 2.05, 95% CI 1.09 to 3.91 vs nr-axSpA). Spinal radiographic progression was similar in r22axSpA and nr-axSpA and significantly higher in r3 +axSpA. CONCLUSION Patients with r22axSpA are comparable to nr-axSpA patients but differ from patients with more severe sacroiliac damage with regard to treatment effectiveness and spinal radiographic progression. Therefore, current differentiation between nr-axSpA and radiographic disease seems of limited use for outcome prediction.
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Affiliation(s)
- Adrian Ciurea
- Department of Rheumatology, Zurich University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Kristina Bürki
- Department of Rheumatology, Zurich University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Manouk de Hooge
- VIB Inflammation Research Center, Ghent University, Ghent, Belgium
| | | | | | | | - René Bräm
- Swiss Ankylosing Spondylitis Association, Zurich, Switzerland
| | - Michael J Nissen
- Division of Rheumatology, Geneva University Hospital, Geneva, Switzerland
| | - Burkhard Möller
- Department of Rheumatology, Inselspital Bern, Bern, Switzerland
| | - Diego Kyburz
- Department of Rheumatology, Basel University Hospital, Basel, Switzerland
| | | | - Oliver Distler
- Department of Rheumatology, Zurich University Hospital, University of Zurich, Zurich, Switzerland
| | - Almut Scherer
- Swiss Clinical Quality Management in Rheumatic Diseases SCQM, Zurich, Switzerland
| | - Raphael Micheroli
- Department of Rheumatology, Zurich University Hospital, University of Zurich, Zurich, Switzerland
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Michelena X, Zhao SS, Dubash S, Dean LE, Jones GT, Marzo-Ortega H. Similar biologic drug response regardless of radiographic status in axial spondyloarthritis: data from the BSRBR-AS registry. Rheumatology (Oxford) 2021; 60:5795-5800. [PMID: 33502476 PMCID: PMC8645273 DOI: 10.1093/rheumatology/keab070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/05/2021] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES To describe the baseline characteristics, bDMARD response and drug survival of axSpA patients in the British Society for Rheumatology Biologics Register in Ankylosing Spondylitis (BSRBR-AS) according to radiographic status. METHODS BSRBR-AS is a national prospective cohort including axSpA participants classified according to the ASAS criteria. In this analysis, baseline data of patients starting bDMARDs were compared. Ankylosing Spondylitis Disease Activity Scores (ASDAS) for low disease status, clinically important improvement (CII) and major improvement (MI) at one year were used to assess treatment response. Cox proportional hazard analysis was performed after adjusting for clinically relevant cofounders. RESULTS 1,145 axSpA patients were included. Higher male prevalence, older age and longer disease duration was seen in the r-axSpA subgroup. Based on a complete case analysis (290 patients), two thirds of patients achieved ASDAS low disease state at one year regardless of radiographic status (nr-axSpA: 64.2% vs r-axSpA: 66.1). No statistically significant differences were seen between the subgroups in attaining ASDAS CII (nr-axSpA: 50.7% vs r-axSpA: 44.7%) or MI (nr-axSpA: 20% vs r-axSpA: 18.7%). Drug survival probability curves were similar for both subgroups and hazard ratio for nr-axSpA/axSpA was 0.94 (95% CI 0.69-1.28) when adjusted for sex, age, baseline ASDAS-CRP, smoking status, disease duration, HLA-B27 and prescribed biologic. CONCLUSIONS Although there appeared to be some differences in the baseline characteristics when exploring this cohort according to radiographic status which are likely related to the natural history of the disease, the level of biologic response and drug survival was comparable between nr-axSpA and r-axSpA.
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Affiliation(s)
- Xabier Michelena
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Sizheng Steven Zhao
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Sayam Dubash
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Linda E Dean
- Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, UK
| | - Gareth T Jones
- Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, UK
| | - Helena Marzo-Ortega
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
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