The interaction between host genetics and the microbiome in the pathogenesis of spondyloarthropathies

6-formylindolo[3, 2-b]carbazole alters gut microbiota and prevents the progression of ankylosing spondylitis in mice

Ankylosing spondylitis (AS), is known as a chronic inflammatory autoimmune disease, there is evidence to suggest that gut microbiota disorders may be related to the occurrence and development of AS. Studies have shown that 6-formylindolo[3, 2-b]carbazole (FICZ) has the ability to modulate intestinal homeostasis and inhibit inflammatory responses. The purpose of this work is to evaluate the protective role of FICZ in treating AS and elucidate potential mechanisms. FICZ was administered to the proteoglycan (PG)-induced AS mice for 7 consecutive weeks. The effects of FICZ on AS mice were evaluated by the disease severity, intestinal histopathology, proinflammatory cytokine levels, and intestinal mucosal barrier function. The gut microbiota compositions were profiled through 16S rDNA high-throughput sequencing. We found that FICZ significantly reduced the severity of AS and resulted in the downregulating of TNF-α and IL-17A inflammatory cytokines. Moreover, FICZ ameliorated pathological changes in the ileal and improved intestinal mucosal barrier function. Furthermore, FICZ altered the composition of the gut microbiota by increasing the Bacteroidetes/Firmicutes phylum ratio and enriched the genes related to "glycan biosynthesis and metabolism", thus reversing the process of AS. In conclusion, FICZ suppressed the progression of AS and altered gut microbiota in AS mice, which provided new insight into AS therapy strategy.

The Link Between Gastrointestinal Microbiome and Ocular Disorders

The gut-eye axis has been hypothesized to be a factor in many eye pathologies. This review examines papers from PubMed about this topic. Bacterial commensals could either be protective by regulating the immune system or prove to be damaging to the gut mucosal wall and incite an inflammatory process. The balance between the two appears to be crucial in maintaining eye health. Imbalances have been implicated in ophthalmologic conditions. The use of probiotics, dietary modifications, antibiotics, and faecal microbiota transplant in mice with pathologies such as those encountered in our practice appears to reverse disease course or at least prevent its progression. Clinical trials are currently underway to investigate their clinical significance in diseased patients.

Axial spondyloarthritis patients have altered mucosal IgA response to oral and fecal microbiota

Axial spondyloarthritis (axSpA) is an inflammatory arthritis involving the spine and the sacroiliac joint with extra-articular manifestations in the eye, gut, and skin. The intestinal microbiota has been implicated as a central environmental component in the pathogenesis of various types of spondyloarthritis including axSpA. Additionally, alterations in the oral microbiota have been shown in various rheumatological conditions, such as rheumatoid arthritis (RA). Therefore, the aim of this study was to investigate whether axSpA patients have an altered immunoglobulin A (IgA) response in the gut and oral microbial communities. We performed 16S rRNA gene (16S) sequencing on IgA positive (IgA⁺) and IgA negative (IgA^-) fractions (IgA-SEQ) from feces (n=17 axSpA; n=14 healthy) and saliva (n=14 axSpA; n=12 healthy), as well as on IgA-unsorted fecal and salivary samples. PICRUSt2 was used to predict microbial metabolic potential in axSpA patients and healthy controls (HCs). IgA-SEQ analyses revealed enrichment of several microbes in the fecal (Akkermansia, Ruminococcaceae, Lachnospira) and salivary (Prevotellaceae, Actinobacillus) microbiome in axSpA patients as compared with HCs. Fecal microbiome from axSpA patients showed a tendency towards increased alpha diversity in IgA⁺ fraction and decreased diversity in IgA^- fraction in comparison with HCs, while the salivary microbiome exhibits a significant decrease in alpha diversity in both IgA⁺ and IgA^- fractions. Increased IgA coating of Clostridiales Family XIII in feces correlated with disease severity. Inferred metagenomic analysis suggests perturbation of metabolites and metabolic pathways for inflammation (oxidative stress, amino acid degradation) and metabolism (propanoate and butanoate) in axSpA patients. Analyses of fecal and salivary microbes from axSpA patients reveal distinct populations of immunoreactive microbes compared to HCs using the IgA-SEQ approach. These bacteria were not identified by comparing their relative abundance alone. Predictive metagenomic analysis revealed perturbation of metabolites/metabolic pathways in axSpA patients. Future studies on these immunoreactive microbes may lead to better understanding of the functional role of IgA in maintaining microbial structure and human health.

The association between intestinal microbiome and autoimmune uveitis

INTRODUCTION AND OBJECTIVES

The microbiome is strongly implicated in a wide spectrum of immune-mediated diseases, whereas gut commensal microbiota plays a pivotal role in immune and intestinal homeostasis.

MATERIALS AND METHODS

A thorough literature search was performed in PubMed database. An additional search was made in Google Scholar to complete the collected items.

RESULTS

Due to complex interactions with the host genetics and other factors, intestinal dysbiosis has been linked to various immune-mediated disorders. In particular, the role of intestinal microbiota in the pathogenesis of uveitis has been demonstrated by several studies, indicating that changes in the microbiome can trigger autoimmune ocular inflammatory processes or affect their severity.

CONCLUSIONS

This review summarizes how alterations in the intestinal microbiota can conduce to immune-mediated ocular pathologies and how microbiome can be targeted in order to form novel therapeutic approaches to treat these severe and potentially blinding conditions.

Gut dysbiosis associated with worse disease activity and physical function in axial spondyloarthritis

BACKGROUND

Based on clinical and genetic associations, axial spondyloarthritis (axSpA) and inflammatory bowel disease (IBD) are suspected to have a linked pathogenesis. Gut dysbiosis, intrinsic to IBD, has also been observed in axSpA. It is, however, not established to what degree gut dysbiosis is associated with axSpA disease severity. The objective of this study was to compare gut dysbiosis frequency between controls, non-radiographic axial spondyloarthritis (nr-axSpA), and ankylosing spondylitis (AS) patients and investigate whether gut dysbiosis is cross-sectionally associated with axSpA disease activity, physical function, mobility, or pain.

METHODS

Gut dysbiosis was assessed by 16SrRNA analysis of feces from 44/88 nr-axSpA/AS patients (ASAS/mNY criteria) without inflammatory bowel disease (IBD) and 46 controls without IBD or rheumatic disease. The GA-map™ Dysbiosis Test was used, grading gut microbiota aberrations on a 1-5 scale, where ≥3 denotes dysbiosis. Proportions with dysbiosis were compared between the groups. Furthermore, standard axSpA measures of disease activity, function, mobility, and pain were compared between patients (nr-axSpA and AS combined) with and without dysbiosis, univariately, and adjusted for relevant confounders (ANCOVA).

RESULTS

Gut dysbiosis was more frequent in AS than controls (36% versus 17%, p=0.023), while nr-axSpA (25% dysbiosis) did not differ significantly from either AS or controls. Univariately, most axSpA measures were significantly worse in patients with dysbiosis versus those without: ASDAS-CRP between-group difference 0.6 (95% CI 0.2-0.9); BASDAI 1.6 (0.8-2.4); evaluator's global disease activity assessment (Likert scale 0-4) 0.3 (0.1-0.5), BASFI 1.5 (0.6-2.4), and VAS pain (cm) 1.3 (0.4-2.2). Differences remained significant after adjustment for demographics, lifestyle factors, treatments, gut inflammation (fecal calprotectin ≥50 mg/kg), and gut symptoms, except for VAS pain. BASMI and CRP were not associated with dysbiosis.

CONCLUSION

Gut dysbiosis, more frequent in AS patients than controls, is associated with worse axSpA disease activity and physical function, seemingly irrespective of both gut inflammation and treatments. This provides further evidence for an important link between disturbances in gastrointestinal homeostasis and axSpA.

Association Between Infections and Risk of Ankylosing Spondylitis: A Systematic Review and Meta-Analysis

Background

Previous literature on the association between infections and the risk of developing ankylosing spondylitis (AS) presented controversial results. This meta-analysis aimed to quantitatively investigate the effect of infections on the risk of AS.

Methods

We searched the PubMed, Embase, and Web of Science databases until March 26, 2021 for analytical epidemiological studies on the association between infections and the risk of AS. Fixed or random effect models were used to calculate total risk estimates based on study heterogeneity. Subgroup analysis, and sensitivity analysis were also performed. Publication bias was estimated using funnel plots and Begg’s test.

Results

Six case-control articles (n=1,296,239) and seven cohort articles (n=7,618,524) were incorporated into our meta-analysis. The pooled odds ratio (OR) from these case-control studies showed that infections were associated with an increased risk of AS (OR=1.46, 95% confidence interval [CI], 1.23–1.73), and the pooled relative risk (RR) from the cohort studies showed the same findings (RR=1.35, 95% CI, 1.12–1.63). Subgroup analysis showed that infections in participants with unadjusted comorbidities (OR=1.66, 95% CI, 1.35–2.03), other types of infection (OR=1.40, 95% CI, 1.15–1.70), and infection of the immune system (OR=1.46, 95% CI, 1.42–1.49) were associated with the risk of AS in case-control studies. In cohort studies, infections with adjusted comorbidities (RR=1.39, 95% CI, 1.15–1.68), viral infection (RR=1.43, 95% CI, 1.22–1.66), other types of infection (RR=1.44, 95% CI, 1.12–1.86), and other sites of infection (RR=1.36, 95% CI, 1.11–1.67) were associated with an increased risk of AS.

Conclusions

The findings of this meta-analysis confirm that infections significantly increase the risks of AS. This is helpful in providing an essential basis for the prevention of AS via the avoidance of infections.

Reactive Arthritis Post-SARS-CoV-2

Reactive arthritis (ReA) following bacterial infection from the urogenital and gastrointestinal tract is widely described but is not typical post-viral infections. This report presents the second case of ReA after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the United States. A 45-year-old black male with chronic low back pain was hospitalized for 45 days with coronavirus disease 2019 (COVID-19), complicated due to the development of multiorgan failure managed with intubation, extracorporeal membrane oxygenation, and hemodialysis. He was subsequently discharged to an acute rehabilitation facility where he complained of new-onset pain in his shoulders, left elbow, and left knee three weeks after a negative SARS-CoV-2 test. He was readmitted from his acute rehabilitation facility due to recurrent fever and the development of a swollen, warm left knee. Laboratory studies at readmission showed elevated inflammatory markers, negative extensive infectious disease workup, and aseptic inflammatory left knee synovial fluid without crystals. Testing returned negative for most common antibodies seen in immune-mediated arthritides (e.g., rheumatoid arthritis, systemic lupus erythematosus), as well as for common respiratory and gastrointestinal tract pathogens responsible for viral arthritis. The multidisciplinary inpatient medical team deemed the clinical presentation and laboratory findings most consistent with ReA. The patient received a course of oral corticosteroids, followed by a second course due to the recurrence of symptoms weeks after initial treatment and recovery. The current body of medical literature on SARS-CoV-2 pathophysiology supports plausible mechanisms on how this infection may induce ReA. Such a scenario should be considered in the differential of COVID-19-recovered patients presenting with polyarthritis as prompt steroid treatment may help patient recovery.

The Emerging World of Microbiome in Autoimmune Disorders: Opportunities and Challenges

Trillions of commensal bacteria colonizing humans (microbiome) have emerged as essential player(s) in human health. The alteration of the same has been linked with diseases including autoimmune disorders such as multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis. Gut bacteria are separated from the host through a physical barrier such as skin or gut epithelial lining. However, the perturbation in the healthy bacterial community (gut dysbiosis) can compromise gut barrier integrity, resulting in translocation of bacterial contents across the epithelial barrier (leaky gut). Bacterial contents such as lipopolysaccharide and bacterial antigens can induce a systemic inflammatory environment through activation and induction of immune cells. The biggest question in the field is whether inflammation causes gut dysbiosis or dysbiosis leads to disease induction or propagation, i.e., it is inside out or outside in or both. In this review, we first discuss the microbiome profiling studies in various autoimmune disorders, followed by a discussion of potential mechanisms through which microbiome is involved in the pathobiology of diseases. A better understanding of the role of the microbiome in health and disease will help us harness the power of commensal bacteria for the development of novel therapeutic agents to treat autoimmune disorders.

Cardiovascular Disease in Spondyloarthritides

The spondyloarthritides are a group of chronic systemic inflammatory joint diseases, the main types being ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Evidence accumulating during the last decades suggests that patients with AS or PsA carry an increased risk for cardiovascular disease and cardiovascular death. This risk appears to be mediated by systemic inflammation over and above classical cardiovascular risk factors. The excess cardiovascular risk in those patients has been formally acknowledged by scientific organizations, which have called physicians' attention to the matter. The application by Rheumatologists of new effective anti-rheumatic treatments and treat-to-target strategies seems to benefit patients from a cardiovascular point of view, as well. However, more data are needed in order to verify whether anti-rheumatic treatments do have an effect on cardiovascular risk and whether there are differences among them in this regard. Most importantly, a higher level of awareness of the cardiovascular risk is needed among patients and healthcare providers, better tools to recognize at-risk patients and, ultimately, commitment to address in parallel both the musculoskeletal and the cardiovascular aspect of the disease.

Baseline gut microbiome composition predicts metformin therapy short-term efficacy in newly diagnosed type 2 diabetes patients

Background

The study was conducted to investigate the effects of metformin treatment on the human gut microbiome’s taxonomic and functional profile in the Latvian population, and to evaluate the correlation of these changes with therapeutic efficacy and tolerance.

Methods

In this longitudinal observational study, stool samples for shotgun metagenomic sequencing-based analysis were collected in two cohorts. The first cohort included 35 healthy nondiabetic individuals (metformin dose 2x850mg/day) at three time-points during metformin administration. The second cohort was composed of 50 newly-diagnosed type 2 diabetes patients (metformin dose–determined by an endocrinologist) at two concordant times. Patients were defined as Responders if their HbA1c levels during three months of metformin therapy had decreased by ≥12.6 mmol/mol (1%), while in Non-responders HbA1c were decreased by <12.6 mmol/mol (1%).

Results

Metformin reduced the alpha diversity of microbiota in healthy controls (p = 0.02) but not in T2D patients. At the species level, reduction in the abundance of Clostridium bartlettii and Barnesiella intestinihominis, as well as an increase in the abundance of Parabacteroides distasonis and Oscillibacter unclassified overlapped between both study groups. A large number of group-specific changes in taxonomic and functional profiles was observed. We identified an increased abundance of Prevotella copri (FDR = 0.01) in the Non-Responders subgroup, and enrichment of Enterococcus faecium, Lactococcus lactis, Odoribacter, and Dialister at baseline in the Responders group. Various taxonomic units were associated with the observed incidence of side effects in both cohorts.

Conclusions

Metformin effects are different in T2D patients and healthy individuals. Therapy induced changes in the composition of gut microbiome revealed possible mediators of observed short-term therapeutic effects. The baseline composition of the gut microbiome may influence metformin therapy efficacy and tolerance in T2D patients and could be used as a powerful prediction tool.

Microbes, helminths, and rheumatic diseases

There has been a progressive interest on modifications of the human defense system following insults occurring in the interface between our body and the external environment, as they may provoke or worsen disease states. Studies suggest that billions of germs, which compose the gut microbiota influence one's innate and adaptive immune responses at the intestinal level, but these microorganisms may also impact rheumatic diseases. The microbiota of the skin, respiratory, and urinary tracts may also be relevant in rheumatology. Evidence indicates that changes in the gut microbiome alter the pathogenesis of immune-mediated diseases such as rheumatoid arthritis and ankylosing spondylitis but also of other disorders like atherosclerosis and osteoarthritis. Therapeutic strategies to modify the microbiota, including probiotics and fecal microbiota transplantation, have been received with skepticism, which, in turn, has drawn attention back to previously developed interventions such as antibiotics. Helminths adapted to humans over the evolution process, but their role in disease modulation, particularly immune-mediated diseases, remains to be understood. The present review focuses on data concerning modifications of the immune system induced by interactions with microbes and pluricellular organisms, namely helminths, and their impact on rheumatic diseases. Practical aspects, including specific microbiota-targeted therapies, are also discussed.

Role of the IL-23 pathway in the pathogenesis and treatment of enthesitis in psoriatic arthritis

INTRODUCTION

Enthesitis is a key feature of spondyloarthritis (SpA). Several studies have underlined the role of interleukin (IL)-23 in SpA development as a crucial cytokine in the pathogenesis of enthesitis.

AREA COVERED

This review summarizes recent evidence of the role of IL-23 in the pathogenesis of and as a target of the treatment of enthesitis. We review the definition, diagnosis and clinical impact of enthesitis and its connection with microbial infections, gut dysbiosis, and mechanical stress. We also review clinical trials and real-life studies of drugs targeting the p19 or p40 subunits of IL-23.

EXPERT OPINION

Novel therapies targeting the p19 or p40 subunit of IL-23 appear to be promising treatment options for patients with enthesitis. Although we are currently unable to identify the best therapeutic window to target IL-23 in SpA disease evolution, the promising ability of this therapy to control the gut-entheseal axis is increasing our knowledge of SpA pathogenesis.

Defining the phenotype, pathogenesis and treatment of Crohn's disease associated spondyloarthritis

Peripheral and axial spondyloarthritis are the most common extra-intestinal manifestations reported in patients with Crohn's disease. Despite the frequency of Crohn's disease associated spondyloarthritis, clinical diagnostic tools are variably applied in these cohorts and further characterization with validated spondyloarthritis disease activity indexes are needed. In addition, the pathogenesis of Crohn's disease associated spondyloarthritis is not well understood. Evidence of shared genetic, cellular, and microbial mechanisms underlying both Crohn's disease and spondyloarthritis highlight the potential for a distinct clinicopathologic entity. Existing treatment paradigms for Crohn's disease associated spondyloarthritis focus on symptom control and management of luminal inflammation. A better understanding of the underlying pathogenic mechanisms in Crohn's disease associated spondyloarthritis and the link between the gut microbiome and systemic immunity will help pave the way for more targeted and effective therapies. This review highlights recent work that has provided a framework for clinical characterization and pathogenesis of Crohn's disease associated spondyloarthritis and helps identify critical gaps that will help shape treatment paradigms.

Fecal transplants in spondyloarthritis and uveitis: ready for a clinical trial?

PURPOSE OF REVIEW

The intestinal microbiome is thought to play a role in the pathogenesis of inflammatory bowel disease (IBD). There are many shared clinical manifestations between IBD and spondyloarthritis (SpA), of which the most common are peripheral arthritis and uveitis. Clinical overlap along with similar genetics between these diseases suggests a possible shared pathogenetic mechanism, which might center on the intestinal microbiota. In this review, we discuss the available evidence that SpA is a microbiome-driven disease and indicate how SpA-associated uveitis could be tied to gut dysbiosis. We conclude by discussing different treatment paradigms targeting the intestinal microbiome for SpA.

RECENT FINDINGS

Recent studies support the growing evidence of the intestinal microbiome as a crucial player in SpA disease pathogenesis. There is emerging evidence that the gut microbiome may play a causative role in uveitis.

SUMMARY

The field is beginning to discover a new level of understanding how the intestinal microbiome is involved in SpA. Treatment methods to alter intestinal microbiota to treat SpA-related diseases are still in its infancy.

Genome-wide DNA methylation analysis in ankylosing spondylitis identifies HLA-B*27 dependent and independent DNA methylation changes in whole blood

BACKGROUND AND OBJECTIVE

Ankylosing spondylitis is a chronic inflammatory disease characterized by inflammation of the sacroiliac joints and the spine that can lead to significant pain, immobility, and disability. The etiology and pathogenesis of ankylosing spondylitis are incompletely understood, though most patients carry the HLA-B*27 allele. The objective of this study was to evaluate DNA methylation changes in ankylosing spondylitis with the goal of revealing novel mechanistic insights into this disease.

METHODS

Genome-wide DNA methylation analysis was performed in whole blood DNA samples using the Infinium MethylationEPIC array in patients with ankylosing spondylitis compared to age, sex, and race matched patients with osteoarthritis as a non-inflammatory disease control. We studied 24 patients with ankylosing spondylitis, including 12 patients who carry HLA-B*27 and 12 patients who are HLA-B*27 negative. DNA methylation analysis was performed with adjustment for blood cell composition in each sample.

RESULTS

We identified a total of 67 differentially methylated sites between ankylosing spondylitis patients and osteoarthritis controls. Hypermethylated genes found included GTPase-related genes, while hypomethylated genes included HCP5, which encodes a lncRNA within the MHC region, previously associated with genetic risk for psoriasis and toxic epidermal necrolysis. Carrying HLA-B*27 was associated with robust hypomethylation of HCP5, tubulin folding cofactor A (TBCA) and phospholipase D Family Member 6 (PLD6) in ankylosing spondylitis patients. Hypomethylation within HCP5 involves a CpG site that contains a single nucleotide polymorphism in linkage disequilibrium with HLA-B*27 and that controls DNA methylation at this locus in an allele-specific manner.

CONCLUSIONS

A genome-wide DNA methylation analysis in ankylosing spondylitis identified DNA methylation patterns that could provide potential novel insights into this disease. Our findings suggest that HLA-B*27 might play a role in ankylosing spondylitis in part through inducing epigenetic dysregulation.

Usefulness of complex bacteriological and serological analysis in patients with spondyloarthritis

Spondyloarthritis (SpA) is a group of associated chronic systemic inflammatory immune-mediated rheumatic diseases affecting axial and peripheral joints and entheses. The aim of the present study was to identify what parameters are useful to determine in order to better understand the correlation between the disease activity/severity and the microbiological results/immune status against intestinal and/or urogenital pathogens. Microorganisms known to trigger SpA, including Klebsiella spp., Yersinia spp., Salmonella spp., Campylobacter spp. and Chlamydia spp., were analyzed in various specimens (stool, urine, synovial fluid and serum) collected from 27 randomly selected SpA patients and 26 healthy controls using a combined direct and indirect approach relying on conventional culture technique and nucleic acid-based assays together with serological testing by ELISA. Although Escherichia coli derived from phylogroup A prevailed in the gut microflora of the patients and controls, differences were observed regarding the representatives of the other phylogroups with a higher prevalence of E.coli members of phylogenetic group B1 in the stool specimens of patients. Antibodies against the targeted species were detected in SpA patients and controls, and the serological profiles of the former were more diverse and complex. In conclusion, the detection of anti-bacterial antibodies combined with other specific laboratory investigations should be more extensively used to monitor SpA patients in association with their symptoms and in order to determine and administer more effective therapeutics.

Association between food allergy and ankylosing spondylitis: An observational study

Food allergies can alter the gut microbiome composition, increasing the risk of conditions such as ankylosing spondylitis (AS).To identify the association between specific allergens and AS, we investigated the differences in the serum levels of 14 food antigen-specific immunoglobulin (Ig) G between AS patients and healthy participants. The association between the levels of these antibodies and disease activity was assessed by measuring the inflammatory marker C-reactive protein (CRP).We enrolled 75 AS patients and 78 healthy controls who had undergone antigen-specific IgG tests in West China Hospital between January 2015 and October 2017, and performed enzyme-linked immunosorbent assays for specific IgG against 14 food allergens: rice, egg, mushroom, milk, pork, chicken, beef, crab, codfish, corn, soybean, tomato, shrimp, and wheat. The following tests were used to analyze differences between AS patients and healthy controls: χ test for sex, and a 2-tailed Student t-test or Mann-Whitney U test based on the results of Levene test for age and IgG levels. Correlations between IgG and CRP levels were calculated using a Spearman's correlation.AS patients had significantly higher serum levels of beef-, crab-, and pork-specific IgG than did healthy participants. In addition, the serum levels of pork-specific IgG were significantly and positively correlated with CRP.These results suggest that α-Gal, the predominant natural antigen in mammalian red meat, might play a potential role in the pathogenesis of AS, and therefore, AS patients should exclude such allergenic foods, including beef, crab and pork, from their daily diet.

Traditional Chinese medicine (TCM) collaborative care for patients with axial spondyloarthritis (AcuSpA): protocol for a pragmatic randomized controlled trial

Background

Axial spondyloarthritis (AxSpA) is a chronic disease which results in fatigue, pain, and reduced quality of life (QoL). Traditional Chinese medicine (TCM), especially acupuncture, has shown promise in managing pain. Although a TCM collaborative model of care (TCMCMC) has been studied in cancer, there are no randomized controlled trials investigating TCM in AxSpA. Therefore, we will conduct a pragmatic trial to determine the clinical effectiveness, safety, and cost-effectiveness of TCMCMC for patients with AxSpA. We define TCMCMC as standard TCM history taking and physical examination, acupuncture, and TCM non-pharmacological advice and communications with rheumatologists in addition to usual rheumatologic care. The purpose of this paper is to describe the rationale for and methodology of this trial.

Methods/design

This pragmatic randomized controlled trial will recruit 160 patients who are diagnosed with AxSpA and have inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs). Simple randomization to usual rheumatologic care or the intervention (TCMCMC) with a 1:1 allocation ratio will be used. Ten 30-min acupuncture sessions will be provided to patients assigned to the TCMCMC arm. All participants will continue to receive usual rheumatologic care. The primary endpoint — spinal pain — will be evaluated at week 6. Secondary endpoints include clinical, quality of life, and economic outcome measures. Patients will be followed up for up to 52 weeks, and adverse events will be documented.

Discussion

This trial may provide evidence regarding the clinical effectiveness, safety, and cost-effectiveness of a TCMCMC for patients with AxSpA.

Trial registration

ClinicalTrials.gov, NCT03420404. Registered on 14 February 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3117-2) contains supplementary material, which is available to authorized users.

RUNX3 and T-Bet in Immunopathogenesis of Ankylosing Spondylitis-Novel Targets for Therapy?

Susceptibility to ankylosing spondylitis (AS) is polygenic with more than 100 genes identified to date. These include HLA-B27 and the aminopeptidases (ERAP1, ERAP2, and LNPEPS), which are involved in antigen processing and presentation to T-cells, and several genes (IL23R, IL6R, STAT3, JAK2, IL1R1/2, IL12B, and IL7R) involved in IL23 driven pathways of inflammation. AS is also strongly associated with polymorphisms in two transcription factors, RUNX3 and T-bet (encoded by TBX21), which are important in T-cell development and function. The influence of these genes on the pathogenesis of AS and their potential for identifying drug targets is discussed here.

Visions of Eye Commensals: The Known and the Unknown About How the Microbiome Affects Eye Disease

Until recently, the ocular surface is thought by many to be sterile and devoid of living microbes. It is now becoming clear that this may not be the case. Recent and sophisticated PCR analyses have shown that microbial DNA-based "signatures" are present within various ethnic, geographic, and contact lens wearing communities. Furthermore, using a mouse model of ocular surface disease, we have shown that the microbe, Corynebacterium mastitidis (C. mast), can stably colonize the ocular mucosa and that a causal relationship exists between ocular C. mast colonization and beneficial local immunity. While this constitutes proof-of-concept that a bona fide ocular microbiome that tunes immunity can exist at the ocular surface, there remain numerous unanswered questions to be addressed before microbiome-modulating therapies may be successfully developed. Here, the authors will briefly outline what is currently known about the local ocular microbiome as well as microbiomes associated with other sites, and how those sites may play a role in ocular surface immunity. Understanding how commensal microbes affect the ocular surface immune homeostasis has the potential revolutionize how we think about treating ocular surface disease.

Efficacy and safety of faecal microbiota transplantation in patients with psoriatic arthritis: protocol for a 6-month, double-blind, randomised, placebo-controlled trial

INTRODUCTION

An unbalanced intestinal microbiota may mediate activation of the inflammatory pathways seen in psoriatic arthritis (PsA). A randomised, placebo-controlled trial of faecal microbiota transplantation (FMT) infused into the small intestine of patients with PsA with active peripheral disease who are non-responsive to methotrexate (MTX) treatment will be conducted. The objective is to explore clinical aspects associated with FMT performed in patients with PsA.

METHODS AND ANALYSIS

This trial is a randomised, two-centre stratified, double-blind (patient, care provider and outcome assessor), placebo-controlled, parallel-group study. Eighty patients will be included and randomised (1:1) to either placebo (saline) or FMT provided from an anonymous healthy donor. Throughout the study, both groups will continue the weekly self-administered subcutaneous MTX treatment, remaining on the preinclusion dosage (15-25 mg/week). The clinical measures of psoriasis and PsA disease activity used include the Short (2-page) Health Assessment Questionnaire, the Dermatology Quality of Life Index, the Spondyloarthritis Research Consortium of Canada Enthesitis Index, the Psoriasis Area Severity Index, a dactylitis digit count, a swollen/tender joint count (66/68), plasma C reactive protein as well as visual analogue scales for pain, fatigue and patient and physician global assessments. The primary end point is the proportion of patients who experience treatment failure during the 6-month trial period. The number of adverse events will be registered throughout the study.

ETHICS AND DISSEMINATION

This is a proof-of-concept clinical trial and will be performed in agreement with Good Clinical Practice standards. Approvals have been obtained from the local Ethics Committee (DK-S-20150080) and the Danish Data Protection Agency (15/41684). The study has commenced in May 2017. Dissemination will be through presentations at national and international conferences and through publications in international peer-reviewed journal(s).

TRIAL REGISTRATION NUMBER

NCT03058900; Pre-results.

The role of the intestinal microbiome in ocular inflammatory disease

PURPOSE OF REVIEW

The intestinal commensal microbiota are important in shaping immune cell repertoire and are influenced by host genetics. Because of this intricate interaction, an intestinal dysbiosis has been associated with multiple immune-mediated polygenic diseases. This review summarizes the literature on how alterations in the intestinal microbiota contribute to immune-mediated ocular disease, and how to potentially target the gut microbiome for therapeutic benefit.

RECENT FINDINGS

Several groups have demonstrated the importance of the intestinal microbiome in uveitis pathogenesis. Two groups showed that altering the microbiota with oral antibiotics results in reduced uveitis severity, and another group demonstrated that a commensal bacterial antigen activates retina-specific autoreactive T cells, potentially indicating a commensal trigger for uveitis. We have found that commensal bacterial metabolites, short chain fatty acids, can suppress autoimmune uveitis. Age-related macular degeneration is associated with an intestinal dysbiosis, which can be influenced by genetic risk alleles and age-related eye disease study (AREDS) supplementation. Strategies that might be effective for targeting the intestinal microbiota might involve several approaches, including the use of antibiotics, drugs that supplement beneficial bacterial components or target inflammatory bacterial strains, dietary strategies or microbial transplantation.

SUMMARY

The intestinal microbiota are potentially crucial in propagating inflammatory diseases of the eye, and can be targeted for therapeutic benefit.

Short chain fatty acids ameliorate immune-mediated uveitis partially by altering migration of lymphocytes from the intestine

Short chain fatty acids (SCFA) are metabolites of intestinal bacteria resulting from fermentation of dietary fiber. SCFA are protective in various animal models of inflammatory disease. We investigated the effects of exogenous administration of SFCAs, particularly propionate, on uveitis using an inducible model of experimental autoimmune uveitis (EAU). Oral SCFA administration attenuated uveitis severity in a mouse strain-dependent manner through regulatory T cell induction among lymphocytes in the intestinal lamina propria (LPL) and cervical lymph nodes (CLN). SCFA also suppressed effector T cell induction in the CLN and mesenteric lymph nodes (MLN). Alterations in intestinal morphology and gene expression demonstrated in the EAU model prior to the onset of uveitis were blunted by oral SCFA administration. Using a Kaede transgenic mouse, we demonstrated enhanced leukocyte trafficking between the intestine and the eye in EAU. Propionate suppressed T effector cell migration between the intestine and the spleen in EAU Kaede mice. In conclusion, our findings support exogenous administration of SCFAs as a potential treatment strategy for uveitis through the stabilization of subclinical intestinal alterations that occur in inflammatory diseases including uveitis, as well as prevention of trafficking of leukocytes between the gastrointestinal tract and extra-intestinal tissues.

Pathogenesis of ankylosing spondylitis - recent advances and future directions

Over the past 5 years, advances in high-throughput techniques and studies involving large cohorts of patients have led to considerable advances in the identification of novel genetic associations and immune pathways involved in ankylosing spondylitis (AS). These discoveries include genes encoding cytokine receptors, transcription factors, signalling molecules and transport proteins. Although progress has been made in understanding the functions and potential pathogenic roles of some of these molecules, much work remains to be done to comprehend their complex interactions and therapeutic potential in AS. In this Review, we outline the current knowledge of AS pathogenesis, including genetic risk associations, HLA-B27-mediated pathology, perturbations in antigen-presentation pathways and the contribution of the type 3 immune response.

Reactive Arthritis

Reactive arthritis is classified as a spondyloarthropathy. Current concepts of disease suggest an infectious trigger, followed by inflammatory arthritis. Several mechanisms have been proposed to explain the interaction of host susceptibility and microorganism. Diagnosis relies on a compatible clinical syndrome and microbiologic confirmation of the pathogen. Antibiotic therapy seems useful in Chlamydia-triggered arthritis. The role of antibiotics in arthritis triggered by enteric pathogens is less clear. The role of tumor necrosis factor alpha inhibitors in therapy is evolving. Many patients have a course limited to a few months, but others experience extraarticular disease and more prolonged courses.

A Possible Role of Intestinal Microbiota in the Pathogenesis of Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease primarily affecting the sacroiliac joints and the spine, for which the pathogenesis is thought to be a result of the combination of host genetic factors and environmental triggers. However, the precise factors that determine one’s susceptibility to AS remain to be unraveled. With 100 trillion bacteria residing in the mammalian gut having established a symbiotic relation with their host influencing many aspects of host metabolism, physiology, and immunity, a growing body of evidence suggests that intestinal microbiota may play an important role in AS. Several mechanisms have been suggested to explain the potential role of the microbiome in the etiology of AS, such as alterations of intestinal permeability, stimulation of immune responses, and molecular mimicry. In this review, the existing evidence for the involvement of the microbiome in AS pathogenesis was discussed and the potential of intestinal microbiome-targeting strategies in the prevention and treatment of AS was evaluated.

Recent advances and future directions in understanding and treating Chlamydia-induced reactive arthritis

INTRODUCTION

Reactive arthritis (ReA) is an inflammatory disease that can follow gastrointestinal or genitourinary infections. The primary etiologic agent for post-venereal ReA is the bacterium Chlamydia trachomatis; its relative, C pneumoniae, has also been implicated in disease induction although to a lesser degree. Studies have indicated that the arthritis is elicited by chlamydiae infecting synovial tissue in an unusual biologic state designated persistence. We review clinical aspects, host-pathogen interactions, and treatments for the disease. Areas covered: We briefly discuss both the historic and,more extensively, the current medical literature describing ReA, and we provide a discussion of the biology of the chlamydiae as it relates to elicitation of the disease. A summary of clinical aspects of Chlamydia-induced ReA is included to give context for approaches to treatment of the arthritis. Expert commentary: Basic research into the biology and host-pathogen interactions characteristic of C trachomatis has provided a wealth of information that underlies our current understanding of the pathogenic processes occurring in the ReA synovium. Importantly, a promising approach to cure of the disease is at hand. However, both basic and clinical research into Chlamydia-induced ReA has lagged over the last 5 years, including required studies relating to cure of the disease.