Development and Validation of a Sonographic Enthesitis Instrument in Psoriatic Arthritis: The GRAPPA Diagnostic Ultrasound Enthesitis Tool (DUET) Project

Enthesitis is a key feature in psoriatic arthritis (PsA) and may be the initial site of musculoskeletal inflammation in patients with PsA. Ultrasound (US) optimizes the detection of enthesitis, but the lack of a validated sonographic enthesitis scoring system for PsA limits the ability to conduct US-based studies of approaches to improve the early diagnosis of PsA. Creating a sonographic enthesitis scoring system that reliably identifies PsA at early stages is an important step in optimizing early diagnosis and encouraging timely interventions that will ultimately improve longterm outcomes for patients with PsA. The Group for Research and Assessment of Psoriasis and PsA (GRAPPA) US working group has set a goal of improving the evaluation of enthesitis in patients with PsA by using US through the development of a Diagnostic Ultrasound Enthesitis Tool (DUET). This article summarizes the proposed DUET study design and methodology as discussed during the 2019 GRAPPA annual meeting in Paris, France.

The GRAPPA Sonographic Enthesitis Workshop

Enthesitis is a key feature in psoriatic arthritis (PsA) and may be the initial site of musculoskeletal inflammation in patients with PsA. Ultrasound (US) could improve the accuracy of clinical enthesitis assessment, but at present no consensus exists on a global sonographic enthesitis scoring method that can evaluate the extent of enthesitis at the patient level. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) US Working Group has set up a goal to optimize the evaluation of enthesitis in patients with PsA using US through the development and validation of new instruments using a combined data-driven and expert opinion-driven approach. This article summarizes the GRAPPA US Working Group's recent activities and focuses on a 2-day workshop that the group held following the annual 2018 GRAPPA meeting in Toronto, Ontario, Canada.

Association Between Enthesitis and Health-related Quality of Life in Psoriatic Arthritis in Biologic-naive Patients from 2 Phase III Ustekinumab Trials

OBJECTIVE

Evaluate enthesitis, physical function, and health-related quality of life (HRQOL) among patients with psoriatic arthritis (PsA) who are naive to anti-tumor necrosis factor agents.

METHODS

In PSUMMIT 1 and 2, patients with PsA were randomized to placebo or ustekinumab 45 mg or 90 mg. Enthesitis was assessed at weeks 0 and 24 (Maastricht Ankylosing Spondylitis Enthesitis Score). Assessments included Health Assessment Questionnaire-Disability Index (HAQ-DI), Medical Outcomes Study Short Form-36 (SF-36) physical component summary/mental component summary (PCS/MCS), and American College of Rheumatology 20 (ACR20).

RESULTS

At Week 24, 21 had worsened enthesitis, 158 had improved enthesitis, and 412 had unchanged enthesitis. Improved enthesitis was associated with improvements in HAQ-DI and SF-36 MCS. Results were similar for ACR20 responders and nonresponders.

CONCLUSION

Improvement in enthesitis at Week 24 was associated with improvements in physical function/HRQOL regardless of ACR20 response.

Treatment of Dactylitis and Enthesitis in Psoriatic Arthritis with Biologic Agents: A Systematic Review and Metaanalysis

OBJECTIVE

Biologic agents with different mechanisms of action [inhibitors of tumor necrosis factor-α (TNF-α), interleukin (IL)-12/23, and IL-17] showed efficacy in randomized controlled trials (RCT) in the treatment of psoriatic arthritis. We conducted a pooled metaanalysis of these agents for treatment of dactylitis and enthesitis and compared results with the American College of Rheumatology 20 (ACR20) response and Health Assessment Questionnaire-Disability Index (HAQ-DI) scores.

METHODS

A systematic literature search was performed and a pooled metaanalysis of RCT with anti-TNF-α (infliximab, golimumab, adalimumab), anti-IL-12/23 (ustekinumab), and anti-IL-17 (secu kinumab, ixekizumab) was conducted using the random-effects model. Bias was assessed using the Cochrane risk-of-bias tool.

RESULTS

Eighteen RCT were included in the pooled analysis (n = 6981). Both TNF-α inhibitors and novel biologics (ustekinumab, secukinumab, ixekizumab) demonstrated significant resolution of dactylitis at Week 24 with pooled risk ratios (RR) versus placebo of 2.57 (95% CI 1.36-4.84) and 1.88 (95% CI 1.33-2.65), respectively. For resolution of enthesitis at Week 24, RR for TNF-α inhibitors was 1.93 (95% CI 1.33-2.79) versus 1.95 (95% CI 1.60-2.38) for novel biologics. Both biologic categories showed overlapping ranges of ACR20 responses (TNF-α inhibitors: RR = 2.23, 95% CI 1.60-3.11; pooled IL-12/23 and -17: RR = 2.30, 95% CI 1.94-2.72) and similar quality of life improvement scores with mean HAQ-DI score changes of -0.29 (95% CI -0.39 to -0.19) and -0.26 (95% CI -0.31 to -0.22), respectively.

CONCLUSION

The pooled analysis demonstrated that anti-TNF-α agents have the same efficacy as novel agents (ustekinumab, secukinumab, and ixekizumab) in dactylitis and enthesitis.

Association of Physical Activity and Medication with Enthesitis on Ultrasound in Psoriatic Arthritis

OBJECTIVE

Enthesitis is a manifestation of psoriatic arthritis (PsA), but its symptoms are difficult to interpret clinically. We investigated the associations of ultrasonographic changes in entheses with clinical characteristics in patients with PsA, and compared enthesis changes of patients aged 35 to 60 years with healthy volunteers of that age.

METHODS

Consecutive patients with PsA participated in this cross-sectional study, irrespective of enthesitis complaints and age. We collected data about complaints, physical activity and activity avoidance, medication, and clinical enthesitis. Inflammatory and structural enthesis changes were scored with the modified MAdrid Sonographic Enthesitis Index (MASEI). Among all patients, associations between ultrasound (US) scores and clinical characteristics were investigated using linear regression. We compared US scores of healthy volunteers and patients with PsA aged 35-60 years using Wilcoxon rank-sum tests.

RESULTS

Eighty-four patients with PsA and 25 healthy volunteers participated. In patients with PsA, we found a small association between higher inflammatory-modified MASEI score and older age (β 0.07, 95% CI 0-0.13) and current use of biologics (β 1.56, 95% CI 0.16-2.95). Patients who reported avoiding activities had significantly lower inflammatory-modified MASEI scores (β -1.71, 95% CI -3.1 to -0.32) than those who did not. The patients with PsA aged 35-60 years (n = 50) had similar inflammatory scores as healthy volunteers but higher structural scores (median 6 vs 2; p = 0.01).

CONCLUSION

Within patients with PsA, avoiding physical activity, younger age, and not using biologics were associated with less enthesis inflammation. Patients with PsA and healthy volunteers aged 35 to 60 years displayed similar levels of inflammatory changes of the entheses, but patients had more structural damage.

Influence of Disease Manifestations on Health-related Quality of Life in Early Psoriatic Arthritis

OBJECTIVE

Psoriatic arthritis (PsA) is a multifaceted disease. Affecting joints, skin, entheses, and dactylitis, its effect on health-related quality of life (HRQOL) could be substantial. We aim to assess HRQOL in patients newly diagnosed with PsA and analyze its associations with disease manifestations.

METHODS

Data collected at time of diagnosis from patients with PsA included in the Dutch south-west Early Psoriatic Arthritis cohort (DEPAR) study were used. HRQOL was assessed using 8 domains of the Medical Outcomes Study Short Form-36 (SF-36) questionnaire. Patients were classified based on primary manifestation in arthritis subtypes (i.e., mono-, oligo-, or polyarthritis) and other subtypes (i.e., enthesitis, dactylitis, and axial disease). In all patients, presence of arthritis, enthesitis, dactylitis, psoriasis, and chronic inflammatory back pain was determined. Multivariable linear regression was used to determine associations of PsA manifestations with HRQOL.

RESULTS

Of 405 patients, primary manifestation was peripheral arthritis in 320 (78 monoarthritis, 151 oligoarthritis, and 91 polyarthritis), enthesitis in 37, axial disease in 9, and dactylitis in 39. Mean scores of SF-36 domains were lower than the Dutch reference population and similar across arthritis subtypes. A higher number of enthesitis locations and tender joints, and presence of chronic back pain, were independently associated with worse SF-36 scores. Psoriasis and dactylitis were not associated with worse scores.

CONCLUSION

HRQOL was diminished in PsA at time of diagnosis compared to the Dutch reference population, and tender joints, enthesitis at clinical examination, and back pain as indicators of pain affected HRQOL.

International Treatment Recommendations Update: A Report from the GRAPPA 2016 Annual Meeting

At the 2016 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), the treatment recommendations committee summarized its work and presented its plans for future updates. The committee announced a partnership between GRAPPA and Guideline Central to develop a pocket reference guide to the treatment recommendations. Because key new data appear regularly, the group discussed publishing periodic updates of the recommendations online through the GRAPPA Website as well as a goal of publishing another major update of the recommendations in 2020. The committee also announced that 2 GRAPPA members were awarded a grant from the International League of Associations for Rheumatology to look at potential adaptations of international treatment recommendations for resource-poor settings, particularly in South America and Africa.

Whole-body Magnetic Resonance Imaging in Inflammatory Arthritis: Systematic Literature Review and First Steps Toward Standardization and an OMERACT Scoring System

OBJECTIVE

Whole-body magnetic resonance imaging (WB-MRI) is a relatively new technique that can enable assessment of the overall inflammatory status of people with arthritis, but standards for image acquisition, definitions of key pathologies, and a quantification system are required. Our aim was to perform a systematic literature review (SLR) and to develop consensus definitions of key pathologies, anatomical locations for assessment, a set of MRI sequences and imaging planes for the different body regions, and a preliminary scoring system for WB-MRI in inflammatory arthritis.

METHODS

An SLR was initially performed, searching for WB-MRI studies in arthritis, osteoarthritis, spondyloarthritis, or enthesitis. These results were presented to a meeting of the MRI in Arthritis Working Group together with an MR image review. Following this, preliminary standards for WB-MRI in inflammatory arthritides were developed with further iteration at the Working Group meetings at the Outcome Measures in Rheumatology (OMERACT) 2016.

RESULTS

The SLR identified 10 relevant original articles (7 cross-sectional and 3 longitudinal, mostly focusing on synovitis and/or enthesitis in spondyloarthritis, 4 with reproducibility data). The Working Group decided on inflammation in peripheral joints and entheses as primary focus areas, and then developed consensus MRI definitions for these pathologies, selected anatomical locations for assessment, agreed on a core set of MRI sequences and imaging planes for the different regions, and proposed a preliminary scoring system. It was decided to test and further develop the system by iterative multireader exercises.

CONCLUSION

These first steps in developing an OMERACT WB-MRI scoring system for use in inflammatory arthritides offer a framework for further testing and refinement.

Case-control Study on Dactylitis, Enthesitis, and Anterior Uveitis in Spondyloarthritis Associated with Inflammatory Bowel Diseases: Role of Coexistent Psoriasis

OBJECTIVE

To evaluate the frequency of dactylitis, enthesitis, and anterior uveitis (AU) in spondyloarthritis (SpA) associated with inflammatory bowel disease (IBD-SpA) compared with other SpA, and to assess the role of associated psoriasis in the occurrence of dactylitis and enthesitis.

METHODS

In a 12-month case-control study, the frequency of dactylitis and enthesitis in 29 patients with ulcerative colitis (UC) and 59 with Crohn disease (CD) who satisfied the Spondyloarthritis international Society criteria for axial or peripheral SpA was compared with 176 controls, including 97 (55.1%) with psoriatic arthritis (PsA), 47 (26.7%) with ankylosing spondylitis (AS), and 32 (18.2%) with nonradiographic axial SpA (nr-axSpA). The occurrence of these features in IBD-SpA with and without psoriasis was also evaluated.

RESULTS

Axial, peripheral, or mixed involvement was observed in 46 (52%), 29 (33%), and 13 (15%) patients, respectively; and 14/88 (16%) had psoriasis. Dactylitis was recorded in 4/88 patients (4.5%) with IBD-SpA and in 30 controls (17.4%; p = 0.008), enthesitis in 16 cases (18.1%) and in 78/176 controls (44.3%; p < 0.001), and AU in 3 patients (3.4%) with IBD-SpA and in 26 controls (14.7%; p = 0.01). No significant differences were found between patients with UC-SpA and those with CD-SpA. Dactylitis and enthesitis were significantly more common in patients with IBD-SpA who also had psoriasis compared to those without skin disease (p = 0.009 and 0.003, respectively).

CONCLUSION

Dactylitis, enthesitis, and AU are significantly less frequent in IBD-SpA compared with other types of SpA. Given the frequent association of psoriasis and IBD, overlooking coexistent skin disease may lead to overestimating the frequency of these features.

Ultrasound Evaluation of the Entheses in Daily Clinical Practice during Tumor Necrosis Factor-α Blocking Therapy in Patients with Ankylosing Spondylitis

OBJECTIVE

To assess structural and inflammatory ultrasound (US) lesions of entheses in ankylosing spondylitis (AS) patients with active disease and to evaluate inflammatory lesions after 6 months of tumor necrosis factor (TNF-α) blocking therapy, in daily clinical practice.

METHODS

Consecutive patients with AS were clinically evaluated and underwent US examination of 9 bilateral entheses before and after 6 months of TNF-α blocking therapy. US examination included the following as inflammatory lesions: bone erosions/cortical irregularities, enthesophytes, calcifications as structural lesions; adjacent bursitis, effusion, increased tendon hypoechogenicity or thickness; and positive power Doppler (PD) signal.

RESULTS

At baseline, 105 (95%) of 111 included patients showed US abnormalities. Structural lesions were seen in 74 patients (67%) and inflammatory lesions in 88 (79%). Enthesophytes and positive PD signal were the most prevalent structural and inflammatory lesions, respectively. Most lesions were found at the lower extremities. Additionally, inflammatory lesions occurred at the lateral epicondyle of the elbow. Patients with structural lesions at baseline were significantly older, had longer disease duration, higher modified Stoke AS Spine score, and higher C-reactive protein. Individually, there was a great diversity in changes of inflammatory entheseal lesions during treatment, but on the group level no significant decrease was found.

CONCLUSION

This prospective observational cohort study in daily clinical practice shows a high prevalence of structural and inflammatory US lesions in AS patients with longstanding and active disease. Positive PD signal was the most common inflammatory feature. No significant change in inflammatory US lesions was found after 6 months of TNF-α blocking therapy.

Performance of 3 Enthesitis Indices in Patients with Peripheral Spondyloarthritis During Treatment with Adalimumab

OBJECTIVE

To evaluate the validity of enthesitis indices in patients with peripheral spondyloarthritis (pSpA).

METHODS

The ABILITY-2 study evaluated the efficacy of adalimumab (ADA) versus placebo (PBO) in patients with active pSpA over 12 weeks. Patients received open-label ADA for an additional 144 weeks. Twenty-nine enthesitis sites used in 3 enthesitis scoring systems [Leeds Enthesitis Index (LEI), Spondyloarthritis Research Consortium of Canada (SPARCC) Enthesitis Index, Maastricht Ankylosing Spondylitis Enthesitis Score (MASES)] were assessed; discriminatory capacity and treatment response at Week 12 were calculated by standardized mean difference (SMD) and Guyatt's effect size (ES). Sites showing resolution or new-onset enthesitis from baseline to Week 12 were analyzed.

RESULTS

Overall, 165 patients (ADA, n = 84; PBO, n = 81) were randomized; 143 had ≥ 1 enthesitis site at baseline. The LEI (SMD -0.73, ES -1.07) and SPARCC (SMD -0.56, ES -0.99) enthesitis indices showed higher discriminatory ability and treatment response than MASES (SMD -0.32, ES -0.81). At Week 12, among sites that were positive at baseline, significantly more (p < 0.05) showed resolution among patients treated with ADA versus PBO in the Achilles tendon (60.4% and 36.5%, respectively), medial epicondyle (73.2%, 48.7%), lateral epicondyle (80.6%, 52.8%), and iliac crest (73.5%, 47.2%). Among negative sites at baseline, significantly less (p < 0.05) new-onset enthesitis was observed with ADA versus PBO for Achilles tendon (3.6% and 10.9%, respectively), greater trochanter (3.4%, 14.4%), lateral epicondyle humerus (4.7%, 15.1%), medial femoral condyle (1.6%, 9.2%), and quadriceps insertion superior patella (1.5%, 7.0%).

CONCLUSION

The LEI and SPARCC enthesitis indices showed better discriminatory capacity and treatment response in patients with pSpA versus MASES, likely because these indices contain more peripheral sites.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT01064856.

Psoriatic enthesitis: an update from the GRAPPA 2013 Annual Meeting

The enthesis, attachment site of ligaments, tendons, and joint capsules to bone, has emerged as a complex structure or entheseal organ that dissipates stress to maintain homeostasis. Entheses are also anatomically and functionally integrated with adjacent bursa, fibrocartilage, and synovium in a synovial entheseal complex that may trigger inflammation in response to biomechanical stress. Recent studies have suggested that inflammation in psoriatic arthritis (PsA) arises in the enthesis based on imaging and anatomical data. In this review, the anatomy of the enthesis from a functional perspective is discussed, and the data that support a central role for enthesitis in PsA are outlined. In addition, new animal models that implicate Th17 and tumor necrosis factor pathways in enthesitis are highlighted along with new data that question the primacy of the enthesis in the early stages of PsA. Finally, future studies that incorporate new technologies are outlined. Those studies may address the contribution of entheseal inflammation to initiation and perpetuation of key pathophysiologic pathways in the psoriatic joint.

Hidradenitis suppurativa associated with spondyloarthritis -- results from a multicenter national prospective study

OBJECTIVE

To determine the prevalence and characterize the inflammatory musculoskeletal symptoms of hidradenitis suppurativa (HS), a chronic inflammatory disease of skin appendages.

METHODS

Patients with HS referred to 3 dermatology university hospital centers were systematically screened for peripheral arthritis, dactylitis, inflammatory back pain, or enthesitis. After careful clinical examination, patients were further classified according to clinical and imaging criteria for spondyloarthritis (SpA) using the Amor, European Spondyloarthropathy Study Group (ESSG), and ASsessment in ankylosing spondylitis (ASAS).

RESULTS

We screened 640 patients with HS; 184 had musculoskeletal symptoms. In all, 43 (mean age 39.4 yrs, ± 8.3; 80% women) had arthritis, inflammatory back pain, or enthesitis and were investigated further. Signs of HS preceded the onset of articular symptoms in 39 patients (90%), at a mean interval of 3.6 years. A total of 18 (41%), 24 (55%), and 15 (34%) patients fulfilled the Amor, ESSG, and ASAS criteria, respectively, while synovitis, acne, pustolosis, hyperostosis, and osteitis (SAPHO) syndrome was established in 4 patients. The crude prevalence of SpA in all 640 patients with HS was 3.7% by the ESSG criteria.

CONCLUSION

SpA may occur in patients with HS, with the prevalence in this group exceeding that in the general population. The very short time between skin and joint symptom onset in some cases suggests common pathogenic mechanisms underlying HS and SpA.

Effect of Enthesitis on 1505 Brazilian Patients with Spondyloarthritis

Objective.

To analyze the clinical effect of enthesitis in a large Brazilian cohort of patients with spondyloarthritis (SpA).

Methods.

A common protocol of investigation was prospectively applied to 1505 patients with SpA in 29 centers in Brazil. Clinical and demographic variables and disease indexes were investigated. The Maastricht Ankylosing Spondylitis Enthesitis Score was used to investigate the enthesitis component. Ankylosing spondylitis was the most frequent disease in the group (65.4%). Others were psoriatic arthritis (18.4%), undifferentiated SpA (6.7%), reactive arthritis (3.3%), and enteropathic arthritis (3.2%).

Results.

At least 1 affected enthesis was observed in 54% of the patients with SpA, with a mean of 2.12 ± 2.98 entheses affected. According to the clinical presentation, enthesitis was significantly more frequent in patients with axial + peripheral joint involvement compared to isolated axial or peripheral involvement (p < 0.001). There was a statistical association between the presence of enthesites and axial symptoms (buttock pain, cervical pain, and hip pain), and peripheral symptoms (lower limb arthritis, number of painful and swollen joints; p < 0.05). Patients with enthesitis also presented higher mean scores of Bath Ankylosing Spondylitis Functional Index (BASFI; p < 0.001), Bath Ankylosing Spondylitis Disease Activity Index (p < 0.001), and Ankylosing Spondylitis Quality of Life (ASQoL; p < 0.001). Multivariate logistic regression showed that BASFI (p < 0.0001; OR 74.839), ASQoL (p = 0.0001; OR 14.645), and Achilles tendonitis (p = 0.0059; OR 7.593) were associated with work incapacity.

Conclusion.

The clinical presence of enthesitis in this large cohort of patients with SpA was frequent and was associated with a significant increase in disease activity and decline in functional capacity and quality of life.