Evaluation of the comorbidity burden in patients with ankylosing spondylitis using a large US administrative claims data set

Association of Therapies for Axial Spondyloarthritis on the Risk of Hip and Spine Fractures

OBJECTIVE

People with axial spondyloarthritis (axSpA) have increased fracture risk relative to the general population, possibly related to chronic inflammation. We assessed the impact of treatment with receiving tumor necrosis factor inhibitors (TNFis) and nonbiologic conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) on hip and spine fractures in patients with axSpA, relative to receiving nonsteroidal anti-inflammatory drugs (NSAIDs).

METHODS

We conducted a nested case-control study using 2006 to 2021 data from the Merative MarketScan Database. We included adults 18 to 65 years old with at least one inpatient or at least two outpatient axSpA International Classification of Diseases, Ninth Revision (ICD-9), or International Classification of Diseases, Tenth Revision (ICD-10), diagnosis codes separated by at least seven days. The primary outcome was hip and/or spine fracture, defined by ICD-9 or ICD-10 diagnosis or procedure codes. For each patient with fracture (cases), we selected up to 10 controls without fracture. We evaluated medication exposure (TNFis, csDMARDs, NSAIDs [referent], or none) hierarchically using pharmacy claims and procedure codes. We assessed the relation of medication exposure with hip and spine fracture risk using unconditional logistic regression with confounder adjustment.

RESULTS

Our main analysis included 13,519 individuals with axSpA, comprising 1,229 patients with fracture and 12,290 controls. Individuals receiving TNFis had 29% lower odds of fracture compared to those receiving NSAIDs (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.59-0.85), accounting for age, sex, and diagnosis year. Results were similar in the fully adjusted model (OR 0.75, 95% CI 0.62-0.91) and when stratified by sex.

CONCLUSION

Using a large US insurance claims database, we found evidence for a protective effect of receiving TNFis on fracture risk in patients with axSpA underscoring a potential impact of TNFis in diminishing comorbidities linked with axSpA.

Incidence rates of tuberculosis and inflammatory bowel disease in patients with ankylosing spondylitis treated with biologics in Korea

OBJECTIVE

To describe the incidence rates of inflammatory bowel disease (IBD) and tuberculosis (TB) in Korean patients with ankylosing spondylitis receiving biologics.

METHODS

Data from a Korean claims database between 2010 and 2021 was used to calculate crude incidence rates of TB and IBD using number of events and total patient-years (PYs).

RESULTS

Overall, 43 643 and 43 396 patients were included in TB and IBD cohorts, respectively. Exposure-adjusted incidence rates (EAIRs) of TB for non-exposure, TNF inhibitors (TNFis), and IL-17 inhibitors (IL-17is) were 0.14, 0.25 and 0.12 and of IBD were 0.18, 0.19 and 0.44 per 100 PYs, respectively. Incidence rates during biologic DMARD (bDMARD) non-exposure, adalimumab, etanercept, golimumab, infliximab, secukinumab and ixekizumab exposures for TB were 13.96, 27.79, 14.28, 21.19, 33.62, 12.74 and 0.00 and for IBD were 18.29, 19.98, 22.41, 18.85, 15.73, 44.99 and 0.00 per 10 000 PYs, respectively. Compared with bDMARD non-exposure, adalimumab, golimumab and infliximab exposures were associated with a significantly higher risk of TB. Etanercept and secukinumab exposure showed no significant increase in risk of TB. Compared with bDMARD non-exposure, exposure to biologics did not show a significant difference in risk of IBD.

CONCLUSION

EAIRs of TB and IBD with use of IL-17is in patients with AS were within anticipated low range. IL-17is had numerically lower incidence of TB, and numerically higher incidence of IBD compared with TNFis. Notably, secukinumab showed no increased risk of TB compared with bDMARD non-exposure. Neither TNFis nor IL-17is showed increased risk of IBD compared with bDMARD non-exposure.

Analysis of sleep disorders and their influencing factors in patients with ankylosing spondylitis

OBJECTIVES

Sleep disorders are a common symptom in Ankylosing Spondylitis (AS) patients. In this cross-sectional study, we aimed to understand the current status of sleep disorders in AS patients and to analyze potential factors influencing sleep disorders.

METHODS

A total of 205 AS patients were recruited in the survey. The content included the self-designed demographic data questionnaire, The MOS 36-Item Short Form Health Survey (SF-36), Visual Analogue Scale (VAS), Multidimensional Fatigue Inventory (MF-20), Self-Rating Anxiety and Depression Scale, Pittsburgh Sleep Quality Index questionnaire (PSQI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Metrology Index (BASMI). These data were analyzed using chi-square test, independent sample t-test, Mann-Whitney U test, Pearson correlation analysis, single-factor linear regression analysis, and multiple linear stepwise regression analysis.

RESULTS

The results showed that the average sleep total score was 8.82 ± 4.146, and the prevalence of sleep disorders was approximately 66.8% in AS patients. Age (F = 29.710, P < 0.001), disease duration (F = 13.025, P < 0.001), anxiety (F = 36.060, P < 0.001), depression (F = 11.808, P < 0.001), and quality of life (t = 6.665, P < 0.001) significantly impacted the sleep total score. Pearson correlation analysis revealed a significant negative correlation between SF-36 total score and sleep total score (r = ‒0.449, P < 0.01), while positive correlations were observed for VAS score, fatigue, anxiety, depression, BASDAI, BASFI, BASMI, age, and disease duration (all P < 0.01). Multivariate analysis showed that age, disease duration, nocturnal pain VAS score, total back pain VAS score, peripheral joint pain VAS score, total fatigue score, total anxiety score, and BASMI total score significantly predicted sleep total score (R² = 0.755, F = 45.334, P < 0.001).

CONCLUSION

These findings suggest that medical professionals should pay increased attention to the observed associations between sleep disorders and clinical factors in AS patients, and consider implementing targeted interventions to address sleep-related issues.

Comprehensive Update on Multiple Sclerosis-Associated Uveitis and New Epidemiological Insights from the United Kingdom

Multiple sclerosis (MS)-associated uveitis is characterised most frequently by bilateral intermediate uveitis with peripheral vascular leakage or panuveitis. The interesting association between these autoimmune diseases, which develop in two immune-privileged sites, places some undifferentiated uveitis patients at heightened risk of demyelination and clinical MS precipitation from the use of licensed anti-tumour necrosis factor α (TNFα) biologic therapy. However, their association may also open novel treatment avenues, considering the rapidly expanding arsenal of highly effective MS disease-modifying therapies. Here, we offer new data on MS-uveitis from the first national population-representative matched case-control and cohort study, using IQVIA medical research data (IMRD-UK), a primary care database of 11 million people. Amongst 25 thousand uveitis cases, patients with (any) uveitis are nearly three times more likely than matched controls to develop MS by 15 years follow-up (adjusted Hazard 2.7 (95% CI 2.1-3.6, p < 0.001)), but the proportion of MS-uveitis is low overall (0.72%, 180/24,895 uveitis cases). What tools might enhance MS risk stratification in uveitis patients in the future? In this comprehensive narrative review, we summarise primary observational data informing our epidemiological understanding of the association between MS and uveitis, and its variable clinical presentations, to highlight the state of play, and the important questions that remain in MS-uveitis.

The causal relationship between obstructive sleep apnea and rheumatic disease: A bidirectional Mendelian randomization study

Background and Objective

Multiple studies have shown a substantial association between obstructive sleep apnea (OSA) and rheumatic disease. However, traditional studies are susceptible to confounding factors or reverse causal relationships, and the exact causal relationship still needs to be clearly defined. This study aims to use a bidirectional two-sample Mendelian randomization (MR) analysis to investigate the causal association between OSA and rheumatoid immune diseases.

Methods

We conducted a two-sample bidirectional MR analysis by using large-scale genome-wide association studies (GWAS) summary statistics to investigate whether there is a causal relationship between OSA and rheumatic disease. Inverse variance weighted (IVW) was used as the primary analysis approach, supplemented by MR-Egger and Weighted median methods. Sensitivity analyses were conducted to ensure the robustness of the results.

Results

The MR predicted ankylosing spondylitis (AS) was associated with risk of OSA (IVW: OR = 1.0239, 95% CI = 1.0086 to 1.0394, P = 0.0021; MR-Egger: OR = 1.0374, 95% CI = 1.0089 to 1.0668, P = 0.0326; weighted median: OR = 1.0287, 95% CI = 1.0109 to 1.0467, P = 0.0014). However, no bidirectional causal association was found between other rheumatic disease and OSA. The sensitivity analysis confirmed the robustness of the results.

Conclusions

Our analysis suggests a potential causal relationship between AS and OSA. There was no direct causal relationship between OSA and other rheumatic disease. We need more experimental research on specific pathological and physiological mechanisms in the future.

Spondyloarthritis and Risk of Malignancy: A Narrative Review on a Still Controversial Issue

Current literature regarding cancer risk in rheumatic and musculoskeletal diseases (RMDs) is particularly poor and controversial, even though the incidence of malignancy in some patients with RMDs is considered to be increased compared with the general population. Malignancy may be a major comorbidity in subjects with spondyloarthritis (SpA) as the result of multifactorial mechanisms, from disease pathogenesis to the iatrogenic effect of immunomodulating drugs. Several recommendations for screening and management of cancer risk have been developed in recent years with the aim of improving the different outcomes in these patients. The goal of this narrative review is to provide an overview of the currently available evidence on the risk of malignancy connected with RMDs and examine the association of SpA with cancer and the potential impact of its treatment with biologic and targeted synthetic disease-modifying anti-rheumatic drugs on development of malignancy.

Sleep disorders in rheumatoid arthritis, axial spondyloarthritis and psoriatic arthritis

Sleep disorders are relatively common among patients with inflammatory arthritis (IA) and have a substantial impact on their quality of life. Although patients frequently recognize poor sleep as an important component of their disease, dyssomnias remain often underdiagnosed and untreated in routine clinical practice. This narrative review examines the prevalence, mechanism, risk factors and management of dyssomnias in rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA). Relevant articles were retrieved from PUBMED, Scopus and DOAJ. The pathomechanism of sleep disorders in IA is multifactorial and partially differs in RA, axSpA and PsA, however, comparative studies are lacking. Various factors affecting sleep quality, including disease activity, pain, mood disorders, fatigue and female gender, have been examined, but their interplay complicates establishing clear causal relationships. The bidirectional link between sleep quality and rheumatic disease activity highlights the complexity of this issue and demonstrates the importance of holistic management of rheumatic patients. Both pharmacological (e.g., hypnotics, NSAIDs, antidepressants, cannabidiol) and non-pharmacological (e.g., psychotherapy, physical activity) interventions for improving sleep were analyzed. Additionally, questionnaires currently used for assessing sleep were discussed. This review aims to provide a comprehensive overview of sleep disorders across the three most common types of IA, emphasizing the need to develop reliable and patient-friendly tools for everyday clinical practice and further comparative research.

Association between ankylosing spondylitis and neurodegenerative diseases: Systematic review and meta-analysis

BACKGROUND

Increasing evidence indicates the mechanism of overlapping immune dysfunction and inflammation disorder shared by ankylosing spondylitis (AS) and neurodegenerative diseases (NDs). However, the exact correlation between the two is still unclear. Different studies have reported inconsistent results about how AS and NDs are related.

OBJECTIVE

This study aimed to investigate the association between AS and risk of NDs.

METHODS

We searched electronic databases including PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials to identify studies reporting relationship between NDs risk and AS published before April 10th, 2024. Pooled odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) were estimated. All analyses were conducted using Stata V.12.0 software.

RESULTS

A total of 15 comparisons out of 10 studies involving 851,936 participants were included. The results showed that the risk of NDs was higher among AS patients than those who were not (OR: 1.36, 95% CI: 1.15-1.60, P<0.001). In addition, subgroup analysis showed that AS was associated with an increased risk of Parkinson's disease (PD) development (OR: 1.55, 95% CI: 1.31-1.83, P<0.001), whereas there is no observed association with Alzheimer's disease (AD) and dementia (OR: 1.22, 95% CI: 0.96-1.55, P=0.098; OR: 1.34, 95% CI: 0.96-1.87, P=0.089, respectively).

CONCLUSION

The current meta-analysis identified AS as a risk factor for the development of NDs. Clinicians should be aware of the potential association between these diseases. Further research is necessary to confirm the causal relationship and underlying mechanisms between AS and NDs.

Opioid Treatment for Adults With and Without Systemic Autoimmune/Inflammatory Rheumatic Diseases: Analysis of 2006-2019 United States National Data

OBJECTIVES

This study compared opioid prescribing among ambulatory visits with systemic autoimmune/inflammatory rheumatic diseases (SARDs) or without and assessed factors associated with opioid prescribing in SARDs.

METHODS

This cross-sectional study used the National Ambulatory Medical Care Survey between 2006 and 2019. Adult (≥18 years) visits with a primary diagnosis of SARDs, including rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or systemic lupus erythematosus were included in the study. Opioid prescribing was compared between those with vs without SARDs using multivariable logistic regression accounting for the complex survey design and adjusting for predisposing, enabling, and need factors within Andersen's Behavioral Model of Health Services Use. Another multivariable logistic regression examined the predictors associated with opioid prescribing in SARDs.

RESULTS

Annually, an average of 5.20 million (95% confidence interval [CI] 3.58-6.82) visits were made for SARDs, whereas 780.14 million (95% CI 747.56-812.72) visits were made for non-SARDs. The SARDs group was more likely to be prescribed opioids (22.53%) than the non-SARDs group (9.83%) (adjusted odds ratio [aOR] 2.65; 95% CI 1.68-4.18). Among the SARDs visits, patient age from 50 to 64 (aOR 1.95; 95% CI 1.05-3.65 relative to ages 18-49) and prescribing of glucocorticoids (aOR 1.75; 95% CI 1.20-2.54) were associated with an increased odd of opioid prescribing, whereas private insurance relative to Medicare (aOR 0.50; 95% CI 0.31-0.82) was associated with a decreased odds of opioid prescribing.

CONCLUSION

Opioid prescribing in SARDs was higher compared to non-SARDs. Concerted efforts are needed to determine the appropriateness of opioid prescribing in SARDs.

Risk of cardiovascular disease decreases over time in psoriatic arthritis but not in spondylarthritis: meta-analysis of longitudinal studies

OBJECTIVE

SpA and PsA represent two frequent inflammatory rheumatic disorders characterized by an increased burden on quality of life due to the association of several comorbidities, especially cardiovascular disease (CVD). The estimated prevalence of CVD ranges from 12 to 19% and differs between the two diseases, however, the incidence of CVD is not completely known. We aimed to systematically review the literature and perform a meta-analysis of controlled observational studies to assess the incidence rate of CVD over time in SpA and PsA.

METHODS

We performed a systematic literature review (SLR) of longitudinal studies with a study period of at least 5 years, including SpA/PsA patients and general population. The main outcome was the occurrence of CVD, including ischaemic heart disease, stroke and death from CV causes. We then performed a random-effects model for meta-analysis.

RESULTS

The SLR included 34 articles, mainly focused on the association between SpA/PsA and CVD. Twenty-four articles were then selected for the meta-analysis. The overall incidence of CVD was increased in PsA [hazard ratio (HR) 1.28 (95% CI 1.15, 1.43)] and in SpA [HR 1.45 (95% CI 1.22, 1.72)] compared with the general population, with consistency across the different types of CVDs. Interestingly the incidence tended to decrease over time in PsA but not in SpA.

CONCLUSION

The SLR and meta-analysis confirmed the increased incidence of CVD in both SpA and PsA patients compared with the general population, although the increase seems to be less prominent in PsA than in SpA. Future studies are needed to confirm our findings.

[H3K27me3 Expression Level and Its Epigenetic Regulation Mechanisms in Th17 Cell Differentiation in Patients With Ankylosing Spondylitis]

Objective

To investigate the roles of histone H3K27me3 methylation and its regulatory enzymes JMJD3 and EZH2 in the differentiation of Th17 cells in ankylosing spondylitis (AS), to unveil their potential involvement in the pathogenesis of AS, and to provide new strategies and targets for the clinical treatment of AS by analyzing the methylation state of H3K27me3 and its interactions with Th17-related factors.

Methods

A total of 84 AS patients (42 active AS patiens and 42 patients in the stable phase of AS) were enrolled for the study, while 84 healthy volunteers were enrolled as the controls. Blood samples were collected. Peripheral blood mononuclear cells were isolated. ELISA assay was performed to examine Th17 cells and the relevant cytokines IL-21, IL-22, and IL-17. The mRNA expressions of RORc, JAK2, and STAT3 were analyzed by RT-PCR, the protein expressions of RORc, JAK2/STAT3 pathway protein, H3K27me3 and the relevant protease (EZH2 and JMJD3) were determined by Western blot. Correlation between H3K27me3, EZH2 and JMJD3 and the key signaling pathway molecules of Th cell differentiation was analyzed by Pearson correlation analysis.

Results

The mRNA expressions of RORc, JAK2, and STAT3 were significantly higher in the active phase group than those in the stable phase group ( P<0.05). The relative grayscale values of H3K27me3 and EZH2 in the active phase group were lower than those of the stable phase group, which were lower than those of the control group, with the differences being statistically significant ( P<0.05). The relative grayscale values of JMJD3, RORc, JAK2, pJAK2, STAT3, and pSTAT3 proteins were significantly higher in the active phase group than those in the stable phase group, which were higher than those in the control group (all P<0.05). The proportion of Th17 and the expression level of inflammatory factors in the active period group were higher than those in the other two groups (P<0.05). H3K27me3 was negatively correlated with RORc, JAK2, STAT3, and IL-17, JMJD3 was positvely correlated with JAK2, STAT3, and IL-17, and EZH2 was negatively correlated with JAK2, STAT3, and IL-17 (all P<0.05).

Conclusion

The low expression of H3K27me3 in AS is influenced by the gene loci JMJD3 and EZH2, which can regulate the differentiation of Th17 cells and thus play a role in the pathogenesis and progression of AS.

Relationship Between Ankylosing Spondylitis and Cerebrovascular Disorders: A Systematic Review

Cerebrovascular events are linked to ankylosing spondylitis. Accelerated atherosclerosis and endothelial dysfunction against a backdrop of inflammation have been widely blamed for the increased cerebrovascular risk in ankylosing spondylitis. The absence of a comprehensive review encouraged us to consider the link between ankylosing spondylitis and cerebrovascular diseases. Web of Science, PubMed, Medline, Scopus, and EMBASE were searched to identify studies published from 2000 to June 10, 2023. All observational and cohort studies reporting myocardial infarction or stroke and considering classic cerebrovascular risk in ankylosing spondylitis patients and healthy controls were included. Most of the included studies reported that the risk of cerebrovascular disorders was greater in ankylosing spondylitis than in the general population. Also, most studies showed that for both sexes, the prevalence of cardiovascular illnesses rose with age, and this trend was consistent across all subgroups of cardiovascular disorders. Also, most studies reported that the rate of cerebrovascular accidents in ankylosing spondylitis patients was higher than in control groups. Some studies reported that the risk of developing an ischemic stroke was higher in young patients with ankylosing spondylitis, while others did not. Our systematic analysis found that most studies agreed that ankylosing spondylitis patients had a higher risk of cerebrovascular diseases than the general population. Still, this increased risk was influenced by several factors that need further research exploration.

Pain in axial spondyloarthritis: role of the JAK/STAT pathway

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that is characterized by new bone formation in the axial musculoskeletal system, with X-ray discriminating between radiographic and non-radiographic forms. Current therapeutic options include non-steroidal anti-inflammatory drugs in addition to biological disease-modifying anti-rheumatic drugs that specifically target tumor necrosis factor-alpha (TNFα) or interleukin (IL)-17. Pain is the most critical symptom for axSpA patients, significantly contributing to the burden of disease and impacting daily life. While the inflammatory process exerts a major role in determining pain in the early phases of the disease, the symptom may also result from mechanical and neuromuscular causes that require complex, multi-faceted pharmacologic and non-pharmacologic treatment, especially in the later phases. In clinical practice, pain often persists and does not respond further despite the absence of inflammatory disease activity. Cytokines involved in axSpA pathogenesis interact directly/indirectly with the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) signaling cascade, a fundamental component in the origin and development of spondyloarthropathies. The JAK/STAT pathway also plays an important role in nociception, and new-generation JAK inhibitors have demonstrated rapid pain relief. We provide a comprehensive review of the different pain types observed in axSpA and the potential role of JAK/STAT signaling in this context, with specific focus on data from preclinical studies and data from clinical trials with JAK inhibitors.

Long-term safety of Ixekizumab in adults with psoriasis, psoriatic arthritis, or axial spondyloarthritis: a post-hoc analysis of final safety data from 25 randomized clinical trials

BACKGROUND

We report long-term, end-of-study program safety outcomes from 25 randomized clinical trials (RCTs) in adult patients with psoriasis (PsO), psoriatic arthritis (PsA), or axial spondyloarthritis (axSpA) [including ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA)] who received ≥ 1 dose of Ixekizumab (IXE) over 5 years (PsO) or up to 3 years (PsA, axSpA).

METHODS

This integrated safety analysis consists of data from patients who received any dose of IXE, across 25 RCTs (17 PsO, 4 PsA, 4 axSpA). Rates of treatment-emergent adverse events (TEAEs), serious adverse events (SAEs) and selected adverse events (AEs) of interest were analyzed for all pooled studies by years of therapy and overall, through March 2022. Results were reported as exposure-adjusted incidence rates (IRs) per 100 patient-years (PY) overall and at successive year intervals.

RESULTS

Six thousand eight hundred ninety two adult patients with PsO, 1401 with PsA, and 932 with axSpA (including AS and nr-axSpA), with a cumulative IXE exposure of 22,371.1 PY were included. The most commonly reported TEAE across indications was nasopharyngitis (IRs per 100 PY: 8.8 (PsO), 9.0 (PsA), 8.4 (axSpA)). SAEs were reported by 969 patients with PsO (IR 5.4), 134 patients with PsA (IR 6.0), and 101 patients with axSpA (IR 4.8). Forty-five deaths were reported (PsO, n = 36, IR 0.2; PsA, n = 6, IR 0.3; axSpA, n = 3, IR 0.1). TEAEs did not increase during IXE exposure: IRs per 100 PY, PsO: 88.9 to 63.2 (year 0-1 to 4-5), PsA: 87 to 67.3 (year 0-1 to 2-3), axSpA: 82.1 to 55.4 (year 0-1 to >  = 2). IRs per 100 PY of discontinuation from IXE due to AE were 2.9 (PsO), 5.1 (PsA), and 3.1 (axSpA). IRs per 100 PY of injection site reactions were 5.9 (PsO), 11.6 (PsA) and 7.4 (axSpA); Candida: 1.9 (PsO), 2.0 (PsA), and 1.2 (axSpA); depression, major adverse cerebro-cardiovascular events and malignancies: ≤ 1.6 across all indications. Adjudicated IRs per 100 PY of inflammatory bowel disease were ≤ 0.8 across indications (0.1 [PsO]; 0.1 [PsA]; 0.8 [axSpA]).

CONCLUSIONS

In this integrated safety analysis, consisting of over 22,000 PY of exposure, the long-term safety profile of IXE was found to be consistent with previous, earlier reports, with no new safety signals identified.

TRIAL REGISTRATION

NCT registration numbers for RCTs included in this integrated analysis can be found in Additional File 1.

Trends in Fracture Rates Over Two Decades Among Veterans With Ankylosing Spondylitis

OBJECTIVE

There is an increased risk of fracture in individuals with ankylosing spondylitis (AS) compared to the general population, possibly due to systemic inflammatory effects. The use of tumor necrosis factor inhibitors (TNFi) may reduce fracture risk by inhibiting inflammation. We assessed fracture rates in AS versus non-AS comparators and whether these rates have changed since the introduction of TNFi.

METHODS

We used the national Veterans Affairs database to identify adults ≥18 years old with ≥1 International Classification of Diseases, Ninth Revision (ICD-9)/ICD-10 code for AS and at least 1 disease-modifying antirheumatic drug prescription. As comparators, we selected a random sample of adults without AS diagnosis codes. We calculated fracture incidence rates for AS and comparators, with direct standardization to the cohort structure in 2017. To compare fracture rates from 2000 to 2002 (pre-TNFi) versus 2004-2020 (TNFi era), we performed an interrupted time series analysis.

RESULTS

We included 3,794 individuals with AS (mean age 53 years, 92% male) and 1,152,805 comparators (mean age 60 years, 89% male). For AS, the incidence rate of fractures increased from 7.9/1,000 person-years in 2000 to 21.6/1,000 person-years in 2020. The rate also increased among comparators, although the ratio of fracture rates (AS/comparators) remained relatively stable. In the interrupted time series, the fracture rate for AS patients in the TNFi era was nonsignificantly increased compared to the pre-TNFi era.

CONCLUSION

Fracture rates have increased over time for both AS and non-AS comparators. The fracture rate in individuals with AS did not decrease after TNFi introduction in 2003.

Extra-musculoskeletal manifestations driving the therapeutic decision-making in patients with Spondyloarthritis: a 12-month follow-up prospective cohort study

BACKGROUND

The extra-musculoskeletal manifestations (EMMs) such as recurrent acute anterior uveitis (rAAU), psoriasis (Ps), and inflammatory bowel disease (IBD), are related to the Spondyloarthritis (SpA), as well as they are associated with disease activity and poor prognosis. However, there are no data addressing its relevance regarding therapeutic decision-making in clinical practice.

OBJECTIVE

To evaluate the impact of EMMs to drive the treatment decision-making in patients with SpA in a 12-month follow-up.

PATIENTS AND METHODS

SpA patients, according to the axial and peripheral ASAS classification criteria, as well as CASPAR criteria, with any active EMM, defined as main entry criteria, were included in this longitudinal cohort study. Individuals with a history of any disease or condition that could be associated with some of the studied endpoints, including neoplasms and infectious diseases, were excluded. Specific tools related to each EMM, including Psoriasis Area Severity Index (PASI), ophthalmologic evaluation, according to the Standardization of Uveitis Nomenclature (SUN) criteria, and gut complaints were used at baseline and during the 3-, 6- and 12-month of follow-up as outcomes measures over time. Descriptive and inferential analyses were used appropriately, including Pearson's correlation test, chi-squared test, and ANOVA. P value less than 0.05 was considered as significant.

RESULTS

A total of 560 patients were enrolled, of whom 472 meet the eligibility criteria. The majority (N = 274; 59.6%) had one or more EMM related to SpA umbrella concept. Among the EMM, the one that most influenced therapeutic decision-making was psoriasis (28.5%), followed by uveitis (17.5%) and IBD (5.5%), regardless of musculoskeletal manifestations. Clinical improvement of EMMs outcomes was observed in most patients over 12-month follow-up, especially in those with rAAU and IBD (P < 0.001).

CONCLUSION

Our results showed that EMMs guided the therapeutic decision-making in half of SpA patients, regardless of musculoskeletal condition, suggesting the inter-disciplinarity among the rheumatologist, ophthalmologist, dermatologist, and gastroenterologist plays a crucial role to manage them.

Prevalence of sleep disturbance in patients with ankylosing spondylitis: a systematic review and meta-analysis

BACKGROUND

Ankylosing Spondylitis (AS) patients face several challenges due to the nature of the disease and its physical and psychological complications. Sleep disorders are among the most important concerns. Sleep disorders can aggravate the signs and symptoms of the disease and ultimately reduce the quality of patients' lives. This study uses a systematic review and meta-analysis to pool the reported prevalence of sleep disorders among AS patients.

METHODS

To find related studies, the WoS, PubMed, ScienceDirect, Scopus, Embase, and Google Scholar databases were systematically searched without a lower time limit. Heterogeneity among the identified studies was checked using the I2 index, and the Begg and Mazumdar correlation test examined the existence of published bias. Comprehensive Meta-Analysis (v.2) software was adopted to analyze the data.

RESULTS

In the review of 18 studies with a sample size of 5,840, the overall pooled prevalence of sleep disorders among AS patients based on the random effects method was found to be 53% (95% CI: 44.9-61). The highest and lowest prevalence was in Egypt at 90% and Australia at 19.2%, respectively. Our meta-regression results show that with the increase in 'sample size' and 'year of publication', the overall prevalence of sleep disorders in patients with AS decreases (p < 0.05).

CONCLUSION

The results of the present study indicate a high and significant prevalence of sleep disorders among AS patients. Thus, health policymakers and healthcare providers must focus on timely diagnosis and effective educational and therapeutic interventions for the prevention and proper treatment of sleep disorders in this population of patients.

Therapeutic consequences in patients with both inflammatory rheumatic diseases and multiple sclerosis

Dealing with patients with both multiple sclerosis (MS) and inflammatory rheumatic disorders (IRDs) is not uncommon for a rheumatologist, as there is a statistical association between SpA and MS. As several CNS demyelinating events have been reported in patients treated with TNF inhibitor (TNFi), the pre-existing demyelinating disease was considered a contraindication for TNFi. However, this contraindication is mainly based on a randomized controlled trial in MS and not on large epidemiological studies. According to the last epidemiological studies, TNFi might not be an inducer of MS. Moreover, there are no clear recommendations on the use of the other DMARDs in patients suffering from an IRD and MS. In this review, we summarize the link between MS and IRDs and the impact of DMARDs on MS, especially TNFi. We also look at the impact of disease-modifying drugs for adults with MS and IRDs.

The International Map of Axial Spondyloarthritis Survey: A US Patient Perspective on Diagnosis and Burden of Disease

OBJECTIVE

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that causes inflammation in the axial skeleton, resulting in structural damage and disability. We aimed to understand the effect of axSpA on work activity, day-to-day function, mental health, relationships, and quality of life and to examine barriers to early diagnosis.

METHODS

A 30-minute quantitative US version of the International Map of Axial Spondyloarthritis survey was administered online to US patients aged 18 years and older with a diagnosis of axSpA who were under the care of a health care provider from July 22 to November 10, 2021. This analysis describes demographics, clinical characteristics, journey to axSpA diagnosis, and disease burden.

RESULTS

We surveyed 228 US patients with axSpA. Patients had a mean diagnostic delay of 8.8 years, with a greater delay in women versus men (11.2 vs. 5.2 years), and 64.5% reported being misdiagnosed before receiving an axSpA diagnosis. Most patients (78.9%) had active disease (Bath Ankylosing Spondylitis Disease Activity Index score ≥4), reported psychological distress (57.0%; General Health Questionnaire 12 score ≥3), and experienced a high degree of impairment (81.6%; Assessment of Spondyloarthritis International Society Health Index score ≥6). Overall, 47% of patients had a medium or high limitation in activities of daily living, and 46% were not employed at survey completion.

CONCLUSION

The majority of US patients with axSpA had active disease, reported psychological distress, and reported impaired function. US patients experienced a substantial delay in time to diagnosis of axSpA that was twice as long in women versus men.

Increased Risk of Acute Coronary Syndrome in Ankylosing Spondylitis Patients With Uveitis: A Population-Based Cohort Study

Background

Uveitis, a sight-threatening ocular inflammatory state, is associated with autoimmune diseases and systemic inflammation. This prolonged systemic inflammation may cause plaque formation in coronary arteries, subsequently resulting in acute coronary syndrome (ACS).

Methods

This retrospective, population-based study (15-year period) used the Longitudinal Health Insurance Database based on the National Health Insurance Research Database in Taiwan. Chi-square and Student's t-tests were used to examine differences between the study and comparison cohorts for categorical and continuous variables, respectively. Fine and Gray's competing risk model was used to determine the hazard ratio of the risk of ACS. Furthermore, the cumulative risk of ACS was determined using Kaplan-Meier analysis.

Results

A total of 1,111 patients with AS and uveitis were enrolled in this study cohort, and 4,444 patients with AS without uveitis were enrolled in the comparison cohort. After adjustment for age, sex, and comorbidities, patients with AS and uveitis demonstrated an increased risk of ACS compared to those without uveitis (adjusted hazard ratio: 1.675, p<0.001). In addition, Kaplan-Meier analysis revealed that patients with AS and uveitis had a significantly higher risk of ACS than those without uveitis (p<0.001). Age, diabetes mellitus, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, asthma, and systemic steroids were significant risk factors for ACS. Both anterior uveitis and posterior segment involvement were associated with an increased risk of ACS in patients with AS. All-cause mortality was higher in the uveitis group (9.81%) than in the non-uveitis group (8.10%) (p=0.015).

Conclusion

Our analysis revealed that uveitis could potentially be a predictor of ACS in patients with AS. However, further prospective controlled studies are required to assess the association between uveitis and ACS in patients with AS.

Mortality rates in patients with ankylosing spondylitis with and without extra-articular manifestations and co-morbidities: A retrospective cohort study

Objective

To examine the mortality rates in hospitalised patients with ankylosing spondylitis (AS), and the association of extra-articular manifestations (EAM) and co-morbidities with mortality rates.

Methods

The study was a retrospective population-based cohort study using linked administrative data of hospitalised AS patients (n=1,791) and a matched comparison group (n=8,955). Mortality data for patients were obtained from the Western Australian Death Register. The presence of EAM and co-morbidities were identified from hospital records. Mortality rates were compared between the two groups using Cox proportional hazard models, overall and stratified by a history of EAM, comorbidities and smoking status.

Results

Crude mortality rates were significantly higher in AS patients than the comparison group (HR:1.85, 95%CI:1.62-2.12) with excess mortality in the AS group associated with cardiovascular disease (HR:5.32, 95%:3.84-7.35), cancer (HR:1.68, 95%CI:1.27-2.23), external causes (HR:3.92, 95%CI:2.28-6.77) and infections (HR:25.92, 95%CI:7.50-89.56). When patients were stratified by a history of EAM, cardiovascular disease, and smoking the risk of mortality was elevated in both patients with and without each risk factor. Within patients with AS, a history of cardiovascular disease (HR:6.33, 95%CI:4.79-8.38), diabetes (HR:2.81, 95%CI:1.99-3.95), smoking (HR:1.49, 95%CI:1.18-1.89) and EAM (HR:1.62, 95%CI: 1.24–2.11) were associated with an increased risk of mortality.

Conclusion

The presence of co-morbidities, EAMs, and smoking contribute to an increased risk of all-cause mortality in hospitalised AS patients compared to the comparison group. These results support the need to prevent or reduce the occurrence of co-morbidity and smoking in AS patients.

A Road Map of the Axial Spondyloarthritis Continuum

Axial spondyloarthritis (axSpA) is a chronic, immune-mediated inflammatory disease characterized by inflammatory low back pain, inflammation in peripheral joints and entheses, and other extra-articular or systemic manifestations. Although our understanding of the natural history of axSpA has been limited by incomplete knowledge of disease pathogenesis, axSpA is increasingly understood as a spectrum of axial, peripheral, and extra-articular inflammatory conditions that includes nonradiographic axSpA and radiographic axSpA, also known as ankylosing spondylitis. In this narrative review, we present a road map of this axSpA continuum, highlighting genetic risk factors for the development of axSpA, triggers of disease, and reasons for and implications of diagnostic delay. We present a detailed overview of the spectrum of axSpA clinical manifestations and highlight factors known to influence the risk of disease progression. Finally, we provide some expert commentary on the practical use of this road map to assist health care providers in the identification of axSpA in clinical practice.

Tumor necrosis factor inhibitor (TNFi) persistence and reasons for discontinuation in a predominantly male cohort with axial spondyloarthritis

Although tumor necrosis factor inhibitors (TNFi) have favorably altered the treatment landscape for patients with axial spondyloarthritis (axSpA), there is limited data regarding TNFi persistence and reasons for discontinuation. This is an observational time-to-event study utilizing data collected for a prospective multiple-disease registry of US Veterans with axSpA treated with TNFi therapies and recruited over a 10 year period. Clinical, serological, and comorbid parameters were collected. Corporate Data Warehouse Pharmacy files provided courses of the 5 TNFi agents, and response to treatment was documented. Individual TNFi persistence was established utilizing univariate and multivariate Cox proportional models, and reasons for discontinuation were obtained by physician chart review. Two-hundred and fifty-five axSpA patients received 731 TNFi courses. A majority of patients (84.3%) had TNFi persistence at 12 months; 63.5% and 47.1% at 24 and 36 months, respectively. Compared to adalimumab, infliximab demonstrated greater persistence, certolizumab the least. Age, smoking status, BMI, comorbidity burden, inflammatory markers and HLA-B27 did not predict TNFi persistence or discontinuation. Stroke and peripheral arterial disease increased the probability of TNFi discontinuation. Secondary non-response (SNR) was the most common reason for discontinuation (46% of all courses); non-adherence (6%) and clinical remission (2%) were uncommon. Pain score at enrollment, myocardial infarction, African American race and inflammatory bowel disease (IBD) predicted TNFi response. While initial persistence of TNFi treatment was high, a large proportion of the patients discontinued initial TNFi therapy by 3 years, primarily due to loss of efficacy. While further research identifying potential predictors of TNFi discontinuation in axSpA is warranted, access to alternate disease-modifying therapies is needed.

Prevalence and factors related to sleep apnoea in ankylosing spondylitis

An increased prevalence of obstructive sleep apnoea (OSA) has been suggested in patients with ankylosing spondylitis (AS) in a few controlled studies. We aimed to study the prevalence of OSA compared to controls and to investigate if disease-related and non-disease-related factors were determinants of OSA in AS patients. One hundred and fifty-five patients with AS were included in the Backbone study, a cross-sectional study that investigates severity and comorbidities in AS. Controls were recruited from the Swedish CArdioPulmonary bioImage Study. To evaluate OSA, the participants were asked to undergo home sleep-monitoring during one night’s sleep. For each AS patient 45–70 years old, four controls were matched for sex, age, weight, and height. OSA was defined as an apnoea-hypopnoea index (AHI) ≥ 5 events/hour. Sixty-three patients with AS were examined with home sleep-monitoring, and 179 controls were matched with 46 patients, 45–70 years. Twenty-two out of 46 (47.8%) patients with AS vs. 91/179 (50.8%) controls had OSA (AHI ≥ 5 events/hour), P = 0.72. No differences in the sleep measurements were noted in AS patients vs. controls. In logistic regression analysis adjusted for age and sex, higher age, higher BMI, and lesser chest expansion were associated with the presence of OSA in the 63 AS patients. In the current study, patients with AS did not have a higher prevalence of OSA compared to matched controls. AS patients with OSA had higher BMI, were older, and had lesser chest expansion because of more severe AS compared to patients without OSA.

Key points
• Patients with ankylosing spondylitis did not have a higher prevalence of obstructive sleep apnoea versus matched controls.
• Patients with ankylosing spondylitis and obstructive sleep apnoea were older and had higher body mass index versus patients without obstructive sleep apnoea.
• Patients with ankylosing spondylitis and obstructive sleep apnoea had lesser chest expansion versus patients without obstructive sleep apnoea.

Increased proportion of comorbidities but no deterioration of sexual quality of life during a 5-year follow-up in patients with axial spondyloarthritis in the biologic treatment era

OBJECTIVE

To explore patient perception of sexual quality of life (SQOL), an important category of QOL, in male and female patients with axial SpA (axSpA) after a 5 year follow-up.

METHODS

A broad spectrum of demographic, disease-related, treatment and SQOL data was collected at baseline and at the 5 year follow-up. SQOL was assessed by the SQOL-Female (SQOL-F) questionnaire. For statistical analysis, McNemar's tests, paired t-tests and multiple regression analyses were applied.

RESULTS

A total of 245 axSpA patients (168 men and 77 women) from outpatient clinics were examined (mean age 46 years, mean disease duration 11.9 years at baseline). Compared with baseline, the patients had lower CRP, lower Maastricht Ankylosing Spondylitis Enthesitis Scores, lower BASFI scores, less use of smoking and significantly more patients were treated with biologic DMARDs at the 5 year follow-up. Patient perception of SQOL was basically unchanged at the 5 year follow-up despite a significantly increased proportion of comorbidities, including cardiovascular, endocrine and gastrointestinal disease. A decrease in SQOL after 5 years was observed only in patients exercising <1 h/week at baseline (P = 0.048) and in patients >65 years old.

CONCLUSION

In our axSpA patients, no statistically significant changes in SQOL were observed over 5 years, despite a significant increase in comorbidities. Overall disease symptoms decreased, indicating better disease control. Increased use of biologic drugs at the 5 year follow-up may have contributed to this favourable outcome.

Incidence of extra-articular manifestations in ankylosing spondylitis, psoriatic arthritis and undifferentiated spondyloarthritis: results from a national register-based cohort study

OBJECTIVES

To estimate the incidence and strength of association of extra-articular manifestations [EAMs, here: anterior uveitis (AU), IBD and psoriasis] in patients with AS, undifferentiated SpA (uSpA) and PsA, compared with controls.

METHODS

Three mutually exclusive cohorts of patients aged 18-69 years with AS (n = 8517), uSpA (n = 10 245) and PsA (n = 22 667) were identified in the Swedish National Patient Register 2001-2015. Age-, sex- and geography-matched controls were identified from the Swedish Population Register. Follow-up began 1 January 2006, or six months after the first SpA diagnosis, whichever occurred later, and ended at the first date of the EAM under study, death, emigration, 70 years of age, and 31 December 2016. Incidence rates (IRs) and incidence rate ratios were calculated for each EAM, and stratified by sex and age.

RESULTS

Incidence rate ratios for incident AU, IBD and psoriasis were significantly increased in AS (20.2, 6.2, 2.5), uSpA (13.6, 5.7, 3.8) and PsA (2.5, 2.3, n.a) vs controls. Men with AS and uSpA had significantly higher IRs per 1000 person-years at risk for incident AU than women with AS (IR 15.8 vs 11.2) and uSpA (IR 10.1 vs 6.0), whereas no such sex difference was demonstrated in PsA or for the other EAMs.

CONCLUSIONS

AU, followed by IBD and psoriasis, is the EAM most strongly associated with AS and uSpA. Among the SpA subtypes, AS and uSpA display a largely similar pattern of EAMs, whereas PsA has a considerably weaker association with AU and IBD.

Secukinumab for the treatment of psoriasis, psoriatic arthritis, and axial spondyloarthritis: Physical and pharmacological properties underlie the observed clinical efficacy and safety

Psoriasis, psoriatic arthritis, and axial spondyloarthritis are systemic inflammatory diseases, each commonly manifesting as a spectrum of symptoms, complications, and comorbidities that arise differently in individual patients. Drugs targeting inflammatory cytokines common to the pathogenesis of each of these conditions have been developed, although their specific actions in the different tissues involved are variable. For a drug to be effective, it must be efficiently delivered to and locally bioactive in disease-relevant tissues. Detailed clinical data shed light on the therapeutic effects of individual biologics on specific domains or clinical manifestations of disease and assist in guiding treatment decisions. Pharmacologic, molecular, and functional properties of drugs strongly impact their observed safety and efficacy, and an understanding of these properties provides complementary insight. Secukinumab, a fully human monoclonal IgG1/κ antibody selectively targeting interleukin (IL)-17A, has been in clinical use for >6 years in the treatment of moderate to severe psoriasis, psoriatic arthritis, and both radiographic (also known as ankylosing spondylitis) and nonradiographic axial spondyloarthritis. In this review, we discuss pharmacokinetic and pharmacodynamic data for secukinumab to introduce clinicians to the pharmacological properties of this widely used drug. Understanding how these properties affect the observed clinical efficacy, safety, and tolerability of this drug in the treatment of IL-17A-mediated systemic inflammatory diseases is important for all physicians treating these conditions.

Comparison of Men and Women With Axial Spondyloarthritis in the US-Based Corrona Psoriatic Arthritis/Spondyloarthritis Registry

OBJECTIVE

To compare patient characteristics and disease burden between men and women with axial spondyloarthritis (axSpA) in the US-based Corrona Psoriatic Arthritis/Spondyloarthritis (PsA/SpA) Registry.

METHODS

Patients aged ≥ 18 years with axSpA enrolled in the Corrona PsA/SpA Registry between March 2013 and November 2018 who were not concurrently diagnosed with PsA were included. Patient demographics, clinical characteristics, disease activity, patient-reported symptoms, work productivity, and treatment history at enrollment were compared between men and women, using t tests or Wilcoxon rank-sum tests for continuous variables and chi-square or Fisher exact tests for categorical variables.

RESULTS

Of 498 patients with axSpA and available sex information, 307 (61.6%) were men and 191 (38.4%) were women. Compared with men, women had higher disease activity as measured by Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, and physician global assessment, and had higher tender/swollen joint counts and enthesitis scores (all P ≤ 0.01). Women also had worse patient-reported symptoms (pain, fatigue, Health Assessment Questionnaire for the Spondyloarthropathies, and EuroQol visual analogue scale; all P < 0.05), had greater work and activity impairment, and were less likely to work full time than men. Prior conventional synthetic disease-modifying antirheumatic drug and prednisone use was more common in women than in men (both P < 0.05). Additionally, women were more likely to have diagnoses of depression and fibromyalgia (both P < 0.01).

CONCLUSION

In this US registry of patients with axSpA, women had higher overall disease burden and more peripheral manifestations than men. Improved awareness of sex differences in the presentation of axSpA may aid physicians in earlier identification and improved disease management.

Effects of Therapies on Cardiovascular Events in Ankylosing Spondylitis: A Systematic Review and Meta-Analysis

INTRODUCTION

Non-steroidal anti-inflammatory drugs (NSAIDs) and tumor necrosis factor inhibitors (TNFi) are the most common therapies used in AS, however, the associated long-term cardiovascular risk is unclear. We performed a systematic review and meta-analysis on the association of therapies used for ankylosing spondylitis (AS) such as NSAIDs and TNFi on cardiovascular events (CVE) in AS.

METHODS

A comprehensive search was performed from database inception to May 29, 2020 to include controlled studies of AS treated with NSAIDs, oral small molecules, or biologics reporting CVE. Study-specific risk ratios (RR) were pooled using a random effects model.

RESULTS

Nine non-randomized studies from 1570 studies screened fulfilled inclusion criteria. Among NSAID users as a whole versus no NSAIDs, no increased risk of CVE (composite outcome) was observed; however, the risk of cerebrovascular accident was significantly lower (RR 0.58, 95% CI 0.37-0.93, I2 = 66%). Cox-2 inhibitor use was associated with reduced risk of all CVE (RR 0.48, 95% CI 0.33-0.70, I2 = 0%). Non-selective NSAIDs were not associated with any increased/decreased risk of any CVE. Meta-analysis of three studies of MI did not show a significant association with TNFi (RR 0.88, 95% CI 0.57-1.35, I2 = 76%).

CONCLUSIONS

In this meta-analysis of non-randomized studies, NSAID users as a whole and users of non-selective NSAIDs did not seem to have a higher risk of any CVE. Limited data suggest a lower risk of composite CVE outcome with Cox-2 inhibitors, unlike the increased risk reported in the general population. No significant association between TNFi and MI was observed. The certainty in evidence was very low due to all studies being observational. More studies are needed to study the association between TNFi use and CVE in general to evaluate a possible protective role in AS.

Positive association of Parkinson's disease with ankylosing spondylitis: a nationwide population-based study

Background

Ankylosing spondylitis (AS) is characterized by excessive production of inflammatory cytokines. Recent evidence suggests that inflammation underlies the neurodegenerative process of Parkinson’s disease (PD). Whether AS has an influence on the development of PD is unclear. We aimed to examine a relationship, if any exists between AS and PD.

Methods

A population-based matched cohort study was performed using data from the 2000–2010 Taiwan National Health Insurance database. 6440 patients with AS and 25,760 randomly selected, age- and sex-matched controls were included in this study. The risk of PD in the AS cohort was evaluated by using a Cox model.

Results

This study revealed a positive association between AS and the risk of PD regardless of sex and age (aHR 1.75, p < .001). Particularly, AS cohort to non-AS cohort relative risk of PD significantly increased for the patients aged below 49 and above 65 years (aHR 4.70, p < .001; aHR 1.69, p < .001, respectively) and the patients with and without comorbidities (aHR 1.61, p < .001; aHR 2.71, p < .001, respectively). Furthermore, NSAID use was associated with lower risk of PD (aHR 0.69, p < .05). However, the risk of PD was higher (aHR 2.40, p < .01) in patients with AS receiving immunosuppressants than in those not receiving (aHR 1.70, p < .001).

Conclusions

Patients with AS had an increased risk of PD which might be related to underlying chronic inflammation. Further research is required to elucidate the underlying mechanism.

Recognizing Axial Spondyloarthritis: A Guide for Primary Care

Axial spondyloarthritis (axSpA) is an important cause of chronic low back pain and affects approximately 1% of the US population. The back pain associated with axSpA has a characteristic pattern referred to as inflammatory back pain (IBP). Features of IBP include insidious onset before age 45 years, association with morning stiffness, improvement with exercise but not rest, alternating buttock pain, and good response to treatment with nonsteroidal anti-inflammatory drugs. In patients with IBP, it is essential to look for other features associated with spondyloarthritis (SpA), such as enthesitis, dactylitis, peripheral arthritis, extra-articular manifestations (eg, psoriasis, uveitis, or inflammatory bowel disease), human leukocyte antigen B27 positivity, and a family history of SpA. Axial SpA is underrecognized, and a delay of several years between symptom onset and diagnosis is common. However, with new and effective therapies available for the treatment of active axSpA, early recognition and diagnosis are of critical importance. For this narrative review, we conducted a literature search of English-language articles using PubMed. Individual searches were performed to identify potential articles of interest related to axSpA (search terms: ["axSpA" OR "axial SpA" OR "axial spondyloarthritis" OR "ankylosing spondylitis"]) in combination with terms related to IBP ("inflammatory back pain" OR "IBP" OR "chronic back pain" OR "CBP" OR "lower back pain" OR "LBP"), diagnosis (["diagn∗" OR "classification"] AND ["criteria" OR "recommend∗" OR "guidelines"]), and referral ("refer∗"). No date range was formally selected, as we were interested in providing an overview of the evolution of these concepts in clinical practice. We supplemented the review with insights based on our clinical expertise. Patients with chronic back pain should be screened for IBP and other SpA features; suspicion for axSpA should trigger referral to a rheumatologist for further evaluation.

Increased Risk of Inflammatory Bowel Disease Among Patients With Ankylosing Spondylitis: A 13-Year Population-Based Cohort Study

AIM

Ankylosing spondylitis (AS) primarily affects the axial skeleton and extraarticular structures. Small-scaled studies have reported that the incidence and prevalence of inflammatory bowel disease (IBD) are higher in patients with AS than in the general population. This study determined the incidence of IBD in patients with AS using a large scale population-based cohort dataset.

METHODS

This was a retrospective cohort study. Patient data were collected from the Taiwan National Health Insurance Research Database from 2000 to 2012. We enrolled 3,804 patients with AS and 7,608 non-AS patients. The endpoint was IBD diagnosis by using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding 555 and 556 after at least three outpatient visits or one hospital admission, until the end of 2012. The Kaplan-Meier analysis was performed to discriminate the cumulative incidence of IBD and the log-rank test was used to test the significance. A Cox proportional hazard model was used to estimate the hazard ratio (HR) for IBD between the AS and non-AS groups.

RESULTS

Among the population as a whole the Cox proportional hazard regression indicated that patients aged ≥65 years [adjusted HR (aHR): 2.48, 95% confidence interval (CI): 1.38-4.47] or with comorbidity of cancer (aHR: 3.51, 95% CI: 1.40-8.80) had a higher HR for IBD. Kaplan-Meier curves of cumulative incidence proportion of IBD indicated that patients with AS had a higher risk of IBD than the non-AS group in the subgroup aged <40 years (HR: 2.85, 95% CI: 1.51-5.40, p = 0.001).

CONCLUSIONS

Patients with AS aged <40 years had a higher IBD risk than did those without AS in Taiwan. Clinicians and patients should be aware of this association.

Prevalence and impact of comorbidities in axial spondyloarthritis: systematic review and meta-analysis

OBJECTIVES

Comorbidities are common in people with axial spondyloarthritis (axSpA). In this systematic review and meta-analysis, we aimed to: (i) describe the prevalence of commonly reported comorbidities, (ii) compare comorbidities between axSpA and control populations, and (iii) examine the impact of comorbidity burden on axSpA outcomes.

METHODS

We systematically searched Medline, PubMed, Scopus and Web of Science using a predefined protocol in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We excluded studies of only one comorbid condition or a few closely related diseases within one organ system. Where possible, meta-analysis was performed using random-effects models.

RESULTS

A total of 40 studies were included for analysis. 36 studies reported prevalence of comorbidities, amounting to a combined sample size of 119 427 patients. The number of comorbidities studied ranged from 3 to 43. The most prevalent individual comorbidities were hypertension (pooled prevalence 23%), hyperlipidaemia (17%) and obesity (14%). Eleven studies consistently showed higher prevalence of comorbidities in axSpA than controls, particularly large differences were seen for depression [pooled odds ratio (OR) 1.80] and heart failure (OR 1.84). Comorbidities (total number of and individual conditions) were also associated with axSpA disease activity, functional impairment, quality of life, work productivity and mortality.

CONCLUSIONS

Comorbidities are common in axSpA, particularly cardiovascular diseases and risk factors. Most comorbidities were more prevalent in axSpA patients than in control populations. Overall comorbidity burden, and many individual conditions, were associated with axSpA outcomes including worse disease severity, work productivity and mortality.

Trabecular Bone Score (TBS) Predicts Fracture in Ankylosing Spondylitis: The Manitoba BMD Registry

INTRODUCTION

Ankylosing spondylitis (AS) is a chronic inflammatory disease of the spine characterized among other features by spinal boney proliferation, back pain, loss of flexibility, and increased fracture risk. Overlying bone limits the utility of bone mineral density (BMD) by dual X-ray absorptiometry (DXA) in the spine. Trabecular bone score (TBS) is a bone texture measurement derived from the spine DXA image that indicates bone quality and fracture risk independent of BMD.

METHODOLOGY

Using the Manitoba Bone Density Program database, patients with diagnosis codes for ankylosing spondylitis, baseline DXA and lumbar spine TBS were identified. Incident nontraumatic fractures (major osteoporotic [MOF], clinical spine, hip, and all fracture) were identified from population based databases. Cox-proportional hazard models are presented.

RESULTS

We identified 188 patients with diagnosed AS. TBS was lower in those with incident MOF (1.278 ± 0.126, compared to 1.178 ± 0.136, p < 0.001). Unadjusted TBS and FRAX-MOF-BMD adjusted predicted major osteoporotic fracture (N = 19) (hazard ratio [HR] 2.04, 95% confidence interval [CI]: 1.28-2.26, p = 0.003; HR 1.81, 95% CI: 1.11-2.96, p = 0.018). TBS unadjusted and FRAX-MOF-BMD adjusted also predicted clinical spine fracture (N = 7) (HR 2.50, 95% CI: 1.17-5.37; p = 0.019; HR 2.40 95% CI: 1.1-5.25; p = 0.028). Higher HRs were observed for prediction of hip fracture (N = 6), but these did not achieve statistical significance (FRAX-adjusted HR 1.74, 95% 0.73-4.17; p = 0.211). Unadjusted models show TBS was predictive of all fracture (N = 27) (HR 1.60, 95% CI: 1.08-2.39; p = 0.020), which was borderline significant after adjustment for FRAX-MOF-BMD (HR 1.51, 95% CI: 1.00-2.29; p = 0.052).

CONCLUSION

We report the first analysis of TBS for fracture prediction as an incident event in AS. TBS independently predicted major osteoporotic and clinical spine fracture in AS independent of FRAX.

Clinical characteristics and comorbidities in adult-onset Still's disease using a large US administrative claims database

OBJECTIVES

We aimed to describe clinical characteristics, treatment patterns and major comorbidities of a US-based adult-onset Still's disease (AOSD) cohort.

METHODS

Administrative claims data from Truven MarketScan were collected from 2009 to 2015. An AOSD case was defined as ≥1 M06.1 International Classification of Diseases 10th revision (ICD-10) medical claim code. We extracted data for the AOSD cohort (n = 106) and 1:5 matched controls (n = 530) without AOSD. Outcomes of interest and a novel claims-based set of Yamaguchi criteria were identified by relevant ICD 9th revision (ICD-9) and ICD-10 codes. Bivariate descriptive analyses were conducted on all variables. Comorbidity rates and rate ratios were calculated in AOSD cases and matched controls. Statistical significance of cohort differences was determined to compare AOSD cases and matched controls.

RESULTS

The AOSD cohort, with a mean age of 43.08 (standard deviation, s.d. 13.9) years and with female predominance (68.9%) was observed over a mean of 750.12 (637.6) days. A total of 35.9% of AOSD patients fulfilled claims-based Yamaguchi criteria compared with 0.4% matched controls (P< 0.05). We identified severe AOSD-related complications, including macrophage activation syndrome (4.7%) and acute respiratory distress syndrome (12.3%). Treatment commonly involved systemic glucocorticoids (62.2%), MTX (51%) and anakinra (24.5%). Compared with matched controls, serious infections were significantly increased (rate ratio 2.58, 95% CI: 1.53, 4.37, P = 0.0004), while hyperlipidaemia (0.54, 95% CI: 0.35, 0.85; P = 0.008) and obesity (0.30, 95% CI: 0.15, 0.62; P = 0.001) were significantly decreased in AOSD patients.

CONCLUSION

We characterized a first US-based AOSD cohort using a large national administrative claims database, and identified key complications, treatments and comorbidities.

Risk of Malignancy in Spondyloarthritis: A Systematic Review

Systematic inflammatory diseases, including rheumatoid arthritis (RA), are associated with an increased risk of malignancies. However, the pathogenesis of spondyloarthritis (SpA), which includes both ankylosing spondylitis and psoriatic arthritis, is different from RA, and the risk of malignancy and sites involved may also be different. It is important to better understand associations of SpA with site-specific cancers to facilitate appropriate cancer screening. The goal of this review was to examine the association of SpA with malignancy and the potential impact of therapy for SpA on development of malignancy.

Understanding differences between men and women with axial spondyloarthritis

Axial spondyloarthritis (axSpA) is a chronic inflammatory immune-mediated disease resulting in inflammatory low back pain and other inflammatory manifestations in peripheral joints and entheses. AxSpA encompasses both ankylosing spondylitis (AS), in which patients present with definitive sacroiliitis visible on radiographic imaging, as well as nonradiographic axSpA (nr-axSpA), in which such changes may not be discernable. Emerging evidence suggests that women and men experience axSpA differently. Although the prevalence of AS is approximately 2- to 3- fold higher in men than in women, nr-axSpA occurs with roughly equal frequency in women and men. The goal of this review is to increase awareness of sex differences in axSpA by exploring the distinct manifestations of disease and disease characteristics in women, the overall clinical burden, recommendations for diagnosis, and potential treatment options. We summarize and contextualize the results of recent studies that illuminate sex differences in nr-axSpA and AS, including differences in disease manifestation and progression. It is important that sex differences in axSpA are understood and considered when diagnosing and treating the spectrum of axSpA, including AS and nr-axSpA.

Role of HLA-B27 in the comorbidities observed in Axial Spondyloarthritis: Data from COMOSPA

OBJECTIVE

To analyze the potential association between the presence of HLA-B27 and the different comorbidities observed in Axial Spondyloarthritis patients.

METHODS

A comparative cross-sectional study including Axial Spondyloarthritis patients from COMOSPA registry. COMOSPA is a worldwide registry that includes a wide set of anthropometric and clinical variables from 3984 patients with Spondyloarthritis. The registry also includes the most frequent comorbidities observed in Spondyloarthitis such as obesity, hypertension, diabetes, hyperlipidemia, heart ischemic disease, stroke, renal failure, neoplasms, peptic ulcer, diverticulitis, chronic obstructive pulmonary disease, and the presence of osteoporosis. A descriptive analysis and a multiple logistic regression model was performed including all variables assessed.

RESULTS

2370 patients fulfilled ASAS criteria of Axial Spondyloarthritis patients and were included in the study. 1858 (78.4%) of them were HLA-B27 positive. HLA-B27 positive Axial Spondyloarthritis patients presented significantly higher percentage of male sex, longer disease duration, higher percentage of definite Ankylosing Spondylitis, higher CRP levels, and were also more frequent tobacco consumers and excessive alcohol intakers compared to the negatives. However, disease activity measured by BASDAI, BASFI and ASDAS-CRP were all significantly higher in the HLA-B27 negative patients compared to the positive ones. The only association observed between any comorbidity and presence of HLA-B27 genotype was the presence of osteoporosis, even after adjusting in the multivariate analysis for all variables assessed.

CONCLUSION

The association observed between the HLA-B27 genotype and the presence of osteoporosis in Axial Spondyloarthritis patients could be of great relevance given the impact of osteoporosis in the phenotypical frame of these patients.

Conceptualization of Heterogeneity of Chronic Diseases and Atherosclerosis as a Pathway to Precision Medicine: Endophenotype, Endotype, and Residual Cardiovascular Risk

The article discusses modern approaches to the conceptualization of pathogenetic heterogeneity in various branches of medical science. The concepts of endophenotype, endotype, and residual cardiovascular risk and the scope of their application in internal medicine and cardiology are considered. Based on the latest results of studies of the genetic architecture of atherosclerosis, five endotypes of atherosclerosis have been proposed. Each of the presented endotypes represents one or another pathophysiological mechanism of atherogenesis, having an established genetic substrate, a characteristic panel of biomarkers, and a number of clinical features. Clinical implications and perspectives for the study of endotypes of atherosclerosis are briefly reviewed.

Ankylosing Spondylitis Is Associated With Risk of New-Onset Obstructive Sleep Apnea: A Nationwide Population-Based Cohort Study

Objectives: Investigating the risk of obstructive sleep apnea(OSA) among ankylosing spondylitis (AS) patients based on administrative healthcare databases.

Methods: We conducted a nationwide cohort study by using the Taiwan National Health Insurance Research Database with 1997–2013 claim records. The AS cohort included 2,210 patients who were newly diagnosed between 2003 and 2013. Randomly selected non-AS controls were matched at a 1:4 ratio. The endpoint was set as OSA occurrence or the end of 2013. Cumulative incidences, hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated after adjusting for age, gender, comorbidities, and co-medication. Multivariate analyses were performed using the Cox proportional hazards model. Due to the violation of the proportionality assumption, landmark analysis was conducted to explore the risk of OSA during specific follow-up periods.

Results: The adjusted HR (aHR) of OSA in the AS group was 2.826 (95% C.I. = 1.727–4.625) compared to the control group. On landmark analysis, aHR was 7.919 (95% C.I. = 3.169–19.792) for the AS group 0–24 months from the index date and decreased to 1.816 (95% C.I. = 0.944–3.494) at ≥ 24 months from the index date. The increased risks of OSA in the AS group compared to the control group were found for both males and females (aHRs were 4.533 and 2.672). On age-stratified analysis, a significant risk only for the 40–59 age group with aHR of 3.913 (95% C.I. = 1.890–8.102).

Conclusions: A higher risk of developing OSA was found among newly diagnosed AS cohort during the maximum 11-year follow-up period, especially within 2 years after newly diagnosed AS and in the 40–59 age group.

Depression/anxiety symptoms in axial spondyloarthritis and psoriatic arthritis patients in Serbia: a pilot study

To assess prevalence and change of depression/anxiety symptoms in spondyloarthritis patients and feasibility of depression/anxiety questionnaires. 43 Patients with axial spondyloarthritis (axSpA) and 27 patients with psoriatic arthritis (PsA) were consecutively recruited. There were 34 patients on biologics and 36 patients on nonbiologics. Patients were not previously treated for depression. The demographic variables, pain, patient global assessment, laboratory, clinical findings, diseases activity scores, Beck Depression Inventory (BDI) and Depression Anxiety and Stress Scale-short version (DASS-21) were collected. The study visits were at the beginning, after 1 month, after 3 and after 6 months. In axSpA and PsA patients on biologics, BDI and DASS-21 were significantly lower compared to nonbiologics group during time. The axSpA patients on biologics had significantly lower BDI and depression severity by BDI at each time point and lower DASS-21 after 1, 3 and 6 months. BDI in PsA patients who received biological therapy was significantly lower after 3 and 6 months. In biologics groups, BDI significantly decreased after 3 months in axSpA patients and after 1 month in PsA patients. In axSpA patients, there was a medium correlation between BDI and axial pain, patient global assessment and disease activity scores. The biological therapy significantly affected the depression/anxiety symptoms in axSpA and PsA during time. BDI moderately correlated with pain and disease activity in axSpA. BDI and DASS-21 are easy to use in daily practice.

Thoracic Manifestations of Ankylosing Spondylitis, Inflammatory Bowel Disease, and Relapsing Polychondritis

Ankylosing spondylitis, inflammatory bowel disease (IBD), and relapsing polychondritis are immune-mediated inflammatory diseases with variable involvement of lungs, heart and the chest wall. Ankylosing spondylitis is associated with anterior chest wall pain, restrictive lung disease, obstructive sleep apnea, apical fibrosis, spontaneous pneumothorax, abnormalities of cardiac valves and conduction system, and aortitis. Patients with IBD can develop necrobiotic lung nodules that can be misdiagnosed as malignancy or infection. Relapsing polychondritis involves large airways in at least half of the patients. Relapsing polychondritis can mimic asthma in some patients. Medications used to treat these inflammatory conditions can cause pulmonary complications such as infections, pneumonitis, and rarely serositis.

The promise and perils of 'Big Data': focus on spondyloarthritis

PURPOSE OF REVIEW

This review will describe the available large-scale data sources to study spondyloarthritis (SpA), enumerate approaches to identify SpA and its disease-related manifestations and outcomes, and will outline existing and future methods to collect novel data types [e.g. patient-reported outcomes (PRO), passive data from wearables and biosensors].

RECENT FINDINGS

In addition to traditional clinic visit-based SpA registries, newer data sources, such as health plan claims data, single and multispecialty electronic health record (EHR) based registries, patient registries and linkages between data sources, have catalyzed the breadth and depth of SpA research. Health activity tracker devices and PRO collected via PROMIS instruments have been shown to have good validity when assessed in SpA patients as compared to legacy disease-specific instruments. In certain cases, machine learning outperforms traditional methods to identify SpA and its associated manifestations in EHR and claims data, and may predict disease flare.

SUMMARY

Although caution remains in the application of newer data sources and methods including the important need for replication, the availability of new data sources, health tracker devices and analytic methods holds great promise to catalyze SpA research.

Multimorbidity in Axial Spondyloarthropathy and Its Association with Disease Outcomes: Results from the Ankylosing Spondylitis Registry of Ireland Cohort

Objective.

Multimorbidity, the coexistence of 2 or more conditions in an individual, is associated with morbidity and mortality in the general population. This study aims to describe the prevalence of multimorbidity in axial spondyloarthropathy (axSpA) and assess its association with disease outcome measures.

Methods.

This cross-sectional study was conducted within the Ankylosing Spondylitis Registry of Ireland (ASRI) cohort. Structured standardized assessment was performed. Multimorbidity was considered as the presence of at least 1 physician-diagnosed chronic condition (excluding extraarticular manifestations) in addition to axSpA. Validated outcome measures were collected: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), Health Assessment Questionnaire (HAQ), AS Quality of Life (ASQoL), and Bath AS Metrology Index (BASMI). Adjusted multiple regression was performed to investigate the association between multimorbidity and disease outcomes.

Results.

A total of 734 patients from 12 centers were included: 77% male, mean (SD) age 45 (12) years. Of the cohort, 55% (n = 403) were multimorbid. Multimorbid patients were significantly (p < 0.01) older than axSpA-only patients [50 (12) vs 40 (11) yrs]. Obesity was the most prevalent chronic condition, affecting 27%. Multimorbid patients had more severe disease than patients with axSpA only. After adjusting for confounders, multimorbidity was associated with higher BASDAI (ß 0.7, 95% CI 0.34–1.05), BASMI (ß 0.45, 95% CI 0.09–0.80), BASFI (ß 0.5, 95% CI 0.23–0.78), HAQ (ß 0.07, 95% CI 0.00–0.13), and ASQoL (ß 0.87, 95% CI 0.28–1.46).

Conclusion.

Multimorbidity is prevalent in axSpA and is associated with more severe disease.

Incidence rates of inflammatory bowel disease in patients with psoriasis, psoriatic arthritis and ankylosing spondylitis treated with secukinumab: a retrospective analysis of pooled data from 21 clinical trials

OBJECTIVES

Here, we present the reported incidence rates of inflammatory bowel disease (IBD) in patients receiving treatment with secukinumab for psoriasis (PsO), psoriatic arthritis (PsA) or ankylosing spondylitis (AS), in a pooled analysis of 21 clinical trials.

METHODS

Data from all patients who had received at least one dose of secukinumab were included. Safety analyses were conducted to evaluate cumulative IBD rates as well as per-year rates, by indication. Crohn's disease (CD), ulcerative colitis (UC) and IBD unclassified (IBDU) events were analysed using exposure-adjusted incidence rates (patient incidence rates per 100 patient-years (PY)).

RESULTS

A total of 7355 patients with a cumulative exposure of 16 226.9 PY were included in the pooled analysis. Among 5181 patients with PsO, there were 14 cases of UC, 5 cases of CD and 1 case of IBDU, with exposure adjusted incidence rates (EAIRs) of 0.13, 0.05 and 0.01, respectively. Of these 20 cases, 14 were new-onset. In 1380 patients with PsA, there were 3 cases of UC, 3 cases of CD and 2 cases of IBDU (EAIRs 0.08, 0.08 and 0.05); 7 of these represented new-onset cases. Among 794 patients with AS, there were 4 cases of UC, 8 cases of CD and 1 case of IBDU (EAIRs 0.2, 0.4 and 0.1); 9 were new-onset cases. In the per year analysis, the EAIRs for each indication did not increase over time with secukinumab treatment.

CONCLUSIONS

In this pooled secukinumab safety analysis of 7355 patients across 21 clinical trials, cases of IBD events (including CD, UC and IBDU) were uncommon.

Understanding and managing secondary osteoporosis

INTRODUCTION

The term secondary osteoporosis (SO) identifies a reduction of bone mass related to a well-established disease or pharmacological agent. The identification of the underlying disease often represents a challenging situation in clinical practice.

AREAS COVERED

The prevalence of SO in the real world may vary, ranging from 17% to 80%; therefore, search for a form of SO represents a pillar when evaluating patients with osteoporosis. Guidelines for treatment of specific secondary forms of osteoporosis, such as glucocorticoid-induced osteoporosis, have been published even though often neglected in clinical practice. For the majority of SO, there are currently no specific guidelines concerning treatment with only few trials showing the effect of bone-active drugs on fracture risk reduction.

EXPERT OPINION

Healthcare professionals should be aware of the secondary forms of osteoporosis, in particular when the reason for reduced skeletal resistance is uncertain or when bone mineral density results are unsatisfactory in a patient compliant to therapy. In a few cases (such as, for example: no response to therapy, better classification of bone involvement in patients with kidney failure, suspicion of rare metabolic bone disease) bone biopsy is needed to investigate the patient. This review highlights recent advances in understanding and managing SO.

Should clinicians pay more attention to the potential underdiagnosis of osteoporosis in patients with ankylosing spondylitis? A national population-based study in Taiwan

OBJECTIVES

There are limited studies describing the association between ankylosing spondylitis (AS) and osteoporosis. We conducted a nationwide retrospective cohort study to investigate this epidemiologic evidence.

METHODS

Data were obtained from the Taiwan National Health Insurance Research Database (NHIRD). Of 10,290 participants, 2,058 patients with AS and 8,232 patients without AS were enrolled from the NHIRD between 2000 to 2013. Cumulative incidences of osteoporosis were compared between 2 groups. Cox regression model was used to estimate the hazard ratio (HR) of developing osteoporosis after controlling for demographic and other co-morbidities, and subgroup analyses were conducted to examine the risk factors for osteoporosis in AS patients.

RESULTS

The incidence rate ratio (IRR) of osteoporosis in AS patients was 2.17 times higher than that non-AS group (95% confidence interval [CI], 1.83-2.57). The adjusted HRs of osteoporosis for AS patients after controlling for demographic characteristics and comorbid medical disorders was 1.99 (95% CI 1.68-2.36). Among AS group, after adjustment for major comorbidities, old age (≥65 years, HR 4.32, 95% CI 3.01-6.18), female sex (HR 2.48, 95% CI 1.87-3.28), dyslipidemia (HR 1.44, 95% CI 1.01-2.06) were risk factors associated with osteoporosis.

CONCLUSIONS

This cohort study demonstrated that patients with AS had a higher risk of developing osteoporosis, especially in those aged over 65, female sex and with dyslipidemia in this patient group.