Body mass index influences the response to infliximab in ankylosing spondylitis

Does obesity affect treatment response to secukinumab and survival in ankylosing spondylitis? Real-life data from the TURKBIO Registry

OBJECTIVES

The aim of this study was to evaluate the impact of obesity on the treatment response to secukinumab and drug survival rate in patients with ankylosing spondylitis (AS).

METHODS

We performed an observational cohort study that included AS patients based on the biological drug database in Turkey (TURKBIO) Registry between 2018 and 2021. The patients were divided into three groups: normal [body mass index (BMI) < 25 kg/m2], overweight (BMI: 25-30 kg/m2), and obese (BMI ≥ 30 kg/m2). Disease activity was evaluated at baseline, 3, 6, and 12 months. Drug retention rates at 12 months were also investigated.

RESULTS

There were 166 AS patients using secukinumab (56.6% male, mean age: 44.9 ± 11.6 years). The median follow-up time was 17.2 (3-33.2) months. Forty-eight (28.9%) patients were obese. The mean age was higher in the obese group than in others (P = .003). There was no statistically significant difference in Bath Ankylosing Spondylitis Disease Activity Index 50, Assessment of SpondyloArthritis international Society 20 (ASAS20), ASAS40, Ankylosing Spondylitis Disease Activity Score (ASDAS) low disease activity, and ASDAS clinically important improvement responses between the three groups at 3, 6, and 12 months, although they were numerically lower in obese patients. Drug retention rates at 12 months were similar in all groups (P > .05).

CONCLUSIONS

This study suggested that obesity did not affect secukinumab treatment response and drug retention in AS patients.

Body mass index does not affect response of rituximab in patients with rheumatoid arthritis: results from the TURKBİO registry

Background/aim

Adipose tissue produces several inflammatory mediators. Thus, obesity affects the disease course and the responses to the antirheumatic agents in inflammatory diseases. The aim of the study was to determine whether the body mass index (BMI) is involved in the response to rituximab in rheumatoid arthritis (RA).

Materials and methods

This multicenter retrospective study included 206 RA patients who received rituximab from the Turkish Biologic (TURKBIO) registry between 2011 and the end of May 2017. Demographic and clinical data including age, sex, disease type, disease duration, and previous or current treatment with disease-modifying antirheumatic drugs (DMARDs) and biological drug durations are stored in the database. Patients with a BMI ≥30 kg/m2 were classified as obese, and patients with a BMI <30 kg/m2 were classified as nonobese. Kaplan-Meier survival analysis was performed to estimate the drug survival. The subgroups were compared using the log-rank test.

Results

The mean BMI of 206 patients included in the study was 27.05 (17.2-43.4) kg/m2. There were 59 (28.6%) patients in the obese group and 147 (71.4%) patients in the nonobese group. The mean age, female percentage, and baseline disease activity score 28 (DAS28) were higher in the obese group than in the nonobese group. However, the ΔDAS28 at both 6 and 12 months were not significantly different between the groups (p = 0.785 and p = 0.512, respectively). Patient pain Visual Analogue Scale (VAS), patient fatigue VAS, and patient global VAS scores were also significantly higher at baseline in the obese group (p = 0.003, p = 0.006, and p = 0.006, respectively). However, no significant difference was found in terms of changes in patient pain VAS, patient fatigue VAS, patient global VAS and physician global VAS scores at 6 and 12 months compared to those at baseline. Rituximab treatment was ongoing for 71.2% of the obese and 63.3% of the nonobese patients (p = 0.279). The median drug survival duration was 77 months in the obese group and 62 months in the nonobese group (p = 0.053). The estimated drug survival rates for rituximab were not statistically significantly different in the obese and nonobese groups. Rituximab-related side effects were also similar between the groups.

Conclusion

In obese and nonobese patients with RA, rituximab treatment exhibits similar side effects and similar long-term efficacy. These results suggest that obesity does not alter drug survival for rituximab and response rates, in RA and rituximab may be a favorable treatment agent in patients with RA and obesity.

Arjunolic acid modulate pancreatic dysfunction by ameliorating pattern recognition receptor and canonical Wnt pathway activation in type 2 diabetic rats

BACKGROUND

Arjunolic acid (AA) is a potent phytochemical with multiple therapeutics effects. In this study, AA is evaluated on type 2 diabetic (T2DM) rats to understand the mechanism of β-cell linkage with Toll-like receptor 4 (TLR-4) and canonical Wnt signaling. However, its role in modulating TLR-4 and canonical Wnt/β-catenin crosstalk on insulin signaling remains unclear during T2DM. Aim The current study is aimed to examine the potential role of AA on insulin signaling and TLR-4-Wnt crosstalk in the pancreas of type 2 diabetic rats.

METHOD

Multiple methods were used to determine molecular cognizance of AA in T2DM rats, when treated with different dosage levels. Histopathological and histomorphometry analysis was conducted using masson trichrome and H&E stains. While, protein and mRNA expressions of TLR-4/Wnt and insulin signaling were assessed using automated Western blotting (jess), immunohistochemistry, and RT-PCR.

RESULTS

Histopathological findings revealed that AA had reversed back the T2DM-induced apoptosis and necrosis caused to rats pancreas. Molecular findings exhibited prominent effects of AA in downregulating the elevated level of TLR-4, MyD88, NF-κB, p-JNK, and Wnt/β-catenin by blocking TLR-4/MyD88 and canonical Wnt signaling in diabetic pancreas, while IRS-1, PI3K, and pAkt were all upregulated by altering the NF-κB and β-catenin crosstalk during T2DM.

CONCLUSION

Overall results, indicate that AA has potential to develop as an effective therapeutic in the treatment of T2DM associated meta-inflammation. However, future preclinical research at multiple dose level in a long-term chronic T2DM disease model is warranted to understand its clinical relevance in cardiometabolic disease.

Effect of body mass index on treatment response of biologic-/targeted synthetic-DMARDs in patients with rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis. A systematic review

BACKGROUND

Overweight and/or obese patients with inflammatory arthritis (IA) have higher disease activity and lower chances of achieving and/or maintaining the treatment targets. Weight/obesity also appears to negatively affect the response to tumor necrosis factor (TNF) inhibitors in patients with IA, including rheumatoid arthritis -RA, psoriatic arthritis -PsA, axial spondyloarthritis -AxSpA. We conducted a systematic literature review (SLR) for the effect of weight/body-mass-index (BMI) in the efficacy of all approved b- and targeted-synthetic (ts)- DMARDs for the treatment of IA.

METHODS

For this PROSPERO-registered SLR, we searched PubMed, Scopus and Cohrane-Library from inception up to June 21st 2022. Clinical-trials (randomized and non-randomized) and observational studies of RA, PsA or AxSpA patients that reported the effect of weight/BMI on response (all possible outcomes) to b/ts-DMARDs were included. Risk-of-bias was assessed via RoB2-Cochrane-tool and Newcastle-Ottawa-scale for randomized and non-randomized studies, respectively.

FINDINGS

Out of 996 references, 75 eventually fulfilled the inclusion criteria (of which 10 studies were retrieved through manual-search). Among the included studies (TNF-inhibitors: 34, IL-12/23 inhibitors: 4, IL-23 inhibitor: 1, IL-17 inhibitors: 7, tocilizumab: 18, abatacept: 8, rituximab: 3, JAK-inhibitors: 5), most had medium RoB. Efficacy of TNF-inhibitors was affected by BMI in all forms of IA. Data are not robust to compare the effect among various TNF-inhibitors. In contrast, favorable results of IL-23 and IL-17 inhibitors did not appear to be influenced by increased BMI in PsA or AxSpA patients. Similar evidence exists for tocilizumab (in RA) and for abatacept (in RA and PsA), while no conclusion can be drawn for rituximab. More data are needed for JAK-inhibitors, although the effect of weight/BMI does not seem to be significant so far.

INTERPRETATION

Weight/BMI should be considered in the treatment-plan of patients with IA, with its effect being more pronounced for TNF-inhibitors compared to other b/ts-DMARDs.

Drug retention rate and predictive factors of drug survival for secukinumab in radiographic axial spondyloarthritis

The drug retention rate has been an important indicator for evaluating the treatment tolerance. Unfortunately, our knowledge of the secukinumab retention rate in radiographic axial spondyloarthritis (r-AxSpA) is limited. The objective of this study was to assess the retention rate of secukinumab and evaluate predictive factors of drug survival based on data from a real-life cohort. We retrospectively assessed 147 r-AxSpA patients between May 2018 and January 2020 from the HUR-BIO database. Secukinumab retention rates were analyzed using the Kaplan-Meier method and Cox proportional hazard model was used for predictors factors. The global retention rate of secukinumab was 55% at 12 months. r-AxSpA patients with obesity had a lower frequency of secukinumab discontinuation (29% vs. 50%, p = 0.013) in comparison r-AxSpA patients without obesity. In multivariate analysis, multiple TNFi usage had a higher risk of secukinumab discontinuation [HR 1.99 (1.09-3.62), p = 0.024]; on the other hand, obesity had a lower risk [HR 0.45 (0.27-0.90), p = 0.008]. Except for not using multiple TNFi, this real-life analysis showed for the first time that obesity is not an adverse risk factor for secukinumab drug retention in r-AxSpA. Secukinumab, which is an interleukin-17A inhibitor, could act via a different pathway than tumor necrosis factor inhibitors (TNFi). The identification of predictive factors such as obesity that may affect the individual drug selection may provide more appropriate biologic treatment strategies for r-AxSpA.

2021 EULAR recommendations regarding lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases

OBJECTIVES

A European League Against Rheumatism taskforce was convened to review the literature and develop recommendations on lifestyle behaviours for rheumatic and musculoskeletal diseases (RMDs).

METHODS

Six lifestyle exposures (exercise, diet, weight, alcohol, smoking, work participation) and seven RMDs (osteoarthritis, rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis, systemic lupus erythematosus, systemic sclerosis, gout) were considered. The taskforce included health professionals in rheumatology, geriatricians, epidemiologists, public health experts, people with RMDs and exposure domain experts. Systematic reviews were conducted to gather available evidence, from which recommendations were developed.

RESULTS

Five overarching principles and 18 specific recommendations were defined based on available evidence. The overarching principles define the importance of a healthy lifestyle, how lifestyle modifications should be implemented, and their role in relation to medical treatments. Exercise recommendations highlight the safety and benefits of exercise on pain and disability, particularly among people with osteoarthritis and axial spondyloarthritis. The diet recommendations emphasise the importance of a healthy, balanced diet for people with RMDs. People with RMDs and health professionals should work together to achieve and maintain a healthy weight. Small amounts of alcohol are unlikely to negatively affect the outcomes of people with RMDs, although people with rheumatoid arthritis and gout may be at risk of flares after moderate alcohol consumption. Smokers should be supported to quit. Work participation may have benefits on RMD outcomes and should be discussed in consultations.

CONCLUSIONS

These recommendations cover a range of lifestyle behaviours and can guide shared decision making between people with RMDs and health professionals when developing and monitoring treatment plans.

Separating the effects of childhood and adult body size on inflammatory arthritis: a Mendelian randomisation study

OBJECTIVES

Using Mendelian randomisation (MR), we examined whether childhood body size affects risk of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), gout and systemic lupus erythematosus (SLE) after accounting for the effect of adult body size.

METHODS

Genetic instruments for childhood (age 10 years) and adult body size were derived using data from 453 169 individuals from the UK Biobank study (313 and 580 variants respectively), which have been previously validated using body mass index data from three independent populations. Genome-wide association data comprised 22 350 RA, 9069 AS, 3609 PsA, 13 179 gout and 5201 SLE cases. For each outcome, we conducted univariable MR to estimate the total effects of childhood and adult body size, and multivariable MR to examine the independent effect of childhood body size after accounting for adult body size.

RESULTS

Genetically predicted childhood body size had a total effect on risk of PsA (OR 2.18 per change in body size category; 95% CI 1.43 to 3.31), gout (OR 2.18; 95% CI 1.43 to 3.31) and SLE (OR 2.44; 95% CI 1.14 to 5.22), but not RA (OR 0.95; 95% CI 0.70 to 1.29) or AS (OR 0.96; 95% CI 0.61 to 1.52). After accounting for adult body size, the direct effect of childhood body size was little changed for PsA (OR 1.92; 1.14 to 3.25) and SLE (OR 2.69; 1.24 to 5.87) but was attenuated for gout (OR 1.40; 95% CI 0.94 to 2.09).

CONCLUSIONS

Our findings suggest that, for PsA and SLE, the risk conferred from having a larger body size during childhood may not be fully reversable even when a healthy size is achieved in adulthood.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

Obesity Accelerates Age Defects in Human B Cells and Induces Autoimmunity +

Aging is associated with systemic inflammation and decreased production of protective antibodies while the production of autoimmune antibodies is increased. Our results have shown that the human obese adipose tissue (AT), which increases in size with aging, contributes to systemic and B cell intrinsic inflammation, reduced protective and increased pathogenic B cell responses leading to increased secretion of autoimmune antibodies.

With this R56 funding, we have been able to investigate the cellular and molecular mechanisms by which the human obese AT induces intrinsic B cell inflammation and dysfunctional B cell responses, stimulates the secretion of autoimmune antibodies, whose specificity has been characterized, and engages different AT cell types in antigen presentation pathways to allow secretion of these autoimmune antibodies. Briefly, immune cells are recruited to the AT by chemokines released by both non-immune (adipocytes) and by resident and infiltrating immune cells. We have identified several mechanisms responsible for the release of “self” antigens, and we have shown that reduced oxygen availability and hypoxia, cell cytotoxicity and DNA damage induce cell death and lead to further release of pro-inflammatory cytokines, “self” protein antigens, cell-free DNA and lipids. We have also identified different antigen presenting cells in the AT, responsible for the activation of pathogenic B cells, class switch and secretion of autoimmune IgG antibodies. The experiments performed have allowed the discovery of novel mechanisms for pathogenic responses and the identification of pathways to target in order to promote better humoral immunity during aging.

Factors associated with remission at 5-year follow-up in recent onset axial spondyloarthritis: results from the DESIR cohort

Objective

The factors contributing to long-term remission in axial SpA (axSpA) are unclear. We aimed to characterize individuals with axSpA at the 5-year follow-up to identify baseline factors associated with remission.

Methods

We included all patients from the DESIR cohort (with recent-onset axSpA) with an available Ankylosing Spondylitis Disease Activity Score–CRP (ASDAS-CRP) at 5-year follow-up. Patients in remission (ASDAS-CRP < 1.3) were compared with those with active disease by demographic, clinical, biological and imaging characteristics. A logistic model stratified on TNF inhibitor (TNFi) exposure was used.

Results

Overall, 111/449 patients (25%) were in remission after 5 years. Among those never exposed to TNFi, 31% (77/247) were in remission compared with 17% (34/202) of those exposed to TNFi. Patients in remission after 5 years were more likely to be male, HLA-B27+, have a lower BMI, and a higher education level. Baseline factors associated with 5-year remission in patients never exposed to TNFi included lower BASDAI [adjusted odds ratio (OR_a) 0.9, 95% CI: 0.8, 0.9) and history of peripheral arthritis (OR_a 2.1, 95% CI: 1.2, 5.3). In those exposed to TNFi, remission was associated with higher education level (OR_a 2.9, 95% CI: 1.6, 5.1), lower enthesitis index (OR_a 0.8, 95% CI: 0.7, 0.9), lower BASDAI (OR_a 0.9, 95% CI: 0.9, 0.9) and lower BMI (OR_a 0.8, 95% CI: 0.7, 0.9).

Conclusion

This study highlights the difficulty in achieving 5-year remission in those with recent-onset axSpA, especially for the more active cases, despite the use of TNFi. Socio-economic factors and BMI are implicated in the outcome at 5 years.

Underweight and obesity are strong predictors of clinical outcomes in patients with ankylosing spondylitis: data from the Smart-phone SpondyloArthritis Management System

Background

The aim of this study was to examine the impact of underweight, overweight and obesity on clinical outcomes and treatment responses to biologics in Chinese patients with ankylosing spondylitis (AS).

Methods

Body mass index (BMI) was available in 1074 patients from the Smart-phone SpondyloArthritis Management System. Patients were categorized into four groups based on BMI: underweight, normal weight, overweight and obesity. Multivariable median regression analyses examined the effect of underweight and obesity on clinical outcomes and treatment response to biologics.

Results

Among 1074 patients with AS, normal weight accounted for 49.1%, while underweight, overweight, and obesity for 8.1%, 30.1%, and 12.0%, respectively. Compared to patients with normal weight, patients with underweight, overweight and obesity had an increased disease activity, while patients with underweight and obesity had a significantly poor Bath Ankylosing Spondylitis Functional Index and Assessment of Spondyloarthritis International Society Health Index scores. For tumor necrosis factor (TNF)-α inhibitor users, BMI was found to be negatively correlated with changes in disease activity in the multivariate regression model (all p < 0.05). Besides, the patients using TNF-α inhibitor in the overweight or obesity categories were much less likely to achieve a significant reduction on disease activity during follow-up period in the multivariate regression model (all p < 0.05), taking these with normal-weight patients as a reference.

Conclusions

Both underweight and obesity except for overweight were associated independently with worse disease activity, physical function and health status. Overweight and obesity might impact on treatment responses to biologics in patients with AS. This argues that weight management, to maintain it at a normal level, should be one of the disease management strategies in patients with AS.

Alcohol misuse is associated with poor response to systemic therapies for psoriasis: findings from a prospective multicentre cohort study

BACKGROUND

Factors that might influence response to systemic treatment for moderate-to-severe psoriasis are varied, and generally, are poorly understood, aside from high bodyweight, suggesting that other unidentified factors may be relevant in determining response to treatment. The impact of alcohol misuse on treatment response has not been previously investigated.

OBJECTIVES

To investigate whether alcohol misuse is associated with poor response to treatment for psoriasis.

METHODS

This was a prospective cohort study in which response to systemic therapies was assessed using the Psoriasis Area and Severity Index (PASI). The CAGE (Cut down, Annoyed, Guilty, Eye opener) questionnaire was used to screen for alcohol misuse. A multivariable factional polynomial linear regression model was used to examine factors associated with change in PASI between baseline and follow-up.

RESULTS

The cohort comprised 266 patients (biologic cohort, n = 134; conventional systemic cohort, n = 132). For the entire cohort, the median (interquartile range) PASI improved from 13 (10·0-18·3) at baseline to 3 (1·0-7·5) during follow-up. A higher CAGE score [regression coefficient: 1·40, 95% confidence interval (CI) 0·04-2·77]; obesity (1·84, 95% CI 0·48-3·20); and receiving a conventional systemic rather than a biologic therapy (4·39, 95% CI 2·84-5·95) were significantly associated with poor response to treatment; whereas a higher baseline PASI (-0·83, 95% CI -0·92 to -0·74) was associated with a better response to treatment.

CONCLUSIONS

The poor response to therapy associated with alcohol misuse and obesity found in people with psoriasis calls for lifestyle behaviour change interventions and support as part of routine clinical care. Targeting interventions to prevent, detect and manage alcohol misuse among people with psoriasis is needed to minimize adverse health consequences and improve treatment response.

[The effect of obesity on disease activity of inflammatory rheumatic diseases]

One of the most recent scientific fields is the interaction between the immune system and metabolic processes. These interactions increasingly involve intracellular and extracellular signaling molecules and their receptors as well as molecular mechanisms that are used by both systems. The result of these intensive interactions is characterized by the term "metaflammation" and involves in particular, the ubiquitous adipose tissue present throughout the body. The links identified to date between the immune system and metabolism play a greater role in inflammatory rheumatic joint diseases than previously thought. In general, a markedly high body mass index (BMI) in particular, is associated with increased inflammatory activity and this is independent of the underlying disease entity. A higher BMI at the beginning of an immunomodulatory therapy also causes a more difficult response to the medication. Thus, the current scientific objective is to identify the individual "immuno-metabolic" pathways in order to apply the medications specifically to the site of action. Furthermore, all newer therapeutic agents, especially those specifically acting against individual immunological molecules, should be systematically analyzed with respect to their metabolic concomitant effects and their influence on metabolic comorbidities.

B Cells with a Senescent-Associated Secretory Phenotype Accumulate in the Adipose Tissue of Individuals with Obesity

Senescent cells accumulate in the adipose tissue (AT) of individuals with obesity and secrete multiple factors that constitute the senescence-associated secretory phenotype (SASP). This paper aimed at the identification of B cells with a SASP phenotype in the AT, as compared to the peripheral blood, of individuals with obesity. Our results show increased expression of SASP markers in AT versus blood B cells, a phenotype associated with a hyper-metabolic profile necessary to support the increased immune activation of AT-derived B cells as compared to blood-derived B cells. This hyper-metabolic profile is needed for the secretion of the pro-inflammatory mediators (cytokines, chemokines, micro-RNAs) that fuel local and systemic inflammation.

Body Mass Index and Disease Activity in Chronic Inflammatory Rheumatic Diseases: Results of the Cardiovascular in Rheumatology (Carma) Project

OBJECTIVE

Since obesity has been associated with a higher inflammatory burden and worse response to therapy in patients with chronic inflammatory rheumatic diseases (CIRD), we aimed to confirm the potential association between body mass index (BMI) and disease activity in a large series of patients with CIRDs included in the Spanish CARdiovascular in rheuMAtology (CARMA) registry.

METHODS

Baseline data analysis of patients included from the CARMA project, a 10-year prospective study of patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), and psoriatic arthritis (PsA) attending outpatient rheumatology clinics from 67 Spanish hospitals. Obesity was defined when BMI (kg/m²) was >30 according to the WHO criteria. Scores used to evaluate disease activity were Disease Activity Score of 28 joints (DAS28) in RA, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in AS, and modified DAS for PsA.

RESULTS

Data from 2234 patients (775 RA, 738 AS, and 721 PsA) were assessed. The mean ± SD BMI at the baseline visit were: 26.9 ± 4.8 in RA, 27.4 ± 4.4 in AS, and 28.2 ± 4.7 in PsA. A positive association between BMI and disease activity in patients with RA (β = 0.029; 95%CI (0.01- 0.05); p = 0.007) and PsA (β = 0.036; 95%CI (0.015-0.058); p = 0.001) but not in those with AS (β = 0.001; 95%CI (-0.03-0.03); p = 0.926) was found. Disease activity was associated with female sex and rheumatoid factor in RA and with Psoriasis Area Severity Index and enthesitis in PsA.

CONCLUSIONS

BMI is associated with disease activity in RA and PsA, but not in AS. Given that obesity is a potentially modifiable factor, adequate control of body weight can improve the outcome of patients with CIRD and, therefore, weight control should be included in the management strategy of these patients.

Evaluation of Nutritional Status and Methods to Identify Nutritional Risk in Rheumatoid Arthritis and Spondyloarthritis

Patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) experience several nutritional challenges and are prone to develop malnutrition. This observational study aimed to perform a comprehensive nutritional assessment of outpatients diagnosed with RA and SpA, as well as to evaluate methods to identify nutritional risk. Nutritional status was investigated by anthropometric measures, body composition (DXA, dual energy X-ray absorptiometry), and handgrip strength (HGS). Nutritional risk was classified by Nutritional Risk Screening 2002 (NRS2002) and malnutrition was defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria and fat-free mass index (FFMI; kg/m², <16.7 (M), <14.6 (F)). Out of 71 included patients, 46 (66%) were abdominally obese, 28 (39%) were obese in terms of body mass index (BMI), and 33 (52%) were obese in terms of the fat mass index (FMI; kg/m², ≥8.3 (M), ≥11.8 (F)). Malnutrition was identified according to FFMI in 12 (19%) patients, according to GLIM criteria in 5 (8%) patients, and on the basis of BMI (<18.5 kg/m²) in 1 (1%) patient. None were identified by NRS2002 to be at nutritional risk. Our study revealed high prevalence of abdominal obesity and low FFMI. Waist circumference was a good indicator of FMI. BMI, NRS2002, and HGS did not capture patients with malnutrition identified by DXA.

Influence of smoking and obesity on treatment response in patients with axial spondyloarthritis: a systematic literature review

To assess whether smoking and obesity are predictors of poor treatment response in patients with axial spondyloarthritis (axSpA). A systematic literature review was performed by searching in MEDLINE and EMBASE up to June 2019 with a strategy based on the PICO approach: Population: patients with axSpA; Intervention or exposure: smoking or obesity; Comparison: non-smokers (for smoking) and normal-weight individuals (for obesity); and Outcome: any response criteria currently validated for axSpA. The 2009 Oxford Centre for Evidence-based Medicine levels were used for assessing the studies quality. Out of 1873 references retrieved, 46 studies were selected for full-text review and 12 for data extraction: six stratified patients by smoking and six by obesity. All were longitudinal observational studies, except one, which was cross-sectional. Overall, these studies included 5291 patients (3917 for smoking and 1333 for obesity), and all these patients were on anti-tumor necrosis factor (anti-TNF) therapy. The quality of evidence was graded as level 2b except that from the cross-sectional study which was graded level 4. For smoking, the evidence found is inconsistent: two studies finding negative effects in response to anti-TNF while the other four found no differences in clinical response to this therapy. Regarding obesity, the evidence is more consistent: five of the six studies describing a negative influence in response to anti-TNF. According to the scientific evidence in patients with axSpA, obesity is associated with a more unsatisfactory response to anti-TNF therapy. A poorer response in smokers has yet to be demonstrated. Key Points • Identifying predictors of treatment response in axSpA, especially those that are modifiable, is relevant. • Obesity increases the risk of poorer response to anti-TNF agents in patients with axSpA. • Scientific evidence for smoking habit as a predictor of treatment response in axSpA is inconclusive.

A Real-World Evaluation of the Long-Term Safety and Efficacy of Infliximab in the Treatment Moderate-to-Severe Psoriasis

Introduction

Psoriasis is a chronic immune-mediated inflammatory skin disease that occurs in 2.5–3.5% of the general population. Infliximab (INF), a TNF-α inhibitor biologic agent, is a long-standing efficacious treatment for psoriasis; however, not all patients sustain a long-term response (LTR) because of a number of factors including antibody production. There is a paucity of studies assessing infliximab efficacy over a period ≥ 5 years.

Methods

A retrospective cohort chart review of our clinic patients who had undergone ≥ 5 years of treatment with infliximab for chronic plaque psoriasis was performed. The following variables were recorded and analyzed with the Fisher exact test: age, sex, body mass index ([BMI]; normal weight [NW], overweight [OW], obese [OB]), changes in infliximab strength (dose or frequency), concomitant systemic therapy, and side effects. Clinical improvement was assessed by comparing the total body surface area (tBSA) affected by psoriasis before and after treatment.

Results

There was a significant difference in likelihood of achieving LTR between the NW, OW and OB groups (p = 0.044). Non-normal-weight patients (OW + OB) were significantly more likely to achieve and sustain LTR than NW patients (OR 9.07, p = 0.020). There were no other significant associations for the other evaluated variables.

Limitations

Patients who began treatment with infliximab before 2009 (prior to the use of the clinic’s electronic medical record) were excluded. The Psoriasis Area and Severity Index (PASI) was not available for this study.

Conclusion

Surprisingly, patients who are overweight or obese are more likely to obtain long-term clinical benefit in their psoriasis symptoms with infliximab therapy than patients who are normal weight.

Electronic supplementary material

The online version of this article (10.1007/s13555-020-00436-1) contains supplementary material, which is available to authorized users.

Obesity Increases Disease Activity of Norwegian Patients with Axial Spondyloarthritis: Results from the European Map of Axial Spondyloarthritis Survey

OBJECTIVE

To investigate the prevalence of overweight and obesity, as well as the association between body mass index (BMI) and disease activity in patients with axial spondyloarthritis (axSpA).

METHODS

Norwegian axSpA patients from the European Map of Axial Spondyloarthritis (EMAS) survey were included in this analysis. Sociodemographic, anthropomorphic, and disease-related variables (HLA-B27, comorbidities, BASDAI, and self-reported spinal stiffness) were reported. Patients were categorized into under/normal weight (BMI < 25 kg/m²), overweight (BMI ≥ 25 to < 30 kg/m²), and obese (≥ 30 kg/m²).

RESULTS

Of the 509 participants in the EMAS survey, 35% were categorized as under/normal weight, 39% overweight, and 26% obese. Compared to under/normal-weight patients, overweight patients had significantly higher degree of spinal stiffness (mean (SD) 7.91 ± 2.02 vs 7.48 (2.15) and number of comorbidities (2.45 ± 2.11, vs 1.94), both p < 0.001. Obese patients had significantly higher disease activity (BASDAI mean (SD) 5.87 ± 1.78 vs 4.99 ± 2.08, p < 0.001), degree of spinal stiffness (8.18 ± 2.03 vs 7.48 ± 2.15, p = 0.006), and number of comorbidities (3.43 ± 2.43 vs 1.94. ± .38, p < 0.001) than under/normal weight patients. After adjusting for gender and age, obesity proved to be independently associated with disease activity.

CONCLUSION

Obesity was associated with higher reported BASDAI score, and being overweight or obese was associated with a higher degree of spinal stiffness and number of comorbidities compared to under/normal weight respondents. The results highlight the serious impact of obesity on health status, and obesity should therefore be considered as a modifiable risk factor for disease activity within the disease management of axSpA.

Association of body mass index on disease activity in axial spondyloarthritis: systematic review and meta-analysis

OBJECTIVES

In axial spondyloarthritis (axSpA), higher body mass index (BMI) is associated with worse outcomes including response to biologics. Further clarity is needed on whether BMI is associated with disease activity overall, independent of treatment response. We performed a systematic review and meta-analysis to assess the association between BMI and disease activity as reported by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) or Ankylosing Spondylitis Disease Activity Score (ASDAS) in axSpA.

METHODS

We systematically searched for studies evaluating BMI and disease activity as the exposure and outcome of interest, respectively, in axSpA. Using random effects models, we estimated summary standardised mean differences (SMDs) and 95% CIs of BASDAI or ASDAS, comparing obese (BMI>30 kg/m²) or overweight/obese (BMI>25 kg/m²) individuals to those with normal BMI (18.5-24.9 kg/m²).

RESULTS

Twelve studies were included in the meta-analysis. Among all studies reporting the BASDAI at baseline, the pooled SMD of the BASDAI for those with an obese or overweight/obese BMI compared to a normal BMI was 0.38 (95% CI 0.21 to 0.55, I² =75.2%), indicating a significant association of higher BMI with higher BASDAI score. The pooled SMD of the ASDAS for those with an obese or overweight/obese BMI compared to a normal BMI was 0.40 (95% CI 0.27 to 0.54, I²=0%). Findings were robust across subgroup analyses.

CONCLUSION

These results demonstrate an association between an overweight/obese BMI and higher disease activity in studies of axSpA. Future longitudinal studies of BMI and disease activity should assess how this association changes over time.

The Interrelations between Biological and Targeted Synthetic Agents Used in Inflammatory Joint Diseases, and Obesity or Body Composition

Obesity is a comorbidity that plays a role in the development and severity of inflammatory joint diseases, including rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis. The relationships between obesity and adipose tissue and the treatments given for inflammatory joint diseases are bidirectional. In fact, biological agents (bDMARDs) and targeted synthetic agents (tsDMARDs) may influence body weight and body composition of treated patients, while obesity in turn may influence clinical response to these agents. Obesity is a prevalent comorbidity mainly affecting patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA) with specific phenotypes. Tumour necrosis factor alpha (TNFα) inhibitors have been associated with changes in body composition by improving lean mass, but also by significantly increasing fat mass, which localized toward the abdominal/visceral region. The IL-6 inhibitor tocilizumab is associated with an increase in lean mass without change in fat mass. The clinical response to TNFα inhibitors is attenuated by obesity, an effect that is less pronounced with IL-6 inhibitors and the B-cell depletion agent rituximab. Conversely, body weight has no influence on the response to the costimulation inhibitor abatacept. These effects may be of help to the physician in personalized medicine, and may guide the therapeutic choice in obese/overweight patients.

The bone mineral density of hip joint was reduced in the initial stage of ankylosing spondylitis?

The osteoporosis was common complication of ankylosing spondylitis (AS), but it was frequently unrecognized in the initial stage of the disease. This study was to compare areal bone mineral density (BMD) of hip joints in early AS patients with that in healthy controls, to explore the progress of bone loss in cortex and spongiosa in early AS.Quantitative computed tomography (QCT) of hip was performed in 60 AS patients (modified New York criteria for AS, with grade 2 sacroiliitis in computed tomography) and 57 healthy controls. The QCT measurements of AS patients were compared with the measurements of healthy controls.The AS patients had lower areal BMD in cortical bone and total bone of proximal femur in early AS patients (P < .01), than the controls. But there were not significant different of areal BMD in spongiosa of proximal femur between the early AS patients and healthy controls. Strong correlations were found between body mass index BMI, areal BMD in cortical bone (rs = 0.410, P < .001; rs = 0.422, P < .001) and total bone (rs = 0.368, P < .001; rs = 0.266, P = .003) both in AS patients and healthy controls.The results indicate that osteopenia/osteoporosis is general in early stage of AS. What is more, the osteopenia/osteoporosis in cortex is earlier than in spongiosa of proximal femur in early AS.

A systematic review of the association of obesity with the outcomes of inflammatory rheumatic diseases

This was a systematic review of the literature on the association between obesity and the outcome of inflammatory rheumatic diseases. We conducted a literature search using PubMed®, Embase and PsycINFO®. Articles were classified into three categories based on the effects of obesity on the outcomes of inflammatory rheumatic diseases. The subject population, country, type of studies, number of patients, measurement of obesity and outcomes assessed were presented. Quality was appraised using Kmet et al's criteria. 4,331 articles were screened and 60 were relevant to the objective. Obesity had a negative, positive and neutral association with outcomes of inflammatory rheumatic diseases in 38 (63.3%) studies with 57,612 subjects, 11 (18.3%) studies with 3,866 subjects, and 11 (18.3%) studies with 3,834 subjects, respectively. In most studies, the disease population had been diagnosed with rheumatoid arthritis (RA). Tumour necrosis factor-α inhibitors were mostly associated with negative outcomes. More studies examining subjects outside Europe and North America and diseases other than RA are warranted.

Immunophenotyping of Human B Lymphocytes in Blood and in Adipose Tissue

The human obese subcutaneous adipose tissue (SAT) contributes to systemic and B cell intrinsic inflammation, reduced B cell responses, and increased secretion of autoimmune antibodies. Immune cells are recruited to the SAT by chemokines released by both adipocytes and infiltrating immune cells. We describe here the characterization of B lymphocytes from the SAT and blood (control) of obese females undergoing weight reduction surgeries (breast reduction or panniculectomy). We show how to isolate the immune cells from the blood and SAT, how to characterize B cells and their subsets, and how to measure markers of activation and/or transcription factors in SAT-derived B cells and B cell subsets. We also show how to evaluate other immune cell types infiltrating the SAT, including T cells, NK cells, monocyte/macrophages, in order to measure relative proportions of these cell types as compared to the blood.

Treatment Failure of TNF-α Inhibitors in Obese Patients With Inflammatory Bowel Disease-A Cohort Study

BACKGROUND

In treatment of inflammatory bowel disease (IBD) with anti-tumor necrosis factor-α agents (anti-TNF-α), obesity has been suspected as a cause of accelerated loss of response (LOR). We sought to determine whether overweight IBD patients have accelerated LOR when treated with anti-TNF-α agents, compared with normal weight IBD patients.

METHODS

We identified a cohort of adult IBD patients treated with anti-TNF-α agents at a Danish university hospital. Patients were grouped according to body mass index (BMI), and our main outcome was time to LOR. We performed survival analyses on LOR and calculated hazard ratios (HRs) with the normal weight group as the reference, while adjusting for confounders.

RESULTS

Of 210 eligible patients, 92 (44%) experienced LOR. One hundred eighty patients were treated with infliximab and 30 with adalimumab, 114 (54%) were normal weight, 51 (24%) were overweight, and 45 (21%) were obese. Regression analysis produced the following adjusted HRs, compared with the normal weight group: overweight 0.89 (95% confidence interval [CI], 0.51-1.56) and obese 1.31 (95% CI, 0.76-2.24), thus showing no statistically significant association between BMI and time to LOR. Subgroup analyses produced similar results, except for obese ulcerative colitis patients having an adjusted HR of 2.42 (95% CI, 1.03-5.70).

CONCLUSIONS

In IBD patients treated with anti-TNF-α agents, we found no overall association between increased BMI and accelerated LOR.

Identifying demographic, social and clinical predictors of biologic therapy effectiveness in psoriasis: a multicentre longitudinal cohort study

Background

Biologic therapies have revolutionized the treatment of moderate‐to‐severe psoriasis. However, for reasons largely unknown, many patients do not respond or lose response to these drugs.

Objectives

To evaluate demographic, social and clinical factors that could be used to predict effectiveness and stratify response to biologic therapies in psoriasis.

Methods

Using a multicentre, observational, prospective pharmacovigilance study (BADBIR), we identified biologic‐naive patients starting biologics with outcome data at 6 (n = 3079) and 12 (n = 3110) months. Associations between 31 putative predictors and outcomes were investigated in univariate and multivariable regression analyses. Potential stratifiers of treatment response were investigated with statistical interactions.

Results

Eight factors associated with reduced odds of achieving ≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90) at 6 months were identified (described as odds ratio and 95% confidence interval): demographic (female sex, 0·78, 0·66–0·93); social (unemployment, 0·67, 0·45–0·99); unemployment due to ill health (0·62, 0·48–0·82); ex‐ and current smoking (0·81, 0·66–0·99 and 0·79, 0·63–0·99, respectively); clinical factors (high weight, 0·99, 0·99–0·99); psoriasis of the palms and/or soles (0·75, 0·61–0·91); and presence of small plaques only compared with small and large plaques (0·78, 0·62–0·96). White ethnicity (1·48, 1·12–1·97) and higher baseline PASI (1·04, 1·03–1·04) were associated with increased odds of achieving PASI 90. The findings were largely consistent at 12 months. There was little evidence for predictors of differential treatment response.

Conclusions

Psoriasis phenotype and potentially modifiable factors are associated with poor outcomes with biologics, underscoring the need for lifestyle management. Effect sizes suggest that these factors alone cannot inform treatment selection.

What's already known about this topic?

Biologic therapy used in the treatment of moderate‐to‐severe psoriasis differs in its effectiveness across patients.

Previous research has indicated that patients with a higher body mass index, who smoke or who have smoked, and with a lower baseline Psoriasis Area and Severity Index (PASI) are less likely to have a good outcome with biologic therapy for the treatment of moderate‐to‐severe psoriasis.

What does this study add?

This large‐scale study in a real‐world setting confirms that weight, smoking status and baseline PASI are associated with effectiveness of biologic therapy.

There is evidence that non‐white ethnicity, female sex, unemployment, psoriasis of the palms and soles and the presence of small chronic plaques are associated with poor outcomes with biologics.

There is some evidence that men have a comparatively worse response to etanercept, relative to adalimumab, than women. Otherwise, most factors do not appear to be predictors of differential treatment response.

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Inflammation, obesity and rheumatic disease: common mechanistic links. A narrative review

Obesity represents a rising global health concern, linked to significant social, psychological and physical burden to the individual affected, people around them and the society as a whole. Obesity has been described as a low-grade inflammatory condition, associated with increased production of pro-inflammatory mediators like tumor necrosis factor alpha or interleukin 6 and altered expression of adipokines. Adipokines, mainly produced by adipose tissue, have mixed pro- and anti-inflammatory properties. Obesity rarely exists on its own; instead, it tends to coexist with (often multiple) other comorbidities, including metabolic, cardiovascular, and rheumatic and musculoskeletal diseases (RMDs). In the case of RMDs, evidence is rapidly accumulating on common mechanistic pathways implicated in the inflammatory states seen between RMDs and obesity. Although there remain unanswered questions on the exact mechanisms of inflammation that link obesity to RMDs, what is becoming increasingly known is the association between obesity and adverse clinical outcomes in RMDs. This narrative review discusses insights into mechanisms of inflammation linking obesity and RMDs and evidence on the impact of obesity on treatment response and important disease outcomes. We highlight the importance of targeting obesity, a common and modifiable comorbidity, as part of the routine care of people with RMDs.

Obesity and Response to Infliximab in Patients with Inflammatory Bowel Diseases: Pooled Analysis of Individual Participant Data from Clinical Trials

OBJECTIVES

To assess whether obesity may affect response to infliximab, we conducted an individual participant data pooled analysis using data from clinical trials of infliximab in inflammatory bowel diseases (IBD), using the Yale Open Data Access (YODA) Project.

METHODS

We analyzed individual participant data from four clinical trials of infliximab in adults with IBD (ACCENT-I, SONIC, ACT-1, and -2). Patients were categorized as obese (body mass index [BMI] ≥ 30 kg/m²) vs. non-obese, and by quartiles based on BMI or weight at time of trial entry. Primary outcome was clinical remission (Crohn's disease activity index [CDAI] < 150 or pediatric CDAI <10, Mayo Clinic Score <3); secondary outcomes were clinical response and mucosal healing. Multivariable logistic regression analysis was performed, after adjusting for sex, smoking, disease activity, and concomitant prednisone and/or immunomodulators.

RESULTS

We included 1205 infliximab-treated patients (mean age 37 years, 51.6% males, 14% obese). Obesity was not associated with odds of achieving clinical remission (obese vs. non-obese: adjusted OR, 0.93 [95% CI, 0.47-1.46]; Q4 vs. Q1: aOR, 0.94 [0.61-1.47], p-value for trend = 0.97), clinical response (Q4 vs. Q1: aOR, 0.84 [0.52-1.35], p = 0.45) or mucosal healing (Q4 vs. Q1: aOR, 1.13 [0.55-2.34], p = 0.95). These results were consistent across strata based on disease type (Crohn's disease and ulcerative colitis) and trial design (induction and maintenance therapy).

CONCLUSIONS

Based on individual participant data pooled analysis, obesity is not associated with inferior response to infliximab in patients with IBD. Future studies examining the association between obesity and fixed-dose therapies are warranted.

Obesity and response to anti-tumor necrosis factor-α agents in patients with select immune-mediated inflammatory diseases: A systematic review and meta-analysis

OBJECTIVES

We sought to evaluate the association between obesity and response to anti-tumor necrosis factor-α (TNF) agents, through a systematic review and meta-analysis.

METHODS

Through a systematic search through January 24, 2017, we identified randomized controlled trials (RCTs) or observational studies in adults with select immune-mediated inflammatory diseases-inflammatory bowel diseases (IBD), rheumatoid arthritis (RA), spondyloarthropathies (SpA), psoriasis and psoriatic arthritis (PsA)-treated with anti-TNF agents, and reporting outcomes, stratified by body mass index (BMI) categories or weight. Primary outcome was failure to achieve clinical remission or response or treatment modification. We performed random effects meta-analysis and estimated odds ratios (OR) and 95% confidence interval (CI).

RESULTS

Based on 54 cohorts including 19,372 patients (23% obese), patients with obesity had 60% higher odds of failing therapy (OR,1.60; 95% CI,1.39-1.83;I2 = 71%). Dose-response relationship was observed (obese vs. normal BMI: OR,1.87 [1.39-2.52]; overweight vs. normal BMI: OR,1.38 [1.11-1.74],p = 0.11); a 1kg/m2 increase in BMI was associated with 6.5% higher odds of failure (OR,1.065 [1.043-1.087]). These effects were observed across patients with rheumatic diseases, but not observed in patients with IBD. Effect was consistent based on dosing regimen/route, study design, exposure definition, and outcome measures. Less than 10% eligible RCTs reported outcomes stratified by BMI.

CONCLUSIONS

Obesity is an under-reported predictor of inferior response to anti-TNF agents in patients with select immune-mediated inflammatory diseases. A thorough evaluation of obesity as an effect modifier in clinical trials is warranted, and intentional weight loss may serve as adjunctive treatment in patients with obesity failing anti-TNF therapy.

Impact of obesity on the efficacy of different biologic agents in inflammatory diseases: A systematic review and meta-analysis

OBJECTIVE

Obesity is a worldwide epidemic and a growing body of evidence suggests that it may affect the body's response to biologic agents. We investigated the influence of obesity on the efficacy of different biologic agents used to treat inflammatory diseases.

METHODS

Medline, EMBASE and the Cochrane Database were searched using relevant MeSH and keyword terms for obesity and bDMARDs. Articles were selected if they reported a clinical response in obese subjects relative to other BMI categories. Response and remission outcomes were assessed using meta-analysis and all other reported outcomes were summarized.

RESULTS

Among the 3850 records retrieved, 24 articles met the inclusion criteria, including 10 on rheumatoid arthritis (RA), 4 on axial spondyloarthritis (axSpA), 4 on Crohn's disease (CD), 4 on psoriasis (Ps) and 2 on psoriasic arthritis (PsA). Four biological disease-modifying anti-rheumatic drugs (bDMARDs) - anti-TNF agents, T cell co-stimulation inhibitor (abatacept), IL-6 inhibitor (tocilizumab), and B-cell depletion therapy (rituximab) - were involved. The meta-analysis showed that the odds to reach a good response or achieve remission were lower in obese (BMI>30kg/m²) than non-obese (BMI≤30kg/m²) patients who were treated with anti-TNF agents (good responder % in RA: OR 0.34, 95% CI 0.18-0.64; remission% in RA: OR 0.36, 95% CI 0.21-0.59; BASDAI50% in axSpA: OR 0.41, 95% CI 0.21-0.83), but no significant difference between obese and non-obese was found in patients treated with abatacept (good responder % in RA: OR 0.75, 95% CI 0.42-1.36; remission% in RA: OR 0.84, 95% CI 0.65-1.09) and tocilizumab (good responder % in RA: OR 1.08, 95% CI 0.44-2.63; remission% in RA: OR 0.91, 95% CI 0.50-1.66).

CONCLUSION

Obesity hampered the effect of anti-TNF agents, but not those of abatacept and tocilizumab, suggesting that a personalized treatment strategy should be considered for obese patients with inflammatory diseases.

Evaluation of the comorbidity burden in patients with ankylosing spondylitis treated with tumour necrosis factor inhibitors using a large administrative claims data set

Objectives

Comorbidity incidence rates among US patients with ankylosing spondylitis (AS) treated with tumour necrosis factor inhibitors (TNFis) are inadequately understood. This study compared the relative occurrence of comorbidities between patients with AS treated with TNFis and those not treated with TNFis.

Methods

Adults aged ≥18 years enrolled in the MarketScan Commercial and Medicare Supplemental databases with a diagnosis of AS between 1 January 2008 and 30 June 2015 were eligible. Patients were divided into two groups, those treated with TNFis (TNFi users) and those not treated with TNFis (TNFi nonusers) during the 12 months after the index date, defined as the date of first TNFi treatment or a randomly assigned date for TNFi nonusers. Patients had to have continuous enrolment for 24 months with no AS diagnosis or TNFi therapy pre‐index and a follow‐up period of ≥12 months postindex. The incidence of new comorbidities was evaluated in patients and adjusted for baseline characteristics.

Key findings

A total of 3077 TNFi users and 3830 TNFi nonusers were included. A higher proportion of TNFi users had a new diagnosis of inflammatory bowel disease (hazard ratio [HR], 2.00), including Crohn's disease (HR, 2.45) and ulcerative colitis (HR, 1.65), as well as uveitis (HR, 1.68) and sleep apnoea (HR, 1.21) after initiation of TNFi therapy than TNFi nonusers.

Conclusions

Patients with AS treated with TNFis had higher incidence rates of IBD, uveitis and sleep apnoea after initiation of TNFi therapy than patients not treated with TNFi therapy.

Aging, Obesity, and Inflammatory Age-Related Diseases

The increase in the prevalence of obesity represents a worldwide phenomenon in all age groups and is pathologically and genetically correlated with several metabolic and cardiovascular diseases, representing the most frequent age-related diseases. Obesity superimposed on aging drastically increases chronic low-grade inflammation (inflammaging), which is an important link between obesity, insulin resistance, and age-associated diseases. Immune cells of both the innate and the adaptive immune systems infiltrate the adipose tissue (AT) and during obesity induce inflammatory responses associated with metabolic switches and changes in phenotypes and function of immune cell subsets. Obesity poses new health problems especially when it occurs in the context of other diseases, many of them frequently affect elderly subjects. An emerging problem is the decreased proportion of patients with obesity achieving clinical response to therapy. In this review, we will discuss the reciprocal influences of immune cell and AT inflammation in aging and age-associated diseases and the complex relationship of nutrient and energy-sensing homeostatic checkpoints, which contribute to shape the phenotype of the AT. We will specifically examine type-2 diabetes, rheumatoid arthritis, osteoarthritis, cognitive impairment, and dementia, where obesity plays a significant role, also in shaping some clinical aspects.

Patients with Crohn's Disease with High Body Mass Index Present More Frequent and Rapid Loss of Response to Infliximab

BACKGROUND

Infliximab (IFX) is effective in inducing and maintaining remission in patients with luminal and anoperineal Crohn's disease (CD). However, treatment failure within 12 months after initiating IFX is observed in a significant proportion of patients. The aim of the present study was to determine whether the body mass index (BMI) affects response to IFX during the first year of treatment in patients with CD.

METHODS

All patients with luminal CD who began IFX between January 2010 and May 2014 were prospectively included. BMI was calculated before IFX treatment was begun, and patients were divided into 3 groups: normal BMI (BMI < 25 kg/m), overweight patients (BMI of 25.0-30 kg/m), and obese patients (BMI > 30.0 kg/m). The primary outcome was to evaluate the rate and delay of IFX optimization during the first year of treatment among normal weight, overweight, and obese patients.

RESULTS

One hundred forty patients were included. Demographic and clinical characteristics at IFX initiation were comparable among the 3 groups. Within 12 months after the initiation of IFX, the rate of IFX optimization was significantly higher in overweight and obese patients than in the normal BMI group: 52%, 56%, and 20%, respectively (P = 0.0002). The median time until optimization of IFX was significantly shorter in overweight and obese patients than in the normal BMI group: 7, 7, and 10 months, respectively (P = 0.03). A BMI >25 kg/m was significantly associated with IFX optimization within 12 months on multivariate analysis.

CONCLUSION

This is the first study to show that optimization of IFX is more frequent and faster in obese and overweight patients with CD and occurs within 12 months after beginning IFX, suggesting that an induction regimen with higher doses of IFX and a tight control of IFX concentrations may be needed in these patients.

Muscle wasting in male TNF-α blocker naïve ankylosing spondylitis patients: a comparison of gender differences in body composition

Objective

To assess gender differences in body composition (BC) in a cohort of AS patients naïve to TNF-α blockers.

Methods

Patients included fulfilled the Modified New York criteria for AS. Demographic information and disease activity measures (ASDAS and BASDAI) were reported. BC was measured by whole body DXA. Body fat percentage (BF%), fat mass index (FMI), fat free mass index (FFMI) and android/gynoid fat ratio were reported and compared between men and women and with the reference population (percentiles).

Results

Seventy consecutive patients were included; 60% were men. Demographic variables were similar, except for dyslipidaemia (57.1% of men; 14.3% of women). Women had significantly more fat (BF%, FMI), and less muscle (FFMI) than men, but below the median of the reference population. Male AS patients had a markedly low FFMI (31.7th percentile) compared with the reference population. In the whole group, after multivariate analysis, an ASDAS CRP >3.5 was related to lower fat free mass content. In men, a significant relationship between having a high disease activity (ASDAS, BASDAI) and lower BF% or FMI percentile was found, but in women it was the opposite.

Conclusion

Muscle wasting, measured as low FFMI compared with the reference population, was found in male TNF-α blocker naïve AS patients, especially in those with active disease. Women had higher volumes of body fat than men, but near the median of the reference population. The relationships between fat content and disease activity support the complex association between adipose tissue and inflammation.

The effects of pre-obesity on quality of life, disease activity, and functional status in patients with ankylosing spondylitis

OBJECTIVE:

This study was an investigation of effects of pre-obesity on clinical characteristics and quality of life in patients with ankylosing spondylitis (AS).

METHODS:

Total of 28 AS patients and 30 age- and sex-matched healthy controls were included in the study. Patients and controls with any systemic inflammatory disease and/or cognitive and mental problems were excluded. Disease activity and functional capacity were measured using the Bath Ankylosing Spondylitis Disease Activity Index and Bath Ankylosing Spondylitis Functional Index. For quality of life assessment, 36-Item Short Form Health Survey was used in both groups, and AS group also responded to Ankylosing Spondylitis Quality of Life questionnaire.

RESULTS:

There was no significant difference in sociodemographic characteristics between AS patients and healthy controls (p>0.05). Mean quality of life scores were significantly lower in the pre-obese AS patients compared with controls (p<0.05). Functional capacity was positively and significantly associated with body mass index (BMI) (p=0.024) and disease activity was significantly associated with female gender (p=0.011).

CONCLUSION:

Increased BMI in patients with AS is factor that affects quality of life, disease activity, and functional capacity. Multidisciplinary rehabilitation programs will support improved quality of life for pre-obese patients with AS.

Impact of obesity on the response to tumor necrosis factor inhibitors in axial spondyloarthritis

BACKGROUND

Few studies have investigated the impact of obesity on the response to tumor necrosis factor inhibitors (TNFi) in patients with axial spondyloarthritis (axSpA). The aim of our study was to investigate the impact of different body mass index (BMI) categories on TNFi response in a large cohort of patients with axSpA.

METHODS

Patients with axSpA within the Swiss Clinical Quality Management (SCQM) program were included in the current study if they fulfilled the Assessment in Spondyloarthritis International Society (ASAS) criteria for axSpA, started a first TNFi after recruitment, and had available BMI data as well as a baseline and follow-up visit at 1 year (±6 months). Patients were categorized according to BMI: normal (BMI 18.5 to <25), overweight (BMI 25-30), and obese (BMI >30). We evaluated the proportion of patients achieving the 40% improvement in ASAS criteria (ASAS40), as well as Ankylosing Spondylitis Disease Activity Score (ASDAS) improvement and status scores at 1 year. Patients having discontinued the TNFi were considered nonresponders. We controlled for age, sex, HLA-B27, axSpA type, BASDAI, BASMI, elevated C-reactive protein (CRP), current smoking, enthesitis, physical exercise, and co-medication with disease-modifying antirheumatic drugs, as well as with nonsteroidal anti-inflammatory drugs in multiple adjusted logistic regression analyses.

RESULTS

A total of 624 axSpA patients starting a first TNFi were considered in the current study (332 patients of normal weight, 204 patients with overweight, and 88 obese patients). Obese individuals were older, had higher BASDAI levels, and had a more important impairment of physical function in comparison to patients of normal weight, while ASDAS and CRP levels were comparable between the three BMI groups. An ASAS40 response was reached by 44%, 34%, and 29% of patients of normal weight, overweight, and obesity, respectively (overall p = 0.02). Significantly lower odds ratios (ORs) for achieving ASAS40 response were found in adjusted analyses in obese patients versus patients with normal BMI (OR 0.27, 95% confidence interval (CI) 0.09-0.70). The respective adjusted ASAS40 OR in overweight versus normal weight patients was 0.62 (95% CI 0.24-1.14). Comparable results were found for the other outcomes assessed.

CONCLUSIONS

Obesity is associated with significantly lower response rates to TNFi in patients with axSpA.

Fat Mass Lowers the Response to Tumor Necrosis Factor-α Blockers in Patients with Ankylosing Spondylitis

OBJECTIVE

Our main objective was to assess the relationship between body composition (BC) and response to tumor necrosis factor-α (TNF-α) blocker treatment in patients with ankylosing spondylitis (AS). Our secondary objective was to evaluate the change of BC after treatment, accounting for sex and age.

METHODS

All included patients fulfilled the modified New York criteria for AS and were naive to TNF-α blocker. They were followed for at least 6 months after the start of etanercept or adalimumab. The Ankylosing Spondylitis Disease Activity Score containing C-reactive protein (ASDAS-CRP) and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were reported. BC was assessed by whole body dual-energy X-ray absorptiometry. Body fat percentage (BF%), fat mass index (FMI), and fat free mass index (FFMI) were reported as absolute values and as percentiles.

RESULTS

Forty-one patients were included (61% men). The median followup was 14.3 months (interquartile range 8.4-19.4). After multivariate regression analysis, more fat at baseline (BF%, FMI, or FMI percentile) was significantly related with a lower chance of achieving a clinically important improvement of the ASDAS-CRP or BASDAI after treatment. The body composition did not change significantly after treatment, but there was a trend toward muscle recovery in men (FFMI change from 34.0th to 37.4th percentile).

CONCLUSION

Higher body fat content at baseline was independently associated with a worse response to treatment with TNF-α blockers, measured by ASDAS-CRP and BASDAI change, and might contribute to the lower response rates in female patients. Also, there is a trend toward muscle mass recovery in male patients after treatment.

Ankylosing spondylitis patients at risk of poor radiographic outcome show diminishing spinal radiographic progression during long-term treatment with TNF-α inhibitors

Objective

To investigate the influence of patient characteristics on the course of spinal radiographic progression in a large prospective longitudinal cohort study of ankylosing spondylitis (AS) patients treated long-term with TNF-α inhibitors.

Methods

Consecutive patients from the Groningen Leeuwarden AS (GLAS) cohort starting TNF-α inhibitors with spinal radiographs at least available at baseline and 6 years of follow-up were included. Radiographs were scored using mSASSS by two independent readers. Generalized estimating equations (GEE) were used to explore the associations between baseline characteristics and spinal radiographic progression. The course of radiographic progression in patients with and without risk factors for poor radiographic outcome was investigated using different time models (linear and non-linear). Single linear imputation was used in case of missing radiographic data at the intermediate (2 or 4 years) follow-up visits.

Results

80 AS patients were included with mean baseline mSASSS 8.7±13.3. Baseline syndesmophytes, male gender, older age, longer symptom duration, smoking, and higher BMI were significantly associated with more radiographic damage over time. GEE analysis in patients with these risk factors revealed that radiographic progression followed a non-linear course with mean mSASSS progression rates reducing from max. 2.8 units over 0–2 years to min. 0.9 units over 4–6 years. The GEE model revealed a linear course with overall very low progression (≤1 mSASSS units/2yrs) in patients without risk factors. Complete case analysis in 53 patients showed similar results.

Conclusion

AS patients at risk of poor radiographic outcome showed the highest but diminishing spinal radiographic progression during long-term treatment with TNF-α inhibitors.

Systematic Evaluation of Corticosteroid Use in Obese and Non-obese Individuals: A Multi-cohort Study

Background: Although the use of corticosteroids has been linked to high incidence of weight gain, no data are available concerning the differences in corticosteroid use between a diverse obese population and non-obese individuals. The main purpose of this study was to systematically explore the use of corticosteroids in obese subjects compared to non-obese controls. In addition, we also explored self-reported marked weight gain within obese subjects. Methods: Two hundred seventy-four obese outpatients (median [range] BMI: 40.1 kg/m² [30.5-67.0]), and 526 non-obese controls (BMI: 24.1 kg/m² [18.6-29.9]) from two different Dutch cohort studies were included. Corticosteroid use at the time of clinic or research site visit for up to the preceding three months was recorded in detail. Medical records and clinical data were evaluated with regard to age and body mass index in relation to corticosteroid use, single or multiple type use, and administration forms. Results: Recent corticosteroid use was nearly twice as high for obese subjects than for non-obese controls (27.0% vs. 11.9% and 14.8%, both P<.001). Largest differences were found for use of local corticosteroids, in particular inhaled forms, and simultaneous use of multiple types. Marked weight gain was self-reported during corticosteroid use in 10.5% of the obese users. Conclusion: Corticosteroid use, especially the inhaled agents, is higher in obese than in non-obese individuals. Considering the potential systemic effects of also local corticosteroids, caution is warranted on the increasing use in the general population and on its associations with weight gain.

Characteristics of hip involvement in patients with ankylosing spondylitis in Korea

BACKGROUND/AIMS

To evaluate the clinical course of hip arthritis and the risk factors for hip joint replacement in patients with ankylosing spondylitis (AS).

METHODS

In this retrospective analysis, we evaluated 488 AS patients at a single tertiary hospital. At baseline and the most recent visit to the outpatient clinic from the patients with hip arthritis in AS, radiographic hip arthritis was evaluated using the Bath Ankylosing Spondylitis Radiology Hip Index (BASRI-h). Also the average of the hip joint space width (interbone distance) at three distinct sites between the acetabulum and femoral head was recorded.

RESULTS

Among 488 patients with AS, 60 patients (12.3%) had hip arthritis. Erythrocyte sedimentation rate were associated with hip involvement (odds ratio, 1.01; 95% confidence interval [CI], 1.00 to 1.02; p = 0.004). Long disease duration and advanced axial disease were associated with severe hip arthritis (3 ≥ BASRI-h) at baseline. BASRI-h and interbone distance did not significantly change in patients with hip involvement during the follow-up period of 81.4 ± 35.7 months. Five patients had hip joint replacement surgery during follow-up period. The body mass index (BMI) and BASRI-h at baseline were associated with joint replacement surgery (hazard ratio [HR], 1.30; 95% CI, 1.00 to 1.67; p = 0.049 and HR, 20.64; 95% CI, 2.39 to 178.11; p = 0.006, respectively).

CONCLUSIONS

Most of the patients with hip arthritis in AS showed no significant radiographic progression during the follow-up period. High BMI and advanced hip arthritis at baseline were associated with hip joint replacement surgery in patients with AS.

Pharmacogenetics of ustekinumab in patients with moderate-to-severe plaque psoriasis

Aim/Materials & methods: Few studies have evaluated the influence of pharmacogenetics in psoriatic patients treated with ustekinumab. We evaluated 121 polymorphisms to study a possible association between these SNPs and the response to ustekinumab (PASI75 at 4 months; n = 69). Results/Conclusion: The adjusted results (false discovery rate) showed an association between five SNPs in TNFRSF1A, HTR2A, NFKBIA, ADAM33 and IL13 genes, and poor response to ustekinumab. Furthermore, six SNPs in CHUK, C17orf51, ZNF816A, STAT4, SLC22A4 and Corf72 genes were associated with better response to ustekinumab. However, there was no significant association between response to ustekinumab and SNPs in HLA-C as it has been recently described. Finally, a higher weight was obtained in nonresponders than responders (p = 0.018). Further studies would be necessary to be closer to personalized medicine.

Body mass index and response to abatacept in rheumatoid arthritis

BACKGROUND

Previous studies suggested that obesity could negatively affect the response to antitumour necrosis factor-α (TNFα) agents in rheumatoid arthritis (RA). However, data are lacking on whether obesity affects the response to abatacept (ABA). We aimed to determine whether body mass index (BMI) affects the response to ABA in RA.

MATERIALS AND METHODS

In this multicenter retrospective study, we included RA patients who received ABA. BMI was calculated at the initiation of treatment. After 6 months of treatment, change from baseline in DAS28, pain on a visual analog scale, erythrocyte sedimentation rate and C-reactive protein level, tender and swollen joint count were analysed. The primary endpoint was decrease in DAS28 ≥ 1·2. Secondary outcomes were good response and remission by EULAR criteria.

RESULTS

At baseline, among 141 RA patients included, the median [interquartile range] BMI was 26·0 [22·9-30·8] kg/m². The number of patients with normal weight, overweight and obesity was 64 (45·4%), 38 (27%) and 39 (27·6%), respectively. Baseline characteristics did not differ among the three BMI subgroups. Univariate analysis revealed no difference in BMI between responders and nonresponders: DAS28 decrease ≥ 1·2 (25·0 [23·4-31·3] vs. 26·3 [22·9-30·2], P = 0·95), EULAR good response (26·4 [23·5-30·9] vs. 26·0 [22·9-30·6], P = 0·96) and remission (26·7 [21·7-30·3] vs. 26·0 [23·0-30·1], P = 0·83).

CONCLUSION

In our real-life study, BMI did not affect the response to ABA in RA. If confirmed, these results suggest that obesity is not a limitation of ABA use in RA.