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Aydin SZ, Deodhar A. Are all entheses the same? Rheumatology (Oxford) 2024; 63:1-2. [PMID: 37326834 DOI: 10.1093/rheumatology/kead288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/26/2023] [Accepted: 06/06/2023] [Indexed: 06/17/2023] Open
Affiliation(s)
- Sibel Zehra Aydin
- Faculty of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Atul Deodhar
- Division of Arthritis and Rheumatic Diseases, Oregon Health and Science University, Portland, OR, USA
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Balulu G, Furer V, Wollman J, Levartovsky D, Aloush V, Elalouf O, Sarbagil-Maman H, Mendel L, Borok S, Paran D, Elkayam O, Polachek A. The association between sonographic enthesitis with sonographic synovitis and tenosynovitis in psoriatic arthritis patients. Rheumatology (Oxford) 2024; 63:190-197. [PMID: 37166435 DOI: 10.1093/rheumatology/kead202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/25/2023] [Accepted: 04/19/2023] [Indexed: 05/12/2023] Open
Abstract
OBJECTIVES To examine the association between sonographic enthesitis with sonographic synovitis and tenosynovitis in PsA patients, and the association between sonographic enthesitis and clinical characteristics. METHODS Consecutive PsA patients that fulfilled the ClASsification criteria for Psoriatic ARthritis (CASPAR) were prospectively recruited. Each patient was evaluated by comprehensive clinical and sonographic assessment (greyscale and Doppler), the latter including 52 joints, 40 tendons and 14 entheses [according to MAdrid Sonography Enthesitis Index (MASEI) plus lateral epicondyles] performed by an experienced sonographer blinded to the clinical data. The US enthesitis score was further categorized to inflammatory (hypoechogenicity, thickening, bursitis and Doppler) and structural (enthesophytes/calcifications and erosions) subcategories. Multivariate linear regression models assessed the association between enthesitis and the selected variables. RESULTS A total of 158 PsA patients [mean (s.d.) age 52.3 (13) years, 88 (55.7%) females] were analysed. Multivariate linear regression analyses showed a significant association between sonographic enthesitis and sonographic synovitis (β = 0.18, P = 0.008) and between sonographic enthesitis and sonographic tenosynovitis (β = 0.06, P = 0.02). These associations were derived from the enthesitis inflammatory subcategory of the MASEI (P < 0.05). Associations between enthesitis and synovitis were also demonstrated on the level of the elbow, knee and ankle joints (P < 0.05). In addition, sonographic enthesitis was significantly associated with older age, male sex, swollen joint count, CRP level and physical occupation. CONCLUSIONS Sonographic enthesitis is associated with sonographic synovitis and tenosynovitis. The severity of sonographic enthesitis may represent a marker for inflammatory activity in other musculoskeletal domains.
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Affiliation(s)
- Gavriel Balulu
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victoria Furer
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Wollman
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Levartovsky
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Valerie Aloush
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Elalouf
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Sarbagil-Maman
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Mendel
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sara Borok
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daphna Paran
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ari Polachek
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Tsechelidis OB, Sabido-Sauri R, Aydin SZ. Enthesitis in Spondyloarthritis Including Psoriatic Arthritis-To Inject or Not To Inject?: A Narrative Review. Clin Ther 2023; 45:852-859. [PMID: 37716837 DOI: 10.1016/j.clinthera.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE Enthesitis is a key manifestation of psoriatic arthritis (PsA) and spondyloarthritis (SpA) and is considered to be the tissue where the disease initiates. Enthesitis leads to pain and substantial limitations in patients with PsA. Treatment is key in achieving remission or minimal disease activity. Whether it is safe to apply injections to entheseal tissue is unknown. This narrative review aimed to summarize the literature on the efficacy and tolerability of entheseal corticosteroid (CS) injections. METHODS The published literature was searched through PubMed as well as identifying relevant articles from their citations, for articles on the anatomic location of the injection, tissue characteristics (eg, whether there is a tendon sheath), blind versus imaging-guided and entheseal versus perientheseal injections, and related studies in animals. Given that articles on SpA are limited, those on mechanical enthesopathies were also included. FINDINGS The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA are limited. In most articles on entheseal injection, the entheseal tissue has not actually been targeted. The decision of entheseal injection should be made on an individual basis, with consideration of the use of CS injection as the last treatment option following more conservative measures such as NSAIDs, physiotherapy, rest, and lifestyle modifications. Entheseal injection should be avoided in high-risk patients, such as those who have rupture at the enthesis. Diagnostic ultrasound is advised to ensure the presence of inflammation that can potentially benefit from corticosteroid injection, as well as the absence of rupture. In the authors' perspective, perientheseal injections should be tried before intraentheseal injections. Finally, ultrasound guidance for needle placement is strongly encouraged. IMPLICATIONS The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA is limited. With the lack of quality data, recommendations on entheseal corticosteroid injection remain expert opinion.
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Affiliation(s)
| | - Ricardo Sabido-Sauri
- Department of Rheumatology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Sibel Zehra Aydin
- Department of Rheumatology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada.
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Mease PJ, Orbai AM, FitzGerald O, Bedaiwi M, Dona L Fleishaker, Mundayat R, Young P, Helliwell PS. Efficacy of tofacitinib on enthesitis in patients with active psoriatic arthritis: analysis of pooled data from two phase 3 studies. Arthritis Res Ther 2023; 25:153. [PMID: 37608391 PMCID: PMC10464128 DOI: 10.1186/s13075-023-03108-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 07/05/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Tofacitinib is an oral Janus kinase inhibitor for the treatment of psoriatic arthritis (PsA). This post hoc analysis assessed tofacitinib efficacy on enthesitis by baseline location and severity, and impact on disease activity and patient-reported outcomes (PROs), in patients with PsA. METHODS Data were pooled from two phase 3 studies (NCT01877668/NCT01882439) in patients with PsA receiving tofacitinib 5 or 10 mg twice daily to month (M)6 or placebo to M3. Endpoints were: change from baseline in Leeds Enthesitis Index (LEI) or Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC); proportions of patients with enthesitis, relapsed enthesitis after resolution, de novo enthesitis, low disease activity (LDA) or remission (minimal disease activity/very low disease activity; Psoriatic Arthritis Disease Activity Score; Disease Activity Index for Psoriatic Arthritis, and Composite Psoriatic Disease Activity in Psoriatic Arthritis); and PROs (Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F] total and arthritis pain Visual Analog Scale scores). Descriptive statistics were generated by visit and treatment. Change from baseline in PROs was evaluated by multivariate linear regression. RESULTS Seven hundred ten patients from two studies were included: 479 had LEI > 0; 545 had SPARCC > 0; and 136 had LEI = 0 and SPARCC = 0 at baseline. At baseline, among patients with LEI > 0 or SPARCC > 0, mean LEI and SPARCC across treatments and enthesitis locations/severities ranged from 1.0-4.4 and 1.3-9.4, respectively. Across several baseline enthesitis locations/severities, changes from baseline in LEI and SPARCC up to M3 were greater with tofacitinib (-2.0-0.4 and -3.5-0.2) vs placebo (-0.9-0.4 and -1.5-1.1). Enthesitis at M6 was more common in patients with greater baseline enthesitis severity. At M6, ≤ 40% of patients with baseline LEI > 0 or SPARCC > 0 whose enthesitis had resolved by M1/M3 experienced a relapse, and < 14% of patients with baseline LEI = 0 and SPARCC = 0 had de novo enthesitis. LDA/remission rates generally increased with tofacitinib over time. Baseline LEI location was significantly associated with change from baseline in arthritis pain score, while baseline SPARCC severity was significantly associated with change from baseline in FACIT-F total and arthritis pain scores. CONCLUSION Tofacitinib treatment resulted in improvements in enthesitis in patients with PsA, regardless of baseline location or severity. TRIAL REGISTRATION NCT01877668;NCT01882439.
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Affiliation(s)
- Philip J Mease
- Rheumatology Research, Swedish Medical Center/Providence St. Joseph Health and University of Washington School of Medicine, Seattle Rheumatology Associates, 601 Broadway, Suite 600, Seattle, WA, 98122, USA.
| | - Ana-Maria Orbai
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Oliver FitzGerald
- Conway Institute for Biomolecular Research, University College Dublin, Dublin, Ireland
| | - Mohamed Bedaiwi
- Division of Rheumatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | | | | | - Philip S Helliwell
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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Furer V, Wollman J, Levartovsky D, Aloush V, Elalouf O, Sarbagil-Maman H, Mendel L, Borok S, Paran D, Elkayam O, Polachek A. Sex-Based Differences in Sonographic and Clinical Findings Among Patients With Psoriatic Arthritis. J Rheumatol 2023; 50:197-203. [PMID: 36243411 DOI: 10.3899/jrheum.220547] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate sex-based sonographic differences in patients with psoriatic arthritis (PsA). METHODS The study population included consecutive prospectively recruited patients with PsA, as determined by the CASPAR (Classification for Psoriatic Arthritis) criteria, who underwent clinical and physical examinations, followed by a detailed ultrasound (US) evaluation (greyscale and Doppler). US evaluation included 52 joints, 40 tendons, and 14 points of entheses (Modified Madrid Sonographic Enthesis Index [MASEI] plus lateral epicondyles) performed by an experienced sonographer blinded to the clinical data. The US score was based on the summation of a semiquantitative score for synovitis, tenosynovitis, and enthesitis. The US enthesitis score was categorized into inflammatory lesions (ie, hypoechogenicity, thickening, bursitis, and Doppler) and structural lesions (ie, enthesophytes/calcifications and erosions). RESULTS The study population of 158 patients included 70 males and 88 females. The males had higher rates of employment (P = 0.01), Psoriasis Area and Severity Index scores (P = 0.04), and mean swollen joint counts (P = 0.04). The total US score and its subcategory scores-the synovitis and tenosynovitis scores-were similar for both sexes, whereas the total enthesitis score and its subcategory score-the inflammatory enthesitis score-were significantly higher for the males compared to the females (P = 0.01 and P = 0.005, respectively). Hypoechogenicity, thickening, and enthesophytes were more prevalent in males compared to females (P < 0.05). Multivariate ordinal logistic regression models showed that male sex was associated with a higher US inflammatory enthesitis score compared to female sex (odds ratio 1.96, P = 0.02). CONCLUSION Sonographic enthesitis was more prevalent in males compared to females with PsA. These differences were not reflected by enthesitis disease activity scores derived from clinical assessment.
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Affiliation(s)
- Victoria Furer
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Wollman
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Levartovsky
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Valerie Aloush
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Elalouf
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Sarbagil-Maman
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Mendel
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sara Borok
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daphna Paran
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Elkayam
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ari Polachek
- V. Furer, MD, J. Wollman, MD, D. Levartovsky, MD, V. Aloush, MD, O. Elalouf, MD, H. Sarbagil-Maman, MD, L. Mendel, MSc, S. Borok, MD, D. Paran, MD, O. Elkayam, MD, and A. Polachek, MD, Department of Rheumatology, Tel Aviv Sourasky Medical Center affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Ventura-Ríos L, Cazenave T, Hernández-Díaz C, Gallegos-Nava S, Gómez-Ruiz C, Rosemffet M, Silva-Luna K, Rodríguez-Henríquez P, Vázquez-Mellado J, Casasola-Vargas J, Cruz-Arenas E, de Miguel EM. Entheseal Involvement in Spondyloarthritis (SpA) and Gout: An Ultrasound Comparative Study. Front Med (Lausanne) 2022; 9:871760. [PMID: 35685413 PMCID: PMC9170994 DOI: 10.3389/fmed.2022.871760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To compare the assessment of entheses in subjects with spondyloarthritis (SpA) with patients with gout by the Madrid Sonographic Enthesis Index (MASEI). Method This cross-sectional study includes videos of entheses evaluated by ultrasound (US) of 30 patients with SpA diagnosed according to the ASAS criteria and 30 patients with gout established by the presence of monosodium urate crystals. Entheses were evaluated for MASEI in 2 Institutes located in two different countries. Demographic and clinical data were registered. Total MASEI score, MASEI-inflammatory, and MASEI-chronic damage were analyzed. Comparisons between groups were obtained by chi-square test and Student's t-test. An inter-reading US reliability was realized. Results Patients with gout were older and had significantly more comorbidities than those with SpA. The total MASEI score was not significantly different among diseases (p = 0.07). MASEI-inflammatory was significantly more prevalent at the Achilles tendon in SpA, while the proximal patellar tendon was in gout. Power Doppler was higher in SpA compared to gout (p = 0.005). MASEI-chronic damage related to calcification/enthesophytes predominated in gout (p = 0.043), while calcaneal erosions did in SpA (p = 0.008). The inter-reader concordance was excellent (0.93, CI 95% 0.87–0.96, p = 0.001). Conclusions SpA and gout similarly involve entheses according to MASE, however, some inflammatory and chronic lesions differ significantly depending on the underlying disease and tendon scanned.
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Affiliation(s)
- Lucio Ventura-Ríos
- Laboratorio de Ultrasonido Musculoesquelético y Articular, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Tomas Cazenave
- Department of Rheumatology, Instituto de Rehabilitación Psicofísica, Buenos Aires, Argentina
| | - Cristina Hernández-Díaz
- Laboratorio de Ultrasonido Musculoesquelético y Articular, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Selma Gallegos-Nava
- Department of Rheumatology, Hospital General Dr. Darío Fernández Fierro, Mexico City, Mexico
| | | | - Marcos Rosemffet
- Department of Rheumatology, Instituto de Rehabilitación Psicofísica, Buenos Aires, Argentina
| | - Karina Silva-Luna
- Service of Rheumatology, Hospital Universitario "Dr. JoséEleuterio González", Monterrey, Mexico
| | | | | | | | - Esteban Cruz-Arenas
- Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Unidad de Vigilancia Epidemiológica Hospitalaria-Investigación Sociomédica, México City, Mexico
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Dubash SR, Alabas OA, Michelena X, Garcia-Montoya L, De Marco G, Merashli M, Wakefield RJ, Emery P, McGonagle D, Tan AL, Marzo-Ortega H. Ultrasound shows swollen joints are the better proxy for synovitis than tender joints in DMARD-naïve early psoriatic arthritis. Rheumatol Adv Pract 2021; 5:rkab086. [PMID: 35284780 PMCID: PMC8908782 DOI: 10.1093/rap/rkab086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/31/2021] [Indexed: 12/20/2022] Open
Abstract
Objective To evaluate the relationship between clinical examination/US synovitis in DMARD-naïve early PsA. Methods Eligible patients underwent matched clinical/US 44-joint assessment for tender and/or swollen joints (TJ/SJ) and US synovitis [grey scale (GS) ≥ 2 or power Doppler (PD) ≥ 1]. Statistical agreement between TJ/SJ, GS ≥ 2 and PD ≥ 1 was calculated by prevalence-adjusted and bias-adjusted κ (PABAK). To derive probabilities of GS ≥ 2/PD ≥ 1, mixed-effects logistic regression-modelled odds of US synovitis in TJ/SJ were conducted. Results In 155 patients, 5616 joints underwent clinical/US examination. Of these joints, 1039 of 5616 (18.5%) were tender, 550 of 5616 (9.8%) were swollen, 1144 of 5616 (20.4%) had GS ≥ 2, and 292 of 5616 (5.2%) had PD ≥ 1. GS ≥ 2 was most prevalent in concomitantly tender and swollen joints [205 of 462 (44%)], followed by swollen non-tender joints [32 of 88 (36.4%)], tender non-swollen joints [148 of 577 (25.7%)] and non-tender non-swollen joints (subclinical synovitis) [759 of 4489 (16.9%)]. Agreement between SJ/PD ≥ 1 was high at the individual joint level (82.6–96.3%, PABAK 0.65–0.93) and for total joints combined (89.9%, PABAK 0.80). SJ/GS ≥ 2 agreement was greater than between TJ/GS ≥ 2 [73.5–92.6% vs 51.0–87.4% (PABAK 0.47–0.85 vs PABAK 0.35–0.75), respectively]. Swelling was independently associated with higher odds of GS ≥ 2 [odds ratio (OR) (95% CI); 4.37 (2.62, 7.29); P < 0.001] but not tenderness [OR = 1.33 (0.87, 2.06); P = 0.192]. Swelling [OR = 8.78 (3.92, 19.66); P < 0.001] or tenderness [OR = 3.38 (1.53, 7.50); P = 0.003] was independently associated with higher odds of PD ≥ 1. Conclusion Synovitis (GS ≥ 2 and/or PD ≥ 1) was more likely in swollen joints than in tender joints in DMARD-naïve, early PsA. Agreement indicated that swollen joints were the better proxy for synovitis, adding to greater understanding between clinical and US assessments.
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Affiliation(s)
- Sayam R Dubash
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Oras A Alabas
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
- School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Xabier Michelena
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
- Rheumatology Unit, Vall d’Hebron Hospital Universitari, Barcelona, Spain
| | - Leticia Garcia-Montoya
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Gabriele De Marco
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Mira Merashli
- Division of Rheumatology, Department of Internal Medicine, American University Hospital, Beirut, Lebanon
| | - Richard J Wakefield
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Paul Emery
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Dennis McGonagle
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Ai Lyn Tan
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Helena Marzo-Ortega
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
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The transition from enthesis physiological responses in health to aberrant responses that underpin spondyloarthritis mechanisms. Curr Opin Rheumatol 2021; 33:64-73. [PMID: 33229975 DOI: 10.1097/bor.0000000000000768] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Despite immunology and translational therapeutics advances in inflammatory arthritis over the past two decades, the enthesis, which is the epicentric of the spondyloarthritis family pathological process, retains many mysteries because of tissue inaccessibility that hampers direct immune study. As entheses are subject to almost continuous mechanical stress and spondyloarthritis is linked to microdamage or injury and joint stress, it is cardinal to understand the physiological changes occurring within the entheses not only to be able to differentiate disease from health but also to understand the transition normal physiology break down and its merges into spondyloarthritis-related disease. RECENT FINDINGS Imaging has played a major role in understanding the enthesis in human. Remarkable insights from enthesis functioning and microdamage in normal and with ageing including those linked to body mass index is emerging. The impact of mechanical stress and degenerative conditions on the development of the secondary entheseal vascular changes is not understood. Of note, ultrasound studies in psoriasis have shown higher power Doppler changes compared to controls pointing towards a role for vascular changes in the development of enthesitis in psoriatic arthritis. SUMMARY The literature pertaining to normal entheses changes with age, microdamage and vascular changes in health is providing a roadmap for understanding of the enthesis and its potential role in evolution of spondyloarthritis including psoriatic arthritis.
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McGonagle D, Aydin SZ, Marzo-Ortega H, Eder L, Ciurtin C. Hidden in plain sight: Is there a crucial role for enthesitis assessment in the treatment and monitoring of axial spondyloarthritis? Semin Arthritis Rheum 2021; 51:1147-1161. [PMID: 34537464 DOI: 10.1016/j.semarthrit.2021.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/05/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To review the evidence surrounding the pathophysiology of enthesitis in axial spondyloarthritis (axSpA), its prevalence and contribution to the overall disease burden, and response to treatment at axial and peripheral sites. METHODS Literature searches of the Cochrane Library, PubMed, and Embase / Medline using the terms "enthesitis", "enthesopathy", "spondyloarthritis", "axial spondyloarthritis", and "ankylosing spondylitis" were conducted. Publications mentioning enthesitis or enthesopathy in the context of pathophysiology, diagnosis, or treatment were included. RESULTS Enthesitis is a common symptom of axSpA, occurring with high prevalence at axial and several peripheral sites. Inflammation at the site of enthesis is an early key manifestation of axSpA. Clinically evaluable enthesitis contributes significantly to the burden of disease, correlating with worse symptomatology and downstream structural damage. Despite its importance in driving axSpA disease processes, enthesitis is somewhat neglected in current approaches to disease assessment and management. Enthesitis is excluded from some commonly used disease activity measures, is not routinely assessed in clinical practice, and many methods of clinical assessment omit key accessible axial sites, such as the spinous processes. CONCLUSION Enthesitis plays a central role in driving the pathophysiology of axSpA. There is a need for a renewed focus on the early detection, measurement and treatment of enthesitis.
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Affiliation(s)
- Dennis McGonagle
- The Leeds Institute of the Rheumatic and Musculoskeletal Disease, University of Leeds, Chapeltown Road, Leeds LS7 4SA, United Kingdom; National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.
| | - Sibel Z Aydin
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Ottawa, and Ottawa Hospital Research Institute, Ottawa, Canada
| | - Helena Marzo-Ortega
- The Leeds Institute of the Rheumatic and Musculoskeletal Disease, University of Leeds, Chapeltown Road, Leeds LS7 4SA, United Kingdom; National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Lihi Eder
- Division of Rheumatology, Department of Medicine, Women's College Research Institute, Women's College Hospital, University of Toronto, Canada
| | - Coziana Ciurtin
- Department of Rheumatology, Centre for Adolescent Rheumatology Versus Arthritis, Department of Medicine, University College London, Rayne Building, London, United Kingdom
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10
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Polachek A, Furer V, Zureik M, Nevo S, Mendel L, Levartovsky D, Wollman J, Aloush V, Tzemach R, Elalouf O, Anouk M, Berman M, Kaufman I, Carmi O, Lahat Y, Eviatar T, Padova H, Sarbagil-Maman H, Borok S, Broyde A, Eder L, Paran D, Elkayam O. Role of ultrasound for assessment of psoriatic arthritis patients with fibromyalgia. Ann Rheum Dis 2021; 80:1553-1558. [PMID: 34215648 DOI: 10.1136/annrheumdis-2021-220562] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/23/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To investigate whether ultrasonography (US), as an objective imaging modality, can optimise the evaluation of disease activity in psoriatic arthritis (PsA) patients with concomitant fibromyalgia syndrome (FMS). METHODS The study population included 156 consecutive PsA patients who were recruited prospectively and fulfilled the ClASsification criteria for Psoriatic ARthritis criteria. The patients underwent complete clinical evaluation including assessment of fulfilment of the 2016 fibromyalgia classification criteria. All of the patients underwent US evaluation including 52 joints, 40 tendons and 14 entheses. The US score was based on the summation of a semiquantitative score (including synovitis, tenosynovitis and enthesitis). Scoring was performed by a sonographer blinded to the clinical data. Spearman's correlation coefficient and multivariate linear regression models were used to examine the association of FMS with clinical and the US scores. RESULTS Forty-two patients (26.9%) with coexisting PsA and FMS were compared with 114 (73.1%) PsA patients without FMS. Patients with PsA and FMS had significantly increased scores for clinical composite indices, including non-Minimal Disease Activity, Composite Psoriatic Disease Activity Index (CPDAI), Disease Activity for Psoriatic Arthritis (DAPSA) and Psoriatic Arthritis Disease Activity Score (PASDAS) (p<0.001). In contrast, the total US score and its subcategories were similar for those with and without FMS. The total US score significantly correlated with CPDAI, DAPSA and PASDAS (p<0.001) in the PsA without FMS but not in the PsA with FMS group. FMS was significantly associated with higher clinical scores (p<0.001) but not with the US score (multivariable linear regression models). CONCLUSIONS US has significantly greater value than composite clinical scores in the assessment of disease activity in PsA patients with FMS.
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Affiliation(s)
- Ari Polachek
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victoria Furer
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mirna Zureik
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Nevo
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Mendel
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Levartovsky
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Wollman
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Valerie Aloush
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Reut Tzemach
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Elalouf
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marina Anouk
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark Berman
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilana Kaufman
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Or Carmi
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Lahat
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Eviatar
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Padova
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Sarbagil-Maman
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sara Borok
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Broyde
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lihi Eder
- Women's College Hospital, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daphna Paran
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Elkayam
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Dubash SR, De Marco G, Wakefield RJ, Tan AL, McGonagle D, Marzo-Ortega H. Ultrasound Imaging in Psoriatic Arthritis: What Have We Learnt in the Last Five Years? Front Med (Lausanne) 2020; 7:487. [PMID: 32984374 PMCID: PMC7477070 DOI: 10.3389/fmed.2020.00487] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/17/2020] [Indexed: 12/13/2022] Open
Abstract
Psoriatic arthritis (PsA) is a complex heterogeneous disease with multiple inter-related pathologies such as synovitis, enthesitis, tendinopathy, and dactylitis. Clinical assessment is limited in its detail to assess pathology, thus in recent years, ultrasound (US) has become more popular, given its high sensitivity to detect inflammatory arthritis and ability to inform clinical decisions. Although a qualitative technique, US findings can be graded semi-quantitatively for grayscale (GS) and power Doppler (PD). Synovitis is frequently present in inflammatory arthritis pathologies, and in PsA, recent evidence shows a propensity for tendon and entheseal lesions. The presence of flexor tenosynovitis and flexor tendon insertional enthesopathy at accessory pulleys is supportive of the “Deep Koebner” concept. Peri-tendinous inflammation—mutual to PsA or rheumatoid arthritis (RA), is associated with soft tissue oedema with PD signal frequently at the flexor tendon compartments in PsA. Research on enthesitis in PsA/PsO has improved understanding in subclinical and clinical PsA, explored associations with progression to PsA, and investigated links to prognosis assessment. Dactylitis is a pathognomonic PsA lesion where US has enhanced knowledge of the disease course and pathology of lesions such as: flexor tenosynovitis; synovitis; and soft tissue oedema. Increased US sensitivity has also brought innovation including promising automated ultrasound scanning techniques. So, what have we learnt in recent years and what are the unmet needs to focus future research initiatives in this disabling disease? This narrative review article assesses the neoteric evidence, bringing into context the knowledge gained and highlighting potential areas of research.
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Affiliation(s)
- Sayam R Dubash
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Gabriele De Marco
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Richard J Wakefield
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Ai Lyn Tan
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Dennis McGonagle
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Helena Marzo-Ortega
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
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12
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Zabotti A, Tinazzi I, Aydin SZ, McGonagle D. From Psoriasis to Psoriatic Arthritis: Insights from Imaging on the Transition to Psoriatic Arthritis and Implications for Arthritis Prevention. Curr Rheumatol Rep 2020; 22:24. [PMID: 32418006 PMCID: PMC7230038 DOI: 10.1007/s11926-020-00891-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW To describe the recent advances in the field towards the prevention and early recognition of Psoriatic Arthritis (PsA). RECENT FINDINGS Defining the preclinical phase of PsA remains challenging since up to 50% of subjects with psoriasis have subclinical imaging enthesopathy, but many of these do not progress to PsA. Nevertheless, there is evidence that subjects with subclinical imaging enthesopathy are at increased risk of developing PsA. In recent years, it has been shown that both PsA and anti-citrullinated protein antibodies (ACPA) positive rheumatoid arthritis (RA) are characterized by a subclinical phase of non-specific or brief duration arthralgia with shared imaging features accounting for joint symptomatology. Sonographically determined tenosynovitis and enthesitis are the key imaging features present in non-specific PsO arthralgia that are at risk of future PsA development. Furthermore, the early phases of PsA are complicated by factors including body mass index (BMI), which is a risk factor for PsA, but BMI is also associated with imaging abnormalities on enthesopathy. Fully disentangling these clinical and imaging factors will be important for enrichment for imminent PsA so that disease prevention strategies can be investigated. Psoriasis patients with arthralgia have a higher prevalence of tenosynovitis and imaging enthesopathy is at higher risk of transitioning to overt PsA.
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Affiliation(s)
- Alen Zabotti
- Department of Medical and Biological Science, Rheumatology Clinic, University of Udine, Udine, Italy
| | - Ilaria Tinazzi
- Unit of Rheumatology, IRCSS Ospedale Sacro Cuore Don Calabria, Negrar, Verona, Italy
| | - Sibel Zehra Aydin
- Faculty of Medicine, Division of Rheumatology, University of Ottawa, the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
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13
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Rossini M, Epis OM, Tinazzi I, Grembiale RD, Iagnocco A. Role of the IL-23 pathway in the pathogenesis and treatment of enthesitis in psoriatic arthritis. Expert Opin Biol Ther 2020; 20:787-798. [PMID: 32129102 DOI: 10.1080/14712598.2020.1737855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Enthesitis is a key feature of spondyloarthritis (SpA). Several studies have underlined the role of interleukin (IL)-23 in SpA development as a crucial cytokine in the pathogenesis of enthesitis. AREA COVERED This review summarizes recent evidence of the role of IL-23 in the pathogenesis of and as a target of the treatment of enthesitis. We review the definition, diagnosis and clinical impact of enthesitis and its connection with microbial infections, gut dysbiosis, and mechanical stress. We also review clinical trials and real-life studies of drugs targeting the p19 or p40 subunits of IL-23. EXPERT OPINION Novel therapies targeting the p19 or p40 subunit of IL-23 appear to be promising treatment options for patients with enthesitis. Although we are currently unable to identify the best therapeutic window to target IL-23 in SpA disease evolution, the promising ability of this therapy to control the gut-entheseal axis is increasing our knowledge of SpA pathogenesis.
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Affiliation(s)
- Maurizio Rossini
- Rheumatology Section, Department of Medicine, University of Verona , Verona, Italy
| | | | - Ilaria Tinazzi
- Unit of Rheumatology, IRCCS Sacro Cuore Don Calabria Hospital , Verona, Italy
| | | | - Annamaria Iagnocco
- Academic Rheumatology Centre, Università Degli Studi Di Torino , Turin, Italy
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