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[Chronic back pain in axial spondylarthritis : Current diagnostic challenges and treatment possibilities]. Z Rheumatol 2023; 82:10-17. [PMID: 36044071 PMCID: PMC9894960 DOI: 10.1007/s00393-022-01256-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Among chronic back diseases, axial spondylarthritis (axSpA) is the entity with the largest spectrum of specific anti-inflammatory treatment modalities; however, from a general medical perspective axSpA is only ranked as another etiology of back pain to be considered after spinal cord or cauda equina compression, bone metastases, epidural abscess or osteomyelitis of the vertebrae, radiculopathy or spinal stenosis. Due to its relatively low prevalence and mostly later occurring sequelae, there is a danger that axSpA will be a relatively neglected entity for specialists. RESULTS This article recapitulates the recommendations of the Assessment of Ankylosing Spondyloarthritis International Society (ASAS). This review addresses the practical aspects of the detailed evaluation of treatment attempts carried out so far with nonsteroidal anti-inflammatory drugs (NSAID) for back pain. Undesired effects on the symptoms of the lower intestinal tract could be of particular interest here. The sex-specific differences in the response to treatment with tumor necrosis factor (TNF) inhibitors in axSpA are mentioned. Further aspects of treatment options with biologics in axSpA are discussed based on a case of maintained remission after a course of interleukin (IL) 17 inhibitors in undifferentiated, HLA-B27 and magnetic resonance imaging (MRI) positive axSpA and long-standing good treatment response to IL-12/23 inhibitor treatment in axial psoriatic arthritis. Furthermore, the literature is discussed with respect to uveitis, carditis and amyloidosis in the context of axSpA. CONCLUSION The early diagnosis in the general medical context and the specific consideration of numerous predictive factors play an increasingly more important role in the personalized treatment of axSpA.
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Salaffi F, Siragusano C, Alciati A, Cassone G, D’Angelo S, Guiducci S, Favalli EG, Conti F, Gremese E, Iannone F, Caporali R, Sebastiani M, Ferraccioli GF, Lapadula G, Atzeni F. Axial Spondyloarthritis: Reshape the Future-From the "2022 GISEA International Symposium". J Clin Med 2022; 11:jcm11247537. [PMID: 36556152 PMCID: PMC9780899 DOI: 10.3390/jcm11247537] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/02/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
The term "axial spondyloarthritis" (axSpA) refers to a group of chronic rheumatic diseases that predominantly involve the axial skeleton and consist of ankylosing spondylitis, reactive arthritis, arthritis/spondylitis associated with psoriasis (PsA) and arthritis/spondylitis associated with inflammatory bowel diseases (IBD). Moreover, pain is an important and common symptom of axSpA. It may progress to chronic pain, a more complicated bio-psychosocial phenomena, leading to a significant worsening of quality of life. The development of the axSpA inflammatory process is grounded in the complex interaction between genetic (such as HLA B27), epigenetic, and environmental factors associated with a dysregulated immune response. Considering the pivotal contribution of IL-23 and IL-17 in axSpA inflammation, the inhibition of these cytokines has been evaluated as a potential therapeutic strategy. With this context, here we discuss the main pathogenetic mechanisms, therapeutic approaches and the role of pain in axSpA from the 2022 International GISEA/OEG Symposium.
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Affiliation(s)
- Fausto Salaffi
- Rheumatology Clinic, Ospedale Carlo Urbani, Università Politecnica delle Marche, 60035 Jesi, Italy
| | - Cesare Siragusano
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, 98125 Messina, Italy
| | - Alessandra Alciati
- Department of Clinical Neurosciences, Hermanas Hospitalarias, Villa San Benedetto Menni Hospital, Como, and Humanitas Clinical and Research Centre, Rozzano, 20089 Milan, Italy
| | - Giulia Cassone
- Rheumatology Unit, Azienda Ospedaliera Policlinico di Modena, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Salvatore D’Angelo
- Rheumatology Institute of Lucania and Rheumatology Department of Lucania, San Carlo Hospital of Potenza, 85100 Potenza, Italy
| | - Serena Guiducci
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
| | - Ennio Giulio Favalli
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, 20122 Milan, Italy
| | - Fabrizio Conti
- Lupus Clinic, Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza University of Rome, 00161 Rome, Italy
| | - Elisa Gremese
- Rheumatology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Florenzo Iannone
- Rheumatology Unit, Department of Emergency Surgery and Organ Transplantations, University of Bari, 70121 Bari, Italy
| | - Roberto Caporali
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, 20122 Milan, Italy
| | - Marco Sebastiani
- Rheumatology Unit, Azienda Ospedaliera Policlinico di Modena, University of Modena and Reggio Emilia, 41125 Modena, Italy
- Correspondence:
| | | | - Giovanni Lapadula
- Rheumatology Unit, Department of Emergency Surgery and Organ Transplantations, University of Bari, 70121 Bari, Italy
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, 98125 Messina, Italy
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Atzeni F, Siragusano C, Masala IF, Antonio C, Valentina P, D'Angelo S. IL-23 in axial spondyloarthritis and psoriatic arthritis: a good fit for biological treatment? Expert Opin Biol Ther 2022; 22:843-853. [PMID: 35722768 DOI: 10.1080/14712598.2022.2090834] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Interleukin 23 (IL-23) is a pro-inflammatory cytokine that plays a protective role against bacterial and fungal infections. However, the dysregulation of the IL-23/IL-17 axis provides a solid substrate for the development of various inflammatory diseases, such as psoriatic arthritis (PsA) and ankylosing spondylitis (AS). AREAS COVERED In different clinical trials, several drugs against IL-23 have shown efficacy and safety towards PsA, with excellent results on skin and joint scores. However, the same drugs did not show the same efficacy in AS, suggesting that IL-23 may not be a relevant driver of the pathobiology and clinical symptoms of active axial spondyloarthritis (axSpA). EXPERT OPINION These drugs have shown an excellent efficacy and a good safety profile towards PsA, while in AS the efficacy of the IL-23 blockade is lacking for reasons not yet known. Several hypotheses have been reported, but further studies will be needed for a greater understanding. This suggests the involvement of pathways or mechanisms for the development of SpA that remain unknown. In order to allow a wide use of IL-23 inhibitors, further clinical trials and long-term prospective studies are necessary.
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Affiliation(s)
- Fabiola Atzeni
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Cesare Siragusano
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Carriero Antonio
- Rheumatology Institute of Lucania (IReL): Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza, Italy.,PhD Scholarship in Translational and Clinical Medicine, Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Picerno Valentina
- Rheumatology Institute of Lucania (IReL): Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza, Italy
| | - Salvatore D'Angelo
- Rheumatology Institute of Lucania (IReL): Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza, Italy
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Zeidler HK. Psoriatic Spondylitis: A Disease Manifestation in Debate: Evidences to Know for the Clinical Rheumatologist. J Clin Rheumatol 2022; 28:38-43. [PMID: 34941618 DOI: 10.1097/rhu.0000000000001815] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT With the advent of classification criteria for psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), patients with axial manifestations associated with psoriasis, initially described in the l950s as a specific entity termed psoriatic spondylitis (PS), are now categorized within PsA, ankylosing spondylitis (AS), and axSpA. Thus, different terms are used to describe axial disease in patients with PsA including PS, axial psoriatic arthritis (axPsA), and psoriatic spondyloarthritis. Patients with PS may present with inflammatory and/or mechanical back pain, but also may display axial disease on imaging despite not complaining of back pain. Cervical spondylitis has been reported in 35% to 75% of patients with PsA. Axial disease is silent in 20% and 25% of patients with axial PsA and PsA, respectively. The majority of axPsA patients have peripheral arthritis alongside the axial involvement, whereas only 2% to 5% of PsA patients have solely axial arthritis with no peripheral arthritis.A debate is currently underway as to whether inflammatory axial disease and psoriasis represent axSpA with psoriasis or a subset of PsA named axPsA. Studies have recognized that axial disease in PsA patients seems to be different demographically, genetically, clinically, and radiographically when compared with AS with or without psoriasis. This narrative review summarizes current knowledge regarding axial involvement of PsA in terms of history, terminology, classification, epidemiology, clinical presentation, imaging, diagnosis, and treatment, with the aim of providing advice for management of PS in clinical evidence-based practice. Data-driven studies are needed to develop clear, nonoverlapping classification criteria for spinal involvement in PsA.
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Wang R, Maksymowych WP. Targeting the Interleukin-23/Interleukin-17 Inflammatory Pathway: Successes and Failures in the Treatment of Axial Spondyloarthritis. Front Immunol 2021; 12:715510. [PMID: 34539646 PMCID: PMC8446672 DOI: 10.3389/fimmu.2021.715510] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/10/2021] [Indexed: 12/24/2022] Open
Abstract
The IL-23/IL-17 pathway has been implicated in the etiopathogenesis of axial spondyloarthritis through studies of genetic polymorphisms associated with disease, an animal model with over-expression of IL-23 that resembles human disease, and observations that cytokines in this pathway can be found at the site of disease in both humans and animal models. However, the most direct evidence has emerged from clinical trials of agents targeting cytokines in this pathway. Monoclonal antibodies targeting IL-17A have been shown to ameliorate signs and symptoms, as well as MRI inflammation in the spine and sacroiliac joints, in patients with radiographic and non-radiographic axial spondyloarthritis. This was evident in patients refractory to non-steroidal anti-inflammatory agents as well as patients failing treatment with tumor necrosis factor inhibitor therapies. Treatment with a bispecific antibody targeting both IL-17A and IL-17F was also effective in a phase II study. Post-hoc analyses have even suggested a potential disease-modifying effect in reducing development of spinal ankylosis. However, benefits for extra-articular manifestations were limited to psoriasis and did not extend to colitis and uveitis. Conversely, trials of therapies targeting IL-23 did not demonstrate any significant impact on signs, symptoms, and MRI inflammation in axial spondyloarthritis. These developments coincide with recent observations that expression of these cytokines is evident in many different cell types with roles in innate as well as adaptive immunity. Moreover, evidence has emerged for the existence of both IL-23-dependent and IL-23-independent pathways regulating expression of IL-17, potentially associated with different roles in intestinal and axial skeletal inflammation.
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Affiliation(s)
- Runsheng Wang
- Division of Rheumatology, Columbia University Irving Medical Center, New York, NY, United States
- Garden State Rheumatology Consultants, Union, NJ, United States
| | - Walter P. Maksymowych
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
- CARE Arthritis, Edmonton, AB, Canada
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Floris A, Congia M, Chessa E, Angioni MM, Piga M, Cauli A. Targeted Therapies in Axial Psoriatic Arthritis. Front Genet 2021; 12:689984. [PMID: 34262600 PMCID: PMC8273289 DOI: 10.3389/fgene.2021.689984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/25/2021] [Indexed: 11/13/2022] Open
Abstract
Specific and high-quality evidence on the efficacy of the current targeted therapies for axial disease in psoriatic arthritis (axPsA) is still scarce. Indeed, almost all the cohorts investigated in clinical trials on PsA consisted of patients with peripheral arthritis, where a small number of them also had axial involvement. Only one randomized controlled trial was so far specifically designed to assess the efficacy of a biological disease-modifying antirheumatic drug (DMARD) in axPsA. For other biological and synthetic targeted DMARDs, the most specific evidence for treatment in axPsA is extrapolated from post-hoc analyses based on PsA patients with concomitant peripheral and axial manifestations. Furthermore, the current trials and post-hoc analysis on axPsA are affected by major limitations, including the lack of a widely accepted definition of axPsA and the lack of specific and validated outcome measures. Finally, poor data are available on the genetics of axPsA, although alleles differentially expressed in different patterns of axPsA might offer advantages in the prospective of personalized medicine in axPsA patients. Overall, this review suggests that there is an urgent need for more reliable evidence derived from studies specifically designed for axPsA and based on a validated definition of axPsA and on specific outcome measures.
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Affiliation(s)
- Alberto Floris
- Unità Operativa Complessa di Reumatologia, Dipartimento di Scienze Mediche e Sanità Pubblica, Azienda Ospedaliero-Universitaria e Università di Cagliari, Monserrato, Italy
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Poddubnyy D, Jadon DR, Van den Bosch F, Mease PJ, Gladman DD. Axial involvement in psoriatic arthritis: An update for rheumatologists. Semin Arthritis Rheum 2021; 51:880-887. [PMID: 34198146 DOI: 10.1016/j.semarthrit.2021.06.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 02/08/2023]
Abstract
Psoriatic arthritis (PsA) is a heterogenous, chronic, inflammatory musculoskeletal disease that can lead to peripheral and axial damage and loss of function. Axial involvement occurs in 25% to 70% of patients with PsA, varying greatly depending on its definition, with the key manifestations being sacroiliitis and/or spondylitis. However, there are no agreed-upon classification or diagnostic criteria for axial involvement in PsA and no consensus on treatment paradigms, which complicates management of PsA. There have only been a few studies assessing biologics in patients with PsA with axial involvement, and most treatment plans are based on evidence from patients with axial spondyloarthritis. Rheumatologists therefore face many challenges in the management of axial PsA, including diagnosis, differential diagnosis, and choice of appropriate treatment. In this review, we summarize the clinical presentation, imaging characteristics, differential diagnoses, treatment options, and prognosis of axial PsA, with the aim of increasing rheumatologists' knowledge of this phenotype of PsA and thereby aiding its optimal management.
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Affiliation(s)
- Denis Poddubnyy
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Deepak R Jadon
- Department of Rheumatology, University of Cambridge, Cambridge, United Kingdom
| | - Filip Van den Bosch
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium, and VIB Center for Inflammation Research, Ghent, Belgium
| | - Philip J Mease
- Swedish Medical Center/Providence St Joseph Health, Seattle, WA, USA, and University of Washington, Seattle, WA, USA
| | - Dafna D Gladman
- Schroeder Arthritis Institute, Krembil Research Institutef, University of Toronto, Toronto Western Hospital, Toronto, ON, Canada
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Lamb YN. Guselkumab in psoriatic arthritis: a profile of its use. DRUGS & THERAPY PERSPECTIVES 2021. [DOI: 10.1007/s40267-021-00840-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
PURPOSE OF REVIEW To review current understanding of the prevalence, clinical features, outcome measures and recent therapeutic trials in axial psoriatic arthritis (axPsA). RECENT FINDINGS The prevalence of axPsA is estimated at 40-50%. However, the definition of axPsA remains unclear, therefore these estimates may be inaccurate. Ax PsA appears to be distinct from ankylosing spondylitis in demographic, clinical, genetic and therapeutic features. Because of the lack of widely accepted definition of axPsA it has been difficult to design therapeutic trials for this domain of PsA. Several studies have demonstrated the uniquness of axPsA. Few recent trials suggest that therapies that work for peripheral arthritis also work for axPsA.
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Vecellio M, Hake VX, Davidson C, Carena MC, Wordsworth BP, Selmi C. The IL-17/IL-23 Axis and Its Genetic Contribution to Psoriatic Arthritis. Front Immunol 2021; 11:596086. [PMID: 33574815 PMCID: PMC7871349 DOI: 10.3389/fimmu.2020.596086] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/25/2020] [Indexed: 12/14/2022] Open
Abstract
Psoriatic arthritis (PsA) is a chronic inflammatory disease belonging to the family of spondyloarthropathies (SpA). PsA commonly aggravates psoriasis of the skin and frequently manifests as an oligoarthritis with axial skeletal involvement and extraarticular manifestations including dactylitis, enthesitis, and uveitis. The weight of genetic predisposition to psoriasis and PsA is illustrated by the concordance rates in monozygotic twins which clearly demonstrate that genomics is insufficient to induce the clinical phenotype. The association of PsA with several single nucleotide polymorphisms (SNPs) at the IL23R locus and the involvement of Th17 cells in the immunopathogenesis of PsA clearly put the IL-23/IL-17 axis in the spotlight. The IL-23 and IL-17 cytokines have a pivotal role in the chronic inflammation of the synovium in PsA and are also prominent in the skin lesions of those with PsA. In this review, we focus on the genetic association of the IL-23/IL-17 axis with PsA and the contribution of these master cytokines in the pathophysiology of the disease, highlighting the main cell types incriminated in PsA and their specific role in the peripheral blood, lesional skin and joints of patients. We then provide an overview of the approved biologic drugs targeting the IL-23/IL-17 axis and discuss the advantages of genetic stratification to enhance personalized therapies in PsA.
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Affiliation(s)
- Matteo Vecellio
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.,Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Vivien Xanath Hake
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Connor Davidson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | | | - B Paul Wordsworth
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
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