Current controversies in spondyloarthritis: SPARTAN

Distinctive Features in Spondyloarthritis Between Women and Man in Moroccan Context: Disease Beginning, Clinical Manifestations, Disease Activity and Function Scores

BACKGROUND

Axial spondyloarthritis (axSpA) is a common group of chronic rheumatic inflammatory diseases, which usually affects the axial skeleton, and are more frequently observed in males than in females. Several differences have been brought up in the clinical presentation of axSpA, according to the patient's gender. In fact; axSpA severity in women tends to be moderate, leading then, to an underdiagnosis in this category of patients. While male axSpA patients seem to set forth more spinal destructions on radiographs.

OBJECTIVE

As the main goal, our study aims to bring up the particularities of female axial spondyloarthritis, all the while comparing them with the male form.

MATERIALS AND METHODS

This is a cross-sectional study carried out in the period lying between January 2012 and December 2017, at a single rheumatology department in Morocco. All patients with an axial spondyloarthritis meeting the Assessment of SpondyloArthritis international Society (ASAS) classification criteria 2010, and who have been admitted in our department, during that period, were included. The data was recorded and analyzed using SPSS v20 univariate and bivariate analysis. A value of p <0.005 has been used to identify factors associated with axSpA in women.

RESULTS

A total of 277 patients were enrolled, of which 147 are female and 130 are male with a sex ratio of 1.1. Cervical stiffness was more common in men. On the other hand, women had more arthritis and enthesitis. However, no considerable divergences have been underscored between the two genders, neither in the prevalence of extra-articular manifestations, nor in disease activity BASDAI and BASFI. Men had more radiographic sacroiliitis compared to women (57.5% vs. 42.5%, p=0.01), more coxitis (66.7% vs. 33.3%, p = 0.0001). The Multivariate logistic regression analysis showed that female gender was associated with a greater age at the diagnosis onset (IC: 1.053-1.103, OR=1.07, p=0.001) and arthritis (IC: 2.37-4.26, OR=2.3, p=0.004). While the male sex was associated with a young age of onset (CI: 4.50-19.52, OR = 9.3), coxitis (CI: 2.53-4.23, OR = 3.3) and smoking (CI: 15.667-900.18, OR = 118.7).

CONCLUSION

The comparison between male and female patients suffering from axial spondyloarthritis found many differences and similarities as well, in the disease expression. This study showed actually that women had the less severe form of spondyloarthritis.

Golimumab for the treatment of axial spondyloarthritis

Axial spondyloarthritis (axSpA) is a chronic, immune-mediated inflammatory disease of the axial skeleton that includes ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA). Patients with AS experience chronic pain due to sacroiliac joint and spinal inflammation, and may develop spinal ankylosing with syndesmophyte formation. Tumor necrosis factor α inhibitors (TNFi) have shown promise in the management of AS and axSpA by targeting the underlying inflammatory process, and providing symptomatic relief. Whether they alter the progression of the disease is uncertain. Golimumab is a fully human IgG1 monoclonal antibody that targets and downregulates the pro-inflammatory cytokine TNF-α. The use of golimumab has been shown to reduce the signs and symptoms of axSpA as well as improve patient function and quality reported outcomes. This review focuses on the biological rationale and the results of clinical trials with golimumab for the treatment of axSpA.

Treating spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis, to target: recommendations of an international task force

BACKGROUND

Therapeutic targets have been defined for diseases like diabetes, hypertension or rheumatoid arthritis and adhering to them has improved outcomes. Such targets are just emerging for spondyloarthritis (SpA).

OBJECTIVE

To define the treatment target for SpA including ankylosing spondylitis and psoriatic arthritis (PsA) and develop recommendations for achieving the target, including a treat-to-target management strategy.

METHODS

Based on results of a systematic literature review and expert opinion, a task force of expert physicians and patients developed recommendations which were broadly discussed and voted upon in a Delphi-like process. Level of evidence, grade and strength of the recommendations were derived by respective means. The commonalities between axial SpA, peripheral SpA and PsA were discussed in detail.

RESULTS

Although the literature review did not reveal trials comparing a treat-to-target approach with another or no strategy, it provided indirect evidence regarding an optimised approach to therapy that facilitated the development of recommendations. The group agreed on 5 overarching principles and 11 recommendations; 9 of these recommendations related commonly to the whole spectrum of SpA and PsA, and only 2 were designed separately for axial SpA, peripheral SpA and PsA. The main treatment target, which should be based on a shared decision with the patient, was defined as remission, with the alternative target of low disease activity. Follow-up examinations at regular intervals that depend on the patient's status should safeguard the evolution of disease activity towards the targeted goal. Additional recommendations relate to extra-articular and extramusculoskeletal aspects and other important factors, such as comorbidity. While the level of evidence was generally quite low, the mean strength of recommendation was 9-10 (10: maximum agreement) for all recommendations. A research agenda was formulated.

CONCLUSIONS

The task force defined the treatment target as remission or, alternatively, low disease activity, being aware that the evidence base is not strong and needs to be expanded by future research. These recommendations can inform the various stakeholders about expert opinion that aims for reaching optimal outcomes of SpA.

Comparison of the clinical expression of patients with ankylosing spondylitis from Europe and Latin America

OBJECTIVE

To compare the clinical, demographic, and serologic characteristics and the treatment of patients diagnosed with ankylosing spondylitis (AS) from Europe (EU) and Latin America (LA).

METHODS

We included 3439 patients from national registries: the Spanish Registry of Spondyloarthritis (REGISPONSER), the Belgian registry (ASPECT), and the Latin American Registry of Spondyloarthropathies (RESPONDIA). We selected patients with diagnosis of AS who met the modified New York classification criteria. Demographic, clinical, disease activity, functional, and metrological measurement data were recorded. Current treatment was recorded. The population was classified into 2 groups: patients with disease duration < 10 years and those with disease duration ≥ 10 years. A descriptive and comparative analysis of variables of both groups was carried out.

RESULTS

There were 2356 patients in EU group and 1083 in LA group. Prevalence of HLA-B27 was 71% in LA group and 83% in EU group (p < 0.001). We found a greater frequency of peripheral arthritis and enthesitis (p < 0.001) in the LA population; prevalence of arthritis was 57% in LA and 42% in EU, and for enthesitis, 54% and 38%. Except for treatment with anti-tumor necrosis factor (anti-TNF), the use of nonsteroidal antiinflammatory drugs (NSAID), corticosteroids, and disease-modifying antirheumatic drugs (DMARD), and the association of anti-TNF and methotrexate use showed a significant difference (p < 0.001) in the 2 populations.

CONCLUSION

The principal differences in the clinical manifestations of patients with AS from EU and LA were the greater frequency of peripheral arthritis and enthesitis in LA group, the higher percentage of HLA-B27 in EU group, and the form of treatment, with a greater use of NSAID, steroids, and DMARD in the LA group.

Ethnic Influence in Clinical and Functional Measures of Brazilian Patients with Spondyloarthritis

Objective.

Spondyloarthritides (SpA) can present different disease spectra according to ethnic background. The Brazilian Registry of Spondyloarthritis (RBE) is a nationwide registry that comprises a large databank on clinical, functional, and treatment data on Brazilian patients with SpA. The aim of our study was to analyze the influence of ethnic background in SpA disease patterns in a large series of Brazilian patients.

Methods.

A common protocol of investigation was prospectively applied to 1318 SpA patients in 29 centers distributed through the main geographical regions in Brazil. The group comprised whites (65%), African Brazilians (31.3%), and people of mixed origins (3.7%). Clinical and demographic variables and various disease index scores were compiled. Ankylosing spondylitis (AS) was the most frequent disease in the group (65.1%); others were psoriatic arthritis (18.3%), undifferentiated SpA (6.8%), enteropathic arthritis (3.7%), and reactive arthritis (3.4%).

Results.

White patients were significantly associated with psoriasis (p = 0.002), positive HLA-B27 (p = 0.014), and use of corticosteroids (p < 0.0001). Hip involvement (p = 0.02), axial inflammatory pain (p = 0.04), and radiographic sacroiliitis (p = 0.025) were associated with African Brazilian descent. Sex distribution, family history, and presence of peripheral arthritis, uveitis, dactylitis, urethritis, and inflammatory bowel disease were similar in the 3 groups, as well as age at disease onset, time from first symptom until diagnosis, and use of anti-tumor necrosis factor-α agents (p > 0.05). Schober test and thoracic expansion were similar in the 3 groups, whereas African Brazilians had higher Maastricht Ankylosing Spondylitis Enthesitis Scores (p = 0.005) and decreased lateral lumbar flexion (p = 0.003), while whites had a higher occiput-to-wall distance (p = 0.02). African Brazilians reported a worse patient global assessment of disease (p = 0.011). Other index scores and prevalence of work incapacity were similar in the 3 groups, although African Brazilians had worse performance in the Ankylosing Spondylitis Quality of Life questionnaire (p < 0.001).

Conclusion.

Ethnic background is associated with distinct clinical aspects of SpA in Brazilian patients. African Brazilian patients with SpA have a poorer quality of life and report worse disease compared to whites.

Prologue: 2009 Joint Meeting of Spondyloarthritis Research and Therapy Network (SPARTAN) and International Genetics of Ankylosing Spondylitis (IGAS)

In July 2009, a 3-day conference was held in Houston, Texas, USA, by members of several groups: the Spondyloarthritis Research and Therapy Network (SPARTAN); the International Genetics of Ankylosing Spondylitis (IGAS); and interested members of the Pan American League of Associations of Rheumatology (PANLAR). The purpose of this meeting was to bring together physician scientists, clinicians, and educators from around the world who are working together to improve their understanding of spondyloarthritis (SpA). In addition to the annual educational and Fellows sessions for SPARTAN members, the conference included a one-day international meeting dedicated to the role of HLA-B27, along with a series of sessions that summarized advances among various collaborative groups and defined opportunities for future genetic initiatives. This supplement provides a review of the SPARTAN and IGAS meetings.

The Genetic Basis of Spondyloarthritis: SPARTAN/IGAS 2009

A joint meeting was held in July 2009 in Houston, Texas, of members of the Spondyloarthritis Research and Therapy Network (SPARTAN), founded in 2003 to promote research, education, and treatment of ankylosing spondylitis (AS) and related forms of spondyloarthritis (SpA), and members of International Genetics of AS (IGAS), founded in 2003 to encourage and coordinate studies internationally in the genetics of AS. The general topic was the genetic basis of SpA, with presentations on the future of human genetic studies; microbes, SpA, and innate immunity; susceptibility of AS to the major histocompatibility complex (MHC) and non-MHC; and individual discussions of the genetics of psoriasis and psoriatic arthritis, uveitis, inflammatory bowel disease, and enteropathic arthritis. Summaries of those discussions are presented.