Sex and gender differences in axial spondyloarthritis: myths and truths

Value of the central sensitisation inventory in patients with axial spondyloarthritis

BACKGROUND

In many patients with axial spondyloarthritis (axSpA), pain persists despite anti-inflammatory medication. Quantitative sensory testing (QST) indirectly assesses altered somatosensory function, though its clinical practicality is limited. The Central Sensitisation Inventory (CSI) could be an alternative in the initial assessment of central sensitisation (CS). This study aimed to investigate the value of the CSI in evaluating CS in patients with axSpA by (1) assessing somatosensory function related to CS with QST and (2) exploring associations between CSI, QST, patient and disease characteristics and pain-related psychosocial factors.

METHODS

Consecutive outpatients from the Groningen Leeuwarden AxSpA cohort underwent QST, including pressure pain threshold (PPT), temporal summation (TS) and conditioned pain modulation (CPM). Participants completed questionnaires assessing CS (CSI), illness perception (Revised Illness Perception Questionnaire, IPQ-R), pain-related worrying (Pain Catastrophising Scale, PCS), fatigue (Modified Fatigue Impact Scale, MFIS), anxiety/depression (Hospital Anxiety and Depression Scale, HADS) and coping. QST measurements were stratified for CSI≥40.

RESULTS

201 patients with axSpA were included; 63% male, 64% radiographic axSpA, median symptom duration 12 years (IQR 5-24), mean Axial Spondyloarthritis Disease Activity Score 2.1±1.0. Patients with CSI≥40 had significantly lower PPTs and higher TS than CSI<40 (p<0.004). No significant differences in CPM were observed. In multivariable linear regression, sex, PCS, IPQ-R Identity, MFIS and HADS anxiety were independently associated with CSI (78% explained variance).

CONCLUSION

In this large cross-sectional study in patients with axSpA, the CSI appears as a useful initial CS assessment questionnaire. When CSI scores indicate CS, considering pain-related psychosocial factors is important. These results emphasise the need for a biopsychosocial approach to manage chronic pain in patients with axSpA.

Ixekizumab Treatment Patterns and Health Care Resource Utilization Among Patients with Axial Spondyloarthritis: A Retrospective United States Claims Database Study

INTRODUCTION

Real-world data on ixekizumab utilization in axial spondyloarthritis (axSpA) are limited. We evaluated ixekizumab treatment patterns and health care resource utilization (HCRU) in patients with axSpA using United States Merative L.P. MarketScan® Claims Databases.

METHODS

This retrospective cohort study included adults with axSpA who initiated ixekizumab during the index period (September 2019-December 2021). Index date was the date of the first ixekizumab claim. All patients had continuous medical and pharmacy enrollment during the 12-month pre-index and follow-up periods. Descriptive statistics were used to assess patient demographics (index date); clinical characteristics (pre-index period); treatment patterns (12-month follow-up period); and HCRU (pre-index and 12-month follow-up periods).

RESULTS

The study included 177 patients (mean age 45.8 years; females 54.8%) with axSpA who initiated ixekizumab. Overall, 79.1% of patients reported prior biologic use; of these, 70.7% received tumor necrosis factor-alpha inhibitors (TNFi) and 49% received secukinumab. The mean (standard deviation [SD]) Charlson Comorbidity Index score was 1.1 (1.3) and ~ 27% of patients reported ≥2 comorbidities. The median (inter-quartile range [IQR]) number of ixekizumab prescription refills was 7 (4-11). The mean (SD) Proportion of Days Covered (PDC) for ixekizumab was 0.6 (0.3) and adherence (PDC ≥80%) was 34.5% (N = 61). Overall, 26.6% (N = 47) of patients switched to a non-index medication and 54.2% (N = 96) of patients discontinued ixekizumab. Among the patients who discontinued ixekizumab (N = 96), 19.8% (N = 19) restarted ixekizumab and 49.0% (N = 47) switched to a non-index medication. The median (IQR) ixekizumab persistence was 268 (120-366) days. Mean axSpA-related outpatient, inpatient, and emergency room visits were similar between the pre-index and follow-up periods. Treatment patterns were largely similar between biologic-experienced patients (N = 140; 79.1%) and the overall population.

CONCLUSIONS

Despite high comorbidity burden and majority of the patients being biologic-experienced, patients initiating ixekizumab for axSpA showed favorable persistence profiles during the 12-month follow-up period.

Low Socioeconomic Status and Female Sex are Associated With Worse Functional Status in Axial Spondyloarthritis

OBJECTIVE

We determined whether socioeconomic status (SES) and sex are associated with functional status (FS) in axial spondyloarthritis (axSpA).

METHODS

We conducted a cohort study of patients with axSpA in the Rheumatology Informatics System for Effectiveness registry. We performed cross-sectional and longitudinal analyses of FS through the Multidimensional Health Assessment Questionnaire (MDHAQ) using generalized estimating equation models. Area Deprivation Index (ADI) was used as an SES proxy. The cross-sectional analysis tested for a linear trend across ADI quintiles for MDHAQ. The longitudinal analysis' outcome was functional decline. We reported predictive margins and assessed for interaction with sex. In the longitudinal analysis, we reported odds of functional decline.

RESULTS

In the cross-sectional analysis (N = 5,658), the mean ± SD age was 53.8 ± 15.2 years, 55.8% were female, and 71.4% were non-Hispanic White. The mean ± SD MDHAQ scores were 1.6 ± 2.0 in men versus 2.1 ± 2.2 in women. Predicted mean MDHAQ scores were 2.2 (95% confidence interval [CI] 1.8-2.7) for the lowest ADI quintile and 1.8 (95% CI 1.4-2.1) for the highest. Women had lower FSs compared to men across quintiles. In the longitudinal analysis (n = 2,341), the proportion with FS decline was 14.3% (95% CI 7.6-25.5%) for the lowest SES quintile compared to 9.6% (95% CI 5.2-17.1%) for the highest. Women had 1.7 (95% CI 1.3-2.2) times higher odds of functional decline compared to men. There was no interaction with sex.

CONCLUSION

In this large sample of patients with axSpA, those with lower SES had worse FS and functional decline. Women had worse FS than men, initially and over time.

Progressive improvement in time to diagnosis in axial spondyloarthritis through an integrated referral and education system

Objectives

To assess the delay in the diagnosis of axial SpA (axSpA) in a real-world cohort over a 16-year period and to evaluate factors associated with this delay. We implemented a service improvement project and evaluated its effectiveness in improving time to diagnosis of axSpA.

Methods

A cohort of axSpA patients newly diagnosed between January 2008 and December 2023 were studied. Surveys were carried out in 2013, 2017, 2019 and 2023 to assess time to diagnosis, which was divided into four periods from onset of inflammatory back pain to year of axSpA diagnosis. The time to diagnosis over the study period was analysed using a statistical process control chart.

Results

Over the study period, 988 referrals were received and 366 (37%) had axSpA. There was a progressive increase in the number of females with axSpA. The mean time to diagnosis significantly decreased from 9.8 years (s.d. 1.2) in 2008 to 1.0 years (s.d. 1.0) in 2023. The greatest delay was from the onset of back pain to first seeing their general practitioners (GPs; mean 3.2 years). There was a significant improvement in the mean time to diagnosis across the time periods through the service improvement interventions.

Conclusion

Structural and organizational change in triage, referral and clinic pathways has led to earlier recognition of axSpA. This is further enhanced through an integrated education program and awareness campaign for the public, GPs and healthcare professionals, including physiotherapists. With continuous quality improvement cycles, we achieved our aim of reducing the mean time to diagnosis to 1 year.

Sex Differences in Time to Initiate Nonsteroidal Anti-Inflammatory Drugs or Biologic Disease-Modifying Antirheumatic Drugs Among Patients With Axial Spondyloarthritis

OBJECTIVE

We evaluated sex differences in time to initiation of receiving nonsteroidal anti-inflammatory drugs (NSAIDs) or biologic disease-modifying antirheumatic drugs (bDMARDs) among patients with axial spondyloarthritis (axSpA).

METHODS

Using the 2013 to 2018 IBM MarketScan Database, we identified 174,632 patients with axSpA aged ≥18 years. We evaluated the time between axSpA diagnosis and the first prescription NSAID dispensing (among those with no baseline NSAIDs reception) or bDMARDs infusion/procedure claim (among those who were dispensed two or more different prescription NSAIDs in the baseline period). Adjusted hazard ratios (aHRs) for time to initiation of patients receiving NSAIDs or bDMARDs were computed using survival analyses. Cox proportional hazard models estimated associations between sex and predictors of treatment initiation.

RESULTS

Average age at diagnosis was 48.2 years, 65.7% were female, and 37.8% were dispensed one or more NSAIDs before axSpA diagnosis. Of those who did not receive two or more different prescription NSAIDs before diagnosis, NSAID reception was initiated earlier in female patients than in male patients (NSAID reception initiators: female patients (32.9%), male patients (29.3%); aHR 1.14, 95% confidence interval [CI] 1.11-1.16). Among those who received two or more different prescription NSAIDs in the baseline period, 4.2% received a bDMARD, whereas 77.9% continued receiving NSAIDs after diagnosis. Time to bDMARD reception initiation was longer for female patients than for male patients (aHR 0.61, 95% CI 0.52-0.72), but bDMARDs were received sooner among those who received NSAIDs in the baseline period.

CONCLUSION

Prescription NSAID reception was more common than initiation of receiving bDMARDs among patients newly diagnosed with axSpA. Female patients appeared more likely to continue receiving NSAIDs after diagnosis, and the time to initiation of receiving bDMARDs was longer for female patients than for male patients.

Navigating the complexity of pain in psoriatic arthritis and axial spondyloarthritis

PURPOSE OF REVIEW

Pain is the most common and often most troublesome feature of chronic autoimmune diseases such as psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA). A predominant concept is that the main source of pain is from disease-induced tissue inflammation and structural damage, activating peripheral nerve fibers which relay to the central nervous system. This mechanism is nociceptive pain and the presumption has been that controlling inflammation will be sufficient to reduce this form of pain. However, despite control of inflammation, patients may still have significant residual pain.

RECENT FINDINGS

We are learning that there are additional pain mechanisms, neuropathic and nociplastic, that are often operative in patients with rheumatologic conditions, that can significantly influence pain experience, quantitation of disease activity, and may benefit from therapeutic approaches distinct from immunotherapy. Neuropathic pain arises from diseased or damaged nerve tissue and nociplastic pain reflects sensitization of the central nervous system due to multiple genetic, neurobiologic, neural network dysregulation, and psychosocial factors. Pain arising from these mechanisms influence assessment of disease activity and thus needs to be factored into decision-making about immunotherapy efficacy.

SUMMARY

This review addresses the importance of accurately assessing the complex mechanisms of pain experience in patients with PsA and AxSpA to more appropriately manage immunomodulatory, neuromodulatory, and nonpharmacologic therapies.

Determinants of health-related quality of life and global functioning and health in axSpA, pSpA and PsA: results from the ASAS-PerSpA study

OBJECTIVES

We aimed to identify determinants of health-related quality of life (HRQoL) and global functioning and health (GH) in axial SpA (axSpA), peripheral SpA (pSpA) and (PsA).

METHODS

The ASAS-perSpA study data were analysed. Models for the three patient groups were run separately to explore factors associated with HRQoL and GH, assessed by EQ-5D and ASAS-HI, respectively.

RESULTS

The analyses included 4185 patients: 2719 with axSpA, 433 with pSpA, and 1033 with PsA.In axSpA, disease activity (β = -0.061), physical function (β = -0.041), female sex (β = -0.019) and fibromyalgia (FM) (β = -0.068) were associated with worse HRQoL; age (β = 0.001) and university education (β = 0.014) were associated with better HRQoL. In pSpA, disease activity (β = -0.04) and physical function (β = -0.054) were associated with worse HRQoL. In PsA, disease activity (β = -0.045), physical function (β = -0.053), axial disease (β = -0.041) and female sex (β = -0.028) were associated with worse HRQoL. In axSpA, disease activity (β = 0.889), physical function (β = 0.887), peripheral disease (β = 0.564), female sex (β = 0.812) and FM (β = 1.639) were associated with worse GH; age (β = -0.013) and university education (β = -0.274) were associated with better GH. In pSpA, physical function (β = 1.142) and female sex (β = 1.060) were associated with worse GH; university education (β = -0.611) was associated with better GH. In PsA, disease activity (β = 0.703), physical function (β = 1.025), axial involvement (β = 0.659), female sex (β = 0.924) and FM (β = 1.387) were associated with worse GH; age (β = -0.024) and university education (β = -0.856) were associated with better GH.

CONCLUSION

Disease activity and physical function are major HRQoL and GH determinants across SpA types, and clinical characteristics and sociodemographic factors play an important role, highlighting the importance of a holistic approach for individual patients.

Increased Risk for Pulmonary Embolism among Patients with Ankylosing Spondylitis-Results from a Large Database Analysis

Background: Axial spondyloarthropathy(AS) is a chronic inflammatory disease primarily affecting the axial skeleton, often characterized by sacroiliitis. While pulmonary embolism (PE), a potentially lethal condition, has been linked to several autoimmune diseases, limited data exist regarding PE risk among patients with AS. Methods: This retrospective cohort study utilized the Clalit Healthcare Services (CHS) database, including 5825 patients with AS and 28,356 matched controls. Follow-up began at the date of first AS diagnosis for patients and at the matched patient's diagnosis date for controls and continued until PE diagnosis, death, or study end date. Results: Prevalence of PE before AS diagnosis in patients compared to controls was 0.4% vs. 0.2% (p < 0.01). The incidence rate of PE was 11.6 per 10,000 person-years for patients with AS and 6.8 per 10,000 person-years for controls. The adjusted hazard ratio (HR) for PE in patients with AS was 1.70 (p < 0.001). Subgroup analysis demonstrated excess risk for PE in patients with AS regardless of gender and age, with variations among AS treatment categories. Discussion: Our findings highlight a significant association between AS and PE, indicating an increased risk in patients with AS independent of age and sex and suggests a subclinical level of inflammation. Preliminary results suggest a protective role of immunosuppressing drugs. Further research into the impact of treatment strategies should be conducted and could inform clinical management and reduce the life-threatening risk of PE in Patients with AS.

Construct validity of Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS) treatment target cut-offs in a BASDAI treat-to-target axial spondyloarthritis cohort: a cross-sectional study

OBJECTIVE

In axial spondyloarthritis (axSpA), the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS) are recommended for use in treat-to-target (T2T) strategies. However, BASDAI disease states may be a less suitable T2T instrument than ASDAS, since BASDAI contains non-disease activity related items. The objective of our study was to investigate the construct validity of BASDAI and ASDAS disease states.

METHOD

We performed a single-centre cross-sectional study on BASDAI and ASDAS construct validity in long-term BASDAI T2T-treated axSpA patients. Our hypothesis was that BASDAI is less representative of disease activity than ASDAS owing to the focus on pain and fatigue, and missing an objective item, e.g. C-reactive protein (CRP). This was operationalized using several subhypotheses.

RESULTS

The study included 242 axSpA patients. BASDAI and ASDAS disease states showed a similar relation to Patient Acceptable Symptom State and T2T protocol adherence. The proportions of patients with high BASDAI and ASDAS disease activity fulfilling Central Sensitization Inventory and fibromyalgia syndrome criteria were similar. The correlation with fatigue was moderate for both BASDAI (Spearman's rho 0.64) and ASDAS (Spearman's rho 0.54) disease states. A high ASDAS was strongly correlated with increased CRP (relative risk 6.02, 95% CI 3.0-12.09), while this correlation was not seen for BASDAI (relative risk 1.13, 95% CI 0.74-1.74).

CONCLUSION

Our study showed moderate and comparable construct validity for BASDAI- and ASDAS-based disease activity states, with the expected exception of association with CRP. Therefore, no strong preference can be given for either measure, although the ASDAS seems marginally more valid.

Sex-specific disparities in disease activity scores among patients with axial spondyloarthritis and their implications for evaluating the response to tumor necrosis factor alpha inhibitor therapy

BACKGROUND

We aimed to investigate whether there are sex differences in disease activity measures among patients with axial spondyloarthritis (axSpA) and to determine any potential impact on the assessment of treatment responses to tumor necrosis factor alpha inhibitors (TNFi).

METHODS

Using the Korean College of Rheumatology Biologics and Targeted Therapy (KOBIO) registry data, we compared sex differences in changes in the Bath Ankylosing Spondylitis Disease Activity Score (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS) levels at baseline and one year after TNFi initiation in patients with axSpA.

RESULTS

This study included 1,753 patients with axSpA who started or changed TNFi, of whom 1,343 (76.6%) were male. At baseline, the mean BASDAI and ASDAS scores of all patients were 5.98 and 3.6, respectively. The BASDAI changes between baseline and the one-year follow-up were independently associated with sex (𝛽 = 0.343, p = 0.011), whereas ASDAS was not (𝛽 = 0.079, p = 0.235). When judging the effect of TNFi at one-year of treatment, male patients were more likely to be assessed as effective by the BASDAI-based criterion (ΔBASDAI ≥ 50% or ≥ 2; OR 1.700, 95% CI 1.200-2.406), while the ASDAS-based criterion (ΔASDAS ≥ 1.1) showed no significant difference between sexes (OR 0.993, 95% CI 0.678-1.455), after adjusting for other baseline characteristics.

CONCLUSIONS

The changes in disease activity before and after TNFi use were significantly different between sexes when measured by BASDAI, but not ASDAS. TNFi treatment effects may be interpreted differently between sexes depending on the disease activity measure used.

Sex Differences in the Effectiveness of First-Line Tumor Necrosis Factor Inhibitors in Psoriatic Arthritis: Results From the European Spondyloarthritis Research Collaboration Network

OBJECTIVE

Women with psoriatic arthritis (PsA) may have reduced tumor necrosis factor inhibitor (TNFi) effectiveness compared to men. We examined sex differences in treatment response and retention rates during 24 months of follow-up among patients with PsA initiating their first TNFi.

METHODS

Data from patients with PsA across 13 European Spondyloarthritis Research Collaboration Network registries starting their first TNFi were pooled. Logistic regression was used to analyze the association between sex and treatment response using low disease activity (LDA) according to the Disease Activity Score in 28 joints using the C-reactive protein level (DAS28-CRP) (<3.2) at six months as the primary outcome. Analyses were adjusted for age, country, conventional synthetic disease-modifying antirheumatic drug treatment, and TNFi start year. Retention rates were explored using the Kaplan-Meier estimator.

RESULTS

We analyzed the treatment response of 7,679 patients with PsA (50% women) with available data on LDA at six months. At baseline, women and men had similar characteristics, including mean DAS28-CRP (women vs men, 4.4 [SD 1.2] vs 4.2 [SD 1.2]), though patient-reported outcome measures were worse in women. At six months, 64% of women and 78% of men had LDA (relative risk [RR] 0.82; 95% confidence interval [CI] 0.80-0.84). This difference was similar after adjustment (RR 0.83; 95% CI 0.81-0.85). TNFi retention rates were evaluated in 17,842 patients with PsA. Women had significantly lower retention rates than men at all time points (women 79%, 64%, and 50% vs men 88%, 77%, and 64% at 6, 12, and 24 months, respectively).

CONCLUSION

Despite comparable disease characteristics at baseline, women with PsA have reduced treatment response and retention rates to their first TNFi, highlighting the need to consider sex differences in PsA research and management.

Burden of disease, pain catastrophizing, and central sensitization in relation to work-related issues in young spondyloarthritis patients

Introduction

Spondyloarthritis (SpA) is a common rheumatic inflammatory disease and can impact patients' work productivity. We aimed to evaluate the impact of pain catastrophizing and central sensitization on work outcomes in young SpA patients and determine the predictive factors of work productivity loss.

Material and methods

We performed a cross-sectional study over 6 months. We included patients aged between 18 and 50 years old, diagnosed with axial or peripheral SpA. Pain catastrophizing and central sensitization were assessed using the Pain Catastrophizing Scale (PCS) and Central Sensitization Inventory (CSI) questionnaire, respectively. Impact of SpA on work productivity and activity impairment during and outside of work was measured with the Work Productivity and Activity Impairment Questionnaire (WPAI: Spondyloarthritis).

Results

A total of 72 patients were enrolled, with a median age of 39 years (28.3-46), 65.3% men, and 54.4% working patients. Median scores of activity impairment outside of work, and work productivity loss were 50% (40-70), and 50% (40-60), respectively. Median absenteeism and presenteeism scores were 0% (IQR 0-7), and 100% (IQR 86.5-100), respectively. Regarding work-related outcomes: activity impairment was positively correlated with CSI and PCS; presenteeism was significantly associated with male sex (p = 0.009); and work productivity loss was positively associated with anxiety, depression, and poor quality of life. Multivariate regression analysis identified predictive factors of work productivity loss: male sex, poor quality of life, and prolonged morning stiffness.

Conclusions

Assessment of the impact of pain catastrophizing and central sensitization on work-related outcomes in patients with SpA is important to understand the burden of illness and to identify early those in need of interventions in clinical practice.

A lower frequency of inflammatory back pain in male patients with ankylosing spondylitis compared with female patients

In routine rheumatology practice, we noticed that a significant number of male ankylosing spondylitis (AS) patients did not experience inflammatory back pain (IBP). Based on this observation, we aimed to investigate the prevalence of IBP in male AS patients and compare it to that in female patients. Patients with AS who fulfilled the modified New York criteria were subjected to a face-to-face interview with a standardized questionnaire that addressed the IBP components based on the Berlin criteria. The study also included 63 patients with chronic mechanical back pain (MBP). Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were measured, and Bath Ankylosing Spondylitis Disease Activity, Function, and Metrology Indexes (BASDAI, BASFI, and BASMI) were evaluated in patients with AS. There were 181 patients with AS (124 males, mean age 41.2 years; 57 females, mean age 44.6 years) and 63 patients with MBP (28 males, mean age 47.2 years; 35 females, mean age 43.5 years). The prevalence of IBP was found to be 87.7% in female and 66.1% in male patients with AS (p = 0.002). The specificity of the criteria was determined to be high both in females (85.7%) and males (89.2%). Female patients with AS had higher BASDAI levels than males (p = 0.048), but no difference was found in BASFI, BASMI, or serum CRP levels between genders. A considerable proportion of male patients with AS did not experience IBP, although they had similar CRP levels compared with females.

Sex differential impact of comorbidities in spondyloarthritis: data from COMOSPA study

OBJECTIVES

To describe and compare the prevalence of comorbidities in female and male patients with spondyloarthritis (SpA) and to assess whether comorbidities had a different impact on disease outcomes in male and female patients.

METHODS

This is a post hoc analysis of the COMOrbidities in SPondyloArthritis study. Differences in comorbidities regarding sex were assessed using logistic regression models. Comorbidities were evaluated for their impact on disease outcomes (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS), Bath Ankylosing Spondylitis Functional Index, European health-related quality of life questionnaire) with linear models, which included sex and comorbidity as explanatory variables and their interaction. Age and treatment with biological synthetic disease-modifying antirheumatic drugs were included as confounders.

RESULTS

We included 3982 patients with SpA (65% male, mean age 43.6 years). Male and female patients with SpA exhibited similar comorbidity profiles, except for a low prevalence of fibromyalgia in males and a higher prevalence of certain cardiovascular risk factors in males (hypertension, dyslipidaemia, renal impairment and ischaemic heart disease). Comorbidities, especially fibromyalgia, correlated with higher disease activity, decreased physical function and reduced health-related quality of life in both sexes. Some comorbidities exhibited sex-specific associations with disease outcomes. Peptic ulcers and high waist circumference had a greater impact on disease activity in females (with a higher impact in BASDAI than in ASDAS). In contrast, osteoporosis had a more pronounced effect on physical function in male patients.

CONCLUSIONS

Comorbidities exert distinct influences on disease activity, physical function and health-related quality of life in male and female patients with SpA. Understanding these sex-specific effects is crucial for improving SpA management, emphasising the importance of assessing disease activity using ASDAS when comorbidities are present to mitigate sex-related disparities in disease assessment.

Factors Associated With Residual Disease in Axial Spondyloarthritis: Results From a Clinical Practice Registry

OBJECTIVE

To explore residual disease, defined as substantial symptoms and disease burden despite a remission or low disease activity (LDA) state, in patients with axial spondyloarthritis (axSpA), and to determine which factors are associated with residual disease.

METHODS

For this cross-sectional observational study, 1 timepoint per patient was used from SpA-Net, a web-based monitoring registry for SpA. Patients with an Ankylosing Spondylitis Disease Activity Score (ASDAS) < 2.1 (LDA) were included. Indicators of residual disease (outcomes) included fatigue (primary outcome), pain, physical functioning, health-related quality of life (HRQOL), and peripheral symptoms. Sex was the primary explanatory factor for residual disease. Other explanatory factors included demographics and disease-related factors. Associations between these factors and presence and extent of residual disease were explored using logistic and linear regression.

RESULTS

In total, 267 patients in an LDA state were included. Mean age was 50.6 (SD 14.3) years and 100 (37.5%) were female. Residual disease occurred frequently (n = 114 [42.7%] had fatigue scores > 4/10; n = 34 [17.8%] had pain scores > 4/10), including in those in remission (ASDAS < 1.3). Physical HRQOL was reduced in 27% and moderate/poor in 33%. Multivariable regression analyses showed that reported fatigue was more severe and prevalent in female patients (fatigue severity [0-10]: Bfemale = 0.78, 95% CI 0.18-1.38; fatigue > 4/10: ORfemale = 3.29, 95% CI 1.74-6.20). Other indicators of residual disease (ie, pain, peripheral symptoms, physical HRQOL) were also more severe and/or more prevalent in females.

CONCLUSION

Residual disease is frequent in patients with axSpA who are in an LDA state, including remission, and it is particularly prevalent in female patients. Future studies should address how to manage or prevent residual disease in axSpA.

Diversity, Equity, and Inclusion: Sex and Gender and Intersectionality With Race and Ethnicity in Psoriatic Disease

Sex (biological attributes associated with being male or female) and gender (sociocultural-driven traits and behaviors related to being a man or a woman) are emerging as important determinants of disease course and response to therapy in patients with psoriasis and psoriatic arthritis (PsA). Although psoriatic disease (PsD) is equally prevalent in men and women, the condition affects them in different and unique ways, giving rise to sex- and gender-related differences in clinical presentation, including baseline disease activity, disease course, and response to treatment. Better understanding of the roles sex and gender play in the development and evolution of PsD has the potential to improve patient care. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) continues its effort to highlight issues related to diversity, equity, and inclusion in people with PsD by dedicating a session during the annual meeting to sex and gender and their intersectionality with race and ethnicity in individuals with PsA.

What do we know about co-stimulatory and co-inhibitory immune checkpoint signals in ankylosing spondylitis?

Ankylosing spondylitis is the main entity of a family of inflammatory diseases affecting many musculoskeletal (sacroiliac joints, spine, and peripheral joints) and extra-musculoskeletal sites, termed spondyloarthritis. While it is debated whether disease onset is primarily driven by autoimmune or autoinflammatory processes, what is certain is that both innate and adaptive immune responses orchestrate local and systemic inflammation, which leads to chronic pain and immobility. Immune checkpoint signals are one key player in keeping the immune system in check and in balance, but their role in disease pathogenesis is still rather elusive. Therefore, we ran a MEDLINE search utilizing the PubMed platform for a variety of immune checkpoint signals in regard to ankylosing spondylitis. In this review, we summarize the experimental and genetic data available and evaluate the relevance of immune checkpoint signalling in the pathogenesis of ankylosing spondylitis. Markers such as PD-1 and CTLA-4 have been extensively studied and facilitate the concept of an impaired negative immune regulation in ankylosing spondylitis. Other markers are either neglected completely or insufficiently examined, and the data is conflicting. Still, some of those markers remain interesting targets to decipher the pathogenesis of ankylosing spondylitis and to develop new treatment strategies.

A comparison of the clinical characteristics and quality of life of male and female patients with non-radiographic axial spondyloarthritis

OBJECTIVE

The aim of this study was to compare the clinical characteristics and quality of life of male and female patients with non-radiographic axial spondyloarthritis (nraxSpA) to determine the differences and similarities.

PATIENTS AND METHODS

The study included 100 patients, comprising 50 males and 50 females, aged 18-65 years, who presented at the Rheumatology Clinic and were diagnosed with nr-axSpA according to the Assessment of Spondyloarthritis International Society (ASAS) criteria. The data of patient age, gender, body mass index, disease duration, and drugs used were recorded. Disease activity was evaluated with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), mobility with the Bath Ankylosing Spondylitis Metrology Index (BASMI), functional status with the Bath Ankylosing Spondylitis Functional Index (BASFI), enthesitis with the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), and quality of life with the Ankylosing Spondylitis Quality of Life (ASQoL). The patients with nr- axSpA were separated into groups as male and female, and the demographic and clinical data were compared.

RESULTS

The mean age of female patients was determined to be statistically significantly higher than that of the male patients (39.04 ± 0.70 vs. 34.28 ± 9.26 years, p:0.014). A statistically greater number of male patients were smokers (p:0.007). The disease duration and time since diagnosis were determined to be significantly longer in females than in males (p:0.029, p:0.004). Peripheral arthritis was determined at a significantly higher rate in females (p < 0.001). The MASES score was 2.66 ± 3.46 in females and 0.52 ± 1.03 in males, and the difference was statistically significant (p < 0.001). The BASDAI score was significantly higher in females (3.74 ± 2.35) than in males (2.88 ± 1.95) (p:0.05). No statistically significant difference was determined between the two groups in respect of BASFI, BASMI, ASQoL, and other parameters.

CONCLUSION

The results showed older age, longer disease duration and time to diagnosis, higher rates of peripheral arthritis, and higher MASES and BASDAI scores in the female patients. Thus, there are some differences between male and female patients. Further studies should determine what kind of changes these differences will make in the clinical status, follow-up and treatment of patients.

Quality of Life and Related Factors in Patients With Ankylosing Spondylitis: A Cross-Sectional Study Using 36-Item Short Form Survey (SF-36)

BACKGROUND

 Ankylosing spondylitis is a chronic condition that affects the vertebral and sacroiliac joints, causing progressive back pain and stiffness. Patients with this condition experience a lower quality of life compared to the general population, with physical health being more impacted than mental health. In Vietnam, little attention has been given to the quality of life of patients with ankylosing spondylitis, and there are conflicting studies on the factors that affect their quality of life. Therefore, it is essential to assess the quality of life of these patients to provide appropriate recommendations for improving their overall well-being.

METHODOLOGY

The descriptive cross-sectional study was conducted on patients with ankylosing spondylitis who visited University Medical Center Ho Chi Minh City from March 2022 to May 2022. Participants were interviewed face-to-face using the 36-item short form survey (SF-36) questionnaire and the visual analogue scale. In addition, some information related to ankylosing spondylitis was also collected through medical records.

RESULTS AND CONCLUSION

Seventy-five patients met the inclusion criteria with a median age of 33 (26 - 37); men accounted for 68%. The mean physical and mental health scores on the SF-36 scale were 37.73 ± 9.30 and 47.04 ± 7.11, respectively. Young age, lower pain score and duration of illness, and higher education were associated with a high physical health score with p<0.05. Similarly, the educational level and occupation were positively correlated, and pain scores were inversely correlated with mental health with p< 0.05.

Burden of disease and impact on quality of life in chronic back pain - a comparative cross-sectional study of 150 axial spondyloarthritis and 150 orthopedic back pain patients

Objective

Chronic back pain (CBP) constitutes one of the most common complaints in primary care and a leading cause of disability worldwide. CBP may be of mechanical or inflammatory character and may lead to functional impairment and reduced quality of life. In this study, we aimed to assess and compare burden of disease, functional capacity, quality of life and depressive symptoms in axial spondyloarthritis (axSpA) patients with orthopedic chronic back pain patients (OBP). We further aimed to identify factors associated with quality of life.

Methods

Cross-sectional survey of a cohort of 300 CBP patients including 150 patients from a University Hospital Orthopedic Back Pain Outpatient Clinic with OBP and 150 patients with confirmed axSpA from a University Hospital Rheumatology Outpatient Clinic. Questionnaire-based assessment of pain character (Inflammatory Back Pain, MAIL-Scale), functional status (FFbH, BASFI), quality of life (WHOQOL-Bref) and depressive symptoms (Phq9) and retrospective medical chart analysis.

Results

Both, OBP and axSpA patients reported on average intermediate pain levels of mostly mixed pain character. Both groups demonstrated a reduced health-related quality of life and the presence of depressive symptoms. However, axSpA patients reported a significantly better subjective quality of life, more satisfaction with their health status and better functional capacity compared to OBP patients (all p < 0.001). In a multivariate regression model, depressive symptoms, mechanical back pain, pain level and age were negative predictors of subjective quality of life, whereas functional capacity was a positive predictor.

Conclusion

Chronic back pain was associated with a high morbidity and reduced quality of life regardless of pain character. We identified multiple factors associated with reduced quality of life. Awareness and addressing of these factors may help to overcome unmet needs and improve quality of life for these patients.

The influence of alexithymia on disease activity and quality of life in patients with axial spondyloarthritis: A cross-sectional study

OBJECTIVE

To evaluate the prevalence of alexithymia and its influence on disease activity, quality of life, and clinical outcomes in axial spondyloarthritis (axSpA) patients.

PATIENTS AND METHODS

This cross-sectional study included 110 (59 men and 51 women) consecutive axSpA patients who agreed to participate at our rheumatology outpatient clinic. Patient demographics, pain, disease activity measures, functionality, quality of life, alexithymia, psychological status, neuropathic pain, and fibromyalgia were evaluated. Patients were divided into 2 groups (without vs with alexithymia) and compared. The risk factors for alexithymia were evaluated.

RESULTS

The prevalence of alexithymia in axSpA patients was 31.8% according to a Toronto Alexithymia Scale-20 cutoff of ≥61. The mean age and body mass index of patients were 41.25 ± 9.64 years and 27.73 ± 4.51 kg/m² , respectively. Most patients with alexithymia were women. Patients with alexithymia had significantly high scores for depression, anxiety, fibromyalgia, disease activity, enthesitis, worse quality of life, and poor functionality (all P < 0.05). Female gender (odds ratio [OR] = 22.359), patient global assessment (OR = 7.873), Bath Ankylosing Spondylitis Functional Index (OR = 1.864), and fibromyalgia symptom severity (OR = 1.303) were found to be independent risk factors for alexithymia.

CONCLUSION

The present study results showed that about one-third of axSpA patients had alexithymia, and the patients with alexithymia had higher disease activity, worse quality of life, and worse functional status than those without alexithymia. Female gender, patient global assessment, functional status, and fibromyalgia symptom severity were found to be important contributing factors to alexithymia.

Effectiveness and safety of secukinumab in ankylosing spondylitis and psoriatic arthritis: a 52-week real-life study in an Italian cohort

BACKGROUND

Secukinumab has shown high efficacy in randomized controlled trials in both ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Here, we investigated its real-life effectiveness and tolerability in a cohort of AS and PsA patients.

METHODS

We retrospectively analyzed medical records of outpatients with AS or PsA treated with secukinumab between December 2017 and December 2019. ASDAS-CRP and DAS28-CRP scores were used to measure axial and peripheral disease activity in AS and PsA, respectively. Data were collected at baseline and after 8, 24, and 52 weeks of treatment.

RESULTS

Eighty-five adult patients with active disease (29 with AS and 56 with PsA; 23 males and 62 females) were treated. Overall, mean disease duration was 6.7 years and biologic-naïve patients were 85%. Significant reductions in ASDAS-CRP and DAS28-CRP were observed at all time-points. Body weight (in AS) and disease activity status at baseline (particularly in PsA) significantly affected disease activity changes. ASDAS-defined inactive disease and DAS28-defined remission were achieved in comparable proportions between AS and PsA patients, at both 24 weeks (45% and 46%) and 52 weeks (65.5% and 68%, respectively); male sex was found an independent predictor of positive response (OR 5.16, P = 0.027). After 52 weeks, achievement of at least low disease activity and drug retention were observed in 75% of patients. Secukinumab was well-tolerated and only mild injection-site reactions were recorded in 4 patients.

CONCLUSION

In a real-world setting, secukinumab confirmed great effectiveness and safety in both AS and PsA patients. The influence of gender on treatment response deserves further attention.

Spondyloarthritis and Sarcopenia: Prevalence of Probable Sarcopenia and its Impact on Disease Burden: The Saspar Study

To evaluate the prevalence of probable, confirmed, and severe sarcopenia in spondyloarthritis (SpA), according to the European Working Group on Sarcopenia in Older People 2019 (EWGSOP2) definition. A total of 103 patients (51% women) with SpA, mean age 47.1 ± 13.7 years, were included and compared to 103 age- and sex-matched controls. Grip strength was measured by dynamometry. Body composition was assessed by whole-body densitometry. In SpA patients gait speed was measured by the 4-m-distance walk test and quality of life was evaluated with a specific health-related questionnaire for sarcopenia (SaRQoL®). Twenty-two SpA patients (21%) versus 7 controls (7%) had a low grip strength, i.e., probable sarcopenia (p < 0.01), 15 SpA (15%) patients and 7 controls (7%) had low Skeletal Muscle mass Index (SMI) (ns), respectively, and 5 and 2% of SpA patients and controls had low grip strength and low SMI, i.e., confirmed sarcopenia (ns). All the sarcopenic SpA patients had a low gait speed, i.e., severe sarcopenia. Finally, probable sarcopenic SpA patients had significantly higher C-Reactive Protein (CRP, p < 0.001) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI score, p < 0.01), lower gait speed (p < 0.001), and SarQoL® score (p < 0.001) than SpA patients with normal grip strength. According to EWGSOP2 definition, the prevalence of probable sarcopenia was significantly higher in SpA patients compared to controls. Probable sarcopenia was associated with higher inflammation and disease activity, impaired muscle performance, and quality of life. These results suggest that muscle strength may be a salient hallmark in SpA.

Worse scores but similar patterns of disease activity: interpreting outcomes in women with axial spondyloarthropathy

OBJECTIVE

The aim of this study was to evaluate the impact of sex on disease activity in axial spondylitis (axSpA).

METHOD

Data were extracted from the Ankylosing Spondylitis Registry of Ireland (ASRI). In this cross-sectional study, patients were analysed on the basis of sex, with a series of comparison analyses performed.

RESULTS

Overall, 886 participants were enrolled in the ASRI [232 (26.2%) women, 644 (72.6%) men]. Females recorded significantly worse Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (4.57 vs 3.83, p < 0.01) and Ankylosing Spondylitis Quality of Life questionnaire (ASQoL) (7.51 vs 6.12, p < 0.01) scores than males. There was a stronger correlation in the Bath Ankylosing Spondylitis Functional and Metrology Indices (BASFI and BASMI) in females (r_s = 0.619, p < 0.01) than in males (r_s = 0.572, p < 0.01). Analysis of factors in BASDAI revealed that the higher total scores in females compared to males were due not to any single component, but to worse scores in all six components of the BASDAI combined. Ranking of components by severity between sexes revealed identical ranking in four of the six components of the BASDAI.

CONCLUSIONS

Women with axSpA reported significantly worse disease activity, quality of life, and functional ability than men. However, the BASDAI capturedsimilar patterns of disease activity. Limitation of spinal mobility in women with axSpA corresponded to greater impairment in functional ability. Further evaluation of disease monitoring tools is required to ensure that disease activity is accurately captured in men and women with axSpA.

Identifying frailty and its associated factors in patients with axial spondyloarthritis

BACKGROUND AND AIM

Frailty is an elderly people phenomenon; however, younger adults with comorbidities may show a higher trajectory of frailty toward older age. The frailty status of middle-aged patients with axial spondyloarthritis (axSpA) remains little researched. We aimed to identify frailty status and to investigate the association of clinical, sociodemographic, and psychosocial factors with frailty.

METHODS

This study included 114 patients aged between 40 and 65 years. The patients were classified as frail, pre-frail, and robust according to Fried's phenotype and the Kihon Checklist (KCL). Physical function, quality of life, depression, anxiety, and disease-related factors were assessed. Between-group comparisons and multinomial logistic regression analysis were performed.

RESULTS

Frailty and pre-frailty prevalences were 20.2% and 49.1% for Fried's phenotype and 36.0% and 33.3% for the KCL. Frail adults had impaired physical function and increased disease activity compared to pre-frail and robust patients. Adjusted multinomial logistic regression analysis revealed that disease activity (odds ratio [OR] = 1.62, 95% CI = 1.12-2.34) and Short Physical Performance Battery (OR = 0.32, 95% CI = 0.18-0.56) were associated with Fried's phenotype-determined frailty. Disease activity (OR = 1.91, 95% CI = 1.11-3.26), Bath Ankylosing Spondylitis Functional Index (OR = 2.70, 95% CI = 1.56-4.67), and depression (OR = 1.55, 95% CI = 1.18-2.02) were associated with the KCL determined frailty.

CONCLUSION

Frailty and pre-frailty are commonly detected in middle-aged individuals with axSpA. Our findings highlight a possible need for frailty screening and preventive programs targeting middle-aged axSpA patients.

Female Sex, Age, and Unfavorable Response to Tumor Necrosis Factor Inhibitors in Patients With Axial Spondyloarthritis: Results of Statistical and Artificial Intelligence-Based Data Analyses of a National Multicenter Prospective Registry

OBJECTIVE

Real-world studies are needed to identify factors associated with response to biologic therapies in patients with axial spondyloarthritis (SpA). The objective was to assess sex differences in response to tumor necrosis factor inhibitors (TNFi) and to explore possible risk factors associated with TNFi efficacy.

METHODS

A total of 969 patients with axial SpA (315 females, 654 males) enrolled in the BIOBADASER registry (2000-2019) who initiated a TNFi (first, second, or further lines) were studied. Statistical and artificial intelligence (AI)-based data analyses were used to explore the association of sex differences and other factors to TNFi response, using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), to calculate the BASDAI50, with an improvement of at least 50% of the BASDAI score, and using the Ankylosing Spondylitis Disease Activity Score, calculated using the C-reactive protein level (ASDAS-CRP).

RESULTS

Females had a lower probability of reaching a BASDAI50 response with a first line TNFi treatment at the second year of follow-up (P = 0.018) and a lesser reduction of the ASDAS-CRP at this time point. The logistic regression model showed lower BASDAI50 responses to TNFi in females (P = 0.05). Other factors, such as older age (P = 0.004), were associated with unfavorable responses. The AI data analyses reinforced the idea that age at the beginning of the treatment was the main factor associated with an unfavorable response. The combination of age with other clinical characteristics (female sex or cardiovascular risk factors and events) potentially contributed to an unfavorable response to TNFi.

CONCLUSION

In this national multicenter registry, female sex was associated with less response to a first-line TNFi by the second year of follow-up. A higher age at the start of the TNFi was the main factor associated with an unfavorable response to TNFi.

Disease activity indexes might not capture the same disease aspects in males and females with ankylosing spondylitis: A real-world nationwide analysis

Background

To evaluate gender differences in disease activity and health status (HS) in patients with radiographic axial spondyloarthritis (r-axSpA)/ankylosing spondylitis (AS).

Methods

Ancillary analysis of the MIDAS study, an observational, non-interventional, cross-sectional and retrospective multicenter nationwide study to assess disease activity and its relationship with HS in clinical practice. Adult patients with AS diagnosis, fulfilling ASAS and modified New York criteria, treated for ≥3 months upon study inclusion according to clinical practice were included. The primary outcome was "disease control" assessed by the percentage of patients in remission and low disease activity (BASDAI and ASDAS-CRP scores). HS was evaluated using the ASAS health index (ASAS-HI). Patients' responses and characteristics were analyzed by gender.

Results

We analyzed 313 patients with AS, 237 (75.7%) males and 76 (24.3%) females. A total of 202 (64.5%) patients had adequate disease control (BASDAI < 4); 69.2% of males [mean (SD) BASDAI 2.9 (2.1)] and 50.0% of females [mean (SD) BASDAI 3.8 (2.4); p = 0.01]. According to ASDAS-CRP, 57.5% of patients were adequately controlled (ASDAS-ID +ASDAS-LDA); 138 (58.2%) males and 42 (55.3%) females. The mean (SD) ASDAS-CRP was 1.9 (1.1); being 1.9 (1.0) in males and 2.0 (1.1) in females. Overall, the impact of AS on HS was low to moderate [mean (SD) ASAS-HI 5.8 (4.4)]; being 5.5 (4.4) for males and 6.8 (4.2) for females (p = 0.02).

Conclusion

This study showed a higher proportion of females with AS and active disease using the BASDAI definition. When using the ASDAS-CRP definition these differences by gender were less pronounced. The impact of disease activity on HS appears to be higher in females than males.

Computed tomography-based assessment of radiographic progression in spine and sacroiliac joints after pregnancy in women with radiographic axial spondyloarthritis

Background

Mechanical stress are one of the pathogenesis of axial spondyloarthritis (axSpA). During pregnancy, the mechanical overload on the spine and pelvis increases due to gravid uterus. We aimed to investigate whether pregnancy affects radiographic progression in patients with radiographic axSpA (r-axSpA) based on computed tomography (CT) evaluations.

Materials and methods

This retrospective study included women with r-axSpA aged 19-49 years who underwent at least two CT evaluations of the whole spine and/or sacroiliac joints (SIJs) at intervals of 2-4 years. To compare radiographic progression after delivery, we classified the patients into two groups: delivery group and controls. The delivery group was restricted to women who had the first CT ∼2 years before delivery and the second CT ∼2 years after delivery. The CT Syndesmophyte Score (CTSS) (0-522) and SIJ scores (0-40) were used to evaluate spinal syndesmophytes and erosion, joint space narrowing, and sclerosis of the SIJs.

Results

A total of 21 women in the delivery group and 38 women in the control group were included. The median (Q1-Q3) CTSS at baseline in the delivery group and controls was 19 (16-23) and 20 (13.25-27.75), and the median progression was 1 (0-3) and 0 (0-1) during the median 2.9-year follow-up, respectively. The median (Q1-Q3) SIJ score at baseline in the delivery group and controls was 13 (8-22) and 11 (6-22), and the median progression was 1.5 (0-3) and 1 (0-2), respectively. Using cut-off 0.5, 52.9, and 61.9% of r-axSpA patients and 39.3 and 44.4% of controls showed progression of whole spine and SIJs, respectively. However, no difference in proportion of spinal and SIJ progression and absolute score changes per time point was observed between two groups. Moreover, the SIJ score changes were comparable according to the delivery method.

Conclusion

Pregnancy and delivery do not affect the radiographic progression of the spine and SIJs in women with r-axSpA assessed by CT.

Assessments zur Erhebung des Fitnesszustandes in Therapiegruppen für Personen mit axialer Spondyloarthritis – eine Machbarkeitsstudie

Hintergrund Die Schweizerische Vereinigung Morbus Bechterew hat die Empfehlungen für körperliche Aktivität der europäischen Rheumaliga in einem Gruppentherapie-Konzept für Personen mit axialer Spondyloarthritis (axSpA) umgesetzt. Dieses Konzept beinhaltet neben der Anleitung zum Training in allen 4 Fitnessdimensionen (Ausdauer, Kraft, Beweglichkeit, Neuromotorik) auch Bewegungsberatung und regelmäßige Fitness-Assessments für die Planung und Dokumentation des individuellen Therapiefortschritts sowie für die Qualitätsevaluation der Therapiegruppen.

Ziel Evaluation der Durchführbarkeit der Fitness-Assessments, indem Physiotherapeut*innen (PT) und Gruppenteilnehmende mit axSpA (TNaxSpA) Akzeptanz, Praktikabilität und Integration beurteilen.

Methode Machbarkeitsstudie in 4 Pilottherapiegruppen. PT führten die Assessmentbatterie, bestehend aus a) Chester Step Test (CST) für die aerobe Fitness, b) modifizierter Rumpfkrafttest für die Rumpfkraft, c) Bath Ankylosing Spondylitis Metrology Index (BASMI) für die Beweglichkeit der Wirbelsäule und d) Single Leg Stance Test (SLST) für das Gleichgewicht, mit den TNaxSpA durch. Anschließend bewerteten die PT und TNaxSpA mittels Fragebögen die Akzeptanz, Durchführbarkeit und Integration. Die Durchführbarkeit der Bewertungen wurde anhand von 3 Stufen (I–III) definiert: Bei einer positiven Bewertung von > 80 % (Stufe I) wurde eine bestimmte Bewertung als geeignet angesehen, bei einer positiven Bewertung von 50–80 % (Stufe II) waren Anpassungen erforderlich, bei einer positiven Bewertung von < 50 % (Stufe III) wurde eine bestimmte Bewertung als nicht geeignet für die Gruppenübungstherapie angesehen und es musste eine neue Auswahl getroffen werden.

Ergebnisse Der BASMI wurde von TNaxSpA und PT mit Stufe I bewertet, es waren keine Anpassungen erforderlich. Der CST, SLST und modifizierte Rumpfkrafttest wurden von TNaxSpA mit Stufe I und von PT mit Stufe II bewertet, notwendige Anpassungen wurden entsprechend definiert.

Schlussfolgerung Aus Sicht der Patient*innen wurde die Durchführbarkeit der Tests in Bezug auf Akzeptanz, Durchführbarkeit und Integration positiv bewertet. Aus Sicht der PT waren einige Personen mit axSpA einsetzbar. Auf diese Weise kann der individuelle Fitnesszustand evaluiert und die Interventionen angepasst werden, sodass die Qualität der Gruppenübungstherapie kontinuierlich evaluiert und gegebenenfalls verbessert werden kann.

Sex- and gender-related differences in psoriatic arthritis

Psoriatic arthritis (PsA) is an inflammatory musculoskeletal disease with a chronic, progressive course. Various aspects of PsA, including its clinical features, disease course and response to treatment, are influenced by sociodemographic characteristics of the patient. This includes patient sex, the biological attributes associated with being male or female, and gender, a sociocultural construct that comprises attitudes, traits and behaviours associated with being a man or a woman. An understanding of sex- and gender-related differences in PsA, as well as their underlying mechanisms, is therefore important for individualized care. In this narrative review, the influence of sex and gender on PsA manifestation and course, patient function and quality of life, and their association with comorbidities are described. Sex- and gender-related disparities in response to advanced therapies and their potential underlying mechanisms are delineated. Differences in pathophysiological mechanisms between male and female patients including genetics, immune and hormonal mechanisms are discussed. Finally, fertility and pregnancy outcomes in PsA are outlined. By adopting sex and gender lenses, this review is aimed at highlighting key differences between male and female patients with PsA and uncovering mechanisms underlying these differences, ultimately promoting individualized care of men and women with PsA and informing future research in this area.

The impact of gender and sex on diagnosis, treatment outcomes and health-related quality of life in patients with axial spondyloarthritis

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic condition, historically considered a predominantly male disease. However, increasing evidence suggests a more equal prevalence between men and women. Of the limited research conducted to date, it is apparent that gender differences exist in terms of time to diagnosis, treatment outcomes and health-related quality of life (HRQoL). Despite this, women are underrepresented in clinical trials and most studies do not stratify by gender to identify potential differences in terms of disease manifestations and treatment response. In this perspectives article, we reflect on the potential biological and social factors contributing to these differences and propose three key areas of education and research that should be prioritised in order to address the unmet needs of female patients with axSpA, namely: (1) to identify ways to increase awareness of disease occurrence in female patients among healthcare professionals (HCPs), (2) to improve understanding of gender differences in disease manifestation and outcomes, and (3) to conduct gender-stratified clinical trials with a representative sample of female patients.

Baseline Characteristics and Treatment Response to Ixekizumab Categorised by Sex in Radiographic and Non-radiographic Axial Spondylarthritis Through 52 Weeks: Data from Three Phase III Randomised Controlled Trials

Objectives

Assess baseline characteristics and treatment response to ixekizumab (IXE) categorised by sex in patients with radiographic axial spondyloarthritis (r-axSpA) and non-radiographic axSpA (nr-axSpA) up to 52 weeks.

Methods

Data were analysed from three randomised controlled trials of IXE through 52 weeks. Patients fulfilled ASAS classification criteria for r-axSpA or nr-axSpA and were randomised to receive 80 mg subcutaneous administration of IXE every 2 weeks (Q2W) or 4 weeks (Q4W), or placebo (16 weeks COAST-V/W; 52 weeks COAST-X). Baseline characteristics and treatment outcomes were assessed. Patients were categorised by sex; methods included non-responder imputation for categorical variables, and modified baseline observation carried forward for continuous efficacy variables.

Results

At presentation, female patients had higher disease burden as reflected by significantly higher spinal pain at night, fatigue scores and pain/swelling in joints other than the neck, back or hip. ASAS40 response rate with the approved label dose, IXEQ4W, was achieved in 39% of male patients with r-axSpA by week 16, and 44% by week 52. For female patients, 16.7% and 33.3% achieved ASAS40 at week 16 and 52, respectively. In nr-axSpA, 46% of male patients achieved ASAS40 at week 16 and 30% at week 52. In total, 23.9% of female patients achieved ASAS40 at week 16, and 30.4% at week 52.

Conclusions

This analysis demonstrates that for the axSpA disease spectrum, female patients present with higher disease burden. Following treatment with IXE, there is a higher proportion of male responders up to 16 weeks, while female patients show less robust responses for the first 16 weeks but larger responses from weeks 16 through 52.

Trial Registration Numbers

NCT02696785, NCT02696798 and NCT02757352.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02132-2.

Spondyloarthritis Among Patients With Uveitis: Can We Improve Referral Pathways?

Delays in diagnosis remain a major gap in the care of patients with axial spondyloarthritis (axSpA). Despite efforts to improve awareness among family physicians and nonrheumatologist specialists, the average duration from onset of symptoms to diagnosis of axSpA is approximately 8 years,¹ which is one of the longest in rheumatology. Such delays in diagnosis are associated with late initiation of therapy and worse disease outcomes.

Sex-Based Medicine Meets Psoriatic Arthritis: Lessons Learned and to Learn

Humorally associated autoimmune diseases generally show a female predominance whereas ankylosing spondylitis, a disease that overlaps with psoriatic arthritis (PsA), shows a male predominance. The present review ascertains the current knowledge of sex-specific differences related to psoriatic arthritis (PsA), a chronic, inflammatory condition associated with psoriasis. Sex differences may have important implications for clinical research in PsA and in terms of epidemiology (incidence, prevalence, lifetime risk, survival, and mortality), clinical, radiological, and laboratory features, and response to treatment. While nationwide surveys and large-scale databases and registries show no sex-specific differences, varying male/female ratios have been reported, ranging from 0.42 to 2.75 (comparable with those reported for psoriasis vulgaris: ranging from 0.28 to 2.38). This may reflect subtle, complex, nonlinear interactions between the biological make-up of the individual (genetic and epigenetic differences), hormonal components including menopausal status, environmental exposures including skeletal physical stressing, and psychological variables. There exists methodological heterogeneity and paucity of data concerning sex-specific differences, in terms of the specific population studied, study design, and the diagnostic criteria utilized. Harmonizing and reconciling these discrepancies would be of crucial importance in achieving the ambitious goals of personalized/individualized medicine and further standardized meta-data and Big Data could help disentangle and elucidate the precise mechanisms of underlying potential PsA sex-specific differences.

Increased risks of aortic regurgitation and atrial fibrillation in radiographic axial spondyloarthritis patients: a 10-year nationwide cohort study

Background:

To compare the incidences of aortic regurgitation, atrial fibrillation (AF), and atrioventricular (AV) block II–III between radiographic axial spondyloarthritis (r-axSpA) patients and the general population (GP).

Methods:

National Health Insurance Services data were used. R-axSpA patients (N = 8877) and the age- and sex-matched GP (N = 26,631) were followed from August 2006 to December 2019. Incidence rates and standardized incidence ratios (SIRs) of aortic regurgitation, AF, and AV block II–III were compared between these groups. Ten-year incidence rates and hazard ratios (HRs) were calculated by the Kaplan–Meier method and Cox regression analysis.

Results:

Incidence rates of aortic regurgitation, AV block II–III, and AF in the r-axSpA group were 0.42, 0.21, and 4.0 per 1000 person-years (PYs), respectively. In the r-axSpA group, the SIR for aortic regurgitation was highest among 40- to 49-year-old men (4.11). Incidence rates of aortic regurgitation and AF were higher in the r-axSpA group than in the GP group (0.42 versus 0.18 per 1000 PYs 4.00 versus 3.13 per 1000 PYs, both p < 0.001, respectively), whereas the difference was insignificant for AV block II–III (0.21 versus 0.14 per 1000 PYs, p = 0.222). In multivariate analysis, r-axSpA was associated with a higher hazard (risk) for the development of aortic regurgitation and AF [HR (95% confidence interval) = 2.55 (1.49–4.37) and 1.20 (1.04–1.39), respectively], but the difference was insignificant for AV block II–III [HR (95% confidence interval) = 1.17 (0.59–2.31)].

Conclusions:

Compared with the GP, r-axSpA patients are at increased risk of aortic regurgitation and AF, but not AV block II–III. These patients should be carefully monitored for occurrence of aortic regurgitation and AF.

Managing puerperium in patients with systemic autoimmune diseases: an update

INTRODUCTION

Puerperium is a critical period for patients affected by autoimmune rheumatic diseases for the risk of disease's flares and difficulties in treating lactating mothers. We want to summarize the literature data about psychological and pharmacological management of these patients and possible risk factors of disease's flares.

AREAS COVERED

We made a narrative review on recent studies about puerperium in rheumatic autoimmune diseases patients.

EXPERT OPINION

The physicians involved in management of patients during puerperium and in the follow-up of babies need to agree on maternal treatment because they need to reassure mothers about the safety of the prescribed medications. Furthermore, women with rheumatic diseases could present some musculoskeletal limitations and psychological problems, such as postpartum depression, which can lead to a sense of inadequacy to the mother's task. Families and physicians should be aware of these possible complications and support the new mothers providing correct counseling and practical help.

The CHRONOS Real-World Evidence of Biologic Treatments in Psoriatic Arthritis in Italy: A Post Hoc Gender Analysis

Background: Phenotypic features and outcome differences between sexes have been reported in psoriatic arthritis (PsA). However, little is known about sex differences in effectiveness of biologics in clinical practice. Methods: Post hoc gender analysis of the CHRONOS, a multicenter, noninterventional, retroprospective Italian real-world study assessing 6-month and 1-year effectiveness of biologics for PsA. Results: Eligible patients were 399, 43.1% men. Sociodemographic characteristics, type of arthritis, baseline Disease Activity Score 28 joints (DAS28), and duration of biologic treatment were rather homogeneous. More men were overweight/obese and naive to biologics. The most frequently used biologics were TNF-inhibitors and secukinumab in both sexes. DAS28 responders were 72.7% (women) and 70.5% (men) at 6 months, and 68.0% in both sexes at 1 year. American College of Rheumatology (ACR) response showed a trend for men versus women to achieve more frequently ACR50 (32.6% vs. 26.5% at 6 months; 34.9% vs. 20.0% at 1 year) and ACR70 (22.3% vs. 12.4% at 6 months and 25.0% vs. 13.0% at 1 year). Global satisfaction with treatment at enrollment and after 6 months was slightly higher among men [mean (standard deviation) Treatment Satisfaction Questionnaire for Medication-9 (TSQM-9) score: 68.6 (18.6) and 69.9 (18.2), respectively] than women [65.3 (18.2), 66.2 (18.5)]. Conclusions: Overall response to biologics for PsA was rather favorable. With similar baseline disease severity, men appear to have a somewhat earlier and better response with higher treatment satisfaction.

Advances in treatment of axial spondyloarthritis are associated with improved patient outcomes: data from the Ankylosing Spondylitis Registry of Ireland (ASRI)

The Ankylosing Spondylitis Registry of Ireland (ASRI) captures both radiographic and non-radiographic axial spondyloarthritis (axSpA) in a large, well characterised cohort. This is a valuable resource for studies in therapeutics and burden of disease, following a period of rapid change in the field of axSpA. This study aims to perform a focused analysis on patient outcomes and pattern of medication usage in axSpA. This is a cross-sectional study of registry data on 885 patients with confirmed axSpA as per the ASAS criteria for axSpA, as diagnosed by a Rheumatologist. Analysis was performed using IBM SPSS version 26. Patients were analysed on the basis of treatment categorised as: no medication, NSAIDs, biologics or combination therapy. Statistical significance was indicated by p value of < 0.05. Currently 885 patients are enrolled in the ASRI, made up of 72.5% (642) males and 26.9% (238) females. The majority of the cohort was categorized as radiographic axSpA 78.3% (693), with 21.7% (192) meeting criteria for non-radiographic disease. Overall 40.6% (359) reported at least one comorbidity. Older age was associated with no medications compared to those on biologic therapy (50.3 vs 45, p = 0.01). Lower levels of disease activity and higher quality of life were noted in those on biologics as compared to NSAIDs alone. This analysis provides detailed epidemiological data on axSpA from a large national registry. These results detail significant differences in prescribing patterns and impact on patient outcomes in axSpA. Ongoing development of registries provides a valuable insight into the real-world effects of axSpA.

Striking sex differences in magnetic resonance imaging findings in the sacroiliac joints in the population

Background

In patients with axial spondyloarthritis (axSpA), magnetic resonance imaging (MRI) is used to detect bone marrow edema (BME) in sacroiliac joints (SIJ) but SIJ BME are also detected in the population. Not much is known about sex differences in that regard.

Objective

To explore sex-specific differences associated with the extent of BME in the SIJ suggestive of axSpA in a general population cohort study.

Methods

Taking advantage of 793 recently evaluated MRIs of subjects < 45 years taking part in the SHIP cohort, we used negative-binomial (NB) count data regression to analyze factors associated with the extent of SIJ BME. Predictors were explored by model-based boosting (MBB), a machine learning approach.

Results

Estimates of NB regression showed strong effects of sex in interaction with age, BMI, back pain, and particularly HLA-B27. The NB regression model showed incidence rate ratios (IRR) for the main effect of sex (females vs. males): 0.94 [95% CI: 0.63; 1.41], HLA-B27: 4.32 [2.09; 9.8], and for the interaction of sex to HLA-B27: 0.22 [0.06; 0.75]. According to MBB, HLA-B27 positivity, BMI, current smoking, back pain in the last 3 months, the interaction of sex and HLA-B27, and delivery in the last 12 months were of highest importance to explain the extent of SIJ BME.

Conclusions

Different factors were associated with the extent of SIJ BME in females and males. Most importantly, HLA-B27 was relevant only in males but not in females in whom a postpartal state was important. This finding may be relevant for the pathogenesis of axSpA.

Spinal Fractures in Ankylosing Spondylitis: Patterns, Management, and Complications in the United States - Analysis of Latest Nationwide Inpatient Sample Data

Objective

Ankylosing spondylitis (AS) is a rheumatic inflammatory disease marked by chronic inflammation of the axial skeleton. This condition, particularly when severe, can lead to increased risk of vertebral fractures attributed to decreased ability of the stiffened spinal column to sustain normal loads. However, little focus has been placed on understanding the locations of spinal fractures and associated complications and assessing the correlation between these. In this review, we aim to summarize the complications and treatment patterns in the United States in AS patients with spinal fractures, using the latest Nationwide Inpatient Sample (NIS) database (2016–2018).

Methods

We analyzed the NIS data of years 2016–2018 to compare the fracture patterns and complications.

Results

A total of 5,385 patients were included. The mean age was 71.63 years (standard deviation [SD], 13.21), with male predominance (83.8%). The most common population is Whites (77.4%), followed by Hispanics (7.9%). The most common fracture level was thoracic level (58.3%), followed by cervical level (38%). Multiple fracture levels were found in 13.3% of the patients. Spinal cord injury (SCI) was associated with 15.8% of the patients. The cervical level had a higher proportion of SCI (26.5%), followed by thoracic level (9.2%). The mean Elixhauser comorbidity score was 4.82 (SD, 2.17). A total of 2,365 patients (43.9%) underwent surgical treatment for the fractures. The overall complication rate was 40.8%. Respiratory complications, including pneumonia and respiratory insufficiency, were the predominant complications in the overall cohort. Based on the regression analysis, there was no significant difference (p=0.45) in the complication rates based on the levels. The presence of SCI increased the odds of having a complication by 2.164 times (95% confidence interval, 1.722–2.72; p≤0.001), and an increase in Elixhauser comorbidity score predicted the complication and in-hospital mortality rate (p≤0.001).

Conclusion

AS patients with spinal fractures have higher postoperative complications than the general population. The most common fracture location was thoracic in our study, although it differs with few studies, with SCI occurring in 1/6th of the patients.

Spondyloarthritides: Theories and beyond

Spondyloarthritides (SpA) are a family of interrelated rheumatic disorders with a typical disease onset ranging from childhood to middle age. If left untreated, they lead to a severe decrease in patients' quality of life. A succesfull treatment strategy starts with an accurate diagnosis which is achieved through careful analysis of medical symptoms. Classification criterias are used to this process and are updated on a regular basis. Although there is a lack of definite knowledge on the disease etiology of SpA, several studies have paved the way for understanding plausible risk factors and developing treatment strategies. The significant increase of HLA-B27 positivity in SpA patients makes it a strong candidate as a predisposing factor and several theories have been proposed to explain HLA-B27 driven disease progression. However, the presence of HLA-B27 negative patients underlines the presence of additional risk factors. The current treatment options for SpAs are Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), TNF inhibitors (TNFis), Disease-Modifying Anti-Rheumatic Drugs (DMARDs) and physiotherapy yet there are ongoing clinical trials. Anti IL17 drugs and targeted synthetic DMARDs such as JAK inhibitors are also emerging as treatment alternatives. This review discusses the current diagnosis criteria, treatment options and gives an overview of the previous findings and theories to clarify the possible contributors to SpA pathogenesis with a focus on Ankylosing Spondylitis (AS) and enthesitis-related arthritis (ERA).

The Need for SPACE to Plan the Future for Spondyloarthritis

"Lifestyle Factors and Disease Activity Over Time in Early Axial Spondyloarthritis: The SPondyloArthritis Caught Early (SPACE) Cohort" by Exarchou et al aimed at looking at the importance of baseline lifestyle factors of BMI, smoking, and alcohol consumption (AC) on disease activity in recent-onset axial spondyloarthritis (axSpA).¹ Does this study add to our knowledge of the natural history of axSpA?

Gender Differences in Ankylosing Spondylitis Patients with Advanced Hip Involvement: Results from A Matched Retrospective Cohort Study

Objective

To determine the gender differences in ankylosing spondylitis (AS) patients with advanced hip involvement.

Methods

We retrospectively analyzed the 373 consecutive AS patients with advanced hip involvement from 2012 to 2017 and divided them into two groups by sex with 340 men and 33 women. Research data on hip involvement in the patients were obtained from medical records and radiographs. The severity of radiographic hip involvement was evaluated by the Bath Ankylosing Spondylitis Radiology Hip Index (BASRI‐hip) scoring system. The data on clinical characteristics, radiographic hip involvement, and laboratory values were compared between the two groups. The comparison was performed again between the two groups after adjusting for the onset age and disease duration by propensity score matching (PSM).

Results

Men underwent total hip arthroplasty earlier than women in the patients, with a median age of 31 years (range, 19–67 years) vs 36 years (range, 23–67 years), respectively (P < 0.05). Hip involvement was found to be younger in men than that in women, with a median age of 18 years (range, 7–56 years) vs 23 years (range, 5–55 years) (P < 0.05), and men with bilateral onset in hips had a higher frequency than women with that (66.2% vs 39.4%) (P < 0.05). There was no gender difference in the proportion of bilateral advanced hip involvement (85.3% vs 72.7%) (P > 0.05). The proportion of the patients who had spinal involvement (89.1% vs 69.7%), flexion contracture in the hip (43.8% vs 24.2%), hip range of motion =0° (53.5% vs 30.3%), and an elevated level of C‐reactive protein (CRP) (69.1% vs 51.5%) was significantly higher in men than that in women (P < 0.05). After adjusting for the onset age and disease duration by PSM (1:1), men with bilateral onset in hips still had a higher frequency than women with that (76.7% vs 40.0%), and the proportion of the patients who had spinal involvement (90.0% vs 66.7%) and an elevated level of CRP (80.0% vs 53.3%) was significantly higher in men than that in women (P < 0.05).

Conclusions

The disease pattern of hip involvement in AS has gender differences, with bilateral onset being the dominant pattern in men and unilateral onset being more common in women. However, the frequency of bilateral advanced hip involvement has no gender difference eventually. The higher prevalence of spinal involvement in men with AS may be responsible for the more severe functional impairment compared with women.

Sex-associated and gender-associated differences in the diagnosis and management of axial spondyloarthritis: addressing the unmet needs of female patients

Emerging evidence suggests that axial spondyloarthritis (axSpA) should not be seen as a predominantly male disease, as the non-radiographic form occurs with roughly equal frequency in women and men. However, men and women experience this disease differently. The purpose of this review is to highlight sex-associated and gender-associated differences in the patient's journey through the diagnosis and management of axSpA, in order to increase the awareness about the unmet needs of female axSpA patients.Female patients experience a longer diagnostic delay compared with men, possibly due to the different pattern of clinical presentations across genders. Therefore, it is crucial to sensitise physicians to pay attention and identify the red flags of axSpA in women and promote early referral to a rheumatologist. Women with a diagnosis of axSpA experience greater limitations in physical function, although they have less structural spinal damage compared with men. Women tend to have less adherence and a lower response to treatment, so more gender-oriented data are needed about drugs used for axSpA, especially biological disease-modifying antirheumatic drugs.Lifestyle factors have a strong impact on the disease course. Interventions regarding physical activity, smoking cessation and diet should be communicated to the patients, with particular attention to the gender-related cultural background.Patients of childbearing age living with axSpA should be engaged in a discussion about reproductive health, in terms of preservation of fertility, management of pregnancy and delivery and use of biologic drugs during pregnancy and breastfeeding.

Central Sensıtızatıon ın Axıal Spondyloarthrıtıs: An Exploratıve Study wıth Quantıtatıve Sensory Testıng and Clınıcal Scales

OBJECTIVE

To evaluate the central sensitization (CS) and the related parameters in patients with axial spondyloarthritis (axSpA).

METHODS

Quantitative sensory testing (QST) which consists of pressure pain threshold (PPT), temporal summation (TS), and conditioned pain modulation (CPM) were applied to the participants. Disease activity, functional status, sleep quality, pain, depression, and fatigue were assessed. Patients were divided as the ones with and without CS according to the central sensitization inventory (CSI) and the results were compared.

RESULTS

One hundred patients and fifty controls were recruited. Sixty axSpA patients had CS. When QST results were compared between the patient and control groups, all PPT scores were found lower (p<0.05) in patients. Regarding the comparison of the patients with and without CS, sacroiliac, and trapezius PPT scores were found lower in the patients with CS (p<0.05). On the other hand, there was no significant difference in the mean TS scores (p>0.05) between patients and controls, and in patients with and without CS. All investigated comorbidities were found to be significantly more frequent (p<0.001) in the patients with CS. In regression analysis female gender, morning stiffness duration, CPM, depression, and fatigue were detected as related parameters with CSI scores.

CONCLUSION

CS and related comorbidities were found to be increased in axSpA patients. This increase should be taken into consideration in the management of these patients.

Effectiveness and cost-effectiveness of longstanding exercise therapy versus usual care in patients with axial spondyloarthritis or rheumatoid arthritis and severe limitations: The protocols of two parallel randomized controlled trials

Objectives

Research on effectiveness and cost‐effectiveness of longstanding exercise therapy in patients with axial SpondyloArthritis (axSpA) or Rheumatoid Arthritis (RA) is scarce, and mainly concerned patients with a relatively favorable health status. We aim to evaluate the effectiveness and cost‐effectiveness of longstanding exercise therapy compared to usual care in the subgroup of patients with axSpA or RA and severe limitations in functioning.

Methods

In two separate, parallel randomized controlled trials the effectiveness and cost‐effectiveness of longstanding, active exercise therapy (52 weeks) compared with usual care (1:1) will be evaluated. The longstanding, active exercise therapy will focus on improving individual limitations in daily activities and participation and will be given by a trained physical therapist in the vicinity of the participant. For each diagnosis, 215 patients with severe limitations in activities and participation will be included. Assessments are performed at baseline, 12, 26, and 52 weeks. The primary outcome measure of effectiveness is the individual level of functioning (activities and participation), as measured with the Patient‐Specific Complaints instrument at 52 weeks. For cost‐effectiveness analyses, the EuroQol (EQ‐5D‐5L) and questionnaires on healthcare use and productivity will be administered. The economic evaluation will be a cost‐utility analysis from a societal perspective. After 52 weeks, the patients in the usual care group are offered longstanding, active exercise therapy as well. Follow‐up assessments are done at 104, 156, and 208 weeks.

Conclusion

The results of these studies will provide insights in the effectiveness and cost‐effectiveness of longstanding exercise therapy in the subgroup of axSpA and RA patients with severe functional limitations.

Disease activity in women with ankylosing spondylitis remains higher under Tumour Necrosis Factor inhibitor treatment than in men: a five-year observational study

OBJECTIVE

To assess sex differences in response, level of disease activity, and drug survival in tumour necrosis factor inhibitor (TNFi)-naïve ankylosing spondylitis (AS) patients.

METHOD

Consecutive AS patients, fulfilling the modified New York criteria, were included in a prospective cohort study at initiation of the first TNFi and followed until this medication was stopped (drug survival). Disease activity scores [AS Disease Activity Score using C-reactive protein (ASDAS-CRP), Bath AS Disease Activity Index (BASDAI), and CRP] were measured at 3, 6, and 12 months, and every subsequent year, up to 5 years. The response was defined by the ASDAS-CRP response criteria (clinically important improvement: ASDAS-CRP decrease ≥ 1.1). Analyses included regression methods for repeated measurements and survival analyses.

RESULTS

Overall, 356 patients were included (34% women, mean ± sd age 46 ± 12 years), with a median disease duration of 12 (interquartile range 6;20) years. Women were less likely than men to achieve a clinically important response after 6 months of TNFi treatment (47% vs 64%; relative risk 1.4, 95% confidence interval (CI) 1.1;1.9, p = 0.02], despite a lack of sex differences in mean ASDAS-CRP levels over 5 year follow-up. Adjusted models for BASDAI over 5 years showed that women had a 0.6 point higher BASDAI score than men (β = 0.6 0.1;1.1 <0.02). Numerically, more women than men discontinued treatment over a period of 5 years (hazard ratio = 1.5, 95% CI 0.9;2.5, p = 0.15).

CONCLUSION

Female AS patients show a lower response to TNFi and a higher disease activity compared to men.