Taiwan Rheumatology Association consensus recommendations for the management of axial spondyloarthritis

Risk of motor vehicle accidents with profound injuries in patients with ankylosing spondylitis: a nationwide, population-based cohort study

Background

Patients with ankylosing spondylitis (AS) suffer from impaired physical activity and are prone to motor vehicle accidents (MVA), but definite instruction regarding the relationship between disease evolvement and MVA and potential risk factors is lacking.

Objectives

To explore the risk factors and their impact on recorded MVA with profound injuries in AS patients with prescriptions.

Design

Nationwide, population-based, matched retrospective cohort study.

Methods

Using Taiwanese administrative healthcare databases, with available claims data from 2003 to 2013, we selected 30,911 newly diagnosed adult AS patients with concurrent prescriptions from 2006 to 2012 as AS patients, along with 309,110 non-AS individuals as the control group, matched in gender, age at index date and year of the index date. The risk of recorded MVA with profound injuries was compared between the two groups in terms of incidence rate ratio (IRR) and log-rank test p-value. Using Cox regression analysis, we studied associations between the risk and AS diagnosis.

Results

The risk of recorded MVA with profound injuries in AS patients was significantly higher than in non-AS individuals, specifically 2 years after AS diagnosis (IRR, 2.00; 95% confidence interval (CI), 1.42-2.81). For patients with follow-up periods >2 years, the adjusted risk was positively associated with suburban residence (adjusted hazard ratio (aHR), 2.18; 95% CI, 1.55-3.06), rural residence (aHR, 1.89; 95% CI, 1.27-2.80), lower insured income (aHR, 1.35; 95% CI, 1.01-1.81) and recorded MVA with profound injuries before AS diagnosis (aHR, 6.16; 95% CI, 2.53-14.96). AS diagnosis (aHR, 1.81; 95% CI, 1.27-2.59) and frequency of ambulatory visits (aHR, 1.01; 95% CI, 1.004--1.02) were specific associated factors for them compared with those with follow-up periods ⩽2 years.

Conclusion

For adult AS patients in Taiwan, factors such as AS disease evolution and frequent ambulatory visits for disease control in the second year of the disease course may significantly increase the risk of recorded MVA with profound injuries beyond 2 years after AS diagnosis.

Bruton's Tyrosine Kinase in Ankylosing Spondylitis

STUDY DESIGN

Prospective case-control study.

OBJECTIVE

To explore the role of Bruton's tyrosine kinase (BTK) in ankylosing spondylitis (AS).

SUMMARY OF BACKGROUND DATA

AS substantially affects patients, impairing the range of motion in the whole spine and peripheral joints, as well as overall quality of life. However, surveillance for this condition is limited, and biomarkers that can predict disease activity are not well documented.

PATIENTS AND METHODS

The expression of the BTK gene in peripheral blood mononuclear cells (PBMCs) was measured using flow cytometry and real-time quantitative polymerase chain reaction in 36 patients with AS and 30 healthy controls. Demographic features, Ankylosing Spondylitis Disease Activity Score-C-reactive protein (CRP) based, Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, HLA-B27, erythrocyte sedimentation rate (ESR), and CRP were evaluated to identify factors associated with BTK expression. Analyses were performed using the Spearman rank correlation test for continuous data, the χ 2 test for categorical data, and that between continuous and dichotomous variables was measured using a point-biserial correlation test. The area under the curve of the receiver operating characteristic curve was used to assess the performance of each candidate biomarker.

RESULTS

BTK gene expression was significantly higher in patients with AS than in controls ( P = 0.026) according to quantitative polymerase chain reaction results. BTK Y223 was also high in CD19 + PBMCs from patients with AS, with CD 19+ BTK Y223+high cells being significantly positively correlated to ESR, CRP, and Ankylosing Spondylitis Disease Activity Score. A negative association was observed between BTK expression and the chest expansion distance. The area under the curve for CD 19+ BTK Y223+ was larger than that for ESR, but CRP still had the largest area.

CONCLUSIONS

BTK expression was higher in PBMCs from patients with AS when compared with controls, and was associated with a higher disease activity index, inflammatory reactants, and arthritis and extra-articular manifestations. These findings suggest that BTK expression may play a crucial role in the inflammatory process in individuals with AS.

Dynamics of T-cell receptor repertoire in patients with ankylosing spondylitis after biologic therapy

INTRODUCTION

Ankylosing spondylitis (AS) is a chronic inflammatory autoimmune disease in which T-cell immune responses play important roles. AS has been characterized by altered T-cell receptor (TCR) repertoire profiles, which are thought to be caused by expansion of disease-related TCR clonotypes. However, how biological agents affect the TCR repertoire status and whether their therapeutic outcomes are associated with certain features or dynamic patterns of the TCR repertoire are still elusive.

MATERIAL AND METHODS

We collected clinical samples from AS patients pre- and post-treatment with biologics. TCR repertoire sequencing was conducted to investigate associations of TCRα and TCRβ repertoire characteristics with disease activity and inflammatory indicators/cytokines.

RESULTS

Our results showed that good responders were associated with an increase in the TCR repertoire diversity with higher proportions of contracted TCR clonotypes. Additionally, we further identified a positive correlation between TCR repertoire diversity and interleukin (IL)-23 levels in AS patients. A network analysis revealed that contracted AS-associated TCR clonotypes with the same complementary-determining region 3 (CDR3) motifs, which represented high probabilities of sharing TCR specificities to AS-related antigens, were dominant in good responders of AS after treatment with biologic therapies.

CONCLUSIONS

Our findings suggested an important connection between TCR repertoire changes and therapeutic outcomes in biologic-treated AS patients. The status and dynamics of TCR repertoire profiles are useful for assessing the prognosis of biologic treatments in AS patients.

The electronic medical record management systems may improve monitoring and control of disease activity in patients with ankylosing spondylitis

To investigate the impact of an electronic medical record management system (EMRMS) on disease activity and the frequency of outpatient visits among patients with ankylosing spondylitis (AS). We identified 652 patients with AS who were followed up for at least 1 year before and after the first Ankylosing Spondylitis Disease Activity Score (ASDAS) assessment and compared the number of outpatient visits and average visit time within 1 year before and after the initial ASDAS assessment. Finally, we analyzed 201 patients with AS who had complete data and received ≥ 3 continuous ASDAS assessments at an interval of 3 months, and we compared the results of the second and third ASDAS assessments with those of the first. The number of annual outpatient visits increased after ASDAS assessment (4.0 (4.0, 7.0) vs. 4.0 (4.0, 8.0), p < 0.001), particularly among those with a high initial disease activity. The average visit time was reduced within 1 year after ASDAS assessment (6.4 (8.5, 11.2) vs. 6.3 (8.3, 10.8) min, p = 0.073), especially among patients whose with an inactive disease activity was < 1.3 (ASDAS C-reactive protein (CRP) 6.7 (8.8, 11.1) vs. 6.1 (8.0, 10.3) min, p = 0.033; ASDAS erythrocyte sedimentation rate (ESR) 6.4 (8.7, 11.1) vs. 6.1 (8.1, 10.0) min, p = 0.027). Among patients who received at least three ASDAS assessments, the third ASDAS-CRP tended to be lower than the first (1.5 (0.9, 2.1) vs. 1.4 (0.8, 1.9), p = 0.058). The use of an EMRMS increased the frequency of ambulatory visits among AS patients with high and very high disease activity and reduced the visit time among those with an inactive disease. Continual ASDAS assessments may help control the disease activity of patients with AS.

No increased risk of alopecia in ankylosing spondylitis patients: A population-based cohort study in Taiwan

AIM

To investigate the association between ankylosing spondylitis (AS) and alopecia.

METHODS

In this cohort study, data from over 1 000 000 patients in the Taiwan Longitudinal Health Insurance Database were extracted. We selected newly diagnosed (outpatient department visit three or more times or admission at least once) patients with AS (ICD-9-CM = 720.0) from 2000 to 2012. For the non-AS comparison group, patients never diagnosed with AS were chosen from 1999 to 2013. In all, 3640 AS patients and 14 560 non-AS controls were selected. Cox proportional hazard model and Kaplan-Meier analysis were used to present the results. The adjusted hazard ratio (HR) in the Cox proportional hazard model was adjusted for age, sex, hypertension, hyperlipidemia, diabetes, atopic dermatitis, and mental disorder.

RESULTS

No increased risk of alopecia in AS patients was shown in the Cox proportional hazard model (crude HR 1.16, P = 0.595; adjusted HR 1.16, P = 0.599). Negative results are found as well in subgroup analysis of different age, sex (age 20-40 y: HR 1.03, P = 0.925; Age ≥40 y: HR 1.49, P = 0.406; Female: HR 1.17, P = 0.759; Male: HR 1.15, P = 0.667), and phenotypes of alopecia (androgenetic alopecia: HR 1.19, 95% confidence interval [CI] 0.58-2.41; alopecia areata: HR 0.98, 95% CI 0.37-2.62). A significant positive correlation is found between atopic dermatitis and alopecia (adjusted HR 8.05, P = 0.039).

CONCLUSION

In this population-based cohort study, we found no association of risk of alopecia and AS.

Dehydroepiandrosterone (DHEA) Sensitizes Irinotecan to Suppress Head and Neck Cancer Stem-Like Cells by Downregulation of WNT Signaling

Purpose

Current treatment options for head and neck squamous cell carcinoma (HNSCC) are limited, especially for cases with cancer stem cell-induced chemoresistance and recurrence. The WNT signaling pathway contributes to maintenance of stemness via translocation of β-catenin into the nucleus, and represents a promising druggable target in HNSCC. Dehydroepiandrosterone (DHEA), a steroid hormone, has potential as an anticancer drug. However, the potential anticancer mechanisms of DHEA including inhibition of stemness, and its therapeutic applications in HNSCC remain unclear.

Methods

Firstly, SRB assay and sphere formation assay were used to examine cellular viability and cancer stem cell-like phenotype, respectively. The expressions of stemness related factors were measured by RT-qPCR and western blotting. The luciferase reporter assay was applied to evaluate transcriptional potential of stemness related pathways. The alternations of WNT signaling pathway were measured by nuclear translocation of β-catenin, RT-qPCR and western blotting. Furthermore, to investigate the effect of drugs in vivo, both HNSCC orthotopic and subcutaneous xenograft mouse models were applied.

Results

We found that DHEA reduced HNSCC cell viability, suppressed sphere formation, and inhibited the expression of cancer-stemness markers, such as BMI-1 and Nestin. Moreover, DHEA repressed the transcriptional activity of stemness-related pathways. In the WNT pathway, DHEA reduced the nuclear translocation of the active form of β-catenin and reduced the protein expression of the downstream targets, CCND1 and CD44. Furthermore, when combined with the chemotherapeutic drug, irinotecan (IRN), DHEA enhanced the sensitivity of HNSCC cells to IRN as revealed by reduced cell viability, sphere formation, expression of stemness markers, and activation of the WNT pathway. Additionally, this combination reduced in vivo tumor growth in both orthotopic and subcutaneous xenograft mouse models.

Conclusion

These findings indicate that DHEA has anti-stemness potential in HNSCC and serves as a promising anticancer agent. The combination of DHEA and IRN may provide a potential therapeutic strategy for patients with advanced HNSCC.

The BASDAI Cut-Off for Disease Activity Corresponding to the ASDAS Scores in a Taiwanese Cohort of Ankylosing Spondylitis

Objectives

The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) has been widely utilized to evaluate disease activity in patients with ankylosing spondylitis (AS) by an arbitrary cut-off of ≥4 to indicate high disease activity and initiate biological therapy. The Ankylosing Spondylitis Disease Activity Score (ASDAS) is a new composite index to assess AS disease activity states that have been defined and validated. ASDAS ≥2.1 was selected as a criterion to start biological therapy. The purpose of this study was to estimate the corresponding BASDAI and ASDAS cut-off in a Taiwanese AS cohort.

Methods

From November 2016 to October 2018, we assessed the ASDAS and the BASDAI regularly and recorded demographic data for 489 AS patients in Taichung Veterans General hospital (TCVGH) using an electronic patient-reported data system linked to electronic medical records. We used receiver operating characteristic curves with Youden's J statistic to determine the BASDAI values that correspond to ASDAS disease activity cut-offs (i.e., 1.3, 2.1, and 3.5).

Results

In our population, the best trade-off BASDAI values corresponding to ASDAS -C-reactive protein (CRP) 1.3, 2.1, and 3.5 were 2.1, 3.1, and 3.7, respectively. The optimal BASDAI values corresponding to ASDAS-erythrocyte sedimentation rates 1.3, 2.1, and 3.5 were 2.0, 2.6, and 4.8, respectively.

Conclusion

We propose a revised BASDAI cut-off based on our data, as BASDAI scores are commonly used globally. A more reasonable, lower BASDAI cut-off to initiate or change biological therapy will bring us closer to better decisions to treat AS patients.

Factors Associated with the Risk of Major Adverse Cardiovascular Events in Patients with Ankylosing Spondylitis: A Nationwide, Population-Based Case-Control Study

Background: Potential risk factors for major adverse cardiovascular events (MACE) in patients with ankylosing spondylitis (AS) requiring medical therapy should be investigated. Methods: We identified newly diagnosed AS patients without previous MACE from 2004 to 2012 using the National Health Insurance Research Database, matched MACE cases with non-MACE controls at a 1:4 ratio for age, gender, AS duration, and index date, and included 947 AS patients with MACE and 3896 matched controls for final analyses. By using conditional logistic regression analyses, we examined the associations of MACE with low income, urbanisation, comorbidities, common extra-articular manifestations (EAM), and medications, including nonsteroidal anti-inflammatory drugs (NSAID) of three categories (traditional NSAIDs, selective cyclooxygenase-2 inhibitors (COX-2i), and preferential COX-2is) with their annual cumulative defined daily dose (cDDD) within a year before MACE development. Results: MACE development was associated with the use of selective COX-2is (especially with annual cDDD > 132) and corticosteroids, residence in rural regions, and well-known associated comorbidities, but not with the use of traditional NSAIDs, preferential COX-2i, biologics, methotrexate, sulfasalazine, and common EAMs. Conclusions: The risk factors of MACE in newly diagnosed AS patients include residence in rural regions, well-known associated comorbidities, and the use of corticosteroids and selective COX-2is. A major limitation was the lack of information on individual lifestyle patterns and disease activity.

Glucocorticoids in spondyloarthritis-systematic review and real-world analysis

OBJECTIVE

The objective of this study was to identify and summarize the efficacy and safety of systemic glucocorticoids (GCs) and local injections of GC in SpA.

METHODS

PubMed (Medline) and EMBASE were searched with pre-defined keywords for relevant articles in English reporting randomized controlled trials (RCTs), non-randomized interventional studies and non-randomized observational studies of the efficacy of GC in SpA, with five or more patients, for inclusion in a systematic literature review. Local injections of GC included IA and entheseal injections, but excluded SI joint injections.

RESULTS

Out of 9657 records identified, there were 14 studies on the use of systemic GCs in SpA (364 patients), including two RCTs of oral prednisolone. On pooling data from two placebo-controlled RCTs (≤24 weeks), BASDAI 50 was 4.2 times more likely (95% CI: 1.5, 11.5) and Ankylosing Spondylitis Assessment Group (ASAS) 20 was twice more likely (95% CI: 1.1, 3.64) to occur in patients on high-dose oral prednisolone (± taper). Pulsed GCs led to dramatic improvements that lasted a few weeks to a few months. There were no deaths or major adverse events. There were 10 studies (560 patients) on local GCs in SpA. IA injection was effective in achieving a sustained response in 51.5-90% of joints at 6 months. Entheseal injections led to reduced pain and improved US parameters.

CONCLUSION

There were limited studies on either systemic or local injections of GCs in SpA. However, there was good evidence of efficacy with the use of high-dose systemic GCs in the short term (≤6 months) in SpA. Both IA and entheseal injections seemed safe and effective.

Heart Involvement in a Moroccan Population with Spondyloarthritis: A Cross-sectional Study

OBJECTIVES

The aim of this study was to investigate the prevalence of cardiac manifestations and their predictive factors in Moroccan patients with spondyloarthritis (SpA).

METHODS

We have conducted a cross-sectional study over four months at the Department of Rheumatology in Mohammed VI University Hospital of Oujda, Morocco. All SpA patients fulfilled the 2009 Assessment SpondyloArthritis international Society (ASAS) criteria. Every patient had a cardiac check up including clinical examination, 12-lead electrocardiogram (ECG) and transthoracic echocardiography (TTE). Multiple logistic regression was used to analyze the associated factors with cardiac manifestations.

RESULTS

We included 64 men and 30 women with a mean age of 37.32 ± 12.65 years old. The mean disease duration was 10.60 ± 7.61 years. Patients had a mean Ankylosing Spondylitis Disease Activity Score (ASDAS) CRP of 2.25 ± 1.38, a mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of 2.88 ± 2.26 and a mean Bath Ankylosing Spondylitis Functional Index (BASFI) of 33.52 ± 30.49. Traditional cardiovascular risk factors (CVRF) included dyslipidemia in 14.9%, hypertension in 9.6% and type 2 diabetes in 7.4% of the cases. Eight patients (8.5%) smoked and 3 patients (3.2%) used alcohol whereas 20 patients (21.3%) had a history of smoking and 5 patients (6.3%) a history of alcohol. Cardiac manifestations were found in 12 patients (13.3%): 3.3% had aortic regurgitation (AR), 1.1% had aortic dilatation, 1.1% had aortic valve thickening (AVT), 2.2% had mitral thickening, 1.1% had mitral regurgitation (MR), 1.1% had mitral stenosis (MS), 3.3 had pericarditis and 2.2% had complete right bundle branch block (RBBB). In multivariate analysis, cardiac involvement was significantly associated with extra-articular manifestations (OR = 6.05; 95% CI: 1.197-30.607, p = 0.029).

CONCLUSION

Based on these results, cardiac involvement was common and associated with the severity of the disease; hence, early detection of cardiac abnormalities and targeted treatment strategies of SpA and comorbidities are necessary to control the systemic inflammation and improve the excess of cardiovascular mortality in this group of patients.

Therapeutic exercises and rehabilitation in axial spondyloarthropathy: Balancing benefits with unique challenges in the Asia-Pacific countries

The burden of axial spondyloarthropathy (axSpA) in the Asia-Pacific region is substantial. The management of axSpA has been revolutionized with the advent of biological therapy where the disease activity, functional disability and negative psychological affect can be mitigated to a great extent. On the other hand, exercise remains an essential component of the treatment of axSpA at all stages, which is often discounted or underused. This is compounded by a gap in demand and supply between increasing number patients with axSpA and paucity of trained specialists and rehabilitation personnel in the Asia-Pacific countries. The acceptability and uptake of therapeutic exercise is strikingly poor in this region because of multiple factors such as lack of awareness among health professionals and the general population, poor healthcare infrastructure, lack of resources and limited accessibility to rehabilitation services. Health authorities and professional bodies in these countries need to work in tandem to expand healthcare facilities, encourage training opportunities and promote safe and effective exercise interventions which is accessible to the general population and individuals with axSpA. Adequate patient education, optimum control of disease activity and strict adherence to therapeutic exercise is essential to predict the best clinical outcome. In this narrative review we have appraised the impact of therapeutic exercise in this era of biological therapies in axSpA and have explored the challenges of rehabilitation services in the Asia-Pacific countries. Overall, the available quality of evidence is mixed, acknowledging the beneficial role of exercise and optimum usage and protocols pertaining to axSpA specific exercises and therefore further research is warranted.

Examining Treatment Decision-Making Among Patients With Axial Spondyloarthritis: Insights From a Conjoint Analysis Survey

Objective

The number of therapies for axial spondyloarthritis (axSpA) is increasing. Thus, it has become more challenging for patients and physicians to navigate the risk‐benefit profiles of the various treatment options. In this study, we used conjoint analysis—a form of trade‐off analysis that elucidates how people make complex decisions by balancing competing factors—to examine patient decision‐making surrounding medication options for axSpA.

Methods

We conducted an adaptive choice‐based conjoint analysis survey for patients with axSpA to assess the relative importance of medication attributes (eg, chance of symptom improvement, risk of side effects, route of administration, etc) in their decision‐making. We also performed logistic regression to explore whether patient demographics and disease characteristics predicted decision‐making.

Results

Overall, 397 patients with axSpA completed the conjoint analysis survey. Patients prioritized medication efficacy (importance score 26.8%), cost (26.3%), and route of administration (13.9%) as most important in their decision‐making. These were followed by risk of lymphoma (9.5%), dosing frequency (7.2%), risk of serious infection (6.0%), tolerability of side effects (5.3%), and clinic visit and laboratory test frequency (4.8%). In regression analyses, there were few significant associations between patients’ treatment preferences and sociodemographic and axSpA characteristics.

Conclusions

Treatment decision‐making in axSpA is highly individualized, and demographics and baseline disease characteristics are poor predictors of individual preferences. This calls for the development of online shared decision‐making tools for patients and providers, with the goal of selecting a treatment that is consistent with patients’ preferences.

Taiwan Rheumatology Association consensus recommendations for the management of axial spondyloarthritis

Aim

To establish guidelines for the clinical management of axial spondyloarthritis that take into account local issues and clinical practice concerns for Taiwan.

Method

Overarching principles and recommendations were established by consensus among a panel of rheumatology and rehabilitation experts, based on analysis of the most up‐to‐date clinical evidence and the clinical experience of panelists. All Overarching Principles and Recommendations were graded according to the standards developed by the Oxford Centre for Evidence Based Medicine, and further evaluated and modified using the Delphi method.

Results

The guidelines specifically address issues such as local medical considerations, National Health Insurance reimbursement, and management of extra‐articular manifestations.

Conclusion

It is hoped that this will help to optimize clinical management outcomes for axial spondyloarthritis in Taiwan.