Clinical Manifestations and Diagnosis of Axial Spondyloarthritis

Rapid and Sustained Effect of Ixekizumab on Patient Global, Spinal Pain, Stiffness, and Fatigue in Chinese Patients with Radiographic Axial Spondyloarthritis

INTRODUCTION

Ixekizumab, an interleukin 17A (IL-17A) inhibitor, has demonstrated rapid and sustained improvement in the signs and symptoms in patients with active radiographic axial spondyloarthritis (r-axSpA) in global and Chinese populations. We studied the effect of ixekizumab on patient-reported outcomes (PROs) (including patient global, spinal pain, stiffness, and fatigue) and overall health-related quality of life (HRQoL) of ixekizumab in the phase 3 study in China.

METHODS

In this Chinese phase 3, randomized, double-blind, placebo-controlled study, patients with r-axSpA were randomized (1:1) to receive ixekizumab 80 mg every 4 weeks (IXEQ4W; starting dose 160 mg) or placebo for 16 weeks. At week 16, patients receiving placebo were switched to IXEQ4W, and those receiving IXEQ4W continued, until week 52. Data for patient global, spinal pain, spinal pain at night, stiffness, and fatigue were collected through week 52. Minimally clinical important differences (MCIDs) were determined for spinal pain and spinal pain at night. The subgroup analyses by baseline disease duration since diagnosis and baseline C-reactive protein (CRP) level were conducted post hoc.

RESULTS

Compared with placebo, patients treated with IXEQ4W reported significantly greater improvement with a rapid onset in changes from baseline of PROs (patient global, spinal pain, spinal pain at night, stiffness, and fatigue) through week 16. Improvements were maintained through week 52. A similar trend of improvement was also observed in MCID response in spinal pain and spinal pain at night. The improvement in overall HRQoL was supported by EQ-5D-5L assessment. Subgroup analyses demonstrated that IXEQ4W provided significantly greater efficacy at week 16 compared with placebo, irrespective of baseline disease duration or baseline CRP level.

CONCLUSION

IXEQ4W provided rapid and sustained improvement in clinically relevant PROs and overall HRQoL through 1-year treatment in Chinese patients with r-axSpA. Regardless of the baseline disease duration or baseline CRP level, consistent efficacy was observed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04285229.

Illuminating the impact of γδ T cells in man and mice in spondylarthritides

Spondylarthritides (SpA) are a group of autoinflammatory diseases affecting the spine, peripheral joints, and entheses, including axial spondyloarthritis (axSpA) and psoriatic arthritis. AxSpA has a multifactorial etiology that involves genetic predispositions, such as HLA-B27 and IL-23R. Although HLA-B27 is strongly associated with axSpA, its role remains unclear. GWAS studies have demonstrated that genetic polymorphisms related to the IL-23 pathway occur throughout the spectrum of SpA, including but not limited to axSpA and PsA. IL-23 promotes the production of IL-17, which drives inflammation and tissue damage. This pathway contributes not only to peripheral enthesitis but also to spinal inflammation. γδ T cells in axSpA express IL-23R and RORγt, crucial for their activation, although specific pathogenic cells and factors remain elusive. Despite drug efficacy in PsA, IL-23R inhibition is ineffective in axSpA. Murine models provide valuable insights into the intricate cellular and molecular interactions that contribute to the development and progression of SpA. Those models are useful tools to elucidate the dynamics of γδ T cell involvement, offering insights into disease mechanisms and potential therapeutic targets. This review aims to illuminate the complex interplay between IL-23 and γδ T cells in SpA pathogenesis, emphasizing their roles in chronic inflammation, tissue damage, and disease heterogeneity.

Factors Associated with Poor Mental Health in Patients with Axial Spondyloarthritis: Results from the International Map of Axial Spondyloarthritis (IMAS)

BACKGROUND

This study aims to assess the prevalence of poor mental health in axial spondyloarthritis (axSpA) and its associated factors in a large sample of patients from the International Map of Axial Spondyloarthritis (IMAS) study from around the globe.

METHODS

IMAS is a cross-sectional online survey (2017-2022) that includes 5557 unselected patients with axSpA worldwide. Mental health was evaluated by the 12-item General Health Questionnaire (GHQ-12) and the cut-off point for poor mental health was set at 3. Logistic regression analysis was used to evaluate relationships between the investigated factors and poor mental health (GHQ-12≥3) in patients with axSpA (n=4335).

RESULTS

Of 5351 patients, the mean of GHQ-12 was 4.7 and 59.4% were having poor mental health, being 69.9% in South Africa, 63.7% in Latin America, 60.8% in Europe, 54.3% in North America and 51.8% in Asia. Overall, 40.5% and 37.2% of patients experienced anxiety and depression. The factors associated with poor mental health were younger age (OR=0.99), female gender (OR=1.16), being on sick leave or unemployed (OR=1.63), non-physical activity (OR=1.22), smoking (OR=1.20), higher Bath Ankylosing Spondylitis Disease Activity Index [BASDAI] (OR=1.42), functional limitation (OR=1.02) and shorter symptoms duration (OR=0.98).

CONCLUSIONS

Globally, 6 in 10 patients with axSpA had poor mental health, with a higher proportion in South Africa and lower in Asia. The factors associated with poor mental health include domains such as younger age, female gender, employment difficulties, harmful habits, disease burden and symptom duration. A holistic management approach to axSpA should encompass both physical and mental health.

[Current treatment for spondyloarthritis: focus on netakimab. A review]

Spondyloarthritis (SpA) is a group of rheumatic diseases that includes ankylosing spondylitis (AS), psoriatic arthritis (PsA) and a number of other diseases. SpA lead to a significant social problem, since it is a common pathology that debuts mainly at a young age, significantly impairing the ability to work and the ability to social contacts of the most active part of the population. For all the main types of chronic progressive SpA, biological agents (biologics) are of great importance in patients with persistent activity despite standard treatment, especially in the case of predominantly axial involvement, since in this case it is actually the only option for effective treatment, in addition to the constant use of non-steroidal anti-inflammatory drugs (NSAIDs). Over the past decade, interleukin-17A (IL-17A) inhibitors have taken the first place in therapy of SpA, because, according to modern ideas about pathogenesis, IL-17A may be a key target for therapeutic intervention in SpA. In terms of ensuring availability for Russian patients with SpA, it is of particular importance to the introduction of the original medication from the group of IL-17A inhibitors Netakimab (NTK). This review presents data from randomized clinical trials of NTK phases I, II and III in AS and PsA also post-registration observational studies of phase IV, including analysis of subpopulations of patients of special interest, in particular, patients with psoriatic spondylitis. NTK demonstrated high effectiveness in the treatment of SpA both in randomized clinical trials and in clinical practice. The drug is characterized by a rapid onset of clinical action and persistent maintenance of the achieved improvement, a complex effect on various manifestations of the disease, is able to have a structure-modifying effect and slow down the progression of both the erosive process and osteoproliferation. The safety profile of NTK is generally typical for the entire group of IL-17 inhibitors. The drug has low immunogenicity, which allows us to count on the possibility of many years of effective use. Resolutions of expert councils on the use of NTK in AS and PsA support the inclusion of this drug in clinical guidelines.

Exploring associations with depressive and anxiety symptoms among Syrian patients with ankylosing spondylitis undergoing biological treatment: A cross-sectional study

People with ankylosing spondylitis (AS) are vulnerable group to experience mood disorders. It is crucial to identify factors that contribute to depression and anxiety in order to improve outcomes. This study seeks to determine the rates of depression and anxiety in Syrian AS patients, as well as identify potential predictors for these conditions. This cross-sectional study was conducted using convenience sampling at the Biological Treatment Unit of the Rheumatology Department of the Damascus Hospital. Data were collected from face-to-face interviews with patients using validated structural questionnaire. A multivariate linear regression model was used to investigate potential predictive factors of depressive and anxiety symptoms. Of the 103 patients, 49.5% showed clinically significant depressive symptoms, and 36.9 % showed clinically significant anxiety symptoms. Multivariate linear regression indicated that depressive and anxiety symptoms were predicted by job layoff, hip pain, positive history of mental distress, poor quality of life, severe fatigue, and high frequency of sleep disturbance with relatively high explanatory powers. depressive and anxiety symptoms were predicted by disease activity scores but with low explanatory power. This study demonstrated high levels of that depressive and anxiety symptoms among Syrian patients with AS undergoing biological treatment. Poor quality of life, severe fatigue, and high-frequency sleep disturbances are major predictive factors for depressive and anxiety symptoms. Screening for depression and anxiety holds significant importance in the comprehensive management of ankylosing spondylitis even in the context of concurrent biological treatment administration.

Certolizumab pegol in the treatment of axial spondyloarthritis

Axial spondyloarthritis is a chronic, immune-mediated systemic inflammatory disease encompassing ankylosing spondylitis and nonradiographic axial spondyloarthritis. TNF inhibitors are the preferred second line therapy for patients with active axial spondyloarthritis. Certolizumab pegol is a TNF inhibitor approved for treatment of both. Three large phase III trials (RAPID-axSpA, C-axSpAnd and C-OPTIMISE) and one large phase IV trial (CIMAX) establish its clinical efficacy in treatment of active disease and maintenance of remission for both diseases. Real world evidence demonstrates clinical efficacy and benefits including reduced bone loss, reduced risk of uveitis, safety in pregnancy and lactation and index drug survival of 10 years. It is generally well tolerated, though can be associated with increased risk of serious infections.

Common differential diagnosis of low back pain in contemporary medical practice: a narrative review

With a wide range of etiologies, low back pain (LBP) presents a true clinical challenge, finding its origins both in intrinsic spinal and systemic conditions, as well as referred ones. This review categorizes the LBP into these three groups and aims to offer a comprehensive look at the tools required to diagnose and differentiate them. The intrinsic etiologies are based on conditions that affect the musculoskeletal components of the lumbar spine, such as intervertebral disc disease, stenosis, muscular imbalance, and facet joint degeneration. The systemic causes usually extend beyond local structures. Such are the cases of neoplasia, infections, and chronic inflammation. The diagnosis is rendered even more complex by adding the referred pain, which only manifests in the lower back yet arises in more distant locations. By synthesizing the literature that encompasses the problem, this review aims to augment the understanding of the differential diagnoses of LBP by showcasing the subject's nuances. This categorization provides a structured approach to a patient-centered diagnosis, which could facilitate the medical practitioners' efforts to navigate this pathology more effectively.

Effectiveness of bDMARDs in ankylosing spondylitis patients by biologic use: experience from the CorEvitas PsA/SpA Registry

OBJECTIVE

To describe bDMARD initiators by biologic experience among ankylosing spondylitis (AS) patients and change in disease activity and patient-reported outcomes (PROs) in real-world US patients.

METHODS

We included patients ≥18 years with AS based on physician diagnosis enrolled between 3/2013 and 11/2019 in the CorEvitas Psoriatic Arthritis (PSA)/Spondyloarthritis Registry (NCT02530268). Patients concurrently diagnosed with PSA were excluded. Baseline (bDMARD initiation) demographics, comorbidities, disease characteristics, treatment, and PROs were collected. Response rates and changes in disease activity and PROs between baseline and 6- and 12- month follow-up visits were calculated.

RESULTS

Of the 489 AS patients in the PsA/SpA Registry, 254 AS (52.0%) patients initiated a bDMARD at enrollment or during follow-up (total initiations: AS = 313). Of the 313 AS initiations, 179 (57.2%) had a 6-month follow-up, 122 (39.0%) had a 12-month follow-up, and 94 (30.0%) had a 6- and 12-month follow-up visit. For those AS initiators with a 6-month follow-up, the mean age was 49.1 years, 44.4% were female, and 70.4%, 47.5%, 96.1%, and 46.9% had never used cDMARDs, TNFis, non-TNFis, and bDMARDs, respectively. Of these 179 AS initiators, 20.1% and 14.0% achieved ASAS20/40, respectively. Further, only 34% achieved low disease activity (ASDAS <2.1). When stratified by biologic-naivete and biologic-experience, the ASAS 20/40 achievement rates were 26.2% and 14.7%, and 21.4% and 7.4%, respectively, for this cohort.

CONCLUSION

Although AS patients initiate bDMARDs, many do not achieve optimal treatment responses. Future research is needed to investigate the aspects associated with inadequate improvement and treatment response to bDMARDs.

A concept elicitation study to understand the relationship between sleep and pain in rheumatoid arthritis and axial spondyloarthritis

PURPOSE

This qualitative study (GSK study: 213635) was designed to better understand sleep disturbance as experienced by individuals with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA), and the relationship between sleep disturbance and pain and other aspects of the disease and disease activity.

METHODS

Sixty-minute, one-on-one, concept elicitation interviews were conducted with 30 participants (15 with RA and 15 with axSpA) from the US. Interviews were audio-recorded and transcribed verbatim. Interview transcripts were coded and analyzed to explore themes related to pain and sleep disturbance, and relationships among those themes.

RESULTS

Pain was a prominent driver of sleep disturbance; 12 participants with RA (80%) and 14 with axSpA (93%) reported that pain impacted their ability to fall asleep, while all 15 with RA (100%) and 14 with axSpA (93%) reported that pain impacted their ability to stay asleep. Two-thirds of participants with RA (67%) or axSpA (60%) described a bi-directional relationship, whereby pain worsened sleep disturbance and sleep disturbance further aggravated pain. Factors other than pain, such as fatigue and emotional health, were also reported as important contributors to sleep disturbance (RA: n = 12/15, 80%; axSpA: n = 14/15, 93%). Participants with RA or axSpA described complex interconnections between fatigue, emotional health, pain, and sleep, often labeling these relationships as "vicious cycles". Notably, half of all participants reported sleep disturbance occurring without pain or other understood causes.

CONCLUSION

These perspectives collected from people with RA or axSpA suggest that reducing sleep disruption directly may offer clinically relevant benefits.

Radiological Insights into Sacroiliitis: A Narrative Review

Sacroiliitis is the inflammation of the sacroiliac joint, the largest axial joint in the human body, contributing to 25% of lower back pain cases. It can be detected using various imaging techniques like radiography, MRI, and CT scans. Treatments range from conservative methods to invasive procedures. Recent advancements in artificial intelligence offer precise detection of this condition through imaging. Treatment options range from physical therapy and medications to invasive methods like joint injections and surgery. Future management looks promising with advanced imaging, regenerative medicine, and biologic therapies, especially for conditions like ankylosing spondylitis. We conducted a review on sacroiliitis using imaging data from sources like PubMed and Scopus. Only English studies focusing on sacroiliitis's radiological aspects were included. The findings were organized and presented narratively.

Beyond the horizon: Innovations and future directions in axial-spondyloarthritis

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease of the spine and sacroiliac joints. This review discusses recent advances across multiple scientific fields that promise to transform axSpA management. Traditionally, axSpA was considered an immune-mediated disease driven by human leukocyte antigen B27 (HLA-B27), interleukin (IL)-23/IL-17 signaling, biomechanics, and dysbiosis. Diagnosis relies on clinical features, laboratory tests, and imaging, particularly magnetic resonance imaging (MRI) nowadays. Management includes exercise, lifestyle changes, non-steroidal anti-inflammatory drugs and if this is not sufficient to achieve disease control also biological and targeted-synthetic disease modifying anti-rheumatic drugs. Beyond long-recognized genetic risks like HLA-B27, high-throughput sequencing has revealed intricate gene-environment interactions influencing dysbiosis, immune dysfunction, and aberrant bone remodeling. Elucidating these mechanisms promises screening approaches to enable early intervention. Advanced imaging is revolutionizing the assessment of axSpA's hallmark: sacroiliac bone-marrow edema indicating inflammation. Novel magnetic resonance imaging (MRI) techniques sensitively quantify disease activity, while machine learning automates complex analysis to improve diagnostic accuracy and monitoring. Hybrid imaging like synthetic MRI/computed tomography (CT) visualizes structural damage with new clarity. Meanwhile, microbiome analysis has uncovered gut ecosystem alterations that may initiate joint inflammation through HLA-B27 misfolding or immune subversion. Correcting dysbiosis represents an enticing treatment target. Moving forward, emerging techniques must augment patient care. Incorporating patient perspectives will be key to ensure innovations like genetics, microbiome, and imaging biomarkers translate into improved mobility, reduced pain, and increased quality of life. By integrating cutting-edge, multidisciplinary science with patients' lived experience, researchers can unlock the full potential of new technologies to deliver transformative outcomes. The future is bright for precision diagnosis, tightly controlled treatment, and even prevention of axSpA.

Etiological Diagnosis of Uveitis: Contribution of the of the Extra-Ophthalmological Clinical Examination

PURPOSE

Determining uveitis etiology is a challenge. It is based primarily on demographic data and the characteristics of eye examination. It is not clear to what extent extraocular physical signs contribute to elucidating the etiology. This study aimed to establish the contribution of the clinical extra-ophthalmological features for the assessment of the underlying etiology of uveitis.

METHODS

We retrospectively reviewed 1307 patients with uveitis referred to our tertiary center between 2003 and 2021. Uveitis was classified according to the Standardization of Uveitis Nomenclature. Clinical features were collected at diagnosis by internists before the etiological diagnosis was made. The main outcome description was the contribution of clinical features.

RESULTS

Clinical extra-ophthalmological features contributed to the assessment of the underlying etiology of uveitis in 363 (27.8%) patients. The joint and the skin examinations were the most useful for etiological investigations, respectively in 12.3% and 11.8% of patients. Five etiologies of uveitis accounted for 80% of the cases: sarcoidosis, HLA-B27-related uveitis, Behçet's disease, multiple sclerosis, and Vogt-Koyanagi-Harada disease. Clinical extra-ophthalmological features were particularly important in the etiological diagnosis of acute bilateral anterior uveitis and panuveitis.

CONCLUSION

This study suggests that clinical extra-ophthalmological features are essential for the etiological diagnosis of uveitis in more than a quarter of patients. It demonstrates once again the value of collaboration between ophthalmologists and other specialists experienced in performing extra-ophthalmological clinical examinations, particularly in patients with acute bilateral anterior uveitis and panuveitis.

Temporomandibular joint disorders in seronegative spondyloarthritis: what a rheumatologist needs to know?

Temporomandibular joint (TMJ) can be affected in the context of spondyloarthritis (SpA) with detrimental impact on individuals' quality of life. Intra-articular inflammation, synovitis, enthesitis, disc displacement and cervical vertebrae malalignment are some of the pathophysiological phenomena involved. Temporomandibular joint disorders (TMD) incidence appears to be higher in patients with ankylosing spondylitis and psoriatic arthritis, especially when clinical evaluation includes not only imaging but relevant history, TMJ examination and diagnostic criteria for TMD. The Visual Analogue Scale (VAS) pain score and Health Assessment Questionnaire Disability Index (HAQ) quality of life score could be useful tools. Panoramic radiographs and ultrasound can be used for screening but in symptomatic patients magnetic resonance imaging (MRI) is preferable. Conservative management and early pharmacological treatment can prevent permanent joint impairment. For refractory cases, early referral to Legislation for Oral and Maxillofacial Surgery (OMFS) specialists is indicated. The aim of this narrative review is to address the involvement of TMJ in SpA and to encourage clinicians to incorporate TMJ assessment in their physical examination and basic screening.

Prevalence and factors associated with fatigue in patients with axial spondyloarthritis: a systematic review and meta-analysis

Objectives

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease associated with significant morbidity. Fatigue, a widely recognized disease manifestation, has considerable impacts on patients' work productivity, physical function and mental well-being. However, the reported prevalence of fatigue varies across studies, and pooled data are currently lacking. We aimed to characterize the prevalence of fatigue in patients with axSpA and to identify factors associated with fatigue.

Methods

A systematic review and a meta-analysis were conducted to determine the global prevalence of fatigue in patients with axSpA. Databases including CINAHL, Embase, Medline, Cochrane Library, PubMed and Google Scholar were searched from inception until April 2023. Data were extracted, and the quality of studies was assessed. A pooled prevalence of fatigue was determined by using a random-effects model. Meta-analyses were used to determine the observed heterogeneity via subgroup analysis and associations between relevant predictors and the presence of fatigue.

Results

Thirty eligible articles were included in the study, including 7893 patients with axSpA. The pooled prevalence of fatigue in patients with axSpA was 0.56 (95% CI: 0.49, 0.63; I2 = 94.6%), with significant levels of heterogeneity. Among the factors of heterogeneity explored, the geographical region of the study (P = 0.0013) was significant for being a possible source. Poorer quality of life was associated with more fatigue (P < 0.05).

Conclusion

More than half of patients with axSpA experience fatigue, with poorer quality of life being associated with more fatigue.

Impact of sex and gender on axSpA diagnosis and outcomes

Axial spondyloarthritis (axSpA) was historically considered a disease of men, largely due to the recognition of a more severe, progressive phenotype, ankylosing spondylitis (AS; or radiographic axSpA, r-axSpA) aiding the clinical diagnosis [1,2]. Data demonstrating the near equal prevalence of axSpA in women only started to emerge in the last decades, highlighting intrinsic differences in disease phenotype, and clinical and imaging characteristics between sexes, which partly explain the issue of underdiagnosis in women. Similar to the evolving understanding of spondyloarthritis and the diseases that term describes, the concepts of gender and sex also warrant further clarification to accurately assess their potential role in disease pathophysiology and phenotypic expression. This narrative review delves into the most recent evidence from the literature on the true prevalence of sex differences in axSpA, and the impact of sex and gender on diagnosis, disease characteristics and treatment response in this, still underserved, chronic disease.

Accelerated kynurenine pathway downregulates immune activation in patients with axial spondyloarthritis

Various studies reported that the kynurenine (Kyn) pathway plays a pivotal role in regulating the balance between activation and inhibition of the immune system. Proinflammatory cytokines can accelerate the Kyn pathway by altering indoleamine (2, 3)- dioxygenase (IDO) allosteric enzyme activity. Excessive cytokine release and immune system activation have essential roles in the pathogenesis of axial spondyloarthritis (axSpA). We aimed to investigate the relationship of the Kyn pathway with proinflammatory cytokines and with the severity of the disease in patients with axSpA. The study included 104 patients with axSpA and 54 healthy volunteers. The severity of the disease was determined by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The Kyn pathway was evaluated by IDO activity calculated with Kyn/Tryptophan (Trp) ratio. Plasma Trp and Kyn concentrations were measured with tandem mass spectrometry. Serum IL 17/23 and IFN-γ concentrations were measured with ELISA. These groups were compared in terms of IDO, IL-17, IL-23, IFN-γ, and BASDAI. Plasma IDO activity was significantly increased, however, serum IL-17, IL-23, and IFN-γ levels were significantly decreased in patients compared to healthy volunteers. While IFN-γ was positively correlated with the severity of the disease (p = 0.02), it also had a significant inverse correlation with IDO activity (p < 0.001). However, these correlations are weak. As a result of this study, the Kyn pathway is accelerated and proinflammatory cytokine levels are decreased in patients with axSpA. All of these results with an indirect weak negative association between high IDO and low disease activity suggest that an accelerated Kyn pathway may limit the immune system activation in axSpA disease.

Spinal Mobility Limitation Can Be the Main Reason of Kinesiophobia in Ankylosing Spondylitis

Objective The aim of this study is to determine the presence of kinesiophobia in patients with ankylosing spondylitis (AS) and to examine the factors affecting kinesiophobia. Materials and methods Sixty patients with AS participated in the study. Kinesiophobia was evaluated using the Tampa Scale for Kinesiophobia (TSK). Disease activity was assessed using the Bath AS Disease Activity Index (BASDAI) and AS Disease Activity Score with C-reactive protein (ASDAS-CRP), functional status using the Bath AS Functional Index (BASFI), spinal mobility using the Bath AS Metrology Index (BASMI), and quality of life using the AS Quality of Life Questionnaire (ASQoL). Those with a TSK score of >37 were classified as patients with high kinesiophobia, while those with a score of ≤37 as patients with low kinesiophobia. Results High kinesiophobia was detected in 29 (48.3%) patients. Age, disease duration, BASDAI, ASDAS-CRP, BASFI, ASQoL, and BASMI values were higher in these patients. The TSK scores correlated with age, duration of disease, ASDAS-CRP, BASFI, BASMI, and ASQoL (r = 0.697, r = 0.600, r = 0.410, r = 0.690, r = 0.889, and r = 0.576, respectively). As a result of the multivariate binary logistic regression analysis, BASMI was found to be the only statistically significant factor for high kinesiophobia (OR 5.338, 95% CI: 1.133-25.159, p = 0.034). Conclusion Kinesiophobia is seen at a high rate in patients with AS. In this study, the most important risk factor for kinesiophobia is found to be decreased spinal mobility. To prevent kinesiophobia - which prevents exercise, the cornerstone of AS treatment - patients should be encouraged to exercise and be active.

The Interleukine-17 Cytokine Family: Role in Development and Progression of Spondyloarthritis, Current and Potential Therapeutic Inhibitors

Spondyloarthritis (SpA) encompasses a group of chronic inflammatory rheumatic diseases with a predilection for the spinal and sacroiliac joints, which include axial spondyloarthritis, psoriatic arthritis, reactive arthritis, arthritis associated with chronic inflammatory bowel disease, and undifferentiated spondyloarthritis. The prevalence of SpA in the population varies from 0.5 to 2%, most commonly affecting young people. Spondyloarthritis pathogenesis is related to the hyperproduction of proinflammatory cytokines (TNFα, IL-17A, IL-23, etc.). IL-17A plays a key role in the pathogenesis of spondyloarthritis (inflammation maintenance, syndesmophites formation and radiographic progression, enthesites and anterior uveitis development, etc.). Targeted anti-IL17 therapies have established themselves as the most efficient therapies in SpA treatment. The present review summarizes literature data on the role of the IL-17 family in the pathogenesis of SpA and analyzes existing therapeutic strategies for IL-17 suppression with monoclonal antibodies and Janus kinase inhibitors. We also consider alternative targeted strategies, such as the use of other small-molecule inhibitors, therapeutic nucleic acids, or affibodies. We discuss advantages and pitfalls of these approaches and the future prospects of each method.

Qualitative concept elicitation and cognitive debriefing interviews of symptoms, impacts and selected customized PROMIS® Short Forms: a study in patients with axial spondyloarthritis

BACKGROUND

Sleep disturbance, pain, and fatigue are key symptoms/impacts of axial spondyloarthritis (axSpA). Three customized Patient-Reported Outcomes Measurement Information System (PROMIS^®) Short Forms (Sleep Disturbance, Pain Interference, and Fatigue) have been proposed for use in axSpA to assess these key disease concepts. This study was designed to further understand the patient experience of axSpA and evaluate the content validity of the three customized PROMIS^® Short Forms to support their use in axSpA clinical trials.

METHODS

Non-interventional, cross-sectional, qualitative (concept elicitation [CE] and cognitive debriefing [CD]) study. Participants took part in 90-min telephone interviews. The CE section used open-ended questions to elicit information about axSpA symptoms and impacts. The CD section involved a 'think-aloud' exercise where participants read out each instruction, item, and response option for the customized PROMIS^® Short Forms and shared their feedback. Participants also discussed the relevance of the items, response options and recall period. Verbatim interview transcripts were subject to thematic and content analysis.

RESULTS

In total, there were 28 participants (non-radiographic axSpA, n = 12; ankylosing spondylitis, n = 16), from the US (n = 20) and Germany (n = 8). Mean age was 52.8 years, and 57% were male; mean time since diagnosis was 9.5 years. The CE section identified 12 distinct symptoms that characterized axSpA: pain, sleep problems, fatigue/tiredness, stiffness, swelling, vision/eye issues, restricted body movements, headache/migraine, spasms, change in posture/stature, balance/coordination problems, and numbness. Pain, sleep problems, and fatigue/tiredness were experienced by ≥ 90% of participants, occurring simultaneously and exacerbating one another. Participants reported axSpA impacted their lives across six domains of health-related quality of life (HRQoL): physical functioning (100%), emotional wellbeing (89%), work/volunteering (79%), social functioning (75%), activities of daily living (61%) and cognitive functioning (54%). Impacts were most frequently associated with pain, stiffness, and fatigue. CD showed the PROMIS^® instruments were conceptually comprehensive and well understood, with all items relevant to ≥ 50% of participants.

CONCLUSIONS

Pain, sleep problems and fatigue are pivotal symptoms of axSpA and associated with HRQoL impacts. These results were used to update a conceptual model of axSpA which was originally developed based on a targeted literature review. Interpretability and content validity of the customized PROMIS^® Short Forms were confirmed, with each deemed to adequately assess key impacts associated with axSpA, making them suitable for use in axSpA clinical trials.

A review of the pleiotropic actions of the IFN-inducible CXC chemokine receptor 3 ligands in the synovial microenvironment

Chemokines are pivotal players in instigation and perpetuation of synovitis through leukocytes egress from the blood circulation into the inflamed articulation. Multitudinous literature addressing the involvement of the dual-function interferon (IFN)-inducible chemokines CXCL9, CXCL10 and CXCL11 in diseases characterized by chronic inflammatory arthritis emphasizes the need for detangling their etiopathological relevance. Through interaction with their mutual receptor CXC chemokine receptor 3 (CXCR3), the chemokines CXCL9, CXCL10 and CXCL11 exert their hallmark function of coordinating directional trafficking of CD4+ TH1 cells, CD8+ T cells, NK cells and NKT cells towards inflammatory niches. Among other (patho)physiological processes including infection, cancer, and angiostasis, IFN-inducible CXCR3 ligands have been implicated in autoinflammatory and autoimmune diseases. This review presents a comprehensive overview of the abundant presence of IFN-induced CXCR3 ligands in bodily fluids of patients with inflammatory arthritis, the outcomes of their selective depletion in rodent models, and the attempts at developing candidate drugs targeting the CXCR3 chemokine system. We further propose that the involvement of the CXCR3 binding chemokines in synovitis and joint remodeling encompasses more than solely the directional ingress of CXCR3-expressing leukocytes. The pleotropic actions of the IFN-inducible CXCR3 ligands in the synovial niche reiteratively illustrate the extensive complexity of the CXCR3 chemokine network, which is based on the intercommunion of IFN-inducible CXCR3 ligands with distinct CXCR3 isoforms, enzymes, cytokines, and infiltrated and resident cells present in the inflamed joints.

Development of a patient-led clinic visit framework: a case study navigating a patient's journey for rheumatology outpatient clinic consultations in England and Wales

BACKGROUND

Involving patients and members of the public in healthcare planning is beneficial for many reasons including that the outcomes focus on topics relevant to service users. The National Early Inflammatory Arthritis Audit (NEIAA) aims to improve care quality for patients with inflammatory arthritis.

CASE STUDY

This paper presents a case study detailing how the NEIAA Patient Panel worked with NEIAA governance groups, the National Rheumatoid Arthritis Society and the National Axial Spondyloarthritis Society to co-create an outpatient clinic visit framework for rheumatology professionals. A framework was co-created, divided into nine sections: pre-appointment preparation, waiting area (face-to-face appointments), face-to-face consultations, physical examination, establishing a forward plan, post consultation, annual holistic reviews, virtual appointments and key considerations. Providing insight into how the multi-disciplinary team can meet the diverse needs of patients with inflammatory arthritis, this framework now informs the teaching content about people who live with physical and mental disability for Year 3 and 4 undergraduate medical students at King's College London.

CONCLUSION

Patients play an important role in helping to address gaps in health service provision in England/Wales. The co-production of a clinic visit framework, informed by their own lived experience and their own expectations can lead to improved and relevant outcomes for the benefit of patients and raises awareness to medical students what matters to patients with physical disabilities when attending outpatient care.

Practical Significance of Biomarkers in Axial Spondyloarthritis: Updates on Diagnosis, Disease Activity, and Prognosis

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that can lead to ankylosis by secondary ossification of inflammatory lesions, with progressive disability and a significant impact on quality of life. It is also a risk factor for the occurrence of comorbidities, especially cardiovascular diseases (CVDs), mood disorders, osteoporosis, and malignancies. Early diagnosis and treatment are needed to prevent or decrease functional decline and to improve the patient's prognosis. In respect of axSpA, there is an unmet need for biomarkers that can help to diagnose the disease, define disease activity and prognosis, and establish personalized treatment approaches. The aim of this review was to summarize the available information regarding the most promising biomarkers for axSpA. We classified and identified six core categories of biomarkers: (i) systemic markers of inflammation; (ii) molecules involved in bone homeostasis; (iii) HLA-B27 and newer genetic biomarkers; (iv) antibody-based biomarkers; (v) microbiome biomarkers; and (vi) miscellaneous biomarkers. Unfortunately, despite efforts to validate new biomarkers, few of them are used in clinical practice; however, we believe that these studies provide useful data that could aid in better disease management.

Nonradiographic axial spondyloarthritis: expanding the spectrum of an old disease: A narrative review

Nonradiographic axial spondyloarthritis (nr-axSpA) represents a distinct phenotype within the spectrum of axial spondyloarthritis (axSpA), which is characterized by a range of clinical manifestations. Despite a high disease burden that is comparable to ankylosing spondylitis (also known as radiographic axSpA), there is an unmet need to recognize and effectively manage patients with active nr-axSpA.A targeted literature search was conducted in OVID (MEDLINE and Embase databases) to identify articles on nr-axSpA, including its definition, demographics, epidemiology, burden, diagnosis, clinical presentation, and treatment guidelines.The lack of adequate epidemiological data and incomplete understanding of nr-axSpA among rheumatologists and nonrheumatologists contributes to delayed referrals and diagnosis. This delay results in a substantial burden on patients, physically and psychologically, and the healthcare system. Targeted therapies, such as biologics, including inhibitors of tumor necrosis factor or interleukin-17A, have been approved and utilized for the management of nr-axSpA, and other novel therapeutics with different mechanisms of action are in development. Raising awareness among US internists regarding the prevalence of nr-axSpA, disease burden, clinical presentation, diagnostic tools, and available treatments is important for improved disease management.Future clinical investigations focusing on the development of markers that aid early diagnosis and predict treatment response may also improve the management of nr-axSpA. This review provides an overview of nr-axSpA with the aim of raising awareness of the disease among US internists, with an overarching goal to contribute toward the improved recognition and timely referral of these patients to rheumatologists for diagnosis and management.

Pain in Axial Spondyloarthritis: More to It Than Just Inflammation

The conceptual paradigm of axial spondyloarthritis (axSpA) has evolved and now comprises an expanded spectrum that includes more females and patients with little or no radiographic changes in sacroiliitis or syndesmophyte formation in the spine.¹ This broadened paradigm is often, but not always, characterized by an inflammatory magnetic resonance imaging (MRI) signature.