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Tapering biologics in axial spondyloarthritis: A systematic literature review. Int Immunopharmacol 2022; 112:109256. [PMID: 36150228 DOI: 10.1016/j.intimp.2022.109256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The emergence of biologics has improved the management of patients with rheumatic disease, mainly with spondyloarthritis (SpA). Sustained remission has become a reachable goal thanks to the treat to target strategy. Contrary to rheumatoid arthritis, data on biologic optimization among SpA patients in remission is scarce and still a subject of debate. The main objective of this systematic review was to provide the most up-to-date published literature regarding biologic tapering in axial spondyloarthritis. METHODS This systematic review followed the preferred reporting items for systematic reviews guidelines. Original articles from Pubmed and Scopus, published until December 20th 2021, and tackling tapering strategies of the biologics in patients with axial SpA were included RESULTS: Fourteen studies met the inclusion criteria. They were published between 2008 and 2020. The most studied molecules were Etanercept (ETN) (n = 13), Infliximab (IFX) (n = 6), Adalimumab (ADA) (n = 5), certolizumab pegol (CZP) (n = 2), Golimumab (n = 1) and ETN biosimilar. There are no studies published regarding anti-IL 17 tapering strategy. Patient-tailored dose reduction of anti TNF-α agents was successful in preserving stable low disease activity in most of the studies with remission rates ranging between 20.2 % and 93.7 %. Complete treatment discontinuation is associated with a high risk of flares. CONCLUSION To conclude, published data indicate that a progressive tapering strategy for anti TNF-α therapy is successful among axial SpA in sustained remission. However, further studies with more homogenized tapering strategies are needed in order to ascertain the specific implication of each subset for a better holistic approach.
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2
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Baraliakos X, Østergaard M, Lambert RG, Eshed I, Machado PM, Pedersen SJ, Weber U, de Hooge M, Sieper J, Poddubnyy D, Rudwaleit M, van der Heijde D, Landewé RB, Maksymowych WP. MRI lesions of the spine in patients with axial spondyloarthritis: an update of lesion definitions and validation by the ASAS MRI working group. Ann Rheum Dis 2022; 81:1243-1251. [PMID: 35609977 DOI: 10.1136/annrheumdis-2021-222081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Spinal MRI is used to visualise lesions associated with axial spondyloarthritis (axSpA). The ASAS MRI working group (WG) updated and validated the definitions for inflammatory and structural spinal lesions in the context of axSpA. METHODS After review of the existing literature on all possible types of spinal MRI pathologies in axSpA, the group (12 rheumatologists and two radiologists) consented on the required revisions of lesion definitions compared with the existing nomenclature of 2012. In a second step, using 62 MRI scans from the ASAS classification cohort, the proposed definitions were validated in a multireader campaign by global (absent/present) and detailed (inflammation and structural) lesion assessment at the vertebral corner (VC), vertebral endplate, facet joints, transverse processes, lateral and posterior elements. Intraclass correlation coefficient (ICC) was used for analysis. RESULTS Revisions were made for both inflammatory (bone marrow oedema, BMO) and structural (fat, erosion, bone spur and ankylosis) lesions, including localisation (central vs lateral), extension (VC vs vertebral endplate) and extent (minimum number of slices needed), while new definitions were suggested for the type of lesion based on lesion maturity (VC monomorphic vs dimorphic). The most reliably assessed lesions were VC fat lesion and VC monomorphic BMO (ICC (mean of all 36 reader pairs/overall 9 readers): 0.91/0.92; 0.70/0.67, respectively. CONCLUSIONS The lesion definitions for spinal MRI lesions compatible with SpA were updated by consensus and validated by a group of experienced readers. The lesions with the highest frequency and best reliability were fat and monomorphic inflammatory lesions at the VC.
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Affiliation(s)
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Robert Gw Lambert
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada and Medical Imaging Consultants, Edmonton, Alberta, Canada
| | - Iris Eshed
- Department of Diagnostic Imaging, Sheba Medical Center, affiliated to the Sackler school of medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Pedro M Machado
- Department of Rheumatology, University College London, London, UK
- Centre for Rheumatology and MRC Centre for Neuromuscular Diseases, University College London, London, UK
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Susanne Juhl Pedersen
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ulrich Weber
- Practice Buchsbaum, Rheumatology, Schaffhausen, Switzerland
| | - Manouk de Hooge
- VIB Inflammation Research Center, Ghent University, Ghent, Belgium and Rheumatology Department, Ghent University Hospital, Gent, Belgium
| | - Joachim Sieper
- Charité - Universitätsmedizin Berlin and German Rheumatism Research Centre, Berlin, Germany
| | - Denis Poddubnyy
- Charité - Universitätsmedizin Berlin and German Rheumatism Research Centre, Berlin, Germany
| | | | | | - Robert Bm Landewé
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, and Atrium Medical Center, Heerlen, The Netherlands
| | - Walter P Maksymowych
- Department of Medicine, University of Alberta, Edmonton, Canada; CARE Arthritis, Edmonton, Alberta, Canada
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3
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Lindqvist E, Olofsson T, Jöud A, Geijer M, Wallman JK, Mogard E. How good is the agreement between clinical diagnoses and classification criteria fulfilment in axial spondyloarthritis? Results from the SPARTAKUS cohort. Scand J Rheumatol 2022:1-10. [PMID: 35695036 DOI: 10.1080/03009742.2022.2064183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To study the agreement between clinical axial spondyloarthritis (axSpA) diagnoses and fulfilment of the Assessment of SpondyloArthritis international Society (ASAS) axSpA and modified New York (mNY) classification criteria, and to compare disease/health status between axSpA subtypes. METHOD Patients with prevalent, clinical axSpA attending a rheumatology clinic were enrolled in a cross-sectional study. Assessments included physical evaluation, laboratory testing, questionnaires, and appropriate imaging, allowing classification. Standard axSpA outcome measures were compared between patients fulfilling mNY/radiographic versus non-radiographic axSpA (r-axSpA/nr-axSpA) criteria. RESULTS Of 239 consecutively included patients, 141 fulfilled ASAS r-axSpA and/or mNY criteria, while 57 fulfilled nr-axSpA criteria. The agreement between r-axSpA and mNY criteria fulfilment was 94%. The positive predictive value (PPV) of a clinical ankylosing spondylitis (AS) diagnosis for mNY criteria fulfilment was 71%; the PPV of an undifferentiated axSpA (u-axSpA) diagnosis for fulfilment of nr-axSpA criteria was 30% and 40% for mNY criteria. Patients with r-axSpA/AS were older, more often men, and had longer disease duration, more uveitis, and worse spinal mobility than nr-axSpA patients, who had more enthesitis and dactylitis. CONCLUSION We found an overall good concordance between clinical axSpA diagnoses and classification criteria fulfilment, with 83% fulfilling ASAS axSpA and/or mNY criteria. Regarding axSpA subtypes, the concordance was weaker, and although the ICD-10 code for AS correctly identified patients meeting mNY criteria in 71% of cases, one-third of mNY-positive patients lacked an AS diagnosis. Moreover, clinical u-axSpA diagnoses could not serve as a proxy to identify nr-axSpA, highlighting the importance of thorough classification in research on axSpA subtypes.
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Affiliation(s)
- Elisabet Lindqvist
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
| | - Tor Olofsson
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
| | - Anna Jöud
- Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Mats Geijer
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Radiology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan K Wallman
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
| | - Elisabeth Mogard
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
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4
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Truong SL, McEwan T, Bird P, Lim I, Saad NF, Schachna L, Taylor AL, Robinson PC. Australian Consensus Statements for the Assessment and Management of Non-radiographic Axial Spondyloarthritis. Rheumatol Ther 2021; 9:1-24. [PMID: 34962620 PMCID: PMC8814294 DOI: 10.1007/s40744-021-00416-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/09/2021] [Indexed: 12/02/2022] Open
Abstract
Background The understanding of non-radiographic axial spondyloarthritis (nr-axSpA) has accelerated over the last decade, producing a number of practice-changing developments. Diagnosis is challenging. No diagnostic criteria exist, no single finding is diagnostic, and other causes of back pain may act as confounders. Aim To update and expand the 2014 consensus statement on the investigation and management of non‐radiographic axial spondyloarthritis (nr-axSpA). Methods We created search questions based on our previous statements and four new topics then searched the MEDLINE and Cochrane databases. We assessed relevant publications by full-text review and rated their level of evidence using the GRADE system. We compiled a GRADE evidence summary then produced and voted on consensus statements. Results We identified 5145 relevant publications, full-text reviewed 504, and included 176 in the evidence summary. We developed and voted on 22 consensus statements. All had high agreement. Diagnosis of nr-axSpA should be made by experienced clinicians, considering clinical features of spondyloarthritis, blood tests, and imaging. History and examination should also assess alternative causes of back pain and related conditions including non-specific back pain and fibromyalgia. Initial investigations should include CRP, HLA-B27, and AP pelvic radiography. Further imaging by T1 and STIR MRI of the sacroiliac joints is useful if radiography does not show definite changes. MRI provides moderate-to-high sensitivity and high specificity for nr-axSpA. Acute signs of sacroiliitis on MRI are not specific and have been observed in the absence of spondyloarthritis. Initial management should involve NSAIDs and a regular exercise program, while TNF and IL-17 inhibitors can be used for high disease activity unresponsive to these interventions. Goals of treatment include improving the frequent impairment of social and occupational function that occurs in nr-axSpA. Conclusions We provide 22 evidence-based consensus statements to provide practical guidance in the assessment and management of nr-axSpA. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00416-7.
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Affiliation(s)
- Steven L Truong
- School of Medicine and Dentistry, Griffith University, Brisbane, QLD, Australia.
- Coast Joint Care, Maroochydore, QLD, Australia.
| | - Tim McEwan
- School of Clinical Medicine, University of Queensland, Herston Rd, Herston, QLD, 4006, Australia
| | - Paul Bird
- St George Hospital Clinical School, University of New South Wales, Sydney, Australia
| | | | - Nivene F Saad
- Metro South Hospital and Health Service, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
| | - Lionel Schachna
- Department of Rheumatology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Andrew L Taylor
- Department of Rheumatology, Medical School, Fiona Stanley Hospital, University of Western Australia, Perth, Australia
| | - Philip C Robinson
- Metro North, Hospital and Health Service, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, University of Queensland, Royal Brisbane and Women's Hospital, Bowen Bridge Road, Herston, QLD, 4006, Australia
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Hayward RJ, Machado PM. Classification Criteria in Axial Spondyloarthritis: What Have We Learned; Where Are We Going? Rheum Dis Clin North Am 2021; 46:259-274. [PMID: 32340700 DOI: 10.1016/j.rdc.2020.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Spondyloarthritis (SpA) is a chronic inflammatory condition that can have a predominately peripheral or axial presentation. Axial SpA (axSpA) affects the axial skeleton with either radiographic (r-axSpA) or nonradiographic (nr-axSpA) changes. Radiographic changes are a late disease feature and earlier disease stages can be identified by incorporating other imaging methods. The diagnosis of axSpA is a clinical diagnosis and classification criteria are not aimed to be diagnostic tools. The split between r-axSpA and nr-axSpA is artificial and we should move toward the unifying concept of axSpA. Our understanding of genetics, biomarkers, and immunopathophenotypes will drive further refinement of classification criteria.
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Affiliation(s)
- Rhys J Hayward
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Watford Road, Harrow, Middlesex HA1 3UJ, London, UK; Department of Rheumatology, University College London Hospitals NHS Foundation Trust, 3rd Floor, 250 Euston Road, NW1 2PG, London, UK
| | - Pedro M Machado
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Watford Road, Harrow, Middlesex HA1 3UJ, London, UK; Department of Neuromuscular Diseases, University College London, 1st Floor, Russell Square House, 10-12 Russell Square, WC1B 5EH, London, UK; Centre for Rheumatology, University College London, Room 415, 4th Floor, Rayne Institute, 5 University St, Bloomsbury, London WC1E 6JF.
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6
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Kiil RM, Mistegaard CE, Jurik AG, Christiansen AA, Hendricks O, Schiøttz-Christensen B, Loft AG. Diagnosing axial spondyloarthritis by multidiciplinary team conference at 3.5 years' follow-up in a cohort of patients with disease features according to the ASAS criteria. Scand J Rheumatol 2021; 51:291-299. [PMID: 34263690 DOI: 10.1080/03009742.2021.1933584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES During the past two decades, magnetic resonance imaging (MRI) has increasingly been used diagnostically in axial spondyloarthritis (axSpA), and in 2009 MRI was introduced in the Assessment of SpondyloArthritis Society (ASAS) classification criteria. In clinical practice, there is a risk of overdiagnosis if MRI findings are not related to clinical and biochemical findings. The aim of this study was to provide an estimate of the prevalence of axSpA in a cohort of clinical patients with low back pain and findings suggestive of axSpA according to ASAS through consensus diagnosis at a multi-disciplinary team (MDT) conference, and to describe the performance of the features included in the ASAS criteria. METHOD Consensus diagnoses of axSpA at MDT conferences were retrospectively established at 3.5 years' follow-up in a cohort of 84 patients, initially referred with disease features according to the ASAS criteria. Patients were examined clinically regarding spondyloarthritis features, and biochemical tests and MRI of the sacroiliac joints and entire spine were performed at baseline and after a mean of 3.5 years. RESULTS According to the MDT consensus, 25 patients (30%) of the total cohort had axSpA at follow-up; 40% of individuals who fulfilled the ASAS criteria at baseline had axSpA, and 37% at follow-up; 96% of axSpA patients according to the MDT consensus met the ASAS criteria at baseline and 92% at follow-up. CONCLUSION Approximately one-third of the included patients had axSpA when evaluated at the MDT conference. The ASAS criteria had low predictive value, but high sensitivity at both baseline and follow-up.
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Affiliation(s)
- R M Kiil
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - C E Mistegaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - A G Jurik
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - A A Christiansen
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark
| | - O Hendricks
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark
| | - B Schiøttz-Christensen
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Research Department, Spine Centre of Southern Denmark, Hospital Lillebaelt, Middelfart, Denmark
| | - A G Loft
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
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7
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Wordsworth BP, Cohen CJ, Davidson C, Vecellio M. Perspectives on the Genetic Associations of Ankylosing Spondylitis. Front Immunol 2021; 12:603726. [PMID: 33746951 PMCID: PMC7977288 DOI: 10.3389/fimmu.2021.603726] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/05/2021] [Indexed: 12/11/2022] Open
Abstract
Ankylosing spondylitis (AS) is a common form of inflammatory spinal arthritis with a complex polygenic aetiology. Genome-wide association studies have identified more than 100 loci, including some involved in antigen presentation (HLA-B27, ERAP1, and ERAP2), some in Th17 responses (IL6R, IL23R, TYK2, and STAT3), and others in macrophages and T-cells (IL7R, CSF2, RUNX3, and GPR65). Such observations have already helped identify potential new therapies targeting IL-17 and GM-CSF. Most AS genetic associations are not in protein-coding sequences but lie in intergenic regions where their direct relationship to particular genes is difficult to assess. They most likely reflect functional polymorphisms concerned with cell type-specific regulation of gene expression. Clarifying the nature of these associations should help to understand the pathogenic pathways involved in AS better and suggest potential cellular and molecular targets for drug therapy. However, even identifying the precise mechanisms behind the extremely strong HLA-B27 association with AS has so far proved elusive. Polygenic risk scores (using all the known genetic associations with AS) can be effective for the diagnosis of AS, particularly where there is a relatively high pre-test probability of AS. Genetic prediction of disease outcomes and response to biologics is not currently practicable.
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Affiliation(s)
- B Paul Wordsworth
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford Institute of Musculoskeletal Sciences, Oxford, United Kingdom.,Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Carla J Cohen
- Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Connor Davidson
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Matteo Vecellio
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford Institute of Musculoskeletal Sciences, Oxford, United Kingdom.,Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, United Kingdom.,Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
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8
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Maksymowych WP, Lambert RG, Baraliakos X, Weber U, Machado P, Pedersen SJ, Hooge MD, Sieper J, Wichuk S, Poddubnyy D, Rudwaleit M, van der Heijde D, Landewe R, Eshed I, Ostergaard M. Data-driven definitions for active and structural MRI lesions in the sacroiliac joint in spondyloarthritis and their predictive utility. Rheumatology (Oxford) 2021; 60:4778-4789. [DOI: 10.1093/rheumatology/keab099] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/15/2021] [Indexed: 12/17/2022] Open
Abstract
Abstract
Objectives
To determine quantitative SI joint MRI lesion cut-offs that optimally define a positive MRI for inflammatory and structural lesions typical of axial SpA (axSpA) and that predict clinical diagnosis.
Methods
The Assessment of SpondyloArthritis international Society (ASAS) MRI group assessed MRIs from the ASAS Classification Cohort in two reading exercises where (A) 169 cases and 7 central readers; (B) 107 cases and 8 central readers. We calculated sensitivity/specificity for the number of SI joint quadrants or slices with bone marrow oedema (BME), erosion, fat lesion, where a majority of central readers had high confidence there was a definite active or structural lesion. Cut-offs with ≥95% specificity were analysed for their predictive utility for follow-up rheumatologist diagnosis of axSpA by calculating positive/negative predictive values (PPVs/NPVs) and selecting cut-offs with PPV ≥ 95%.
Results
Active or structural lesions typical of axSpA on MRI had PPVs ≥ 95% for clinical diagnosis of axSpA. Cut-offs that best reflected a definite active lesion typical of axSpA were either ≥4 SI joint quadrants with BME at any location or at the same location in ≥3 consecutive slices. For definite structural lesion, the optimal cut-offs were any one of ≥3 SI joint quadrants with erosion or ≥5 with fat lesions, erosion at the same location for ≥2 consecutive slices, fat lesions at the same location for ≥3 consecutive slices, or presence of a deep (i.e. >1 cm depth) fat lesion.
Conclusion
We propose cut-offs for definite active and structural lesions typical of axSpA that have high PPVs for a long-term clinical diagnosis of axSpA for application in disease classification and clinical research.
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Affiliation(s)
| | - Robert G Lambert
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
- Medical Imaging Consultants, Edmonton, Canada
| | | | - Ulrich Weber
- Department of Rheumatology, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Pedro M Machado
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust
- Centre for Rheumatology and MRC Centre for Neuromuscular Diseases, University College London, London, UK
| | - Susanne J Pedersen
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Manouk de Hooge
- VIB Inflammation Research Center, Ghent University
- Rheumatology Department, Ghent University Hospital, Ghent, Belgium
| | - Joachim Sieper
- Department of Rheumatology, Charité – Universitätsmedizin Berlin and German Rheumatism Research Centre, Berlin
| | | | - Denis Poddubnyy
- Department of Rheumatology, Charité – Universitätsmedizin Berlin and German Rheumatism Research Centre, Berlin
| | - Martin Rudwaleit
- Klinikum Bielefeld, Bielefeld
- Department of Rheumatology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - Robert Landewe
- Department of Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam
- Atrium Medical Center, Heerlen, the Netherlands
| | - Iris Eshed
- Sheba Medical Center, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Mikkel Ostergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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9
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The paradigm of non-radiographic sacroiliitis-why the ongoing doubts? Clin Rheumatol 2021; 40:443-446. [PMID: 33405013 DOI: 10.1007/s10067-020-05527-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
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10
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Barnett R, Ingram T, Sengupta R. Axial spondyloarthritis 10 years on: still looking for the lost tribe. Rheumatology (Oxford) 2020; 59:iv25-iv37. [PMID: 33053196 PMCID: PMC7566532 DOI: 10.1093/rheumatology/keaa472] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/14/2020] [Indexed: 12/15/2022] Open
Abstract
Despite the publication of various recommendations, quality standards and referral strategies to promote early diagnosis in axial SpA (axSpA) over the last decade, there remains a significant delay to diagnosis, leading to a lost tribe of undiagnosed, untreated patients with persistent back pain and axSpA symptoms. This review discusses the various factors contributing to diagnostic delay in axSpA, while providing recommendations to improve the diagnostic pathway, for example use of the online Spondyloarthritis Diagnosis Evaluation (SPADE) tool (http://www.spadetool.co.uk/). Significant shortcomings exist at both the primary and secondary care level, with healthcare professionals often lacking knowledge and awareness of axSpA. Myths regarding the classical signs and symptoms still prevail, including the perception of axSpA as a male disease, only occurring in individuals who are HLA-B27 positive with raised inflammatory markers. Individuals within this lost tribe of undiagnosed patients are likely lacking adequate treatment and are thereby at risk of worse clinical outcomes. It is therefore vital that public health initiatives are implemented to improve education of healthcare professionals and to ensure early specialist referral, to ultimately improve the lives of patients with axSpA.
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Affiliation(s)
- Rosemarie Barnett
- Axial Spondyloarthritis Service, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust
- Department of Computer Science, University of Bath
| | - Thomas Ingram
- Axial Spondyloarthritis Service, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust
- Department for Health, University of Bath
| | - Raj Sengupta
- Axial Spondyloarthritis Service, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
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11
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Understanding the paradigm of non-radiographic axial spondyloarthritis. Clin Rheumatol 2020; 40:501-512. [PMID: 32996069 DOI: 10.1007/s10067-020-05423-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 12/17/2022]
Abstract
The concept of axial spondyloarthritis (axSpA) encompasses both non-radiographic (nr-axSpA) and traditional radiographic axSpA (r-axSpA) forms. The former was conceived following the establishment of the ASAS classification criteria for axSpA, which for the first time included the use of magnetic resonance imaging of the sacroiliac joints. This facilitated the classification of patients with axSpA who did not present substantial structural damage. This conception of nr-axSpA revolutionized the classical understanding of axSpA opening new doors for research and broadening the scope of treatment to the entire spectrum of axSpA. In this sense, epidemiologic patterns of the disease were viewed anew, and early diagnosis became a primary objective in the management of the disease. However, despite these advances, this new axSpA subtype led to some concerns within the scientific community. These issues have been addressed by several studies that set out to clarify the concept of nr-axSpA. In this review, we summarize the findings of the most relevant studies including nr-axSpA and then discuss recent advances in understanding disease clinical patterns, burden of disease, and treatment effects. Current scientific research has shown subtle differences between nr-axSpA and r-axSpA. In the near future, these advances will allow for better management of individual patients across the axSpA spectrum.
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12
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Coates LC, Abraham S, Tillett W, Mease PJ, Ramiro S, Wu T, Wang X, Pangan AL, Song IH. Performance and Predictors of Minimal Disease Activity Response in Peripheral Spondyloarthritis Patients Treated With Adalimumab. Arthritis Care Res (Hoboken) 2020; 74:259-267. [PMID: 32937016 DOI: 10.1002/acr.24442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/11/2020] [Accepted: 09/01/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To examine concurrent validity and discrimination of modified minimal disease activity (mMDA) criteria in peripheral spondyloarthritis (pSpA) following OMERACT filter principles and determine predictors of mMDA response. METHODS Four mMDA versions were derived in the ABILITY-2 study using the SPondyloArthritis Research Consortium of Canada (SPARCC) or Leeds Enthesitis Index (LEI) but excluding psoriasis. To assess concurrent validity, mMDA versions were correlated with Peripheral SpondyloArthritis Response Criteria (PSpARC) remission, Ankylosing Spondylitis Disease Activity Score for inactive disease (ASDAS ID), and physician global. Treatment discrimination was assessed between adalimumab and placebo at week 12. Multiple logistic regression was used to determine baseline predictors of long-term mMDA responses and sustained mMDA. RESULTS The four mMDA versions showed a stronger positive correlation with PSpARC remission (rtet >0.95) versus ASDAS ID (rtet >0.75) at week 12 and years 1-3 and were able to show discrimination (p<0.001). Responsiveness was shown at week 12; significantly more patients receiving adalimumab versus placebo achieved all four versions of mMDA. Approximately 40-60% of adalimumab-treated patients achieved mMDA-LEI or SPARCC at years 1-3. Achieving mMDA response after 12 weeks of adalimumab treatment was a robust positive predictor of attaining long-term mMDA through 3 years (odds ratios: 11.38-27.13 for mMDA-LEI; 17.98-37.85 for mMDA-SPARCC). CONCLUSIONS All four versions of mMDA showed concurrent validity and discriminated well between adalimumab and placebo treatment groups. Early mMDA response is a more consistent predictor of long-term mMDA achievement than baseline characteristics. The 5 of 6 versions of mMDA could be an appropriate treatment target in pSpA patients.
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Affiliation(s)
| | - Sonya Abraham
- National Institute for Health Research/Wellcome CRF, Imperial College Healthcare NHS Trust, London, UK
| | - William Tillett
- Royal National Hospital for Rheumatic Diseases, Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Philip J Mease
- Swedish Medical Center/Providence St. Joseph Health and University of Washington, Seattle
| | - Sofia Ramiro
- Leiden University Medical Center, Leiden, and Zuyderland Medical Center, Heerlen, The Netherlands
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13
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Maksymowych WP, Pedersen SJ, Weber U, Baraliakos X, Machado PM, Eshed I, de Hooge M, Sieper J, Wichuk S, Rudwaleit M, van der Heijde D, Landewé RBM, Poddubnyy D, Ostergaard M, Lambert RGW. Central reader evaluation of MRI scans of the sacroiliac joints from the ASAS classification cohort: discrepancies with local readers and impact on the performance of the ASAS criteria. Ann Rheum Dis 2020; 79:935-942. [PMID: 32371388 DOI: 10.1136/annrheumdis-2020-217232] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The Assessment of SpondyloArthritis international Society (ASAS) MRI working group conducted a multireader exercise on MRI scans from the ASAS classification cohort to assess the spectrum and evolution of lesions in the sacroiliac joint and impact of discrepancies with local readers on numbers of patients classified as axial spondyloarthritis (axSpA). METHODS Seven readers assessed baseline scans from 278 cases and 8 readers assessed baseline and follow-up scans from 107 cases. Agreement for detection of MRI lesions between central and local readers was assessed descriptively and by the kappa statistic. We calculated the number of patients classified as axSpA by the ASAS criteria after replacing local detection of active lesions by central readers and replacing local reader radiographic sacroiliitis by central reader structural lesions on MRI. RESULTS Structural lesions, especially erosions, were as frequent as active lesions (≈40%), the majority of patients having both types of lesions. The ASAS definitions for active MRI lesion typical of axSpA and erosion were comparatively discriminatory between axSpA and non-axSpA. Local reader overcall for active MRI lesions was about 30% but this had a minor impact on the number of patients (6.4%) classified as axSpA. Substitution of radiography with MRI structural lesions also had little impact on classification status (1.4%). CONCLUSION Despite substantial discrepancy between central and local readers in interpretation of both types of MRI lesion, this had a minor impact on the numbers of patients classified as axSpA supporting the robustness of the ASAS criteria for differences in assessment of imaging.
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Affiliation(s)
- Walter P Maksymowych
- Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Susanne Juhl Pedersen
- Department of Rheumatology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - Ulrich Weber
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark.,Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Pedro M Machado
- MRC Centre for Neuromuscular Diseases, University College London, London, UK.,Rheumatology, University College London Centre for Rheumatology, London, UK
| | - Iris Eshed
- Radiology, Sheba Medical Center, Tel Hashomer, Israel
| | - Manouk de Hooge
- VIB Center of Inflammation Research, Ghent University, Gent, Belgium
| | - Joachim Sieper
- Medical Department I, Rheumatology, University Clinic Benjamin Franklin, Berlin, Germany
| | - Stephanie Wichuk
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Martin Rudwaleit
- Internal Medicine and Rheumatology, Klinikum Bielefeld Rosenhöhe, Bielefeld, Germany
| | - Désirée van der Heijde
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Rheumatology, Diakonhjemmet Hospital, Norway
| | - Robert B M Landewé
- Amsterdam Rheumatology Center, AMC, Amsterdam, The Netherlands.,Rheumatology, Zuyderland MC, Heerlen, The Netherlands
| | - Denis Poddubnyy
- Department of Rheumatology, Infectious Diseases and Rheumatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Mikkel Ostergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Robert G W Lambert
- Radiology and Diagnostic Imaging and Medical Imaging Consultants, University of Alberta, Edmonton, Alberta, Canada
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14
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Long-Term Effectiveness of Secukinumab in Patients with Axial Spondyloarthritis. Mediators Inflamm 2020; 2020:6983272. [PMID: 32317863 PMCID: PMC7150683 DOI: 10.1155/2020/6983272] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/01/2020] [Accepted: 03/06/2020] [Indexed: 02/07/2023] Open
Abstract
Objectives The primary aim of our study was to evaluate long-term efficacy of secukinumab (SCK) in patients with axial spondyloarthritis (axSpA); secondary aims were to evaluate drug retention rate and to identify differences in the clinical and laboratory assessment according to axSpA clinical features, dosage administered, and biologic treatment lines. Patients and Methods. We collected clinical, demographical, and treatment data from 39 patients affected by axSpA consecutively treated with SCK. Laboratory assessment was based on inflammation parameters; clinical assessment was performed with the Ankylosing Spondylitis Disease Activity Score- (ASDAS-) CRP and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Data were recorded at baseline and every 3 months for the first year and then every 6 months in the second year. Results Twelve males and 27 females were enrolled; both BASDAI and ASDAS-CRP showed a statistically significant reduction during the observation period (p < 0.0001 and p < 0.0001, respectively). C-reactive protein significantly decreased (p = 0.006), with significant reduction at the post hoc analysis between baseline and both 6-month evaluation (p = 0.02) and 24-month visit (p = 0.036). No statistical significance was observed in BASDAI and ASDAS-CRP improvement (p = 0.482 and p = 0.164, respectively) between different dosages administered. No significant differences emerged in the BASDAI and ASDAS-CRP variations between biologic-naïve patients and subjects previously failing to tumour necrosis factor (TNF) inhibitors (p = 0.53 and p = 0.148, respectively). At the end of our observation, 7 out of 39 patients discontinued SCK. The global retention rate at the end of the study period was 78.2%, without any significant differences between biologic-naïve and anti-TNF-failure patients (p = 0.619) or between subjects administered with different SCK dosages (p = 0.614). No adverse events were reported. Conclusions In our cohort, SCK has proved a remarkable effectiveness regardless biologic treatment line and dosages employed. As suggested by the notable drug retention rate, SCK has been able to maintain its effectiveness over a considerable long period of treatment.
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15
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Spinal radiographic progression in axial spondyloarthritis and the impact of classification as nonradiographic versus radiographic disease: Data from the Swiss Clinical Quality Management cohort. PLoS One 2020; 15:e0230268. [PMID: 32196530 PMCID: PMC7083308 DOI: 10.1371/journal.pone.0230268] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 02/25/2020] [Indexed: 11/22/2022] Open
Abstract
Objective To investigate whether spinal radiographic progression relates to structural damage at the sacroiliac level in axial spondyloarthritis (axSpA). Methods Patients classified as nonradiographic (nr-) and radiographic (r-) axSpA in the Swiss Clinical Quality Management cohort with radiographs performed every 2 years, scored according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), were included. The relationship between classification status and spinal progression during 2 years was investigated using binomial generalized estimating equations models with adjustment for sex, ankylosing spondylitis disease activity score (ASDAS) and tumour necrosis factor inhibitor treatment. Baseline spinal damage was considered an intermediate variable and included in sensitivity analyses. Results In total, 88 nr-axSpA and 418 r-axSpA patients contributed to data for 725 radiographic intervals. R-axSpA patients were more frequently male, had a longer disease duration and higher structural damage at baseline. Mean (SD) mSASSS change over 2 years was 0.16 (0.62) units in nr-axSpA and 0.92 (2.78) units in r-axSpA, p = 0.01. Nr-axSpA was associated with a significantly lower progression in 2 years (defined as an increase in ≥2 mSASSS units) in adjusted analyses (OR 0.33, 95%CI 0.13; 0.83), confirmed with progression defined as the formation of ≥1 syndesmophyte. Mediation analyses revealed that sacroiliitis exerted its effect on spinal progression indirectly by being associated with the appearance of a first syndesmophyte (OR 0.09, 95%CI 0.02; 0.36 for nr-axSpA vs r-axSpA). Baseline syndesmophytes were predictors of further progression. Conclusion Spinal structural damage is mainly restricted to patients with r-axSpA, leading to relevant prognostic and therapeutic implications.
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16
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van Lunteren M, van der Heijde D, Sepriano A, Berg IJ, Dougados M, Gossec L, Jacobsson L, Ramonda R, Rudwaleit M, Sieper J, Landewé R, van Gaalen FA. Is a positive family history of spondyloarthritis relevant for diagnosing axial spondyloarthritis once HLA-B27 status is known? Rheumatology (Oxford) 2020; 58:1649-1654. [PMID: 30938446 PMCID: PMC6735817 DOI: 10.1093/rheumatology/kez095] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 02/23/2019] [Indexed: 12/17/2022] Open
Abstract
Objectives A positive family history (PFH) of spondyloarthritis, in particular a PFH of AS or acute anterior uveitis, is associated with HLA-B27 carriership in chronic back pain patients. As it is unknown, the study aimed to investigate if a PFH contributes to diagnosing axial spondyloarthritis (axSpA) once HLA-B27 status is known. Methods In axSpA-suspected patients from the Assessment of SpondyloArthritis international Society (ASAS), DEvenir des Spondyloarthropathies Indifférenciéés Récentes (DESIR) and SPondyloArthritis Caught Early (SPACE) cohorts, logistic regression analyses were performed with HLA-B27 status and PFH according to the ASAS definition (ASAS-PFH) as determinants and clinical axSpA diagnosis as outcome at baseline. Analyses were repeated with a PFH of AS or acute anterior uveitis. Results In total, 1818 patients suspected of axSpA were analysed (ASAS n = 594, DESIR n = 647, and SPACE n = 577). In patients from the ASAS, DESIR and SPACE cohorts, respectively 23%, 39% and 38% had an ASAS-PFH, 52%, 58% and 43% were HLA-B27 positive, and 62%, 47% and 54% were diagnosed with axSpA. HLA-B27 was independently associated with an axSpA diagnosis in each cohort but an ASAS-PFH was not [ASAS cohort: HLA-B27 odds ratio (OR): 6.9 (95% CI: 4.7, 10.2), ASAS-PFH OR: 0.9 (95% CI: 0.6, 1.4); DESIR: HLA-B27 OR: 2.1 (95% CI: 1.5, 2.9), ASAS-PFH OR: 1.0 (95% CI 0.7, 1.3); SPACE: HLA-B27 OR: 10.4 (95% CI: 6.9, 15.7), ASAS-PFH OR: 1.0 (95% CI: 0.7, 1.5)]. Similar negative results were found for PFH of AS and acute anterior uveitis. Conclusion In three independent cohorts with different ethnical backgrounds, ASAS, DESIR and SPACE, a PFH was not associated independently of HLA-B27 with a diagnosis of axSpA. This indicates that in the vast majority of patients presenting with back pain, a PFH does not contribute to the likelihood of an axSpA diagnosis if HLA-B27 status is known.
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Affiliation(s)
- Miranda van Lunteren
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Inger J Berg
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Maxime Dougados
- Rheumatology Department, Paris Descartes University, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris
| | - Laure Gossec
- Rheumatology Department, Sorbonne Université, Paris.,Rheumatology Department, Pitié Salpêtrière Hospital, Paris, France
| | - Lennart Jacobsson
- Department of Rheumatology, University of Gothenburg, Gothenburg, Sweden
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Martin Rudwaleit
- Department of Rheumatology, Charité Campus Benjamin Franklin, Berlin.,Department of Internal Medicine and Rheumatology, Klinikum Bielefeld Rosenhöhe, Bielefeld
| | - Joachim Sieper
- Department of Rheumatology, Charité Campus Benjamin Franklin, Berlin.,German Rheumatism Research Centre, Berlin, Germany
| | - Robert Landewé
- Department of Rheumatology, Amsterdam Rheumatology & Immunology Center, Amsterdam.,Department of Rheumatology, Zuyderland Hospital, Heerlen, the Netherlands
| | - Floris A van Gaalen
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
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17
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Resende GG, Meirelles EDS, Marques CDL, Chiereghin A, Lyrio AM, Ximenes AC, Saad CG, Gonçalves CR, Kohem CL, Schainberg CG, Campanholo CB, Bueno Filho JSDS, Pieruccetti LB, Keiserman MW, Yazbek MA, Palominos PE, Goncalves RSG, Lage RDC, Assad RL, Bonfiglioli R, Anti SMA, Carneiro S, Oliveira TL, Azevedo VF, Bianchi WA, Bernardo WM, Pinheiro MDM, Sampaio-Barros PD. The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis - 2019. Adv Rheumatol 2020; 60:19. [PMID: 32171329 DOI: 10.1186/s42358-020-0116-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 01/22/2020] [Indexed: 12/13/2022] Open
Abstract
Spondyloarthritis is a group of chronic inflammatory systemic diseases characterized by axial and/or peripheral joints inflammation, as well as extra-articular manifestations. The classification axial spondyloarthritis is adopted when the spine and/or the sacroiliac joints are predominantly involved. This version of recommendations replaces the previous guidelines published in May 2013.A systematic literature review was performed, and two hundred thirty-seven studies were selected and used to formulate 29 recommendations answering 15 clinical questions, which were divided into four sections: diagnosis, non-pharmacological therapy, conventional drug therapy and biological therapy. For each recommendation the level of evidence supporting (highest available), the strength grade according to Oxford, and the degree of expert agreement (inter-rater reliability) is informed.These guidelines bring evidence-based information on clinical management of axial SpA patients, including, diagnosis, treatment, and prognosis.
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Affiliation(s)
- Gustavo Gomes Resende
- Universidade Federal de Minas Gerais (UFMG), Alameda Álvaro Celso, 175 / 2° Andar. Santa Efigênia. CEP 30.150-260, Belo Horizonte, MG, Brazil.
| | | | | | | | - Andre Marun Lyrio
- Pontifície Universidade Católica (PUC) de Campinas, Campinas, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | - Ricardo da Cruz Lage
- Universidade Federal de Minas Gerais (UFMG), Alameda Álvaro Celso, 175 / 2° Andar. Santa Efigênia. CEP 30.150-260, Belo Horizonte, MG, Brazil
| | | | | | | | - Sueli Carneiro
- Universidade Federal do Rio De Janeiro (UFRJ), Rio de Janeiro, Brazil
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18
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Kiltz U, Braun J, Becker A, Chenot JF, Dreimann M, Hammel L, Heiligenhaus A, Hermann KG, Klett R, Krause D, Kreitner KF, Lange U, Lauterbach A, Mau W, Mössner R, Oberschelp U, Philipp S, Pleyer U, Rudwaleit M, Schneider E, Schulte TL, Sieper J, Stallmach A, Swoboda B, Winking M. [Long version on the S3 guidelines for axial spondyloarthritis including Bechterew's disease and early forms, Update 2019 : Evidence-based guidelines of the German Society for Rheumatology (DGRh) and participating medical scientific specialist societies and other organizations]. Z Rheumatol 2020; 78:3-64. [PMID: 31784900 DOI: 10.1007/s00393-019-0670-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- U Kiltz
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Claudiusstr. 45, 44649, Herne, Deutschland.
| | - J Braun
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Claudiusstr. 45, 44649, Herne, Deutschland
| | | | - A Becker
- Allgemeinmedizin, präventive und rehabilitative Medizin, Universität Marburg, Karl-von-Frisch-Str. 4, 35032, Marburg, Deutschland
| | | | - J-F Chenot
- Universitätsmedizin Greifswald, Fleischmann Str. 6, 17485, Greifswald, Deutschland
| | - M Dreimann
- Zentrum für Operative Medizin, Klinik und Poliklinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistraße 52, 20251, Hamburg, Deutschland
| | | | - L Hammel
- Geschäftsstelle des Bundesverbandes der DVMB, Metzgergasse 16, 97421, Schweinfurt, Deutschland
| | | | - A Heiligenhaus
- Augenzentrum und Uveitis-Zentrum, St. Franziskus Hospital, Hohenzollernring 74, 48145, Münster, Deutschland
| | | | - K-G Hermann
- Institut für Radiologie, Charité Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | | | - R Klett
- Praxis Manuelle & Osteopathische Medizin, Fichtenweg 17, 35428, Langgöns, Deutschland
| | | | - D Krause
- , Friedrich-Ebert-Str. 2, 45964, Gladbeck, Deutschland
| | - K-F Kreitner
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - U Lange
- Kerckhoff-Klinik, Rheumazentrum, Osteologie & Physikalische Medizin, Benekestr. 2-8, 61231, Bad Nauheim, Deutschland
| | | | - A Lauterbach
- Schule für Physiotherapie, Orthopädische Universitätsklinik Friedrichsheim, Marienburgstraße 2, 60528, Frankfurt, Deutschland
| | | | - W Mau
- Institut für Rehabilitationsmedizin, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, 06097, Halle (Saale), Deutschland
| | - R Mössner
- Klinik für Dermatologie, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland
| | | | - U Oberschelp
- , Barlachstr. 6, 59368, Werne a.d. L., Deutschland
| | | | - S Philipp
- Praxis für Dermatologie, Bernauer Str. 66, 16515, Oranienburg, Deutschland
| | - U Pleyer
- Campus Virchow-Klinikum, Charité Centrum 16, Klinik f. Augenheilkunde, Charité, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - M Rudwaleit
- Klinikum Bielefeld, An der Rosenhöhe 27, 33647, Bielefeld, Deutschland
| | - E Schneider
- Abt. Fachübergreifende Frührehabilitation und Sportmedizin, St. Antonius Hospital, Dechant-Deckersstr. 8, 52249, Eschweiler, Deutschland
| | - T L Schulte
- Klinik für Orthopädie und Unfallchirurgie, Orthopädische Universitätsklinik, Ruhr-Universität Bochum, Gudrunstr. 65, 44791, Bochum, Deutschland
| | - J Sieper
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Deutschland
| | - A Stallmach
- Klinik für Innere Medizin IV, Universitätsklinikum Jena, Am Klinikum 1, 07743, Jena, Deutschland
| | | | - B Swoboda
- Abteilung für Orthopädie und Rheumatologie, Orthopädische Universitätsklinik, Malteser Waldkrankenhaus St. Marien, 91054, Erlangen, Deutschland
| | | | - M Winking
- Zentrum für Wirbelsäulenchirurgie, Klinikum Osnabrück, Am Finkenhügel 3, 49076, Osnabrück, Deutschland
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19
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Jamal M, Korver AM, Kuijper M, Lopes Barreto D, Appels CWY, Spoorenberg APL, Koes BW, Hazes JMW, van Hoeven L, Weel AEAM. The IMPACT study: A clustered randomized controlled trial to assess the effect of a referral algorithm for axial spondyloarthritis. PLoS One 2020; 15:e0227025. [PMID: 31990912 PMCID: PMC6986702 DOI: 10.1371/journal.pone.0227025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 12/09/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A substantial number of patients with chronic low back pain (CLBP) have axial spondyloarthritis (axSpA), but early recognition of these patients is difficult for general practitioners (GPs). The Case Finding Axial Spondyloarthritis (CaFaSpA) referral strategy has shown to be able to identify patients with CLBP at risk for axSpA, but its impact on clinical daily practice is yet unknown. OBJECTIVE To assess the effect of the CaFaSpA referral strategy on pain caused by disability in primary care patients with CLBP. METHODS Within this clustered randomized controlled trial 93 general practices were randomized to either the CaFaSpA referral model (intervention) or usual primary care (control). In each group primary care patients between 18 and 45 years with CLBP were included. The primary outcome was disability caused by CLBP, measured with the Roland Morris Disability Questionnaire (RMDQ) at baseline and four months. Secondary outcome was the frequency of new axSpA diagnosis. Descriptive analyses were performed, and a linear mixed-effects model was used. RESULTS In total 679 CLBP patients were included of which 333 patients were allocated to the intervention group and 346 to the control group. Sixty-four percent were female and mean age was 36.2 years. The mean RMDQ score at baseline was 8.39 in the intervention group and 8.61 in the control group. At four months mean RMDQ score was 7.65 in the intervention group and 8.15 in the control group. This difference was not statistically significant (p = 0.50). Six (8%) out of the 75 finally referred patients, were diagnosed with axSpA by their rheumatologist. CONCLUSIONS The CaFaSpA referral strategy for axSpA did not have an effect on disability after four months caused by CLBP. However, the strategy is able to detect the axSpA patient within the large CLBP population sufficiently. Trial registration number: NCT01944163, Clinicaltrials.gov.
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Affiliation(s)
- Maha Jamal
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
- Department of Rheumatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- * E-mail:
| | - Amber M. Korver
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
- Department of Rheumatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Martijn Kuijper
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Deirisa Lopes Barreto
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Anneke P. L. Spoorenberg
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bart W. Koes
- Department of General Practice, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Johanna M. W. Hazes
- Department of Rheumatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Lonneke van Hoeven
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
- Department of Rheumatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Angelique E. A. M. Weel
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
- Department of Rheumatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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20
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Sepriano A, Ramiro S, van der Heijde D, van Gaalen F, Hoonhout P, Molto A, Saraux A, Ramonda R, Dougados M, Landewé R. What is axial spondyloarthritis? A latent class and transition analysis in the SPACE and DESIR cohorts. Ann Rheum Dis 2020; 79:324-331. [DOI: 10.1136/annrheumdis-2019-216516] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/19/2019] [Accepted: 01/04/2020] [Indexed: 12/12/2022]
Abstract
ObjectivesTo gain expert-judgement-free insight into the Gestalt of axial spondyloarthritis (axSpA), by investigating its ‘latent constructs’ and to test how well these latent constructs fit the Assessment of SpondyloArthritis international Society (ASAS) classification criteria.MethodsTwo independent cohorts of patients with early onset chronic back pain (SPondyloArthritis Caught Early (SPACE)) or inflammatory back pain (IBP) (DEvenir des Spondylarthopathies Indifférenciées Récentes (DESIR)) were analysed. Latent class analysis (LCA) was used to estimate the (unobserved) potential classes underlying axSpA. The best LCA model groups patients into clinically meaningful classes with best fit. Each class was labelled based on most prominent features. Percentage fulfilment of ASAS axSpA, peripheral SpA (pSpA) (ignoring IBP) or both classification criteria was calculated. Five-year data from DESIR were used to perform latent transition analysis (LTA) to examine if patients change classes over time.ResultsSPACE (n=465) yielded four discernible classes: ‘axial’ with highest likelihood of abnormal imaging and HLA-B27 positivity; ‘IBP+peripheral’ with 100% IBP and dominant peripheral symptoms; ‘at risk’ with positive family history and HLA-B27 and ‘no SpA’ with low likelihood for each SpA feature. LCA in DESIR (n=576) yielded similar classes, except for the ‘no-SpA’. The ASAS axSpA criteria captured almost all (SPACE: 98%; DESIR: 93%) ‘axial’ patients, but the ‘IBP+peripheral’ class was only captured well by combining the axSpA and pSpA criteria (SPACE: 78%; DESIR: 89%). Only 4% of ‘no SpA’ patients fulfilled the axSpA criteria in SPACE. LTA suggested that 5-year transitions across classes were unlikely (11%).ConclusionThe Gestalt of axSpA comprises three discernible entities, only appropriately captured by combining the ASAS axSpA and pSpA classification criteria. It is questionable whether some patients with ‘axSpA at risk’ will ever develop axSpA.
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The role of imaging in the diagnosis and management of axial spondyloarthritis. Nat Rev Rheumatol 2019; 15:657-672. [DOI: 10.1038/s41584-019-0309-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2019] [Indexed: 12/15/2022]
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Abstract
Peripheral spondyloarthritis refers to spondyloarthritis with predominant peripheral (arthritis, enthesitis or dactylitis) involvement. Diagnosis can be challenging, particularly in the absence of SpA extra-articular manifestations such as uveitis, psoriasis or inflammatory bowel disease. Evaluation of disease activity should always include assessment of objective signs of inflammation, particularly in the presence of enthesitis as the sole peripheral manifestation, mainly due to the potential misdiagnosis with fibromyalgia tender points. Several recommendations for management/treatment of psoriatic arthritis have been published by EULAR and GRAPPA but none for peripheral SpA in general. NSAIDs and glucocorticoids are recommended as the first step of treatment in all peripheral manifestations, while conventional synthetic (cs) DMARDs seem only efficacious in arthritis. Several biologics and targeted synthetic (ts) DMARDs (TNFi, anti-IL17 and JAK-inhibitors) have been proven to be efficacious in peripheral involvement in PsA (arthritis and enthesitis), but studies on peripheral SpA are lacking.
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Affiliation(s)
- Anna Molto
- Rheumatology Department, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; INSERM (U-1153), CRESS, Paris, France.
| | - Joachim Sieper
- Rheumatology, Charité, Campus Benjamin Franklin, Berlin, 12200, Germany
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Abstract
The triggers and pathogenesis of axial spondyloarthritis (axSpA) are not yet completely understood. However, therapeutic agents targeting tumor necrosis factor-α and interleukin-17 inflammatory pathways have proven successful in suppressing many of the clinical symptoms and signs of axSpA, giving us an indication of which pathways are responsible for initiating and maintaining the inflammation. The mechanisms that eventuate in syndesmophytes and ankyloses are less clear. This review addresses these two critical pathways of inflammation, discussing their nature and these factors that may activate or enhance the pathways in patients with axSpA. In addition, genetic and other markers important to the inflammatory pathways implicated in axSpA are explored, and prognostic biomarkers are discussed. Treatment options available for the management of axSpA and their associated targets are highlighted.
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Affiliation(s)
- Daniel E Furst
- Department of Medicine, Division of Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - James S Louie
- Department of Medicine, Division of Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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Ossum AM, Palm Ø, Cvancarova M, Solberg IC, Vatn M, Moum B, Høivik ML. Peripheral arthritis in patients with long-term inflammatory bowel disease. Results from 20 years of follow-up in the IBSEN study. Scand J Gastroenterol 2019; 53:1250-1256. [PMID: 30353756 DOI: 10.1080/00365521.2018.1518482] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Peripheral arthritis and related musculoskeletal manifestations, often classified as peripheral spondyloarthritis, are frequently seen in patients with inflammatory bowel disease (IBD). Few long-term studies have reported on the prevalence of these conditions. The aim of this study was to determine the prevalence of IBD-related peripheral arthritis and peripheral spondyloarthritis in IBD patients during 20 years of disease course, and to assess whether these conditions were associated with the intestinal IBD severity and activity. MATERIALS AND METHODS In an inception cohort (the IBSEN study), IBD patients were followed prospectively for 20 years. At the 5 year follow-up the patients underwent a rheumatological examination and at the 20 year follow-up they completed a questionnaire with identical questions. When peripheral arthritis was characteristic and not explained by other specific diagnoses, it was defined as IBD-related peripheral arthritis. The Assessment of Spondyloarthritis International Society criteria were used to define peripheral spondyloarthritis, including patients with peripheral arthritis, enthesitis and/or dactylitis. RESULTS After 20 years of follow-up, 441 patients were included (296 ulcerative colitis and 145 Crohn's disease). The prevalence of IBD-related peripheral arthritis was 17.2% and peripheral spondyloarthritis 27.9% during the disease course. IBD severity and activity were not different between those with a history of IBD-related peripheral arthritis or peripheral spondyloarthritis and those without. A higher proportion of women had IBD-related peripheral arthritis and peripheral spondyloarthritis. CONCLUSION During 20 years of disease course, more than every sixth patient had suffered from IBD-related peripheral arthritis and every fourth from peripheral spondyloarthritis.
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Affiliation(s)
- Alvilde Maria Ossum
- a Department of Gastroenterology , Oslo University Hospital , Oslo , Norway.,b Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Øyvind Palm
- c Department of Rheumatology , Oslo University Hospital , Oslo , Norway
| | - Milada Cvancarova
- d Faculty of Public Health , Oslo and Akershus University College , Oslo , Norway
| | | | - Morten Vatn
- e EpiGen Institute, Campus Ahus , Akershus University Hospital , Oslo , Norway
| | - Bjørn Moum
- a Department of Gastroenterology , Oslo University Hospital , Oslo , Norway.,b Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Marte Lie Høivik
- a Department of Gastroenterology , Oslo University Hospital , Oslo , Norway
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López-Medina C, Moltó A. Update on the epidemiology, risk factors, and disease outcomes of axial spondyloarthritis. Best Pract Res Clin Rheumatol 2018; 32:241-253. [PMID: 30527429 DOI: 10.1016/j.berh.2018.10.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/03/2018] [Accepted: 09/09/2018] [Indexed: 12/17/2022]
Abstract
Axial spondyloarthritis (axSpA) is the prototype of a class of a rheumatic chronic inflammatory disease named spondyloarthritis (SpA). The prevalence of axSpA ranges between 0.1% and 1.4% globally, hence showing geographic differences that can be explained mostly by the prevalence of the HLA-B27 antigen. However, not many studies have evaluated the incidence of this disease. Inflammation may be initiated in the enthesis as a consequence of the action of IL-23, which can activate resident T cells. The elevated expression of IL-23 has been explained by three hypotheses: the presence of HLA-B27, variations in the gut microbiome and the biomechanical stress at the enthesis. However, the role of IL-23 in this whole context is still unclear. In axSpA, the presence of syndesmophytes at baseline, systemic inflammation, and smoking may promote the spinal radiographic damage in these patients. The most frequent comorbidity in these patients is osteoporosis, which is directly associated with ankylosis and inflammation.
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Affiliation(s)
- Clementina López-Medina
- Rheumatology Department, Cochin Hospital, Paris, France; Inserm (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France; Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), University of Cordoba, Cordoba, Spain.
| | - Anna Moltó
- Rheumatology Department, Cochin Hospital, Paris, France; Inserm (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
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van Lunteren M, Sepriano A, Landewé R, Sieper J, Rudwaleit M, van der Heijde D, van Gaalen F. Do ethnicity, degree of family relationship, and the spondyloarthritis subtype in affected relatives influence the association between a positive family history for spondyloarthritis and HLA-B27 carriership? Results from the worldwide ASAS cohort. Arthritis Res Ther 2018; 20:166. [PMID: 30075809 PMCID: PMC6091114 DOI: 10.1186/s13075-018-1672-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/12/2018] [Indexed: 12/17/2022] Open
Abstract
Background The Assessment of SpondyloArthritis international Society (ASAS) defines a positive family history (PFH) of spondyloarthritis (SpA) as the presence of ankylosing spondylitis (AS), acute anterior uveitis (AAU), reactive arthritis (ReA), inflammatory bowel disease (IBD), and/or psoriasis in first-degree relatives (FDR) or second-degree relatives (SDR). In two European cohorts, a PFH of AS and AAU, but not other subtypes, was associated with human leukocyte antigen B27 (HLA-B27) carriership in patients suspected of axial SpA (axSpA). Because the importance of ethnicity or degree of family relationship is unknown, we investigated the influence of ethnicity, FDR, or SDR on the association between a PFH and HLA-B27 carriership in patients suspected of axSpA. Methods Baseline data from the ASAS cohort of patients suspected of axSpA were analyzed. Univariable analyses were performed. Each disease (AS, AAU, psoriasis, IBD, ReA) in a PFH according to the ASAS definition was a determinant in separate models with HLA-B27 carriership as outcome. Analyses were stratified for self-reported ethnicity, FDR, and SDR. Analyses were repeated in multivariable models to investigate independent associations. Results A total of 594 patients were analyzed (mean [SD] age 33.7 [11.7] years; 46% male; 52% HLA-B27+; 59% white, 36% Asian, 5% other). A PFH was associated with HLA-B27 carriership in patients with a white (OR, 2.3, 95% CI, 1.4–3.9) or Asian ethnicity (OR, 3.1, 95% CI, 1.6–5.8) and with a PFH in FDR (OR, 2.9, 95% CI, 1.8–4.5), but not with a PFH in SDR (OR, 1.7, 95% CI, 0.7–3.8) or in other ethnicities. A PFH of AS was positively associated with HLA-B27 carriership in all subgroups (white OR, 7.1; 95% CI, 2.9–17.1; Asian OR, 5.7; 95% CI, 2.5–13.2; FDR OR, 7.8; 95% CI, 3.8–16.0; SDR OR, 3.7; 95% CI, 1.2–11.6). A PFH of AAU, ReA, IBD, or psoriasis was never positively associated with HLA-B27 carriership. In the multivariate analysis, similar results were found. Conclusions In the ASAS cohort, a PFH of AS, but not of AAU, ReA, IBD, or psoriasis, was associated with HLA-B27 carriership regardless of white or Asian ethnicity or degree of family relationship. This cohort and two European cohorts show that a PFH of AS and possibly a PFH of AAU can be used to identify patients who are more likely to be HLA-B27-positive and therefore may have an increased risk of axSpA.
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Affiliation(s)
- Miranda van Lunteren
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.,NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Robert Landewé
- Department of Rheumatology, Amsterdam Rheumatology & Immunology Center, Amsterdam, the Netherlands.,Department of Rheumatology, Zuyderland Hospital, Heerlen, the Netherlands
| | - Joachim Sieper
- Department of Rheumatology, Charité Campus Benjamin Franklin, Berlin, Germany.,German Rheumatism Research Centre, Berlin, Germany
| | - Martin Rudwaleit
- Department of Rheumatology, Charité Campus Benjamin Franklin, Berlin, Germany.,Department of Internal Medicine and Rheumatology, Klinikum Bielefeld Rosenhöhe, Bielefeld, Germany
| | - Désirée van der Heijde
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - Floris van Gaalen
- Department of Rheumatology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
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Lim CSE, Sengupta R, Gaffney K. The clinical utility of human leucocyte antigen B27 in axial spondyloarthritis. Rheumatology (Oxford) 2018; 57:959-968. [PMID: 29029331 DOI: 10.1093/rheumatology/kex345] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Indexed: 12/17/2022] Open
Abstract
The association between HLA-B27 and AS was first established in the early 1970s. Since then, our understanding of this disease has changed, such that we now recognize AS to be the extreme of the clinical phenotype within a disease spectrum known as axial SpA (axSpA). Recent advances in therapeutic options have driven the need for earlier diagnosis and many screening strategies have been proposed to facilitate this. In parallel, our understanding of axSpA genetics, and especially the contribution of HLA-B27, has expanded. In this article we will present and discuss the evidence supporting the use of HLA-B27 in clinical practice. We will briefly summarize the evolution of the concept of axSpA, the prevalence of HLA-B27 and axSpA and the potential role of HLA-B27 in the aetiopathogenesis of axSpA and focus on the utility of HLA-B27 in everyday clinical practice.
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Affiliation(s)
| | - Raj Sengupta
- Rheumatology Department, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | - Karl Gaffney
- Rheumatology Department, Norfolk & Norwich University Hospital, Norwich, UK
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29
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Rodrigues Manica S, Sepriano A, Ramiro S, Pimentel Santos F, Putrik P, Nikiphorou E, Norton S, Molto A, Dougados M, van der Heijde D, Landewé RBM, van den Bosch FE, Boonen A. Work participation in spondyloarthritis across countries: analysis from the ASAS-COMOSPA study. Ann Rheum Dis 2018; 77:1303-1310. [PMID: 29860232 DOI: 10.1136/annrheumdis-2018-213464] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/15/2018] [Accepted: 05/15/2018] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To explore the role of individual and country level socioeconomic (SE) factors on employment, absenteeism and presenteeism in patients with spondyloarthritis (SpA) across 22 countries worldwide. METHODS Patients with a clinical diagnosis of SpA fulfilling the ASAS classification criteria and in working age (≤65 years) from COMOSPA were included. Outcomes of interest were employment status, absenteeism and presenteeism, assessed by the Work Productivity and Activity Impairment Specific General Health questionnaire. Three multivariable models were built (one per outcome) using mixed-effects binomial (for work status) or ordinal regressions (for absenteeism and presenteeism), with country as random effect. The contribution of SE factors at the individual-level (eg, gender, education, marital status) and country-level (healthcare expenditure (HCE) per capita, Human Development Index (HDI) and gross domestic product per capita) SE factors, independent of clinical factors, was assessed. RESULTS In total, 3114 patients with SpA were included of which 1943 (62%) were employed. Physical function and comorbidities were related to all work outcomes in expected directions and disease activity also with absenteeism and presenteeism. Higher education (OR 4.2 (95% CI 3.1 to 5.6)) or living in a country with higher HCE (OR 2.3 (1.5 to 3.6)) or HDI (OR 1.9 (1.2 to 3.3)) was positively associated with being employed. Higher disease activity was associated with higher odds for absenteeism (OR 1.5 (1.3 to 1.7)) and presenteeism (OR 2.1 (1.8 to 2.4)). No significant association between individual-level and country-level SE factors and absenteeism or presenteeism was found. CONCLUSIONS Higher education level and higher country SE welfare are associated with a higher likelihood of keeping patients with SpA employed. Absenteeism and presenteeism are only associated with clinical but not with individual-level or country-level SE factors.
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Affiliation(s)
- Santiago Rodrigues Manica
- Department of Rheumatology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal.,NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Alexandre Sepriano
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal.,Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sofia Ramiro
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal.,Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Fernando Pimentel Santos
- Department of Rheumatology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal.,NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | | | - Elena Nikiphorou
- Academic Rheumatology, King's College of London (KCL), London, UK
| | - Sam Norton
- Academic Rheumatology, King's College of London (KCL), London, UK.,Psychology Department, King's College of London (KCL), London, UK
| | - Anna Molto
- Rheumatology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France.,INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - Maxime Dougados
- Rheumatology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France.,INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | | | | | - Filip E van den Bosch
- Department of Internal Medicine, VIB-UGent Center for Inflammation Research, Ghent University, Ghent, Belgium.,Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Annelies Boonen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Proft F, Poddubnyy D. Ankylosing spondylitis and axial spondyloarthritis: recent insights and impact of new classification criteria. Ther Adv Musculoskelet Dis 2018; 10:129-139. [PMID: 29942364 DOI: 10.1177/1759720x18773726] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 04/06/2018] [Indexed: 12/16/2022] Open
Abstract
Development of the Assessment in Spondyloarthritis International Society (ASAS) classification criteria for axial spondyloarthritis (SpA) was one of the major breakthroughs in the field over the past decade. Despite some concerns related to the specificity of the criteria, they stimulated research into the early stage of the disease. This resulted in major advances in the understanding of the course of the disease, revealing predictors of progression, improvement in early diagnosis and treatment in axial SpA. In this review, we summarize the recent developments resulting from the introduction of the ASAS classification criteria for axial SpA and the implications for research and clinical practice.
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Affiliation(s)
- Fabian Proft
- Department of Gastroenterology, Infectiology and Rheumatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
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Kopylov U, Starr M, Watts C, Dionne S, Girardin M, Seidman EG. Detection of Crohn Disease in Patients with Spondyloarthropathy: The SpACE Capsule Study. J Rheumatol 2018; 45:498-505. [PMID: 29449505 DOI: 10.3899/jrheum.161216] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Inflammatory bowel disease (IBD) is generally reported to be associated with spondylarthropathies (SpA) in 5%-15% of cases. Systematic colonoscopic assessment by protocol demonstrated mucosal inflammation characteristic of Crohn disease (CD) in up to one-third of patients with SpA. Video capsule endoscopy (CE) is a superior diagnostic tool to detect small bowel mucosal disease. Our study compared the accuracy of CE to standard colonoscopy for detection of inflammatory bowel lesions in patients with SpA, and to describe predictors of small bowel inflammation (SBI) in this cohort. METHODS Prospective cross-sectional study of adult patients followed for SpA. Patients were evaluated by CE and standard colonoscopy with biopsies. SBI was quantified using the Lewis Score. Additional screening tests included fecal calprotectin (FCP), C-reactive protein (CRP), and a diagnostic panel of serologic, inflammatory and genetic tests (SGI). RESULTS There were 64 patients recruited (53% female, mean age 42 ± 13 yrs). Chronic gastrointestinal (GI) symptoms were present in 57%. CE revealed significant SBI in 27/64 (42.2%), compared to 7/64 (10.9%) by standard colonoscopy (p = 0.035). Elevated FCP was associated with small bowel CD (OR 4.5, 95% CI 1.01-19.9; p = 0.042). No correlation was observed with presence of GI symptoms, CRP, or SGI results. Finding CD led to a change in management in 65.2% of cases. CONCLUSION CE uncovered SBI consistent with CD in 42.2% of patients with SpA, with a significant incremental yield over colonoscopy of 31%. FCP levels were significantly correlated with CE results, while GI symptoms and SGI results were poor predictors of SBI.
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Affiliation(s)
- Uri Kopylov
- From the divisions of Gastroenterology and Rheumatology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- U. Kopylov, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Starr, MD, Division of Rheumatology, Faculty of Medicine, McGill University; C. Watts, MD, Division of Rheumatology, Faculty of Medicine, McGill University; S. Dionne, PhD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Girardin, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; E.G. Seidman, MDCM, FRCPC, FACG, Division of Gastroenterology, Faculty of Medicine, McGill University
| | - Michael Starr
- From the divisions of Gastroenterology and Rheumatology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- U. Kopylov, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Starr, MD, Division of Rheumatology, Faculty of Medicine, McGill University; C. Watts, MD, Division of Rheumatology, Faculty of Medicine, McGill University; S. Dionne, PhD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Girardin, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; E.G. Seidman, MDCM, FRCPC, FACG, Division of Gastroenterology, Faculty of Medicine, McGill University
| | - Craig Watts
- From the divisions of Gastroenterology and Rheumatology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- U. Kopylov, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Starr, MD, Division of Rheumatology, Faculty of Medicine, McGill University; C. Watts, MD, Division of Rheumatology, Faculty of Medicine, McGill University; S. Dionne, PhD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Girardin, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; E.G. Seidman, MDCM, FRCPC, FACG, Division of Gastroenterology, Faculty of Medicine, McGill University
| | - Serge Dionne
- From the divisions of Gastroenterology and Rheumatology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- U. Kopylov, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Starr, MD, Division of Rheumatology, Faculty of Medicine, McGill University; C. Watts, MD, Division of Rheumatology, Faculty of Medicine, McGill University; S. Dionne, PhD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Girardin, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; E.G. Seidman, MDCM, FRCPC, FACG, Division of Gastroenterology, Faculty of Medicine, McGill University
| | - Marc Girardin
- From the divisions of Gastroenterology and Rheumatology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- U. Kopylov, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Starr, MD, Division of Rheumatology, Faculty of Medicine, McGill University; C. Watts, MD, Division of Rheumatology, Faculty of Medicine, McGill University; S. Dionne, PhD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Girardin, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; E.G. Seidman, MDCM, FRCPC, FACG, Division of Gastroenterology, Faculty of Medicine, McGill University
| | - Ernest G Seidman
- From the divisions of Gastroenterology and Rheumatology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
- U. Kopylov, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Starr, MD, Division of Rheumatology, Faculty of Medicine, McGill University; C. Watts, MD, Division of Rheumatology, Faculty of Medicine, McGill University; S. Dionne, PhD, Division of Gastroenterology, Faculty of Medicine, McGill University; M. Girardin, MD, Division of Gastroenterology, Faculty of Medicine, McGill University; E.G. Seidman, MDCM, FRCPC, FACG, Division of Gastroenterology, Faculty of Medicine, McGill University.
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Sykes MP, Hamilton L, Jones C, Gaffney K. Prevalence of axial spondyloarthritis in patients with acute anterior uveitis: a cross-sectional study utilising MRI. RMD Open 2018. [PMID: 29531779 PMCID: PMC5845401 DOI: 10.1136/rmdopen-2017-000553] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objective Acute anterior uveitis (AAU) is the most common extra-articular manifestation of axial spondyloarthritis (axSpA). In this study, patients presenting with AAU were evaluated clinically and with MRI in order to estimate the prevalence of axSpA. Methods Consecutive patients presenting to a university teaching hospital between February 2014 and March 2015 with AAU were invited to participate. Those with a history of chronic back pain (CBP) beginning <45 years were evaluated clinically and with MRI of thoracolumbar spine and sacroiliac joints. Results Of 366 patients with AAU, 57 had a pre-existing diagnosis of axSpA; 77 others fulfilled the study eligibility criteria and 73 (95%) completed the study. Seventeen patients (23.3%) were diagnosed with axSpA by an experienced rheumatologist; of these, eight were human leucocyte antigen-B27 negative. Including those with a previous diagnosis, this equates to a minimum axSpA prevalence of 20.2%; one-quarter of patients were previously undiagnosed. Conclusion This is the first study to actively search for the presence of axSpA in unselected patients presenting with AAU utilising MRI as an essential part of the assessment. There is a significant burden of undiagnosed axSpA in patients with AAU, but there does not appear to be a simple mechanism for screening. We recommend that ophthalmologists refer all patients with AAU with CBP, onset <45 years, to rheumatology for further evaluation.
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Affiliation(s)
- Mark P Sykes
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Louise Hamilton
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Colin Jones
- Department of Ophthalmology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Karl Gaffney
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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Abstract
PURPOSE OF REVIEW The Assessment of Spondyloarthritis International Society (ASAS) axial spondyloarthritis (axSpA) classification criteria marked a major step forward in SpA research, distinguishing axial from peripheral disease, and allowing earlier identification through MRI. This facilitated all aspects of research including epidemiology, therapeutics and patient outcomes. RECENT FINDINGS The ASAS axSpA classification criteria have been applied broadly in research, and were validated in a recent meta-analysis of international studies. Concerns arose because of clinical differences between the clinical and imaging arms, which imply different risk for radiographic progression, and perform differently in validation studies. Low specificity of the MRI finding of sacroiliac joint bone marrow edema may lead to misclassification in populations with low axSpA prevalence. We suggest methodology to improve upon the criteria, including rigorous assessment of potential candidate criteria sets, discrete choice experiments to allow consideration of feature weights, and validation. Separately, assessment of structural and inflammatory MRI abnormalities should be performed to refine the MRI definition of sacroiliitis. SUMMARY The debate regarding the validation and modification of the ASAS axSpA classification criteria should lead to international efforts to build upon the gains made by these criteria, to further refine the axSpA population definitions for research and ultimately improve patient outcomes.
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Lukas C, Cyteval C, Dougados M, Weber U. MRI for diagnosis of axial spondyloarthritis: major advance with critical limitations 'Not everything that glisters is gold (standard)'. RMD Open 2018; 4:e000586. [PMID: 29479474 PMCID: PMC5822619 DOI: 10.1136/rmdopen-2017-000586] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/04/2017] [Accepted: 12/06/2017] [Indexed: 11/09/2022] Open
Abstract
Recognition of axial spondyloarthritis (SpA) remains challenging, as no unique reference standard is available to ascertain diagnosis. Imaging procedures have been used for long in the field, in particular pelvic radiography, to capture structural changes evocative of sacroiliitis, the key feature in SpA. The introduction of MRI of the sacroiliac joints (SIJs) has led to a major shift in recognition of the disorder. MRI has been shown to detect the initial inflammatory processes, in particular osteitis depicted by bone marrow oedema, even in patients having not yet developed structural lesions. In addition, MRI has revealed a previously under-recognised very early clinical phase of the disease where patients have symptomatic axial involvement, but no structural changes. However, what constitutes a ‘positive MRI’ in SpA remains controversial, since both sensitivity and specificity show limitations, and interpretation of MRI lesions in daily practice is critically dependent on the clinical context. There is growing evidence that integration of the assessment of structural changes on dedicated T1 weighted-sequences on MRI may enhance diagnostic utility. The performance of MRI in detecting structural lesions in the SIJs may even be superior to traditional evaluation by pelvic radiography. These findings launched a debate on imaging in SpA, whether MRI, which is advancing early recognition of disease and shows superiority to detect structural changes, should replace traditional conventional radiography of the SIJs.
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Affiliation(s)
- Cédric Lukas
- Department of Rheumatology, University Hospital Lapeyronie, Montpellier, France.,Montpellier University, Montpellier, France
| | - Catherine Cyteval
- Montpellier University, Montpellier, France.,Department of Radiology, University Hospital Lapeyronie, Montpellier, France
| | - Maxime Dougados
- Department of Rheumatology B, Cochin Hospital, Paris, France
| | - Ulrich Weber
- King Christian 10th Hospital for Rheumatic Diseases, Gråsten, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Lubrano E, Perrotta FM, Manara M, D'Angelo S, Addimanda O, Ramonda R, Punzi L, Olivieri I, Salvarani C, Marchesoni A. The Sex Influence on Response to Tumor Necrosis Factor-α Inhibitors and Remission in Axial Spondyloarthritis. J Rheumatol 2017; 45:jrheum.17666. [PMID: 29142035 DOI: 10.3899/jrheum.17666] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the influence of sex on response to treatment and disease remission in patients with axial spondyloarthritis (axSpA). METHODS In this retrospective multicenter study, patients with axSpA, according to the Assessment of Spondyloarthritis international Society (ASAS) criteria for axSpA, and treated with adalimumab, etanercept, golimumab, or infliximab, were studied. We compared clinical characteristics, patient-reported outcomes, disease activity, function, and response to treatment in male and female patients with this disease. RESULTS Three hundred forty patients with axSpA (270 with ankylosing spondylitis, 19 with psoriatic arthritis with axial involvement, and 51 with nonradiographic axSpA) were studied. Male subjects had a significantly higher prevalence of grade IV sacroiliitis, higher levels of serum C-reactive protein, lower Maastricht Ankylosing Spondylitis Enthesitis Score, and fatigue when compared with females. Further, Kaplan-Meier survival curves showed that the rate of partial remission, ASAS40 response, and Ankylosing Spondylitis Disease Activity Score (ASDAS) major improvement, but not ASDAS inactive disease, were significantly lower in female patients. CONCLUSION Our data suggest that female sex was associated with a lower rate of response to treatment and of disease remission in patients with axSpA treated with antitumor necrosis factor-α drugs.
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Affiliation(s)
- Ennio Lubrano
- From the Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Campobasso; Day Hospital of Rheumatology, Azienda Sistema Socio Sanitario (ASST) Centro Specialistico Ortopedico Traumatologico G. Pini-Centro Specialistico Traumatologico-Ortopedico (CTO), Milan; Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Matera; La Struttura Semplice Dipartimentale (SSD) di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna, Bologna; Rheumatology Unit, Department of Clinical and Experimental Medicine (DIMED), University of Padua, Padua; Rheumatology Unit, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy. Supported by the Gruppo di Studio Spondiloartriti e Artropatia Psoriasica - Antonio Spadaro. All authors are members of this group. E. Lubrano, MD, PhD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; F.M. Perrotta, MD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; M. Manara, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO; S. D'Angelo, MD, PhD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; O. Addimanda, MD, PhD, SSD di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna; R. Ramonda, MD, PhD, Rheumatology Unit, DIMED, University of Padua; L. Punzi, MD, PhD, Rheumatology Unit, DIMED, University of Padua; I. Olivieri, MD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; C. Salvarani, MD, IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia; A. Marchesoni, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO. Dr. Ignazio Olivieri died July 28, 2017. Address correspondence to Dr. E. Lubrano, Dipartimento di Medicina e di Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Via Giovanni Paolo II, C/da Tappino, 86100 Campobasso, Italy. E-mail: . Accepted for publication September 12, 2017
| | - Fabio Massimo Perrotta
- From the Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Campobasso; Day Hospital of Rheumatology, Azienda Sistema Socio Sanitario (ASST) Centro Specialistico Ortopedico Traumatologico G. Pini-Centro Specialistico Traumatologico-Ortopedico (CTO), Milan; Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Matera; La Struttura Semplice Dipartimentale (SSD) di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna, Bologna; Rheumatology Unit, Department of Clinical and Experimental Medicine (DIMED), University of Padua, Padua; Rheumatology Unit, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy. Supported by the Gruppo di Studio Spondiloartriti e Artropatia Psoriasica - Antonio Spadaro. All authors are members of this group. E. Lubrano, MD, PhD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; F.M. Perrotta, MD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; M. Manara, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO; S. D'Angelo, MD, PhD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; O. Addimanda, MD, PhD, SSD di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna; R. Ramonda, MD, PhD, Rheumatology Unit, DIMED, University of Padua; L. Punzi, MD, PhD, Rheumatology Unit, DIMED, University of Padua; I. Olivieri, MD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; C. Salvarani, MD, IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia; A. Marchesoni, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO. Dr. Ignazio Olivieri died July 28, 2017. Address correspondence to Dr. E. Lubrano, Dipartimento di Medicina e di Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Via Giovanni Paolo II, C/da Tappino, 86100 Campobasso, Italy. E-mail: . Accepted for publication September 12, 2017
| | - Maria Manara
- From the Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Campobasso; Day Hospital of Rheumatology, Azienda Sistema Socio Sanitario (ASST) Centro Specialistico Ortopedico Traumatologico G. Pini-Centro Specialistico Traumatologico-Ortopedico (CTO), Milan; Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Matera; La Struttura Semplice Dipartimentale (SSD) di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna, Bologna; Rheumatology Unit, Department of Clinical and Experimental Medicine (DIMED), University of Padua, Padua; Rheumatology Unit, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy. Supported by the Gruppo di Studio Spondiloartriti e Artropatia Psoriasica - Antonio Spadaro. All authors are members of this group. E. Lubrano, MD, PhD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; F.M. Perrotta, MD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; M. Manara, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO; S. D'Angelo, MD, PhD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; O. Addimanda, MD, PhD, SSD di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna; R. Ramonda, MD, PhD, Rheumatology Unit, DIMED, University of Padua; L. Punzi, MD, PhD, Rheumatology Unit, DIMED, University of Padua; I. Olivieri, MD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; C. Salvarani, MD, IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia; A. Marchesoni, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO. Dr. Ignazio Olivieri died July 28, 2017. Address correspondence to Dr. E. Lubrano, Dipartimento di Medicina e di Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Via Giovanni Paolo II, C/da Tappino, 86100 Campobasso, Italy. E-mail: . Accepted for publication September 12, 2017
| | - Salvatore D'Angelo
- From the Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Campobasso; Day Hospital of Rheumatology, Azienda Sistema Socio Sanitario (ASST) Centro Specialistico Ortopedico Traumatologico G. Pini-Centro Specialistico Traumatologico-Ortopedico (CTO), Milan; Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Matera; La Struttura Semplice Dipartimentale (SSD) di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna, Bologna; Rheumatology Unit, Department of Clinical and Experimental Medicine (DIMED), University of Padua, Padua; Rheumatology Unit, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy. Supported by the Gruppo di Studio Spondiloartriti e Artropatia Psoriasica - Antonio Spadaro. All authors are members of this group. E. Lubrano, MD, PhD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; F.M. Perrotta, MD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; M. Manara, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO; S. D'Angelo, MD, PhD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; O. Addimanda, MD, PhD, SSD di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna; R. Ramonda, MD, PhD, Rheumatology Unit, DIMED, University of Padua; L. Punzi, MD, PhD, Rheumatology Unit, DIMED, University of Padua; I. Olivieri, MD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; C. Salvarani, MD, IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia; A. Marchesoni, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO. Dr. Ignazio Olivieri died July 28, 2017. Address correspondence to Dr. E. Lubrano, Dipartimento di Medicina e di Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Via Giovanni Paolo II, C/da Tappino, 86100 Campobasso, Italy. E-mail: . Accepted for publication September 12, 2017
| | - Olga Addimanda
- From the Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Campobasso; Day Hospital of Rheumatology, Azienda Sistema Socio Sanitario (ASST) Centro Specialistico Ortopedico Traumatologico G. Pini-Centro Specialistico Traumatologico-Ortopedico (CTO), Milan; Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Matera; La Struttura Semplice Dipartimentale (SSD) di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna, Bologna; Rheumatology Unit, Department of Clinical and Experimental Medicine (DIMED), University of Padua, Padua; Rheumatology Unit, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy. Supported by the Gruppo di Studio Spondiloartriti e Artropatia Psoriasica - Antonio Spadaro. All authors are members of this group. E. Lubrano, MD, PhD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; F.M. Perrotta, MD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; M. Manara, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO; S. D'Angelo, MD, PhD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; O. Addimanda, MD, PhD, SSD di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna; R. Ramonda, MD, PhD, Rheumatology Unit, DIMED, University of Padua; L. Punzi, MD, PhD, Rheumatology Unit, DIMED, University of Padua; I. Olivieri, MD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; C. Salvarani, MD, IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia; A. Marchesoni, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO. Dr. Ignazio Olivieri died July 28, 2017. Address correspondence to Dr. E. Lubrano, Dipartimento di Medicina e di Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Via Giovanni Paolo II, C/da Tappino, 86100 Campobasso, Italy. E-mail: . Accepted for publication September 12, 2017
| | - Roberta Ramonda
- From the Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Campobasso; Day Hospital of Rheumatology, Azienda Sistema Socio Sanitario (ASST) Centro Specialistico Ortopedico Traumatologico G. Pini-Centro Specialistico Traumatologico-Ortopedico (CTO), Milan; Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Matera; La Struttura Semplice Dipartimentale (SSD) di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna, Bologna; Rheumatology Unit, Department of Clinical and Experimental Medicine (DIMED), University of Padua, Padua; Rheumatology Unit, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy. Supported by the Gruppo di Studio Spondiloartriti e Artropatia Psoriasica - Antonio Spadaro. All authors are members of this group. E. Lubrano, MD, PhD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; F.M. Perrotta, MD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; M. Manara, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO; S. D'Angelo, MD, PhD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; O. Addimanda, MD, PhD, SSD di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna; R. Ramonda, MD, PhD, Rheumatology Unit, DIMED, University of Padua; L. Punzi, MD, PhD, Rheumatology Unit, DIMED, University of Padua; I. Olivieri, MD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; C. Salvarani, MD, IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia; A. Marchesoni, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO. Dr. Ignazio Olivieri died July 28, 2017. Address correspondence to Dr. E. Lubrano, Dipartimento di Medicina e di Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Via Giovanni Paolo II, C/da Tappino, 86100 Campobasso, Italy. E-mail: . Accepted for publication September 12, 2017
| | - Leonardo Punzi
- From the Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Campobasso; Day Hospital of Rheumatology, Azienda Sistema Socio Sanitario (ASST) Centro Specialistico Ortopedico Traumatologico G. Pini-Centro Specialistico Traumatologico-Ortopedico (CTO), Milan; Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Matera; La Struttura Semplice Dipartimentale (SSD) di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna, Bologna; Rheumatology Unit, Department of Clinical and Experimental Medicine (DIMED), University of Padua, Padua; Rheumatology Unit, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy. Supported by the Gruppo di Studio Spondiloartriti e Artropatia Psoriasica - Antonio Spadaro. All authors are members of this group. E. Lubrano, MD, PhD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; F.M. Perrotta, MD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; M. Manara, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO; S. D'Angelo, MD, PhD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; O. Addimanda, MD, PhD, SSD di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna; R. Ramonda, MD, PhD, Rheumatology Unit, DIMED, University of Padua; L. Punzi, MD, PhD, Rheumatology Unit, DIMED, University of Padua; I. Olivieri, MD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; C. Salvarani, MD, IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia; A. Marchesoni, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO. Dr. Ignazio Olivieri died July 28, 2017. Address correspondence to Dr. E. Lubrano, Dipartimento di Medicina e di Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Via Giovanni Paolo II, C/da Tappino, 86100 Campobasso, Italy. E-mail: . Accepted for publication September 12, 2017
| | - Ignazio Olivieri
- From the Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Campobasso; Day Hospital of Rheumatology, Azienda Sistema Socio Sanitario (ASST) Centro Specialistico Ortopedico Traumatologico G. Pini-Centro Specialistico Traumatologico-Ortopedico (CTO), Milan; Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Matera; La Struttura Semplice Dipartimentale (SSD) di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna, Bologna; Rheumatology Unit, Department of Clinical and Experimental Medicine (DIMED), University of Padua, Padua; Rheumatology Unit, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy. Supported by the Gruppo di Studio Spondiloartriti e Artropatia Psoriasica - Antonio Spadaro. All authors are members of this group. E. Lubrano, MD, PhD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; F.M. Perrotta, MD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; M. Manara, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO; S. D'Angelo, MD, PhD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; O. Addimanda, MD, PhD, SSD di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna; R. Ramonda, MD, PhD, Rheumatology Unit, DIMED, University of Padua; L. Punzi, MD, PhD, Rheumatology Unit, DIMED, University of Padua; I. Olivieri, MD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; C. Salvarani, MD, IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia; A. Marchesoni, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO. Dr. Ignazio Olivieri died July 28, 2017. Address correspondence to Dr. E. Lubrano, Dipartimento di Medicina e di Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Via Giovanni Paolo II, C/da Tappino, 86100 Campobasso, Italy. E-mail: . Accepted for publication September 12, 2017
| | - Carlo Salvarani
- From the Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Campobasso; Day Hospital of Rheumatology, Azienda Sistema Socio Sanitario (ASST) Centro Specialistico Ortopedico Traumatologico G. Pini-Centro Specialistico Traumatologico-Ortopedico (CTO), Milan; Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Matera; La Struttura Semplice Dipartimentale (SSD) di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna, Bologna; Rheumatology Unit, Department of Clinical and Experimental Medicine (DIMED), University of Padua, Padua; Rheumatology Unit, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy. Supported by the Gruppo di Studio Spondiloartriti e Artropatia Psoriasica - Antonio Spadaro. All authors are members of this group. E. Lubrano, MD, PhD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; F.M. Perrotta, MD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; M. Manara, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO; S. D'Angelo, MD, PhD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; O. Addimanda, MD, PhD, SSD di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna; R. Ramonda, MD, PhD, Rheumatology Unit, DIMED, University of Padua; L. Punzi, MD, PhD, Rheumatology Unit, DIMED, University of Padua; I. Olivieri, MD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; C. Salvarani, MD, IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia; A. Marchesoni, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO. Dr. Ignazio Olivieri died July 28, 2017. Address correspondence to Dr. E. Lubrano, Dipartimento di Medicina e di Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Via Giovanni Paolo II, C/da Tappino, 86100 Campobasso, Italy. E-mail: . Accepted for publication September 12, 2017
| | - Antonio Marchesoni
- From the Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Campobasso; Day Hospital of Rheumatology, Azienda Sistema Socio Sanitario (ASST) Centro Specialistico Ortopedico Traumatologico G. Pini-Centro Specialistico Traumatologico-Ortopedico (CTO), Milan; Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Matera; La Struttura Semplice Dipartimentale (SSD) di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna, Bologna; Rheumatology Unit, Department of Clinical and Experimental Medicine (DIMED), University of Padua, Padua; Rheumatology Unit, Azienda Ospedaliera-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy. Supported by the Gruppo di Studio Spondiloartriti e Artropatia Psoriasica - Antonio Spadaro. All authors are members of this group. E. Lubrano, MD, PhD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; F.M. Perrotta, MD, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise; M. Manara, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO; S. D'Angelo, MD, PhD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; O. Addimanda, MD, PhD, SSD di Medicina e Reumatologia, Istituto Ortopedico Rizzoli, Università di Bologna; R. Ramonda, MD, PhD, Rheumatology Unit, DIMED, University of Padua; L. Punzi, MD, PhD, Rheumatology Unit, DIMED, University of Padua; I. Olivieri, MD, Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera; C. Salvarani, MD, IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia; A. Marchesoni, MD, PhD, Day Hospital of Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico G. Pini-CTO. Dr. Ignazio Olivieri died July 28, 2017. Address correspondence to Dr. E. Lubrano, Dipartimento di Medicina e di Scienze della Salute "Vincenzo Tiberio," Università degli Studi del Molise, Via Giovanni Paolo II, C/da Tappino, 86100 Campobasso, Italy. E-mail: . Accepted for publication September 12, 2017
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Deodhar A, Miossec P, Baraliakos X. Is undifferentiated spondyloarthritis a discrete entity? A debate. Autoimmun Rev 2017; 17:29-32. [PMID: 29108820 DOI: 10.1016/j.autrev.2017.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 09/16/2017] [Indexed: 10/18/2022]
Abstract
The concept of undifferentiated spondyloarthritis has been introduced recently to describe a clinical setting where the classical features of spondyloarthritis (SpA) are not fully present. Whether this is a discrete entity was the basis of a debate during the 4th International Congress on Controversies in Rheumatology & Autoimmunity held in Bologna, Italy 9-11 March 2017. The pro and con aspects of the debate are presented. The implications of the debate are important ranging from diagnostic aspects to consequences for the society and the payers.
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Affiliation(s)
- Atul Deodhar
- Oregon Health & Science University, Portland, OR, USA
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Rudwaleit M. Fibromyalgia is not axial spondyloarthritis. Rheumatology (Oxford) 2017; 57:1510-1512. [DOI: 10.1093/rheumatology/kex372] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Martin Rudwaleit
- Department of Internal Medicine and Rheumatology, Klinikum Bielefeld Rosenhöhe, Bielefeld, Germany
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Pouillon L, Bossuyt P, Vanderstukken J, Moulin D, Netter P, Danese S, Jouzeau JY, Loeuille D, Peyrin-Biroulet L. Management of patients with inflammatory bowel disease and spondyloarthritis. Expert Rev Clin Pharmacol 2017; 10:1363-1374. [PMID: 28879780 DOI: 10.1080/17512433.2017.1377609] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION More than half of the patients with inflammatory bowel disease (IBD) experience at least one extra-intestinal manifestation (EIM). The most common EIM in patients with IBD is spondyloarthritis (SpA). Microscopic intestinal inflammation is documented in almost 50% of the patients with SpA. Areas covered: We give an overview of the classification, the epidemiology and the diagnosis of IBD and SpA. The treatment goals, the pharmacologic management options and the available treatment guidelines in IBD patients with SpA are discussed. Expert commentary: The coexistence of IBD and SpA generates challenges and opportunities for both the gastroenterologist and the rheumatologist. The potential of drugs with a gut-specific mode of action in the treatment of IBD-related arthritis warrants further exploration.
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Affiliation(s)
- Lieven Pouillon
- a Department of Hepato-Gastroenterology , University Hospital Leuven , Leuven , Belgium
| | - Peter Bossuyt
- b Imelda GI Clinical Research Centre , Imeldaziekenhuis Bonheiden , Bonheiden , Belgium
| | - Joke Vanderstukken
- c Department of Immunology-Allergology-Rheumatology , University Hospital Antwerp , Edegem , Belgium
| | - David Moulin
- d UMR 7365 IMoPA CNRS-Université de Lorraine , Biopôle de l'Université de Lorraine, Campus Biologie-Santé , Vandœuvre-lès-Nancy , France
| | - Patrick Netter
- d UMR 7365 IMoPA CNRS-Université de Lorraine , Biopôle de l'Université de Lorraine, Campus Biologie-Santé , Vandœuvre-lès-Nancy , France
| | - Silvio Danese
- e Department of Biomedical Sciences , Humanitas University , Rozzano , Milan , Italy
| | - Jean-Yves Jouzeau
- d UMR 7365 IMoPA CNRS-Université de Lorraine , Biopôle de l'Université de Lorraine, Campus Biologie-Santé , Vandœuvre-lès-Nancy , France
| | - Damien Loeuille
- f Department of Rheumatology , Nancy University Hospital, Université de Lorraine , Vandœuvre-lès-Nancy , France
| | - Laurent Peyrin-Biroulet
- g Inserm U954 and Department of Gastroenterology , Nancy University Hospital, Université de Lorraine , Vandœuvre-lès-Nancy , France
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Chua-Aguilera CJ, Möller B, Yawalkar N. Skin Manifestations of Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, and Spondyloarthritides. Clin Rev Allergy Immunol 2017; 53:371-393. [DOI: 10.1007/s12016-017-8632-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Abstract
The term axial spondyloarthritis covers both patients with non-radiographic and radiographic axial spondyloarthritis, which is also termed ankylosing spondylitis. The disease usually starts in the third decade of life with a male to female ratio of two to one for radiographic axial spondyloarthritis and of one to one for non-radiographic axial spondyloarthritis. More than 90% heritabilty has been estimated, the highest genetic association being with HLA-B27. The pathogenic role of HLA-B27 is still not clear although various hypotheses are available. On the basis of evidence from trials the cytokines tumour necrosis factor (TNF)-α and interleukin-17 appear to have a relevant role in pathogenesis. The mechanisms of interaction between inflammation and new bone formation is still not completely understood but clarification will be important for the prevention of long-term structural damage of the bone. The development of new criteria for classification and for screening of patients with axial spondyloarthritis have been crucial for the early indentification and treatment of such patients, with MRI being the most important existing imaging method. Non-steroidal anti-inflammatory drugs and TNF blockers are effective therapies. Blockade of interleukin-17 is a new and relevant treatment option.
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Affiliation(s)
- Joachim Sieper
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany
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de Winter J, van de Sande M, Landewé R, Baeten D. Reply. Arthritis Rheumatol 2017; 69:1124-1125. [DOI: 10.1002/art.40030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 12/13/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Janneke de Winter
- Academic Medical Center, University of AmsterdamAmsterdam The Netherlands
| | | | - Robert Landewé
- Academic Medical Center, University of AmsterdamAmsterdam The Netherlands
| | - Dominique Baeten
- Academic Medical Center, University of AmsterdamAmsterdam The Netherlands
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Diagnostic confounders of chronic widespread pain: not always fibromyalgia. Pain Rep 2017; 2:e598. [PMID: 29392213 PMCID: PMC5741304 DOI: 10.1097/pr9.0000000000000598] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 03/13/2017] [Accepted: 03/17/2017] [Indexed: 12/11/2022] Open
Abstract
Although chronic widespread pain is the defining feature of fibromyalgia, a myriad of other conditions may present with similar pain complaint leading to misdiagnosis. Conditions that may mimic fibromyalgia may be categorized as musculoskeletal, neurological, endocrine/metabolic, psychiatric/psychological, and medication related. In this review, we examine these various conditions that should be considered in a differential diagnosis and provide direction that will help the clinician differentiate these conditions from fibromyalgia. Introduction: Chronic widespread pain (CWP) is the defining feature of fibromyalgia (FM), a worldwide prevalent condition. Chronic widespread pain is, however, not pathognomonic of FM, and other conditions may present similarly with CWP, requiring consideration of a differential diagnosis. Objectives: To conduct a literature search to identify medical conditions that may mimic FM and have highlighted features that may differentiate these various conditions from FM. Methods: A comprehensive literature search from 1990 through September 2016 was conducted to identify conditions characterized by CWP. Results: Conditions that may mimic FM may be categorized as musculoskeletal, neurological, endocrine/metabolic, psychiatric/psychological, and medication related. Characteristics pertaining to the most commonly identified confounding diagnoses within each category are discussed; clues to enable clinical differentiation from FM are presented; and steps towards a diagnostic algorithm for mimicking conditions are presented. Conclusion: Although the most likely reason for a complaint of CWP is FM, this pain complaint can be a harbinger of illness other than FM, prompting consideration of a differential diagnosis. This review should sensitize physicians to a broad spectrum of conditions that can mimic FM.
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A systematic review of quality-of-life domains and items relevant to patients with spondyloarthritis. Semin Arthritis Rheum 2017; 47:175-182. [PMID: 28487138 DOI: 10.1016/j.semarthrit.2017.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 03/06/2017] [Accepted: 04/05/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To summarize, from the literature, quality-of-life (QoL) domains and items relevant to patients with spondyloarthritis (SpA), and to determine if commonly used SpA patient-reported outcome (PRO) instruments include the identified domains. METHODS We used PRISMA statement for systematic review and searched Medline® , Embase®, and PsycInfo® using relevant keywords. In addition, hand searches of references of the included articles were conducted. All articles were reviewed for inclusion by 2 independent reviewers. QoL domains and items relevant to patients with axial or peripheral SpA were extracted and presented using the adapted World Health Organization Quality-of-Life (WHOQOL) domain framework. SpA PROs were assessed to determine if they included the domains identified. RESULTS We retrieved 14,343 articles, of which 34 articles fulfilled inclusion criteria for review. Twenty-five articles were conducted in the European population. Domains such as negative feelings and activities of daily living were found to be present in 28 and 27 articles, respectively. SpA impacted QoL in all domains of the adapted WHOQOL framework. Domains that differed between types of SpA were financial resources, general levels of independence and medication side effects. Embarrassment, self-image, and premature ageing were items that differed by geographical setting. PROs to capture domains for peripheral SpA were similar for axial SpA. CONCLUSIONS We found that a wide range of domains and items of QoL were relevant to patients with SpA with minimal differences between patients with axial and peripheral SpA. Clinicians may consider using peripheral SpA PROs to measure QoL of patients with axial SpA.
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Sepriano A, Rubio R, Ramiro S, Landewé R, van der Heijde D. Performance of the ASAS classification criteria for axial and peripheral spondyloarthritis: a systematic literature review and meta-analysis. Ann Rheum Dis 2017; 76:886-890. [DOI: 10.1136/annrheumdis-2016-210747] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/19/2017] [Accepted: 01/20/2017] [Indexed: 11/04/2022]
Abstract
ObjectiveTo summarise the evidence on the performance of the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial spondyloarthritis (axSpA) (also imaging and clinical arm separately), peripheral (p)SpA and the entire set, when tested against the rheumatologist's diagnosis (‘reference standard’).MethodsA systematic literature review was performed to identify eligible studies. Raw data on SpA diagnosis and classification were extracted or, if necessary, obtained from the authors of the selected publications. A meta-analysis was performed to obtain pooled estimates for sensitivity, specificity, positive and negative likelihood ratios, by fitting random effects models.ResultsNine papers fulfilled the inclusion criteria (N=5739 patients). The entire set of the ASAS SpA criteria yielded a high pooled sensitivity (73%) and specificity (88%). Similarly, good results were found for the axSpA criteria (sensitivity: 82%; specificity: 88%). Splitting the axSpA criteria in ‘imaging arm only’ and ‘clinical arm only’ resulted in much lower sensitivity (30% and 23% respectively), but very high specificity was retained (97% and 94% respectively). The pSpA criteria were less often tested than the axSpA criteria and showed a similarly high pooled specificity (87%) but lower sensitivity (63%).ConclusionsAccumulated evidence from studies with more than 5500 patients confirms the good performance of the various ASAS SpA criteria as tested against the rheumatologist's diagnosis.
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Ez-Zaitouni Z, Bakker PAC, van Lunteren M, Berg IJ, Landewé R, van Oosterhout M, Lorenzin M, van der Heijde D, van Gaalen FA. Presence of multiple spondyloarthritis (SpA) features is important but not sufficient for a diagnosis of axial spondyloarthritis: data from the SPondyloArthritis Caught Early (SPACE) cohort. Ann Rheum Dis 2017; 76:1086-1092. [DOI: 10.1136/annrheumdis-2016-210119] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 11/25/2016] [Accepted: 12/14/2016] [Indexed: 01/24/2023]
Abstract
ObjectivesConcerns have been raised about overdiagnosis of axial spondyloarthritis (axSpA). We investigated whether patients with chronic back pain (CBP) of short duration and multiple SpA features are always diagnosed with axSpA by the rheumatologist, and to what extent fulfilment of the Assessment of SpondyloArthritis International Society (ASAS) axSpA criteria is associated with an axSpA diagnosis.MethodsBaseline data from 500 patients from the SPondyloArthritis Caught Early cohort which includes patients with CBP (≥3 months, ≤2 years, onset <45 years) were analysed. All patients underwent full diagnostic workup including MRI of the sacroiliac joints (MRI-SI) and radiograph of sacroiliac joints (X-SI). For each patient, the total number of SpA features excluding sacroiliac imaging and human leucocyte antigen B27 (HLA-B27) status was calculated.ResultsBefore sacroiliac imaging and HLA-B27 testing, 32% of patients had ≤1 SpA feature, 29% had 2 SpA features, 16% had 3 SpA features and 24% had ≥4 SpA features. A diagnosis of axSpA was made in 250 (50%) of the patients: 24% with ≤1 SpA feature, 43% with 2 SpA features, 62% with 3 SpA features and 85% with ≥4 SpA features. Of the 230 patients with a positive ASAS classification 40 (17.4%) did not have a diagnosis of axSpA. HLA-B27 positivity (OR 5.6; 95% CI 3.7 to 8.3) and any (MRI-SI and/or X-SI) positive imaging (OR 34.3; 95% CI 17.3 to 67.7) were strong determinants of an axSpA diagnosis.ConclusionsIn this cohort of patients with CBP, neither the presence of numerous SpA features nor fulfilment of the ASAS classification criteria did automatically lead to a diagnosis axSpA. Positive imaging was considered particularly important in making a diagnosis of axSpA.
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Weber U, Jurik AG, Lambert RGW, Maksymowych WP. Imaging in Spondyloarthritis: Controversies in Recognition of Early Disease. Curr Rheumatol Rep 2016; 18:58. [DOI: 10.1007/s11926-016-0607-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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