Therapy of ankylosing spondylitis and other spondyloarthritides: established medical treatment, anti-TNF-alpha therapy and other novel approaches

Real-World Effectiveness and Safety of SDZ ETN, an Etanercept Biosimilar, in Patients with Rheumatic Diseases: Final Results from Multi-Country COMPACT Study

INTRODUCTION

COMPACT, a non-interventional study, evaluated the persistence, effectiveness, safety and patient-reported outcomes (PROs) in patients with rheumatoid arthritis (RA), axial-spondyloarthritis (axSpA) or psoriatic arthritis (PsA) treated with SDZ ETN (etanercept [ETN] biosimilar) in Europe and Canada.

METHODS

Patients (aged ≥ 18 years) who have been treated with SDZ ETN were categorised on the basis of prior treatment status (groups A-D): patients in clinical remission or with low disease activity under treatment with reference ETN or biosimilar ETN and switched to SDZ ETN; patients who received non-ETN targeted therapies and switched to SDZ ETN; biologic-naïve patients who started SDZ ETN after conventional therapy failure; or disease-modifying anti-rheumatic drug (DMARD)-naïve patients with RA considered suitable for treatment initiation with a biologic and started on treatment with SDZ ETN. The primary endpoint was drug persistence, defined as time from study enrolment until discontinuation of SDZ ETN treatment.

RESULTS

Of the 1466 patients recruited, 844 (57.6%) had RA, 334 (22.8%) had axSpA and 288 (19.6%) had PsA. Patients had an ongoing SDZ ETN treatment at the time of enrolment for an observed average of 138 days (range 1-841); 22.7% of patients discontinued SDZ ETN through 12 months of study observation. Overall, all the patients receiving SDZ ETN showed good treatment persistence at 12 months with discontinuation rates of 15.2%, 25.7% and 27.8% in groups A, B and C, respectively. Across all patient groups, no major differences were observed in the disease activity and PRO scores between baseline and month 12. Injection-site reactions were low across the treatment groups.

CONCLUSION

These results support the effectiveness and safety of SDZ ETN treatment in patients with RA, axSpA or PsA in real-life conditions. The treatment persistence rates observed were consistent with previously published reports of patients treated with reference or other biosimilar ETN. No new safety signals were identified.

Can Complete Blood Count Picture Tell Us More About the Activity of Rheumatological Diseases?

Background:

In clinical practice, distinguishing disease activity in patients with rheumatological illnesses is challenging.

Objectives:

We aimed to investigate clinical associations of hemogram-derived indices, namely: red cell distribution width (RDW), mean platelet volume (MPV), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and systemic immune-inflammation index (SII) with disease activity in patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and ankylosing spondylitis (AS).

Methods:

In 250 patients with rheumatological disease and 100 healthy age-matched controls, we investigated disease activity scores and indicators and evaluated their association with hemogram-derived indices values.

Results:

Compared with the control group, RDW, MPV, and PLR significantly increased (P < .001) in the three studied disorders (RA, SLE, and AS), but LMR dramatically decreased. SII was considerably higher in RA and AS patients compared with controls but not in SLE patients. On the other hand, NLR rose dramatically in SLE patients compared with controls (P = .043), but did not change much in RA and AS patients (P > .05). RDW and MPV showed significant changes (P < .001) in the three studied diseases (RA, SLE, and AS) according to disease activity. They significantly increased across worsening activity scores. Only in the SLE group, PLR was significantly increased with disease activity (P < .001), while LMR showed a significant decrease (P = .016).

Conclusions:

Clinicians must pay close attention to complete blood count (CBC) analysis and its various derived ratios to better characterize the activity of rheumatological disorders and anticipate the disease course and prognosis.

Clinical application of mesenchymal stem cells in rheumatic diseases

Mesenchymal stem cells (MSCs) are pluripotent stem cells derived from mesoderm during early development that are characterized by high self-renewal ability and multidirectional differentiation potential. These cells are present various tissues in the human body and can be cultured in vitro. Under specific conditions, MSCs can differentiate into osteoblasts, neuron-like cells, adipocytes and muscle cells and so on, therefore, have a great application value in cell replacement therapy and tissue repair. In recent years, the application of MSCs in rheumatic diseases has received increasing attention. On the one hand, MSCs have the ability to differentiate into bone and cartilage cells; on the other hand, these stem cells are also involved in immune regulation, resulting in the alleviation of inflammation and anti-fibrotic properties and the promotion of vascular repair, thus bringing new hope for the treatment of rheumatic diseases. This article reviews the clinical progress in MSC application for the treatment of rheumatic diseases.

Randomized Cross Over Study Assessing the Efficacy of Non-invasive Stimulation of the Vagus Nerve in Patients With Axial Spondyloarthritis Resistant to Biotherapies: The ESNV-SPA Study Protocol

Axial spondyloarthritis (SpA), is a major cause of chronic pain and disability that profoundly alters the quality of life of patients. Nearly half of patients with SpA usually develop drug resistance. Non-pharmacological treatments targeting inflammation are an attractive alternative to drug administration. Vagus nerve stimulation (VNS), by promoting a cholinergic anti-inflammatory reflex holds promise for treating inflammatory disease. Inflammatory reflex signaling, which is enhanced by electrically stimulating the vagus nerve, significantly reduces cytokine production and attenuates disease severity in animal models of endotoxemia, sepsis, colitis, and other preclinical models of inflammatory diseases. It has been proposed that vagal efferent fibers release acetylcholine (Ach), which can interact with α7-subunit-containing nicotinic receptors expressed by tissue macrophages and other immune cells to rapidly inhibit the synthesis/release of pro-inflammatory cytokines such as TNFα, IL-1β, IL-6, and IL-18. External vagal nerve stimulation devices are now available that do not require surgery nor implantation to non-invasively stimulate the vagal nerve. This double-blind randomized cross-over clinical trial aims to study the change in SpA disease activity, according to Assessment in Ankylosing Spondylitis 20 (ASAS20) definition, after 12 weeks of non-invasive VNS treatment vs. non-specific dummy stimulation (control group). One hundred and twenty adult patients with drug resistant SpA, meeting the ASAS classification criteria, will be included in the study. Patients will be randomized into two parallel groups according to a cross over design: either active VNS for 12 weeks, then dummy stimulation for 12 weeks, or dummy stimulation for 12 weeks, then active VNS for 12 weeks. The two stimulation periods will be separated by a 4 weeks wash-out period. A transcutaneous auricular vagus nerve stimulator Tens Eco Plus SCHWA MEDICO^TM France will be used in this study. The active VNS stimulation will be applied in the cymba conchae of the left ear upon the auricular branch of the vagus nerve, using low intensity (2–5 mA), once à week, during 1 h. Dummy stimulation will be performed under the same conditions and parameters as active VNS stimulation, but at an irrelevant anatomical site: the left ear lobule. This multicenter study was registered on ClinicalTrials.gov: NCT04286373.

Efficacy of a step-down regimen of oral prednisolone in axial spondyloarthritis: result of a double-blind randomized controlled trial (COBRA-AS Study)

OBJECTIVES

To evaluate the efficacy and safety of a step-down regimen of oral prednisolone over 24 weeks in patients of axial SpA (axSpA).

METHODS

This proof-of-concept double-blind randomized controlled trial enrolled patients with active axSpA (BASDAI ≥4) having predominantly axial disease (≤1 active joint currently) and inadequate response to NSAIDs. They were randomized to receive either oral prednisolone (n = 32) or placebo (n = 33) at a dose of 60, 40, 30, 20, 15 and 10 mg daily for 1 week each, following which they received 5 mg prednisolone (or placebo) daily for 18 weeks. The primary endpoint was a 50% improvement in the BASDAI (BASDAI50) at week 24. Analysis was intention to treat.

RESULTS

A BASDAI50 was achieved by 12 of 32 patients (37.5%) in the prednisolone arm and 3 of 33 patients (9.1%) in the placebo arm at 24 weeks [difference 28.4% (95% CI 7.9, 46.7)]. However, there was no difference in achieving a 20 or 40% improvement in the Assessment of SpondyloArthritis international Society response between the groups. Although there was a significant intergroup difference in adjusted ΔBASDAI and ΔAnkylosing Spondylitis Disease Activity Score with CRP at 24 weeks, there was no difference at 12 weeks. There was also no significant difference in ΔBASFI, ΔBAS-G or ΔBASMI at 12 or 24 weeks. No serious adverse events were noted. There was significant weight gain in the first 12 weeks in the prednisolone group vs placebo [0.9 (s.d. 0.4) kg], but not at 24 weeks.

CONCLUSIONS

In this small study, oral prednisolone was efficacious in axSpA in achieving the primary outcome, but many crucial secondary outcomes such as functional improvement were not met. Its impact on bone loss was not studied.Trial registration: CTRI/2018/01/011342.

Health care utilization and cost associated with switching biologics within the first year of biologic treatment initiation among patients with ankylosing spondylitis

BACKGROUND

Costs associated with biologic switching and discontinuation can be high in chronic inflammatory diseases. Inappropriate use of medications may have cost implications for both payers and patients. Understanding of biologic utilization and switching rates is lacking among patients with ankylosing spondylitis (AS).

OBJECTIVE

To compare direct costs of treatment switchers, nonswitchers, and discontinuers among patients with AS who newly initiated a biologic.

METHODS

Patients aged ≥ 18 years with an AS diagnosis and ≥ 1 pharmacy claim for an FDA-approved subcutaneous biologic for AS between January 1, 2016, and December 31, 2016 (identification period) were identified from the Truven Health MarketScan Databases. At the time of biologic initiation (index date), eligible patients were continuously enrolled with medical and pharmacy claims for ≥ 1 year before (baseline period) and ≥ 1 year after the index date (follow-up period). Patients with AS were categorized into 3 mutually exclusive groups of nonswitchers (patients who remained on their index biologic), switchers (patients who had a prescription for a biologic therapy other than their index biologic), and discontinuers (patients who had gaps in prescription claims [> 120 days]) based on their biologic utilization pattern during the 1-year follow-up period. Health care costs (inflated to year 2017 costs) during follow-up were described across the 3 groups separately and by disease. Adjusted health care resource utilization and costs during 1-year follow-up were estimated, controlling for age, sex, fulltime work status, and Charlson Comorbidity Index (Deyo's modification) during the baseline period.

RESULTS

A total of 791 patients with AS who were newly initiating a biologic were categorized as switchers (15.4%), nonswitchers (53.1%), and discontinuers (31.5%). Switchers and discontinuers had higher all-cause health care utilization than nonswitchers during the 1-year follow-up period. Switchers had higher mean total health care costs than nonswitchers ($71,280 vs. $66,573) due to increased medical ($13,897 vs. $12,043) and pharmacy costs ($57,384 vs. $54,530). Discontinuers had the lowest total health care costs ($41,179) but had the highest medical costs ($19,079). Adjusted analyses for covariates confirmed similar trends as the unadjusted analysis, where discontinuers had significantly lower total health care and pharmacy costs but had higher medical costs (with increased emergency department and outpatient visits) than nonswitchers (all P < 0.001). Switchers had increased outpatient visits and costs versus nonswitchers in the adjusted analysis (P < 0.001); small sample sizes in the switcher group may have limited the ability to detect significant trends in the adjusted analysis.

CONCLUSIONS

Biologic switching resulted in higher total health care costs than remaining on the same biologic in patients with AS. These findings highlight the clinical and economic impact of discontinuing or switching biologic therapies in patients with AS, which may inform treatment and/or formulary decision making.

DISCLOSURES

This study was sponsored by Novartis Pharmaceuticals (East Hanover, NJ). Yi, Dai, and Park are employed by Novartis. Piao was an employee of KMK Consulting, supporting Novartis at the time of this study; Zheng is an employee of KMK Consulting and works as a consultant for Novartis. Portions of this work were presented at the 2019 AMCP Managed Care and Specialty Pharmacy Annual Meeting; March 25-28, 2019; San Diego, CA; and AMCP Nexus 2019; October 29-November 1, 2019; National Harbor, MD.

Ectopic bone formation and systemic bone loss in a transmembrane TNF-driven model of human spondyloarthritis

BACKGROUND

The transmembrane-TNF transgenic mouse, TgA86, has been shown to develop spontaneously peripheral arthritis with signs of axial involvement. To assess similarity to human spondyloarthritis, we performed detailed characterization of the axial, peripheral, and comorbid pathologies of this model.

METHODS

TgA86 bone pathologies were assessed at different ages using CT imaging of the spine, tail vertebrae, and hind limbs and characterized in detail by histopathological and immunohistochemical analysis. Cardiac function was examined by echocardiography and electrocardiography and bone structural parameters by μCT analysis. The response of TgA86 mice to either early or late anti-TNF treatment was evaluated clinically, histopathologically, and by μCT analysis.

RESULTS

TgA86 mice developed with 100% penetrance spontaneous axial and peripheral pathology which progressed with time and manifested as reduced body weight and body length, kyphosis, tail bendings, as well as swollen and distorted hind joints. Whole-body CT analysis at advanced ages revealed bone erosions of sacral and caudal vertebrae as well as of sacroiliac joints and hind limbs and, also, new ectopic bone formation and eventually vertebral fusion. The pathology of these mice highly resembled that of SpA patients, as it evolved through an early inflammatory phase, evident as enthesitis and synovitis in the affected joints, characterized by mesenchymal cell accumulation, and neutrophilic infiltration. Subsequently, regression of inflammation was accompanied by ectopic bone formation, leading to ankylosis. In addition, both systemic bone loss and comorbid heart valve pathology were evident. Importantly, early anti-TNF treatment, similar to clinical treatment protocols, significantly reduced the inflammatory phase of both the axial and peripheral pathology of TgA86 mice.

CONCLUSIONS

The TgA86 mice develop a spontaneous peripheral and axial biphasic pathology accompanied by comorbid heart valvular dysfunction and osteoporosis, overall reproducing the progression of pathognomonic features of human spondyloarthritis. Therefore, the TgA86 mouse represents a valuable model for deciphering the role of transmembrane TNF in the pathogenic mechanisms of spondyloarthritis and for assessing the efficacy of human therapeutics targeting different phases of the disease.

Long-Term Effectiveness of Secukinumab in Patients with Axial Spondyloarthritis

Objectives

The primary aim of our study was to evaluate long-term efficacy of secukinumab (SCK) in patients with axial spondyloarthritis (axSpA); secondary aims were to evaluate drug retention rate and to identify differences in the clinical and laboratory assessment according to axSpA clinical features, dosage administered, and biologic treatment lines. Patients and Methods. We collected clinical, demographical, and treatment data from 39 patients affected by axSpA consecutively treated with SCK. Laboratory assessment was based on inflammation parameters; clinical assessment was performed with the Ankylosing Spondylitis Disease Activity Score- (ASDAS-) CRP and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Data were recorded at baseline and every 3 months for the first year and then every 6 months in the second year.

Results

Twelve males and 27 females were enrolled; both BASDAI and ASDAS-CRP showed a statistically significant reduction during the observation period (p < 0.0001 and p < 0.0001, respectively). C-reactive protein significantly decreased (p = 0.006), with significant reduction at the post hoc analysis between baseline and both 6-month evaluation (p = 0.02) and 24-month visit (p = 0.036). No statistical significance was observed in BASDAI and ASDAS-CRP improvement (p = 0.482 and p = 0.164, respectively) between different dosages administered. No significant differences emerged in the BASDAI and ASDAS-CRP variations between biologic-naïve patients and subjects previously failing to tumour necrosis factor (TNF) inhibitors (p = 0.53 and p = 0.148, respectively). At the end of our observation, 7 out of 39 patients discontinued SCK. The global retention rate at the end of the study period was 78.2%, without any significant differences between biologic-naïve and anti-TNF-failure patients (p = 0.619) or between subjects administered with different SCK dosages (p = 0.614). No adverse events were reported.

Conclusions

In our cohort, SCK has proved a remarkable effectiveness regardless biologic treatment line and dosages employed. As suggested by the notable drug retention rate, SCK has been able to maintain its effectiveness over a considerable long period of treatment.

Drug repurposing to improve treatment of rheumatic autoimmune inflammatory diseases

The past century has been characterized by intensive efforts, within both academia and the pharmaceutical industry, to introduce new treatments to individuals with rheumatic autoimmune inflammatory diseases (RAIDs), often by 'borrowing' treatments already employed in one RAID or previously used in an entirely different disease, a concept known as drug repurposing. However, despite sharing some clinical manifestations and immune dysregulation, disease pathogenesis and phenotype vary greatly among RAIDs, and limited understanding of their aetiology has made repurposing drugs for RAIDs challenging. Nevertheless, the past century has been characterized by different 'waves' of repurposing. Early drug repurposing occurred in academia and was based on serendipitous observations or perceived disease similarity, often driven by the availability and popularity of drug classes. Since the 1990s, most biologic therapies have been developed for one or several RAIDs and then tested among the others, with varying levels of success. The past two decades have seen data-driven repurposing characterized by signature-based approaches that rely on molecular biology and genomics. Additionally, many data-driven strategies employ computational modelling and machine learning to integrate multiple sources of data. Together, these repurposing periods have led to advances in the treatment for many RAIDs.

Impact of Cumulative Corticosteroid Dosage on Preventable Hospitalization among Taiwanese Patients with Ankylosing Spondylitis and Inflammatory Bowel Disease

Background: Corticosteroids are commonly prescribed for autoimmune conditions, but their impact on preventable hospitalization rates is unclear. This study sought to investigate the effect of corticosteroid use on hospitalization for ambulatory care sensitive conditions among Taiwanese patients with ankylosing spondylitis (AS) or inflammatory bowel disease (IBD). Methods: This was a retrospective cohort study using adults in the Taiwan National Health Insurance Research database receiving a new diagnosis of AS (n = 40,747) or IBD (n = 4290) between January 2002 and June 2013. Our main outcome measure was odds of preventable hospitalization for eight ambulatory care-sensitive conditions defined by the Agency for Healthcare Research and Quality. Results: In the first quarter (three months) following diagnosis, corticosteroid usage was common among patients with AS and IBD (18.5% and 30%, respectively). For every 100 mg increase in corticosteroid dose per quarter, adjusted odds of preventable hospitalization in the following quarter increased by 5.5% for patients with AS (aOR = 1.055, 95% CI 1.037-1.074) and 6.4% for those with IBD (aOR = 1.064, 95% CI 1.046-1.082). Conclusions: Relatively low doses of corticosteroids significantly increase AS and IBD patients' short-term odds of hospitalization for ambulatory care-sensitive conditions. As recommended by current clinical guidelines, physicians should use corticosteroids sparingly in these populations, and prioritize initiation/escalation of disease-modifying anti-rheumatic drugs for long-term management. If corticosteroids cannot be avoided, patients may require monitoring and/or prophylaxis for corticosteroid-associated comorbidities (e.g., diabetes) which can result in preventable hospitalizations.

Ankylosing spondylitis and mesenchymal stromal/stem cell therapy: a new therapeutic approach

Ankylosing spondylitis (AS) is an inflammatory rheumatoid disease categorized within spondyloarthropathies (SpA) and manifested by chronic spinal arthritis. Several innate and adaptive immune cells and secreted-mediators have been indicated to play a role in AS pathogenesis. Considering the limitations of current therapeutic approaches (NSAIDs, glucocorticoids, DMARDs and biologic drugs), finding new treatments with fewer side effects and high therapeutic potentials are required in AS. Mesenchymal stem cells (MSCs) with considerable immunomodulatory and regenerative properties could be able to attenuate the inflammatory responses and help tissue repair by cell-to-cell contact and secretion of soluble factors. Moreover, MSCs do not express HLA-DR, which renders them a favorable therapeutic choice for transplantation in immune-mediated disorders. In the present review, we describe immunopathogenesis and current treatments restrictions of AS. Afterwards, immunomodulatory properties and applications of MSCs in immune-mediated disorders, as well as recent findings of clinical trials involving mesenchymal stem cell therapy (MSCT) in ankylosing spondylitis, will be discussed in detail. Additional studies are required to investigate several features of MSCT such as cell origin, dosage, administration route and, specifically, the most suitable stage of disease for ideal intervention.

Cervical Epidural Injection in the Management of Refractory Pain and Stiffness in Spondyloarthropathy: A Case Report Series

OBJECTIVES

The primary objective of this case series was to report the use of cervical epidural steroid injection in the management of neck pain and stiffness secondary to spondyloarthropathy in cases refractory to conservative therapy.

METHODS

This was a case report series on three patients with diagnosis of spondyloarthropathy who presented with severe stiffness and non-radicular axial neck pain refractory to conservative therapy. All patients received cervical epidural steroid injections with significant improvement of their axial neck pain and stiffness.

RESULTS

Cervical epidural steroid injections may be effective to improve the axial neck pain and stiffness in patients with diagnosis of spondyloarthropathy refractory to conservative management. Thus, we believe that epidural steroid injections should be considered in the management of patients with spondyloarthopathies.

Influence of CYP2C9 and COX-2 Genetic Polymorphisms on Clinical Efficacy of Non-Steroidal Anti-Inflammatory Drugs in Treatment of Ankylosing Spondylitis

Background

The aim of this study was to evaluate the relationships of CYP2C9 and COX-2 genetic polymorphisms with therapeutic efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) in treatment of ankylosing spondylitis (AS).

Material/Methods

We enrolled 130 AS inpatients and outpatients in the Arthritis and Rheumatism Department of Peking University First Hospital and 106 healthy people getting routine check-ups between September 2013 and July 2014. CYP2C9 and COX-2 genetic polymorphisms were detected by PCR-RFLP. All AS patients underwent medical treatment and 12-week follow-up treatment. Score differences of BASDAI, ASAS20, ASAS50, and ASAS70 for AS patients with different genotypes before and after treatment were compared.

Results

In terms of COX-2-1290A/G and -1195G/A gene polymorphism genotype and allele frequency, the case group and control group were obviously different (all P<0.05), but CYP2C9*3 polymorphism genotype and allele frequency were not statistically different between the 2 groups (P>0.05). AS patients had improved BASDAI, ASAS20, ASAS50, and ASAS70 scores after they received NSAID treatment (all P<0.05). Furthermore, the efficacy of NSAID in treatment of AS and COX-2 gene −1290A/G and −1195G/A polymorphism were associated (all P<0.05), but it is not associated with CYP2C9 *3 polymorphism (all P>0.05).

Conclusions

COX-2-1290A/G and -1195G/A polymorphism may increase AS risk and they both can be considered as biological indicators for prediction of efficacy of NSAIDs in treatment of AS.

Second-line biologic therapy optimization in rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis

OBJECTIVE

The Italian board for the TAilored BIOlogic therapy (ITABIO) reviewed the most consistent literature to indicate the best strategy for the second-line biologic choice in patients with rheumatoid arthritis (RA), spondyloarthritis (SpA), and psoriatic arthritis (PsA).

METHODS

Systematic review of the literature to identify English-language articles on efficacy of second-line biologic choice in RA, PsA, and ankylosing spondylitis (AS). Data were extracted from available randomized, controlled trials, national biologic registries, national healthcare databases, post-marketing surveys, and open-label observational studies.

RESULTS

Some previously stated variables, including the patients׳ preference, the indication for anti-tumor necrosis factor (TNF) monotherapy in potential childbearing women, and the intravenous route with dose titration in obese subjects resulted valid for all the three rheumatic conditions. In RA, golimumab as second-line biologic has the highest level of evidence in anti-TNF failure. The switching strategy is preferable for responder patients who experience an adverse event, whereas serious or class-specific side effects should be managed by the choice of a differently targeted drug. Secondary inadequate response to etanercept (ETN) should be treated with a biologic agent other than anti-TNF. After two or more anti-TNF failures, the swapping to a different mode of action is recommended. Among non-anti-TNF targeted biologics, to date rituximab (RTX) and tocilizumab (TCZ) have the strongest evidence of efficacy in the treatment of anti-TNF failures. In PsA and AS patients failing the first anti-TNF, the switch strategy to a second is advisable, taking in account the evidence of adalimumab efficacy in patients with uveitis. The severity of psoriasis, of articular involvement, and the predominance of enthesitis and/or dactylitis may drive the choice toward ustekinumab or secukinumab in PsA, and the latter in AS.

CONCLUSION

Taking in account the paucity of controlled trials, second-line biologic therapy may be reasonably optimized in patients with RA, SpA, and PsA.

Emerging Role and Therapeutic Implication of Wnt Signaling Pathways in Autoimmune Diseases

The Wnt signaling pathway plays a key role in many biological aspects, such as cellular proliferation, tissue regeneration, embryonic development, and other systemic effects. Under a physiological condition, it is tightly controlled at different layers and arrays, and a dysregulated activation of this signaling has been implicated into the pathogenesis of various human disorders, including autoimmune diseases. Despite the fact that therapeutic interventions are available for ameliorating disease manifestations, there is no curative therapy currently available for autoimmune disorders. Increasing lines of evidence have suggested a crucial role of Wnt signaling during the pathogenesis of many autoimmune diseases; in addition, some of microRNAs (miRNAs), a class of small, noncoding RNA molecules capable of transcriptionally regulating gene expression, have also recently been demonstrated to possess both physiological and pathological roles in autoimmune diseases by regulating the Wnt signaling pathway. This review summarizes currently our understanding of the pathogenic roles of Wnt signaling in several major autoimmune disorders and miRNAs, those targeting Wnt signaling in autoimmune diseases, with a focus on the implication of the Wnt signaling as potential biomarkers and therapeutic targets in immune diseases, as well as miRNA-mediated regulation of Wnt signaling activation in the development of autoimmune diseases.

Investigation of Cardiac Complications and their Incidence in Patients with Ankylosing Spondylitis

INTRODUCTION

Ankylosing Spondylitis (AS) is a chronic inflammatory disease with unknown etiology which involves the sacroiliac and axial joints, but can also cause peripheral conflicts. It also comprises non-joint symptoms such as acute anterior uveitis, cardiac conduction defects, upper lobe pulmonary fibrosis, neurological involvement and renal amyloidosis.

MATERIAL AND METHODS

This study was a cross-sectional descriptive and analytical survey. In this study, 50 patients with AS were examined according to the New York Criteria in Army 501 Hospital in Tehran. Physical examinations, laboratory testing and HLA-B27, as well as X-ray of the spine and sacroiliac joint were taken from all subjects and involvement grading was identified. The control group consisted of 40 healthy people with no evidence of disease. The people resembled the study group in terms of age, sex, smoking, presence of high blood pressure, history of ischemic heart disease and also diabetes.

RESULTS

The mean age of patients in control and study group was 33.97 and 33.65 years, respectively. 37 (92.5%) patients in the control group and 46 in study group (92%) were male. The mean duration of cardiac involvement in patients was 8.6 years with SD=6.26. In AS group, 48 (96%) patients suffered from back pain, 43 from enteritis, 100% from Ankylosing Spondylitis, one from unilateral involvement, 22(44%) from peripheral arthritis and 27 (54%) from HLA-B27.

CONCLUSION

In total, Average heart involvement in the control group and AS group was 13.25 with SD=7.64 and 16.2 with SA=8.54, respectively, indicating no significant difference. In sum, based on the results obtained in this study, some types of heart involvements, such as mitral valve regurgitation and Mitral Valve Prolapse in AS patients are more prevalent than in the normal population.

How good is the coverage and how accurate are exposure data in the Swedish Biologics Register (ARTIS)?

OBJECTIVES

To assess the coverage of the Swedish Biologics Register (Anti-Rheumatic Therapy in Sweden, ARTIS) across indications, and the accuracy of the registered information on treatment with biologics.

METHOD

Through cross-reference of ARTIS to almost complete national health registers on prescriptions (adalimumab and etanercept), outpatient visits, and death/residency during 2008-2010, we assessed: the treatment coverage of ARTIS for each treatment indication, the validity of the registered start and stop dates, ARTIS treatments with no corresponding drug dispensations, and the accuracy of the registered information on concomitant anti-rheumatic therapies.

RESULTS

According to the national health registers, 3945 individuals with a spondyloarthropathy (SpA) and 8032 patients with rheumatoid arthritis (RA) had filled at least one adalimumab or etanercept prescription during the study period. Of these, 86% of those with SpAs and 95% of patients with RA were also found in ARTIS with the corresponding treatment. Tumour necrosis factor (TNF) inhibitor prescriptions had been filled by 95% of patients between the ARTIS start and stop dates (allowing a 90-day window). More than 60 days before and more than 60 days after the registered start date in ARTIS, 5% and 4% respectively of patients had filled their first TNF inhibitor prescription. More than 90 days after the registered stop date in ARTIS, 8% of patients had filled one or more TNF inhibitor prescriptions.

CONCLUSIONS

We observed a high coverage and accuracy of ARTIS data on biologics exposure, for both SpAs and RA. The combination of data from clinical registers such as ARTIS with data from national health registers offers a high quality measurement of actual treatment.

Preoperative computer-based simulations for the correction of kyphotic deformities in ankylosing spondylitis patients

BACKGROUND CONTEXT

A preoperative plan is important to obtain appropriate balance of the sagittal plane in patients with kyphotic deformity. Previous methods to calculate the correction angle are inconvenient and complicated, whereas the method using computer simulations may be very effective and much simpler than existing methods.

PURPOSE

To evaluate the efficacy of preoperative measurements using a computer simulation for corrective osteotomy for the surgical treatment of kyphosis caused by ankylosing spondylitis (AS).

STUDY DESIGN

Retrospective clinical data analysis.

PATIENT SAMPLE

The sample comprises 18 AS patients with fixed kyphotic deformity who underwent corrective osteotomies at our hospital between October 2007 and January 2010.

OUTCOME MEASURES

Thoracic kyphosis, lumbar lordosis, and the sagittal vertical axis (SVA) of the spine were evaluated by preoperative computer simulation and radiologic measurement. Clinical assessments were performed according to the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Short Form-36 (SF-36), and EuroQol-5 dimension (EQ-5D) before and after the surgery.

METHODS

The coincidence between the preoperative computer simulation and postoperative radiologic parameters was evaluated. We also analyzed the changes derived from each clinical and radiologic measurement before and after the surgery.

RESULTS

Mean thoracic kyphosis changed from 32.4° to 31.9°, mean lumbar lordosis was corrected from 11.5° to 26.9°, and the SVA was improved from 125.7 to 65.1 mm after surgery (p<.001). The correlation coefficients within groups between the computer simulations and radiologic parameters were 0.9, 0.6, and 0.7, showing significant congruency. Although BASDAI and BASFI did not significantly differ (p=.53 and p=.45, respectively), SF-36 and EQ-5D were significantly increased (p<.05 and p<.001, respectively).

CONCLUSIONS

Comparisons of preoperative simulations and actual surgical outcomes showed significant coincidences; thus, evaluations through computer simulations before surgery are expected to help predict the level of correction possible after surgery and improve surgical planning.

Ratio of neutrophil/lymphocyte and platelet/lymphocyte in patient with ankylosing spondylitis that are treating with anti-TNF

Ankylosing spondylitis (AS) is a type of chronic inflammatory arthritis resulting in ankylosis of the spine and inflammation in the tendons. After NSAIDs, the use of anti-TNF medications has provided a significant contribution to the treatment of patients with AS. The present study was a retrospective, controlled and multicenter study. A total of 105 patients followed in the outpatient clinics of the Department of Physical Therapy in Abant Izzet Baysal University and Harran University and 50 healthy controls were included in the study. The patients had been receiving anti-TNF therapy at least for 6 months. Hemogram results of the patient and control groups examined retrospectively. There was no significant difference between the groups in terms of N/L ratio; however, the P/L ratio was significantly different between the two groups. The present study found a significantly different P/L ratio in patients with AS when compared to the control group. However, the N/L ratio was not significantly different between the groups. The P/L ratio can be used as a marker to monitor disease progression and indicate subclinical inflammation in patients with AS.

Ankylosing spondylitis in an athlete with chronic sacroiliac joint pain

Ankylosing spondylitis is a disease in which inflammation of joints, most often in the axial skeleton, can lead to reactive fibrosis and eventual joint fusion with associated immobility and kyphosis. The disease often involves extra-articular features, such as uveitis and aortic regurgitation, as well as associated inflammatory conditions of the intestines. Its etiology is unknown. Ankylosing spondylitis most commonly presents in young males (15-30 years old) as persistent low back pain and stiffness that is worse in the morning and at night and improves with activity. The authors report the case of a young male athlete whose symptoms were initially incorrectly diagnosed as sacroiliac joint instability and dysfunction and later as a sacroiliac stress fracture before further workup revealed a seronegative spondyloarthropathy and the diagnosis of ankylosing spondylitis. The patient was prescribed oral indomethacin daily by the attending rheumatologist and started on a slow progression of return to running, jumping, and weight lifting. Within 4 weeks of beginning this treatment, the patient had complete cessation of pain with the medication. At follow-up 1 year after graduation from his university, the patient was nearly symptom free and working in a non-heavy labor job. The purpose of this case report is to remind sports medicine physicians of the prevalence of rheumatologic diseases in general and ankylosing spondylitis in particular and of the various ways in which spondyloarthropathies may present in athletes. Increased suspicion may lead to earlier diagnosis and treatment, potentially reducing illness severity and duration and improving the performance of athletes with this condition.

Regulation of synoviocyte activity by resveratrol in rats with adjuvant arthritis

The aim of this study was to investigate the preventive effects of resveratrol (Res) on rats with adjuvant arthritis (AA) and the mechanism(s) of action. An AA model was established by injection of Freund’s complete adjuvant (FCA). Vascular endothelial growth factor (VEGF) was visualized in joint specimens using immunohistochemistry. IL-1β and TNF-α production in synoviocytes was determined by radioimmunoassay (RIA). The mRNA expression of IL-1β and TNF-α was observed in synoviocytes using the reverse transcription (RT)-PCR method. The synoviocytes of the AA model were stimulated by Res or treated with the protein kinase C (PKC) inhibitor chelerythrine prior to stimulation. The expression of phosphorylated ERK1/2 (p-ERK1/2) was detected by western blotting. Res was able to reduce the elevated levels of IL-1β and TNF-α, and inhibit the mRNA expression of IL-1β and TNF-α in the synoviocytes of the AA model rats. VEGF expression in the Res-treated group was significantly lowered. The protein expression levels of p-ERK1/2 were significantly higher in the Res-treated group compared with those of the model group, while p-ERK1/2 was markedly lower in the group pretreated with chelerythrine. Res has a therapeutic effect on AA rats, which may be correlated with its immunoregulatory actions, and may activate p-ERK1/2 in synoviocytes via PKC.

Biologic therapies for spondyloarthritis: what is new?

The course of axial spondyloarthritis (axSpA), including ankylosing spondylitis (AS), is strongly influenced by the degree of disease activity over time, which is mainly based on inflammation, and by the impairment of function, which is based on structural damage-mainly, new bone formation-and inflammation. In AS, nonsteroidal anti-inflammatory agents are currently recommended as the first choice of medical therapy, and there is also a clear role for regular exercise and physiotherapy in order to preserve and prevent loss of spinal mobility. For patients who have insufficiently responded to conventional medications, there are now four biologics approved for the treatment of patients with active AS in many countries, all directed against TNFα: infliximab, etanercept, adalimumab, and golimumab; studies with certolizumab are currently ongoing. Several studies with patients classified as nonradiographic axSpA have also shown a good response to TNF blockers; in patients with early disease and high CRP levels, the response rates were even better. Long-term studies with TNF blockers have shown declining retention rates over time but sustained clinical efficacy in the patients who remained on treatment. States of drug-free remission are rarely reached and only for relatively short periods of time. More studies including magnetic resonance imaging (MRI) are needed to further examine the lack of effect of anti-TNF treatment on radiographic progression in the axial skeleton. Whether the effect of an early intervention with biologics will prevent the development of bone growth in patients with nonradiographic axial SpA remains to be seen. Biologics other than TNF blockers are currently not recommended for the treatment of patients with axSpA, because of insufficient evidence of clinically relevant efficacy. The anti-IL-17a antibody secukinumab may be efficacious, on the basis of a proof-of-concept trial. Finally, first data on biosimilars of TNF blockers have recently been presented.

The genetics of ankylosing spondylitis and axial spondyloarthritis

Ankylosing spondylitis (AS) and spondyloarthritis are strongly genetically determined. The long-standing association with HLA-B27 is well described, although the mechanism by which that association induces AS remains uncertain. Recent developments include the description of HLA-B27 tag single nucleotide polymorphisms in European and Asian populations. An increasing number of non-MHC genetic associations have been reported, which provided amongst other things the first evidence of the involvement of the IL-23 pathway in AS. The association with ERAP1 is now known to be restricted to HLA-B27 positive disease. Preliminary studies on the genetics of axial spondyloarthritis demonstrate a lower HLA-B27 carriage rate compared with AS. Studies with larger samples and including non-European ethnic groups are likely to further advance the understanding of the genetics of AS and spondyloarthritis.

Insights into the pathogenesis of axial spondyloarthropathy from network and pathway analysis

Background

Complex chronic diseases are usually not caused by changes in a single causal gene but by an unbalanced regulating network resulting from the dysfunctions of multiple genes or their products. Therefore, network based systems approach can be helpful for the identification of candidate genes related to complex diseases and their relationships. Axial spondyloarthropathy (SpA) is a group of chronic inflammatory joint diseases that mainly affect the spine and the sacroiliac joints. The pathogenesis of SpA remains largely unknown.

Results

In this paper, we conducted a network study of the pathogenesis of SpA. We integrated data related to SpA, from the OMIM database, proteomics and microarray experiments of SpA, to prioritize SpA candidate disease genes in the context of human protein interactome. Based on the top ranked SpA related genes, we constructed a SpA specific PPI network, identified potential pathways associated with SpA, and finally sketched an overview of biological processes involved in the development of SpA.

Conclusions

The protein-protein interaction (PPI) network and pathways reflect the link between the two pathological processes of SpA, i.e., immune mediated inflammation, as well as imbalanced bone modelling caused new boneformation and bone loss. We found that some known disease causative genes, such as TNFand ILs, play pivotal roles in this interaction.

Dosage adjustment of anti-tumor necrosis factor-α inhibitor in ankylosing spondylitis is effective in maintaining remission in clinical practice

OBJECTIVE

While remission is possible in patients with ankylosing spondylitis (AS), it is often unclear what attitude should be adopted once remission has occurred. We investigated whether dosage adjustment is an effective means of maintaining remission.

METHODS

This was a retrospective study drawn from clinical situations. Remission was defined using clinical measures [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≤ 20/100 and no peripheral joint disease] and biological measures [C-reactive protein (CRP) levels ≤ normal value]. The tumor necrosis factor-α (TNF-α) inhibitors used were infliximab, adalimumab, and etanercept. Response predictors of remission were evaluated by logistic regression (age, CRP, HLA-B27 positivity, sex, duration of disease, and anti-TNF-α naivety). CRP and BASDAI were evaluated before and after dosage adjustment at about 6, 12, 24, and 36 months.

RESULTS

One hundred eighty-nine patients with AS were included in the study, with a mean followup of 43.5 (± 17.9) months after the introduction of the first anti-TNF-α inhibitor. Mean age was 45.6 (± 12.5) years. Remission had occurred in 65 patients (35%). Significant response predictors of remission were male sex (p = 0.003) and anti-TNF-α naivety (p < 0.001). Dosage adjustment was observed 49 times, and progressively reducing treatment frequency was effective to maintain remission in a large number of patients for 36 months. The cumulative probability of continuing anti-TNF-α after dosage adjustment was 79.0% at 12 months, 70.5% at 24 months, and 58.8% at 36 months.

CONCLUSION

Remission had occurred in 35% of the patients with AS under anti-TNF-α inhibitor therapy. Dosage adjustment and progressively reducing treatment frequency was effective in maintaining remission.

Etanercept in the treatment of recalcitrant enteropathic arthritis: a case report

Introduction

Enteropathic arthritis is one of the recognized extraintestinal manifestations of inflammatory bowel disease and affects up to 25% of patients. The treatment options for refractory disease were rather limited and ineffective until the arrival of biologic therapy in the last few years. The use of etanercept was unique for this disease.

Case presentation

In this case report, a 58-year-old Malay woman with a 17-year history of ulcerative colitis had persistent left knee effusion and synovitis for seven years, despite remission of the primary disease. She had had multiple courses of systemic and intra-articular steroid that caused significant systemic side effects such as impaired fasting glucose, hypertension, cataract, and weight gain. She also had a total left knee replacement for secondary osteoarthritis. But the left knee synovitis and effusion recurred a month after the total knee replacement, and she was subjected to a total synovectomy the following year. In view of failure of remission despite multiple immunosuppressants (100 mg of azathioprine daily, 1 g of sulfasalazine twice a day, 10 mg of prednisolone daily, and 10 mg of methotrexate weekly), 25 mg of subcutaneous etanercept twice weekly was started. After 5 weeks of treatment, complete resolution of left knee effusion and normalization of the inflammatory markers were shown. This continued up to 12 months of follow-up while our patient was on etanercept and 10 mg of methotrexate weekly. No relapse or serious side effects were noted.

Conclusions

This case demonstrates the efficacy of etanercept in recalcitrant enteropathic arthritis with no relapse of the underlying colitis while on treatment. The usage of this tumor necrosis factor inhibitor was unique in this case of rheumatology and gastroenterology.

Treat ankylosing spondylitis with methazolamide

BACKGROUND

Increased bone resorption and new bone information are two characteristics of ankylosing spondylitis (AS). Much evidence has shown that carbonic anhydrase inhibitors can restrain bone resorption. We had detected increased expression of carbonic anhydrase I (CA1) in synovium of patients with AS. This study aimed to evaluate the effectiveness and safety of methazolamide, an anti-carbonic anhydrase drug, for treating patients with AS.

METHODS

Two patients, called as S and L, were diagnosed with active AS based on BASDAI and BASFI assessments, radiographic data and other clinical indices. They took methazolamide tablets at a dose of 25 mg twice every day.

RESULTS

Patient S's BASDAI score fell from 5.4 to 4.4, while patient L's BASDAI fell from 2.4 to 2. Patient S's BASFI score change from 2.7 to 2.9, while patient L's BASFI score fell from 1.2 to 0.2. The ESR values of patient S were considerably reduced, while the ESR value of patient L remained unchanged and in the normal range. The calcium concentration of patient S decreased from 3.05 mmol/L to 2.39 mmol/L. The CT evidence indicates that the articular surfaces of the erosive sacroiliac joints became clearer and the area of the calcium deposits began decreased. No significant systemic side effects were observed in either patient.

CONCLUSIONS

The above results indicate that methazolamide was effective for active AS. Methazolamide may improve AS symptoms by inhibiting carbonic anhydrase activity during the processes of bone reporption and new bone formation.

Critical role for TNF in the induction of human antigen-specific regulatory T cells by tolerogenic dendritic cells

TNF is a pleiotropic cytokine with differential effects on immune cells and diseases. Anti-TNF therapy was shown to be effective in rheumatoid arthritis but proved inefficient or even detrimental in other autoimmune diseases. We studied the role of TNF in the induction of Ag-specific regulatory T cells (Tregs) by tolerogenic vitamin D3-modulated human dendritic cells (VD3-DCs), which previously were shown to release high amounts of soluble TNF (sTNF) upon maturation with LPS. First, production of TNF by modulated VD3-DCs was analyzed upon maturation with LPS or CD40L with respect to both secreted (cleaved) TNF (sTNF) and expression of the membrane-bound (uncleaved) form of TNF (mTNF). Next, TNF antagonists were tested for their effect on induction of Ag-specific Tregs by modulated DCs and the subsequent functionality of these Tregs. VD3-DCs expressed greater amounts of mTNF than did control DCs (nontreated DCs), independent of the maturation protocol. Inhibition of TNF with anti-TNF Ab (blocking both sTNF and mTNF) during the priming of Tregs with VD3-DCs prevented generation of Tregs and their suppression of proliferation of CD4(+) T cells. In contrast, sTNF receptor II (sTNFRII), mainly blocking sTNF, did not change the suppressive capacity of Tregs. Blocking of TNFRII by anti-CD120b Ab during Treg induction similarly abrogated their subsequent suppressive function. These data point to a specific role for mTNF on VD3-DCs in the induction of Ag-specific Tregs. Interaction between mTNF and TNFRII instructs the induction of suppressive Tregs by VD3-DCs. Anti-TNF therapy may therefore act adversely in different patients or disease pathways.

Musculoskeletal manifestations of inflammatory bowel disease

Extraintestinal manifestations develop in ≈25% of patients with inflammatory bowel disease (IBD). Musculoskeletal symptoms are the most common extraintestinal manifestations of IBD, often associated with colonic involvement, and present as either articular (arthritis) or periarticular inflammation including enthesitis, myositis, or soft tissue rheumatism (fibromyalgia). Musculoskeletal manifestations can precede or be synchronous with the development of bowel disease or develop following the diagnosis of IBD. Their clinical course often correlates with IBD activity but it can also be independent of the activity of bowel disease. Controlling intestinal inflammation remains the cornerstone therapeutic approach for the musculoskeletal manifestations of IBD.

Cervical spine osteolysis in a case of undifferentiated spondyloarthropathy with features mimicking neoplasm or infection

STUDY DESIGN

Case Report.

OBJECTIVE

To present a case of undifferentiated spondyloarthropathy with sternocostoclavicular arthro-osteitis and osteolyis of cervical body requiring surgical reconstruction of the spine and describing the findings which resembled multiple metastases or infection.

SUMMARY OF BACKGROUND DATA

Sternocostoclavicular arthro-osteitis is not infrequent in Japan. It has been reported in patients with seronegative spondyloarthropathies as psoriatic arthropathy or its variant, palmoplantar pustulosis. Cervical spine involvement in the seronegative spondyloarthropathy is usually in the form of syndesmophytes, subluxations, or facet erosions/ fusions. To the best of our knowledge, this is the first report on severe osteolytic cervical spondylitis associating anterior chest wall disease, to the extent that surgical reconstruction is needed.

METHODS

A 64 year-old woman presented with neck pain. Cervical spine imaging revealed osteolysis and crumbling of C5 vertebral body. Computed tomography of the thorax showed multiple erosions of the anterior chest wall. Multiple hot spots were detected by bone scan. Biopsies were obtained to exclude neoplasm and infection. Surgical reconstruction via combined anterior-posterior approach was performed to achieve solid spine arthrodesis.

RESULTS

Neoplasm and infection were excluded. Careful reassessment alerted to the diagnosis of undifferentiated spondyloarthropathy. Solid arthrodesis and pain relief could be obtained by surgery together with medical control of the disease.

Psoriatic Arthritis: A Review

Psoriatic arthritis (PsA) is a seronegative inflammatory spondyloarthropathy occurring in individuals with psoriasis. Psoriasis precedes joint disease in approximately 80% of PsA cases. The clinical course of PsA varies from mild arthritis to a severe, debilitating erosive arthropathy that affects functional capacity and quality of life of patients. The incidence of PsA is gender neutral, but a significant genetic component exists. Hallmark clinical features include dystrophic nail changes in the fingers or toes, dactylitis, and enthesitis. Many drugs indicated for use in rheumatoid arthritis have been found useful in the treatment of PsA, suggesting a similar immune-mediated etiology. Nonsteroidal anti-inflammatory drugs and intraarticular corticosteroids are often sufficient to manage mild PsA. Moderate to severe forms of the disease require the initiation of disease modifying anti-rheumatic drugs. Failure of two disease modifying antirheumatic drugs justifies the initiation of biologic therapy with tumor necrosis factor-α inhibitors.

Effect of tumour necrosis factor-alpha receptor 1 genetic deletion on carrageenan-induced acute inflammation: a comparison with etanercept

In the present study, we used tumour necrosis factor-alpha receptor 1 knock-out mice (TNF-alphaR1KO) to evaluate an in vivo role of TNF-alphaR1 on the pathogenesis of inflammatory diseases. We used a murine model of carrageenan-induced acute inflammation (pleurisy), a preclinical model of airway inflammation. The data proved that TNF-alphaR1KO were resistant to carrageenan-induced acute inflammation compared with TNF-alpha wild-type mice. TNF-alphaR1KO showed a significant reduction in accumulation of pleural exudate and in the number of inflammatory cells, in lung infiltration of polymorphonuclear leucocytes and lipid peroxidation and showed a decreased production of nitrite/nitrate in pleural exudates. Furthermore, the intensity and degree of the adhesion molecule intercellular adhesion molecule-1 and P-selectin, Fas ligand (FasL), inducible nitric oxide sythase and nitrotyrosine determined by immunohistochemical analysis were reduced markedly in lung tissues from TNF-alphaR1KO at 4 h and 24 h after carrageenan injection. Moreover, TNF-alpha and interleukin-1beta concentrations were reduced in inflamed areas and in pleural exudates from TNF-alphaR1KO. To support the results generated using pleural inflammation, carrageenan-induced paw oedema models were also performed. In order to elucidate whether the observed anti-inflammatory effects were related to the inhibition of TNF-alpha, we also investigated the effect of etanercept, a TNF-alpha soluble receptor construct, on carrageenan-induced pleurisy. The treatment with etanercept (5 mg/kg subcutaneously 2 h before the carrageenan injection) reduces markedly both laboratory and histological signs of carrageenan-induced pleurisy. Our results showed that administration of etanercept resulted in the same outcome as that of deletion of the TNF-alphaR1 receptor, adding a new insight to TNF-alpha as an excellent target by therapeutic applications.

[Indication for Anti-TNF-alpha Treatment in Patients With Ankylosing Spondylitis in Spain]

OBJECTIVES

To know the perception of Spanish rheumatologists of the profile of the patient with ankylosing spondyloarthritis, candidate for biological therapy treatment. To determine what proportion of patients with ankylosing spondylitis is considered a candidate for this therapy and to know up to what point this decision agrees with the recommendations of the ASAS working group on anti-TNF therapies and with the consensus of the SER METHOD: Rheumatologists from 19 Spanish centers who are experts in treating patients with AS and in the use of anti-TNF drugs participated in this study but they were not aware of the recommendations of the ASAS group and of the SER (unpublished until this work).

RESULTS

One hundred and eighty five patients were included in the study. Spanish rheumatologists indicated that they would start therapy with anti-TNF drugs in altogether 37.8% of the patients. The candidates had the highest values of disease activity, of acute-phase reactants, the worst spinal mobility, worst function, more hip damage, and high sick leave prevalence. Out of the total of the patients considered as candidates for treatment with biological therapies by their rheumatologists, 45.7% did not comply with the ASAS recommendations with respect to prior treatments with NSAIDs and BASDAI and 48.6% did not comply with the SER criteria; 29.1% of the patients who did not comply with the ASAS criteria (NSAIDs-BASDAI) were considered to be candidates for treatment with anti-TNF drugs; 29.6% of the patients who did not comply with the SER criteria were also considered to be candidates. The most important criterion was the clinical activity of the disease.

CONCLUSIONS

The agreement between the criteria applied by the Spanish rheumatologist and proposed by ASAS working group and the SER consensus is low. Axial affectation, activity, and severity in their disease were the criteria used but frequently by the Spanish rheumatologist to indicate biological therapy in patients with AS.

Lumbar spinal osteotomy for kyphosis in ankylosing spondylitis: the significance of the whole body kyphosis angle

Retrospective analysis of 11 consecutive patients with ankylosing spondylitis who underwent lumbar spinal osteotomy for severe kyphosis, with a mean follow up of 4 (2 to 8.5) years. The chin brow vertical angle, thigh flexion angle, and the whole body kyphosis angle (WBKA) were measured on the clinical photographs of the patient in standing. The lumbar lordosis, thoracic kyphosis, total kyphosis, sacral slope, and sagittal balance were measured on the standing radiographs. A closing wedge osteotomy at L3 was done in all patients. Intraoperative neuromonitor with sensory evoked potentials and motor evoked potentials was used routinely. Stable fixation of spine allowed early walking. There were no permanent neurologic complications. The average preoperative WBKA was 41 degrees (20 to 70 degrees). The average correction of lumbar lordosis was 40 degrees, from 21.4 degrees (-10 to 65 degrees) to 61.4 degrees (35 to 85 degrees). The thigh flexion angle improved from 9.7 degrees (4 to 20 degrees) to 0.4 degrees (-4 to 5 degrees), the sacral slope from 11.8 degrees (-5 to 35 degrees) to 31.8 degrees (20 to 45 degrees), and the chin brow vertical angle from 28.2 degrees (10 to 45 degrees) to 2.4 degrees (-5 to 18 degrees). Loss of correction of 5 and 10 degrees was seen in 2 patients. The ability to stand upright and look straight was restored in all patients. The WBKA correlated closely with the amount of lordosis correction in lumbar spine. The intraobserver and interobserver reproducibility of the WBKA was verified by statistical analysis. In our opinion the measurement of the WBKA on the preoperative photograph is helpful in planning the lumbar osteotomy.