Are spondyloarthropathies as common as rheumatoid arthritis worldwide? A review

Genetic Susceptibility and Disease Activity in Ankylosing Spondylitis: The Role of G Protein-Coupled Receptor 35rs4676410 Polymorphism in a Turkish Population

Background: Ankylosing spondylitis (AS) is a chronic inflammatory disorder with a significant genetic predisposition. Genome-wide association studies (GWAS) have identified immune-related loci, including the G Protein-Coupled Receptor 35 (GPR35) gene, as potential contributors to AS pathogenesis. This study aimed to evaluate the association between the rs4676410 polymorphism in the GPR35 gene and both AS susceptibility and disease activity in a Turkish population. Methods: This case-control study included 200 participants (100 AS patients and 100 healthy controls). DNA was isolated from blood samples, and the rs4676410 polymorphism was analyzed using real-time polymerase chain reaction (PCR). Disease activity in AS patients was assessed using the Bath AS Functional Index (BASFI), Bath AS Disease Activity Index (BASDAI), and disease activity scores including C-reactive protein (ASDAS-CRP) scores. Statistical analyses were conducted using IBM SPSS 26. Results: The rs4676410 polymorphism was significantly associated with AS susceptibility. The AA genotype and A allele were more prevalent in AS patients, indicating an increased risk of developing AS. Among disease activity measures, ASDAS-CRP scores were significantly higher in patients with the AA genotype (p = 0.043), while no significant differences were observed for BASFI and BASDAI scores across genotypes. Conclusion: The findings suggest that the rs4676410 polymorphism in the GPR35 gene is associated with AS susceptibility and may influence disease activity through elevated inflammatory responses. These results highlight the potential of the AA genotype and A allele as genetic markers for AS and underscore the importance of integrating genetic insights into personalized treatment approaches.

Evaluation of Sacroiliac Joint Shape in Women with Ankylosing Spondylitis According to Mode of Birth Delivery: A Retrospective Study

Background and Objectives: Ankylosing spondylitis (AS) is a chronic progressive inflammatory process of the axial skeleton and sacroiliac joints (SIJ). Symptoms typically appear between the ages of 20 and 40, although there are also cases of juvenile-onset AS. This suggests that most patients with AS are of reproductive age at the time of diagnosis. The study aimed to identify differences in the shape of the sacroiliac joint depending on the type of birth (vaginal delivery (V/D) and the cesarean section(C/S) in patients with ankylosing spondylitis. Materials and Methods: On pelvis X-ray images of women n = 36 with AS and n = 34 in the control group, 12 landmarks were marked, and differences in SIJ shape between the study groups were assessed using generalized Procrustes Analysis. Results: The results showed that the anterior point of the SIJ had an enlarged shape in the V/D group compared with the C/S group, even in the control group. There was a difference between the mean right and left SIJ shapes of the AS group patients with V/D and the controls with C/S (p = 0.007 and p < 0.001). The superior part of the right SIJ tended to be enlarged in V/D-delivered AS patients, compared to the C/S control group. On the left side, the middle region of the SIJ was statistically enlarged in AS patients with V/D compared to the healthy C/S group. Conclusions: This study demonstrates that vaginal delivery is associated with increased sacroiliac joint (SIJ) enlargement in both healthy individuals and those with ankylosing spondylitis (AS). Our findings suggest that delivery type independently influences SIJ morphology, and cesarean section (C/S) may serve as a protective procedure for preserving SIJ shape in AS patients. These results underline the importance of individualized obstetric planning for AS patients to mitigate potential risks to SIJ morphology.

The incidence and prevalence of ankylosing spondylitis in Thailand using ministry of public health database

Ankylosing spondylitis (AS), an inflammatory condition affecting axial and peripheral joints, exhibits varying prevalence worldwide. This study sought to ascertain AS incidence and prevalence in Thailand from 2017 to 2020. Utilizing national databases, individuals aged 18 and above with primary AS diagnoses (ICD-10 code M45) were identified. AS prevalence and incidence were calculated with 95% confidence intervals. The total number of AS patients was 13,292 patients in 2017. The prevalence of AS was 20.4 per 100,000 populations (95% CI 20.0-20.7) in 2017. The number of new AS cases, identified during 2018-2020, was 6784, 6805, and 6791 patients, respectively. The incidences of AS in 2018, 2019, and 2020 were comparable with the incidence of 10.4 (95% CI 10.1-10.6) per 100,000-person-years. The peak age at diagnosis was 50-59 years of age between 2018 and 2020. The number of female patients was 57.8%, 57.0%, and 57.6%, in 2018, 2019, and 2020, respectively. In conclusion, AS was relatively rare among Thais and comparable between males and females. The prevalence and incidence of AS in Thailand were identified by the Thailand Database Ministry of Public Health. The epidemiological profile of AS in Thailand might help to plan better care, workforce needs, and public health budgets.

The Efficacy and Safety of Biologics in Treating Ankylosing Spondylitis and Their Impact on Quality of Life and Comorbidities: A Literature Review

Ankylosing spondylitis (AS) is a chronic inflammatory arthritis that affects the axial skeleton, causing intense pain, progressive joint destruction, and a gradual reduction in physical function. Additionally, AS can result in extra-musculoskeletal manifestations including inflammatory bowel disease (IBD), psoriasis, and acute anterior uveitis (AAU) affecting patients' quality of life (QoL). Furthermore, AS association with neurological and cardiovascular events has been documented. With the advent of biologics, treating AS has dramatically changed due to their high efficacy and tolerable safety. Nevertheless, there are differences in traits, including rapidity of onset, long-term efficacy, safety profile, and influence on comorbidities. A better understanding of such traits enables clinicians to make the best decision for each patient, increasing persistence, extending medication survival, enhancing patient satisfaction, and reducing the disease effect of AS. A review of the literature published in English in PubMed and Google Scholar databases from 2010 to 2023 was conducted. All relevant results fitting the scope of the topic were included. In this article, we emphasize biologics' efficacy and safety profile in patients with AS. In addition, we discuss the impact of biologics on comorbidities and health-related quality of life (HRQoL).

The Impact of Spondyloarthritis on Health-Related Quality of Life and Healthcare Resource Utilization in Saudi Arabia: A Narrative Review and Directions for Future Research

Spondylarthritis (SpA) is an umbrella term that encompasses a wide range of rheumatological disorders. Several studies demonstrated that SpA is associated with increased healthcare resource utilization (HCRU) and a lower health-related quality of life (HRQoL). This review aimed to summarize the current literature regarding the multidimensional impact of SpA on HRQoL and HCRU in Saudi Arabia and explore the correlation of the extent of severity of SpA with HRQoL and HCRU. Although the prevalence of SpA varies across different populations and is correlated with HLA-B27 prevalence, the magnitude of SpA in the Saudi population has not been extensively evaluated. Few studies have investigated the impact of SpA on HRQoL and HCRU in Saudi Arabia and the Middle East. There is a need to study the cost-effectiveness of various SpA treatment strategies, including biologic disease-modifying anti-rheumatic drugs (bDMARDs), to prioritize healthcare spending in the Saudi healthcare system. Data on SpA in Saudi Arabia and the Middle East region are mainly based on expert views, with few population-based studies compared to other regions. Therefore, there is an imperative need to develop high-quality, national-level epidemiological studies that assess the following: (1) more accurate estimates of the current prevalence of SpA in Saudi Arabia, including the prevalence of axial SpA and psoriatic arthritis; (2) the phenotypes/clinical characteristics of SpA, including disease severity and extra-articular involvement; (3) the impact of SpA on the HRQoL of the patients and the factors that can predict the extent of impaired HRQoL in such population, which can represent the first step in developing psychological interventions that should be personalized to this patient population; (4) the impact of implementing formal assessment of disease activity on the management of the patients and, subsequently, their HRQoL; and (5) the HCRU and costs for patients with SpA, and how treatment patterns can affect this cost.

Ankylosing spondylitis substantially increases health-care costs and length of hospital stay following total hip arthroplasty - National in-patient database study

Introduction

The outcome following major arthroplasty surgeries in patients with ankylosing spondylitis (AS) has tremendously improved over the past decades, due to substantial amelioration in the medical therapies and sophistication of available surgical modalities. Although various studies have already demonstrated the complication rates and challenges faced in AS patients undergoing THA, there is a substantial paucity of data on the actual healthcare burden associated with this disease, and the diverse factors which may affect it.

Methods

Using the National Inpatient Sample (NIS) database (on the basis of ICD-10 CMP codes), patients undergoing THA between the years 2016 and 2019 were identified. These patients were then classified into two categories: group A: patients with a known diagnosis of AS; and group N: those without. The details regarding demographical information, associated co-morbidities, data pertaining to patients' hospital admissions including expenditure incurred, length of stay and complications encountered, were compared. In addition, propensity-score matching was performed to identify a 1:1 matched sample of THA patients without AS.

Results

Overall, 367,890 patients underwent THA; among whom, 501 (0.14%) were known AS patients (group A). Group A included a substantially higher proportion of patients belonging to younger age group (58.6 ± 13.4 versus 65.9 ± 11.4 years; p < 0.001), male sex (67.1% in group A vs 44.1% in group N; p < 0.001), and Asian ethnicity (p < 0.001). Group A patients had a substantially higher risk for longer duration of hospital stay (p < 0.03) and higher overall healthcare expenditure incurred (p < 0.001). As compared to group N, AS patients had a significantly higher risk for developing post-operative anemia [21.8% (group A) vs 11.8% (group N); p < 0.02]; and higher rate of periprosthetic infections [2.4% (group A) vs 1.0% (group N); p < 0.007].

Conclusion

Patients with AS require a significantly longer duration of hospital stay and higher admission-related expenditure following THA, as compared to the general population. These enhanced early health care-associated costs can be attributed to higher complication rates in AS patients. AS patients are prone to higher rates of anemia and peri-prosthetic infections during the early post-THA period.

Effectiveness and cost-effectiveness of combined asynchronous telemonitoring and patient-initiated care for spondyloarthritis: protocol for a pragmatic multicentre randomised controlled trial (TeleSpA Study)

INTRODUCTION

During the COVID-19 pandemic, an accelerated uptake of remote monitoring strategies, replacing traditional face-to-face care, has been observed. However, data on the effects of remote care interventions for patients with rheumatic and musculoskeletal diseases remain scarce and interpretation is hampered by study heterogeneity and research quality concerns. High-quality evidence is required to guide future implementation in clinical practice, with health economic analyses identified as an important knowledge gap. Randomised controlled trials (RCTs) comparing telemonitoring with conventional care for patients with spondyloarthritis (SpA) are currently lacking.

METHODS AND ANALYSIS

TeleSpA is a pragmatic, multicentre RCT investigating the effectiveness and cost-effectiveness of combined asynchronous telemonitoring and patient-initiated follow-up for patients with SpA, compared with conventional care. Two-hundred patients will be recruited at two hospitals and randomised (1:1) to the study intervention or standard care. The primary endpoint is a reduction in the number of follow-up visits by ≥25% in the intervention compared with standard care group, during a 1-year period. Secondary endpoints are (a) non-inferiority of the study intervention with regard to health outcomes, quality of care and patient-reported experience with care; and (b) cost-effectiveness of the intervention, evaluated through a prospective trial-based cost-utility analysis. In addition, experiences with the study intervention will be assessed among patients and healthcare providers, and factors associated with primary and secondary endpoints will be identified.

ETHICS AND DISSEMINATION

This study was approved by the Medical Research Ethics Committee of the Academic Hospital Maastricht/Maastricht University (NL71041.068.19/METC 19-059). Results will be disseminated through publications in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04673825.

Serum fibrinogen to albumin ratio in patients with ankylosing spondylitis: correlation with disease activity and severity

Background

The fibrinogen to albumin ratio (FAR) has risen to prominence as a novel biomarker for various conditions, including systemic inflammation. Therefore, this study aims to assess the role of FAR in ankylosing spondylitis (AS) and its correlation with disease activity, severity, and functional status of AS patients. Thirty adult patients with AS were enrolled, along with 20 healthy age- and sex-matched subjects as controls. Bath Indices were used to determine the disease activity, severity, and functional status.

Results

The patients’ mean age was 35.3 years, including 22 males (73.3%) and eight females (26.7%). The median disease duration was 10 years, ranging from 1 to 28 years. AS cases showed higher FAR than the control group (P < 0.001). Active cases were associated with significantly higher FAR when compared to cases in remission (P < 0.001). FAR showed significant positive correlations with Bath Indices including BASDAI, BASFI, and BASMI scores (P = 0.002, 0.002, < 0.001, 0.019, 0.022).

Conclusion

FAR has been increased in AS, particularly in active cases. FAR has also been associated with the impaired functional status of AS patients. FAR can represent a novel inflammatory parameter for monitoring disease activity and severity in AS.

Inflammasomes and their roles in arthritic disease pathogenesis

The inflammasome is a molecular platform that is created in the cytosolic compartment to mediate the host immunological response to cellular injury and infection. Caspase-1 may be activated by the inflammasome, which leads to the generation of the inflammatory cytokines interleukin-1β (IL-1β) and IL-18 and the beginning of pyroptosis, which is a type of proinflammatory cell death. Scientists have identified a number of different inflammasomes in the last 2 decades. The NLRP3 inflammasome has been studied the most, and its activity may be triggered by a broad range of different inducers. However, activation of the NLRP3 inflammasome in a manner that is not properly controlled is also a factor in the etiology of many human illnesses. Accumulating evidence indicates that the NLRP3 inflammasome plays a significant role in the innate and adaptive immune systems and the development of various arthritic illnesses, such as rheumatoid arthritis, ankylosing spondylitis, and gout. The present review provides a concise summary of the biological properties of the NLRP3 inflammasome and presents the fundamental processes behind its activation and control. We discuss the role of the inflammasome in the pathogenesis of arthritic diseases, such as rheumatoid arthritis, ankylosing spondylitis, and gout, and the potential of newly developed therapies that specifically target the inflammasome or its products for the treatment of inflammatory diseases, with a particular emphasis on treatment and clinical application.

The effect of Aqua Stretching exercises and Pilates on pain, function and spine posture in patients with ankylosing spondylitis: a randomized controlled trial

Background

Aqua Pilates and Aqua Stretch exercises are different and new methods for the rehabilitation of musculoskeletal disorders. This study aimed to compare the effectiveness of Aqua Stretch and Aqua Pilates interventions in the treatment of pain, function, and posture of the spine in ankylosing spondylitis (AS) patients.

Methods

Forty patients participated in this study who were randomly allocated into Aqua Stretch, aqua Pilates, and control. The experimental groups received four 60-min training sessions each week for six weeks. However, the control group had only its routine drug treatment (NSAIDs & Anti TNF). Pain with Visual Analog Scale (VAS), function with Bath Ankylosing Spondylitis Functional Index (BASFI) and 40-m walking test (MWT), quality of life with ankylosing spondylitis quality of life (ASQoL), and posture of the spine with the Spinal Mouse were evaluated. Evaluations were performed before and after the interventions. Repeated measure ANOVA was employed to determine the main and interaction effects.

Results

Aqua Stretch and Aqua Pilates had a significant effect on pain (Aqua-Pilates: P = 0.0001; Aqua-Stretch: P = 0.0001), BASFI (Aqua-Pilates: P = 0.01; Aqua-Stretch: P = 0.02), 40-MWT (Aqua-Pilates: P = 0.006; Aqua-Stretch: P = 0.0001) and ASQoL (Aqua-Pilates: P = 0.01; Aqua-Stretch: P = 0.001), spinal range of motion (ROM) (Aqua-Pilates: P = 0.0001; Aqua-Stretch: P = 0.0001) at a similar ratio. However, the control group did not present any improvement in these factors (P > 0.05). Moreover, the minimal clinically important difference (MCID) revealed that the Aqua Stretch group performed better than the Aqua Pilates group in terms of VAS, ASQOL, and 40-MWT factors.

Conclusions

Aqua Stretch and Aqua Pilates had statistically the same effect on improving pain, function, quality of life, and spinal ROM, while MCID results revealed that the Aqua Stretch group performed better than the Aqua Pilates in terms of VAS-ASQOL-40-MWT.

Trial registration It is notable that local ethics committee approval was obtained (IR.KUMS.REC.1399.1137), and the study was registered in Iranian Registry of Clinical Trials (IRCT; IRCT20190426043377N3; registered on 22/05/2021, https://fa.irct.ir/user/trial/56058/view) and patient recruitments were started on 06/07/2021.

The Epidemiology and Treatment of Ankylosing Spondylitis in Korea

Ankylosing spondylitis is a chronic inflammatory disorder characterized by inflammation of the axial skeleton and sacroiliac joints and to a lesser extent by peripheral arthritis and the involvement of some extra-articular organs. It is paramount for the provision of effective health care delivery to be familiar with the epidemiologic studies on prevalence, mortality, and disability. Furthermore, there is no systematic arrangement of studies related to the treatment of ankylosing spondylitis in Korea. In this review, we addressed Korean ankylosing spondylitis epidemiological studies related to prevalence, genetic factor especially human leucocyte antigen-B27, extra-articular manifestations, infections, mortality, radiologic progression, child-birth, and quality of life. Furthermore, we reviewed Korean ankylosing spondylitis treatment researches about treatment trend, patients' registration program called The KOrean College of Rheumatology BIOlogics and targeted therapy (KOBIO) registry project, biologics and biosimiliars, complications especially infections, and issues about bony progression. There would be value to further studying the epidemiology and treatment of Korean ankylosing spondylitis.

Total hip arthroplasty has higher complication rates in stiff spine patients: a systematic review and network meta-analysis

BACKGROUND

Ankylosing spondylitis (AS) and spinal fusion (SF) classified as stiff spines have been associated with the increased rate of complications following total hip arthroplasty (THA). However, the differences between the two cohorts have inconsistent evidence.

METHODS

We searched for studies comparing complications among stiff spine patients, including SF and AS, who underwent THA in PubMed/MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and Scopus until March 2021. Studies detailing rates of mechanical complications, aseptic loosening, dislocation, infection, and revisions were included. We performed network meta-analyses using frequentist random-effects models to compare differences between cohorts. We used P-score to rank the better exposure with the lowest complications.

RESULTS

Fourteen studies were included in the final analysis. A total of 740,042 patients were included in the systematic review and network meta-analysis. Mechanical complications were highest among SF patients (OR 2.33, 95% CI 1.86, 2.92, p < 0.05), followed by AS patients (OR 1.18, 95% CI 0.87, 1.61, p = 0.82) compared to controls. Long Spinal Fusions had the highest aseptic loosening (OR 2.33, 95% CI 1.83, 2.95, p < 0.05), dislocations (OR 3.25, 95% CI 2.58, 4.10, p < 0.05), infections (OR 2.14, 95% CI 1.73, 2.65, p < 0.05), and revisions (OR 5.25, 95% CI 2.23, 12.32, p < 0.05) compared to AS and controls. Our results suggested that SF with longer constructs may be associated with higher complications in THA patients.

CONCLUSIONS

THAs following SFs have higher mechanical complications, aseptic loosening, dislocations, and infections, especially with longer constructs. AS patients may have fewer complications compared to this cohort.

Glucocorticoids in spondyloarthritis-systematic review and real-world analysis

OBJECTIVE

The objective of this study was to identify and summarize the efficacy and safety of systemic glucocorticoids (GCs) and local injections of GC in SpA.

METHODS

PubMed (Medline) and EMBASE were searched with pre-defined keywords for relevant articles in English reporting randomized controlled trials (RCTs), non-randomized interventional studies and non-randomized observational studies of the efficacy of GC in SpA, with five or more patients, for inclusion in a systematic literature review. Local injections of GC included IA and entheseal injections, but excluded SI joint injections.

RESULTS

Out of 9657 records identified, there were 14 studies on the use of systemic GCs in SpA (364 patients), including two RCTs of oral prednisolone. On pooling data from two placebo-controlled RCTs (≤24 weeks), BASDAI 50 was 4.2 times more likely (95% CI: 1.5, 11.5) and Ankylosing Spondylitis Assessment Group (ASAS) 20 was twice more likely (95% CI: 1.1, 3.64) to occur in patients on high-dose oral prednisolone (± taper). Pulsed GCs led to dramatic improvements that lasted a few weeks to a few months. There were no deaths or major adverse events. There were 10 studies (560 patients) on local GCs in SpA. IA injection was effective in achieving a sustained response in 51.5-90% of joints at 6 months. Entheseal injections led to reduced pain and improved US parameters.

CONCLUSION

There were limited studies on either systemic or local injections of GCs in SpA. However, there was good evidence of efficacy with the use of high-dose systemic GCs in the short term (≤6 months) in SpA. Both IA and entheseal injections seemed safe and effective.

Exploring IL-17 in spondyloarthritis for development of novel treatments and biomarkers

Spondyloarthritis (SpA) is an umbrella term describing a family of chronic inflammatory rheumatic diseases. These diseases are characterised by inflammation of the axial skeleton, peripheral joints, and entheseal insertion sites throughout the body which can lead to structural joint damage including formation of axial syndesmophytes and peripheral osteophytes. Genetic evidence, preclinical and clinical studies indicate a clear role of interleukin (IL)- 23 and IL-17 as mediators in SpA pathogenesis. Targeting the IL-23/-17 pathways seems an efficient strategy for treatment of SpA patients, and despite the remaining challenges the pathway holds great promise for further advances and improved therapeutic opportunities. Much research is focusing on serological markers and imaging strategies to correctly diagnose patients in the early stages of SpA. Biomarkers may facilitate personalised medicine tailored to each patient's specific disease to optimise treatment efficacy and to monitor therapeutic response. This narrative review focuses on the IL-17 pathway in SpA-related diseases with emphasis on its role in pathogenesis, current approved IL-17 inhibitors, and the need for biomarkers reflecting core disease pathways for early diagnosis and measurement of disease activity, prognosis, and response to therapy.

Potential Role of Yoga in the Management of Ankylosing Spondylitis: A Retrospective Study

BACKGROUND

Ankylosing spondylitis (AS) is a chronic autoimmune inflammatory spondyloarthropathy with unclear pathogenesis. The inflammatory pain in AS leads to restricted spinal mobility and significant disability. Yoga is a nonpharmacological intervention that has positive effects on various musculoskeletal-related problems. However, its role in AS is unknown.

OBJECTIVE

The present retrospective study assessed the efficacy of a two-week residential yoga intervention on spinal flexibility among AS patients.

METHODS

The records for 24 male AS patients within the age range 30 to 50 years (average age 38.3 ± 10.5 years) who underwent a two-week residential yoga retreat between 2015 and 2020 were obtained from a yoga center located in South India. Yoga intervention consisted of yoga postures, breathing practices, meditation, a healthy diet, and devotional sessions. Pre and Post data of the sit-and-reach test, blood pressure, heart rate, and symptom score were analyzed using Statistical Package for Social Sciences (SPSS).

RESULTS

Compared to the baseline, the post scores of the sit-and-reach test, systolic blood pressure and heart rate were found to be significantly (P < .05) lower. The symptom score and analgesic medication score also showed significant improvement after two-weeks compared to the baseline.

CONCLUSION

This retrospective study indicates the positive impact of on and analgesic use among AS patients. However, additional studies using robust research designs are warranted.

Long-term effectiveness and safety of infliximab and golimumab in ankylosing spondylitis patients from a Canadian prospective observational registry

BACKGROUND

The objectives of this study were to describe the profile of ankylosing spondylitis (AS) patients treated with either infliximab (IFX) or subcutaneous golimumab (GLM) treatment in Canadian routine care setting along with assessing long-term effectiveness and safety.

METHODS

AS patients who were eligible for treatment with IFX or subcutaneous GLM as per their respective Canadian product monographs were enrolled into the BioTRAC registry from 2005 to 2017. The study visits occurred at baseline and every 6 months thereafter. Effectiveness was assessed by changes in clinical outcomes and acute phase reactants. Safety was evaluated by assessing the incidence of adverse events (AEs) and drug survival rates.

RESULTS

A total of 389 IFX- and 421 GLM-treated patients were enrolled. A significant decrease in disease duration at baseline was observed in the IFX cohort, from a median of 8.0 in 2005-2008 to 1.0 years in 2009-2015 (p < 0.001). A reduction in baseline BASFI score (p = 0.011) and proportion of patients in ASDAS very high disease activity (p = 0.004) was also observed over time. Meanwhile, in the GLM cohort, most disease parameters remained similar from 2010 to 2017. Treatment with both agents significantly improved all disease parameters over time with similar efficacy between the two agents. The incidence of AEs and SAEs were 136 and 131 events/100 PYs and 10.5 and 8.45 events/100 PYs for IFX- and GLM-treated patients, respectively.

CONCLUSION

Both IFX and GLM treatment in AS significantly reduced disease activity in most outcome measures in a similar fashion and were well tolerated in Canadian routine care.

TRIAL REGISTRATION

NCT00741793 .

Evaluating the relationship between dietary intake with inflammatory factors, lipid profile and clinical symptoms in patients with rheumatoid arthritis

BACKGROUND AND AIM

Rheumatoid arthritis (RA) is one of the most common life-threatening and associated with inflammation. The aim of this study was to evaluate the relation between dietary intake, inflammatory factors, lipid profile, medication and clinical outcomes in patients with rheumatoid arthritis.

METHODS

This cross-sectional study were conducted in 72 patients with RA that referred to Rheumatology Clinic, Urmia, Iran. After describing the study and obtaining patient consent, fasting blood samples were collected from all participants in start stage, Nuclear Factor-Kappa B (NF-KB), Oxidized Low-Density Lipoprotein (Ox-LDL), lipid profile and clinical symptoms were record in participants. Also, Data on dietary intake and physical activity were collected with relevant questionnaires.

RESULTS

There was a positive significant relation between energy intakes and low-density lipoprotein Cholesterol (LDL-C) (R = 0.855, P = 0.023), carbohydrate intake with total cholesterol (R = 0.297, P = 0.045), carbohydrate intake and NF-kB (R = 0.292, P = 0.017), fat intakes and Ox-LDL (R = 0.321, P = 0.027), prednisolone and Triglyceride (TG) (R = 0.378, P = 0.016), calcium supplement, folic acid and High-Density Lipoprotein Cholesterol (HDL-C) (R = 0.259, R = 0.34, R = 0.355, P = 0.09 respectively). In addition, the correlation between carbohydrate and energy intakes with HDL-C were negative significant (R = -0.355, P = 0.09 and R = -0.259, P = 0.034). SJC, Tender Joint Count (TJC), Erythrocyte Sedimentation Rate (ESR) and VAS were related to DAS28 and other variables shown no relation with DAS28.

CONCLUSION

There are many factors affecting the clinical symptoms of patients with RA that attention to nutritional and medicinal factors can have a significant role in the clinical symptoms and complications of these patients.

National pharmacological treatment trends for ankylosing spondylitis in South Korea: A national health insurance database study

No studies of the current status of treatment options are available for ankylosing spondylitis (AS) patients in South Korea. This study assesses the current status of AS treatment trends using a nationwide database. This study was conducted using a Korean National Health Insurance System (KNHIS) dataset from 2006 to 2016. We randomly extracted 50% of the total number of patients registered as As patients in the KNHIS. The distribution of the number of patients according to age and gender was analyzed each year. The types and combination methods of drugs used during the study period were estimated yearly. Between 2006 and 2016, the number of AS patients increased linearly by an average of 9% annually, 6372 in 2006 to 15188 in 2016. The study found that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) was the most commonly prescribed pharmacological treatment option, followed by disease-modifying anti-rheumatic drugs (DMARDs) and then biologics. Biologics such as tumor necrosis factor alpha (TNF-α) inhibitors increased from 10% to 35% consistently for 10 years. In terms of combination therapy, DMARDs + NSAIDs accounted for almost 90% of treatments in 2006, but decreased by 65% in 2016. The use of biologics and NSAIDs increased from 3% to 28%. Prescriptions for dual therapies and mono therapies largely dominated prescription habits, accounted for up to approximately 80% of treatments. Among 10- to 14-year-old patients, there was no triple therapy, dual and triple therapies decreased gradually for those 60 and older, and the ratio of conservative treatments has increased. This study shows how South Korea reflects changes in AS treatment trends, along with the emergence of TNF-α inhibitors that are effective in treating AS. Research on clinical outcomes for AS treatments will be needed on following these drug changes.

Is Axial Spondyloarthritis More Common Than Rheumatoid Arthritis?

PURPOSE OF REVIEW

To discuss the disease incidence and prevalence rates of axial spondyloarthritis (axSpA) and ankylosing spondylitis (AS) relative to those of rheumatoid arthritis (RA).

RECENT FINDINGS

According to the most recently published systematic reviews, pooled prevalence estimates for RA are 0.38% in North America, and 0.21 to 0.25% in European subregions, while that of AS is 0.20% in North America and 0.25% in Europe. The estimated prevalence of axSpA has been reported to be approximately twice as common as AS in a study from the USA. This finding has also been supported by studies from northern Norway, central Italy, western Turkey, northern and southern regions of China, and rural Taiwan. These data suggest that axSpA, that encompasses AS, may be more prevalent than RA, at least in some countries. In general, higher occurrences of RA relative to AS have been noted worldwide, both in terms of incidence and prevalence. But axSpA, that encompasses AS, may be more prevalent than RA, at least in some countries. There is a need for concurrently run studies in the same population for a reliable comparison to establish occurrence of RA, AS, and axSpA. It is hoped that the implementation of the ICD-11 codes for axSpA will be helpful in determining a more accurate estimate of its incidence and prevalence.

Clinical significance and prognostic value of tumor necrosis factor-α and dickkopf related protein-1 in ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis (AS) frequently occurs in people aged 30-45 years, and its prevalence is generally believed to be between 0.1% and 1.4% globally. At present, the “gold standard” for diagnosis of AS requires the provision of pelvic X-rays, which makes it more difficult to perform in population-based epidemiological studies. Therefore, the identification of serological indicators related to the diagnosis, treatment, and prognosis of AS patients is of great significance.

AIM

To analyze the therapeutic, diagnostic significance and prognostic value of dickkopf-related protein-1 (DKK-1) and tumor necrosis factor-α (TNF-α) in AS.

METHODS

A total of 113 patients with active AS were selected as the research group, and 100 healthy subjects who underwent physical examination were selected as the control group. The levels of DKK-1 and TNF-α in peripheral blood in the two groups were compared. The diagnostic and predictive values of DKK-1 and TNF-α for AS were analyzed with ROC curves, and the factors influencing AS recurrence were analyzed with COX regression.

RESULTS

Before treatment, the research group showed lower DKK-1 levels but higher TNF-α levels than the control group (both ^aP < 0.05). In the research group, DKK-1 was up-regulated and TNF-α was down-regulated after 12 wk of treatment (^aP < 0.05). The area under the curve, sensitivity and specificity of DKK-1 combined with TNF-α for diagnosing AS were 0.934, 82.30% and 97.00%, respectively. Before treatment, the area under the curve, cutoff value, sensitivity and specificity of DKK-1 for predicting the curative effect were 0.825, 68.42 pg/mL, 73.68% and 80.00%, respectively, and those of TNF-α were 0.863, 32.79 ng/L, 92.11% and 77.33%, respectively. DKK-1 and TNF-α levels after treatment were closely related to the curative effect (^aP < 0.05). C-reactive protein, the Bath Ankylosing Spondylitis Disease Activity Index, DKK-1, and TNF-α were risk factors for AS recurrence (^aP < 0.05).

CONCLUSION

DKK-1 and TNF-α are effective in the diagnosis and treatment of AS and are risk factors for its recurrence. In addition, DKK-1 may be a potential target for the diagnosis of AS.

The effects of total hip arthroplasty in treating hip bony fusion in young and middle-aged patients with ankylosing spondylitis

Background

This study aims to investigate the curative effects of total hip arthroplasty (THA) in treating hip bony fusion for young and middle-aged patients with ankylosing spondylitis (AS).

Methods

The clinical data of 26 young and middle-aged patients with AS (31 coxae), who were treated with THA and followed-up for more than 3 years in the period between February 1998 and May 2013, were retrospectively analyzed. Among these patients, 22 patients were male (25 coxae) and 4 patients were female (6 coxae). Patients’ age ranged within 19–50 years old, with an average of 31.5 years old. The intervals from arthroplasty to the occurrence of hip joint lesions caused by AS ranged within 2–26 years, with an average of 11.2 years. The average Harris score before the surgery was 19.0 ± 11.5 points.

Results

Femoral proximal cleavage fracture occurred in one coxa during the surgery and was fixed by the steel wire cerclage. Sciatic nerve traction injury occurred in one coxa after the surgery, which recovered after 6 months. Posterior hip dislocation occurred in one coxa and was immediately treated with manual reduction. All patients were followed-up, and follow-up duration ranged within 36–123 months, with an average of 46.5 months. In the last follow-up, the average Harris score was 87.1 ± 13.1 points, total passive range of motion was 215.0 ± 22.0°, and passive range of flexion was 90.8 ± 9.3°. All these indexes significantly increased compared with pretreatment (P < 0.01). A periacetabular radiolucent line occurred in one coxa with a width of < 2 mm, and no femoral radiolucent line was found during follow-ups in any patient. Heterotopic ossification occurred in four coxae.

Conclusion

THA treatment for hip bony fusion caused by AS can achieve satisfactory hip function recovery and excellent prosthesis survival rate.

Psychological Changes and Employment Outcomes After Kyphosis Correction in Patients With Ankylosing Spondylitis

STUDY DESIGN

A retrospective study.

OBJECTIVE

To evaluate the psychological changes and employment outcomes following corrective osteotomy in patients with ankylosing spondylitis (AS).

SUMMARY OF BACKGROUND DATA

To date, no study has investigated the changes in psychological status and subsequent improvement in employment outcome after correction of kyphotic deformities in patients with AS.

METHODS

This study included 48 patients with AS who underwent corrective osteotomy for severe kyphotic deformity. Sagittal alignment was assessed radiographically. Clinical status was evaluated using the Short Form-36 Health Survey, psychological status was evaluated using the Hospital Anxiety and Depression Scale (HADS), and employment outcomes were assessed using the Lam Employment Absence and Productivity Scale (LEAPS). The degree of postoperative sagittal alignment correction was measured, and changes in clinical and employment outcomes and psychological status were evaluated. The relationship between the degree of sagittal alignment correction and each evaluation item was analyzed.

RESULTS

Following postoperative sagittal alignment correction, all patients could stand erect and look straight. Significant improvements were observed in the clinical and employment outcomes, as well as in patients' psychological status. The degree of sagittal vertical axis correction was significantly correlated with the HADS depression and the LEAPS total scores. The degree of correction of the chin-brow vertical angle was significantly correlated with the Short Form-36 mental health score, the HADS depression and anxiety scores, and the LEAPS total and productivity subscores. Notably, the improvement in the HADS depression score was significantly correlated with the LEAPS total score.

CONCLUSION

This study demonstrated the psychological changes and subsequent improvement in employment outcomes after corrective osteotomy in patients with AS. The degree of sagittal alignment correction was correlated with improvements in psychological status and employment outcomes.

LEVEL OF EVIDENCE

4.

Characteristics of late-onset spondyloarthritis in Japan: A retrospective cohort study

Spondyloarthritis may be increasingly present in older patients as life expectancy increases. We investigated clinical differences between early-onset and late-onset spondyloarthritis in Japan.We retrospectively reviewed 114 patients consecutively diagnosed with spondyloarthritis. The clinical course of each patient was observed for ≥1 year. We defined early-onset and late-onset spondyloarthritis as <57 or ≥57 years at a median age of this study group, respectively. We compared clinical characteristics between these 2 groups.Disease duration was significantly shorter before diagnosis in the late-onset group (P < .01). Inflammatory back pain (IBP) was significantly more common in the early-onset group (P < .01), whereas dactylitis frequency was significantly higher in the late-onset group. Significantly more patients with early-onset spondyloarthritis were human leukocyte antigen (HLA) B27-positive (P < .01). Articular synovitis, particularly of the wrist, was significantly more common on power Doppler ultrasound (PDUS) in the late-onset group (P < .01). Tenosynovitis or peritendinitis, particularly in the finger and wrist flexors were also more frequent in the late-onset group (P < .001 and P < .05, respectively). Enthesitis of the finger collateral ligament and lateral collateral ligament were significantly more common in the late-onset group (both P < .05). Multiple logistic regression analysis revealed that, comparatively, IBP was significantly and independently much more likely to occur in the early-onset group.The patients with late-onset spondyloarthritis had a lower frequency of IBP and HLA B27 and a higher frequency of dactylitis and PDUS findings in peripheral involvement.

Cost-effectiveness analysis of secukinumab in ankylosing spondylitis from the Canadian perspective

AIM

To assess the cost-effectiveness of interleukin (IL)-17A inhibitor secukinumab vs the currently licensed biologic therapies in ankylosing spondylitis (AS) patients from a Canadian healthcare system perspective.

METHODS

A decision analytic model (semi-Markov) evaluated the cost-effectiveness of secukinumab 150 mg compared to certolizumab pegol, adalimumab, golimumab, etanercept and etanercept biosimilar, and infliximab and infliximab biosimilar in a biologic-naïve population, over 60 years of time horizon (lifetime). The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI 50) response rate was used to assess treatment response at week 12. Non-responders or patients discontinuing initial-line of biologic therapy were allowed to switch to subsequent-line biologics. Model input parameters (short-term and long-term changes in BASDAI and Bath Ankylosing Spondylitis Functional Index [BASFI], withdrawal rates, adverse events, costs, resource use, utilities, and disutilities) were obtained from clinical trials, published literature, and other Canadian sources. Benefits were expressed as quality-adjusted life years (QALYs). Cost and benefits were discounted with an annual discount rate of 1.5% for all treatments.

RESULTS

In the biologic-naïve population, secukinumab 150 mg dominated all comparators, as patients treated with secukinumab 150 mg achieved the highest QALYs (16.46) at the lowest cost (CAD 533,010) over a lifetime horizon vs comparators. In the deterministic sensitivity analysis, results were most sensitive to changes in baseline BASFI non-responders, BASDAI 50 at 3 months and discount rates. Probabilistic sensitivity analysis showed that secukinumab 150 mg demonstrated higher probability of achieving maximum net monetary benefit vs all comparators at various cost thresholds.

CONCLUSIONS

This analysis demonstrates that secukinumab 150 mg is the most cost-effective treatment option for biologic-naïve AS patients compared to certolizumab pegol, adalimumab, golimumab, etanercept and etanercept biosimilar, and infliximab and infliximab biosimilar for a lifetime horizon in Canada. Treatment with secukinumab translates into substantial benefits for patients and the healthcare system.

Real-world effectiveness and safety of adalimumab for treatment of ankylosing spondylitis in Japan

Objective: To evaluate the real-world effectiveness and safety of adalimumab for the treatment of ankylosing spondylitis (AS) in Japan.Methods: All AS patients initiated on adalimumab from 27 October 2010 to 28 May 2015, were enrolled. Patient characteristics at baseline, changes in Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores, and adverse drug reactions (ADRs) for 24 weeks from the first adalimumab treatment were evaluated.Results: Of 403 enrolled patients, 396 and 374 comprised the safety and effectiveness analysis sets, respectively. In the safety analysis set, 266/396 (67.2%) were males, with a mean ± standard deviation (SD) age of 46.3 ± 15.6 years and mean ± SD disease duration of 9.8 ± 9.8 years. Of 236 patients examined for human leukocyte antigen (HLA)-B27, 131 (55.5%) were HLA-B27-positive. In the effectiveness analysis set, the mean ± SD BASDAI score was 4.9 ± 2.3 at baseline (n = 292). Overall, 216 patients had BASDAI data pre- and post-baseline. At 24 weeks, 143 patients had BASDAI scores, and the mean ± SD decrease was -2.0 ± 2.6 (p < .0001). Fifteen serious ADRs occurred in 15 (3.79%) patients; 30 (7.58%) ADRs of infections were reported, of which, five (1.26%) were serious.Conclusion: Safety and effectiveness of adalimumab in this postmarketing observational study were similar to that in previous clinical trials.

Budget impact model of secukinumab for the treatment of moderate-to-severe psoriasis, psoriatic arthritis, and ankylosing spondylitis in Italy: a cross-indication initiative

Objective

Secukinumab, a fully human monoclonal IgG1 antibody that selectively neutralizes the proinflammatory cytokine IL-17A, has been approved in Europe in 2015 for the treatment of adult patients with moderate-to-severe plaque psoriasis, psoriatic arthritis (PsA), and ankylosing spondylitis (AS). This analysis assessed the budget impact of introduction of secukinumab to the Italian market for all three indications from the perspective of the Italian National Health Service.

Materials and methods

A cross-indication budget impact model was developed and included biologic-treated adult patients diagnosed with psoriasis, PsA, and AS. The analyses were conducted over a 3-year time horizon and included direct costs (drug therapy costs, administration costs, diseases-related costs, and adverse events costs). Model input parameters (epidemiology, market share projections, resource use, and costs) were obtained from the published literature and other Italian sources. The robustness of the results was tested via one-way sensitivity analyses: secukinumab cost, secukinumab market share, intravenous administration costs, and adverse events costs were varied by ±10%.

Results

The total patient population for secukinumab over the 3-year timeframe was projected to be 6,648 in the first year, increasing to 12,001 in the third year, for all three indications combined (psoriasis, PsA, and AS). Compared to a scenario without secukinumab in the market, the introduction of secukinumab in the market for the treatment of psoriasis, PsA, and AS showed a cumulative 3-year incremental budget impact of −5%, corresponding to savings of €66.1 million and per patient savings of about €1,855. The majority of the cost savings came from the adoption of secukinumab in AS (58%), followed by PsA (29%) and psoriasis (13%). Sensitivity analyses confirmed the robustness of the results.

Conclusion

Results from this cross-indication budget impact model show that secukinumab is a cost-saving option for the treatment of PsA, AS, and psoriasis patients in Italy.

Have the annual trends of total knee arthroplasty in ankylosing spondylitis patients decreased?

Background

Ankylosing spondylitis (AS) is characterized by osteoproliferation-induced structural damage and spinal inflammation, which lead to spinal deformity and functional disability. Though AS commonly affects the axial skeleton and sacroiliac joints, up to 70% of patients have involvement of the knees and other joints. Despite pharmacological efforts, advancing joint involvement may ultimately require surgical intervention. Total knee arthroplasty (TKA) is effective in managing patients with AS, yet it remains unclear whether or not the annual rates of TKA have been affected. Therefore, the purpose of this study was to evaluate the annual trends of AS patients who underwent TKA. Specifically, we evaluated: (I) the annual trends of TKAs due to AS in the United States population; (II) the annual trends in the proportion of TKAs due to AS in the United States.

Methods

The Nationwide Inpatient Sample (NIS) was used to identify all patients who underwent TKA between 2002 and 2013 (n=6,492,873). Then, a subsequent query was performed to identify TKA patients who had a diagnosis of AS, defined by the International Classification of Disease 9th revision diagnosis code 720.0. The incidence of TKAs with a diagnosis of AS in the United States was calculated using the United States population as the denominator. Regression models were used to analyze the annual trends of AS in patients who underwent TKA.

Results

During the study period, 2,986 patients who had AS who underwent TKA were identified. The annual number of TKAs with a diagnosis of AS increased by 168% from 125 to 335. After normalizing to the US population, the incidence of TKAs with AS increased from 0.58 to 1.38 TKAs per million US adults [IRR =1.08 (95% CI: 1.07-1.09), P<0.001]. Out of the 350,122 TKAs in 2002, 125 (0.04%) were due to AS, whereas, out of the 640,695 TKAs in 2013, 335 (0.05%) were due to AS. The prevalence of AS in those who underwent TKA increased from 2002 to 2013 [coefficient =0.002 (95% CI: 0.001-0.003), P=0.004].

Conclusions

The annual trends of AS patients undergoing TKA significantly increased during the study period. To the authors' best knowledge, this is the first study to evaluate TKA trends in the AS population. The literature has reported on the ability of non-steroidal anti-inflammatory drugs (NSAIDs) and the potential of tumor necrosis factor-alpha (TNFα) inhibitors to hinder bone disease progression in AS, however, this was not shown to support to the significant changes found in TKA trends during the study period.

Classification Terminology and Definitions in Reporting of MRI in Axial Spondyloarthritis

Spondyloarthritis (SpA) is a group of chronic inflammatory conditions which severely impact quality of life. Several criteria have been developed in the past to aid the diagnosis of SpA based on symptoms and radiographic changes during the course of the disease. However, it takes several years before structural changes manifest on conventional radiographs, leading to a diagnostic delay of 6 to 10 years. The use of MRI and its incorporation into the Assessment of Spondyloarthritis (ASAS) criteria, has radically changed the diagnosis of SpA in the last decade by allowing visualisation of both active and chronic inflammatory changes and enabling clinicians to recognise SpA during it’s early stage and initiate treatment. An understanding of the various terminology used in the divisions of disease presentations and their relevant imaging findings are key, along with the use of clear definitions of structural and inflammatory changes on MRI, in ensuring accurate diagnosis and classification of SpA.

Non-radiographic axial spondyloarthritis patients without initial evidence of inflammation may develop objective inflammation over time

Objectives. In patients with active axial spondyloarthritis (axSpA), inflammation in the SIJ or spine on MRI, an elevated CRP level or both are considered useful objective assessments for disease activity and initiation of TNF antagonists. The aim of this post hoc analysis of the randomized, double-blind ABILITY-1 study (NCT00939003) was to assess changes in objective inflammation over time.

Methods. Patients with non-radiographic axSpA (nr-axSpA) were randomized to receive adalimumab 40 mg every other week or placebo for 12 weeks in ABILITY-1. MRIs were performed at baseline and week 12; CRP was measured every 4 weeks.

Results. Of 94 placebo-treated ABILITY-1 patients, 29 (30.9%) had a normal MRI of the SIJs and spine, 57 (60.6%) had normal CRP and 20 (21.3%) had a normal MRI of the SIJs and spine and a normal CRP at baseline. After 12 weeks of placebo, 9/29 (31.0%) patients subsequently developed inflammation on MRI, 14/57 (24.6%) patients developed elevated CRP and 10/20 (50.0%) patients developed a positive MRI and/or elevated CRP through week 12.

Conclusions. Patients who have clinically active disease but who lack objective evidence of inflammation initially may benefit from subsequent retesting for inflammation to guide treatment.

Ankylosing Spondylitis Increases Perioperative and Postoperative Complications After Total Hip Arthroplasty

BACKGROUND

Ankylosing spondylitis (AS) is a chronic autoimmune spondyloarthropathy that primarily affects the axial spine and hips. Progressive disease leads to pronounced spinal kyphosis, positive sagittal balance, and altered biomechanics. The purpose of this study is to determine the complication profile of patients with AS undergoing total hip arthroplasty (THA).

METHODS

The Medicare sample was searched from 2005 to 2012 yielding 1006 patients with AS who subsequently underwent THA. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated for 90-day, 2-year, and the final postoperative follow-up for complications including hip dislocation, periprosthetic fracture, wound complication, revision THA, and postoperative infection.

RESULTS

Compared to controls, AS patients had an RR of 2.50 (CI, 1.04-5.99) of THA component breakage at 90-days post-operatively and 1.99 (CI, 1.10-3.59) at 2-years. The RR of periprosthetic hip dislocation was elevated at 90 days (1.44; CI, 0.93-2.22) and significantly increased at 2-years (1.67; CI, 1.25-2.23) and overall follow-up (1.49; CI, 1.14-1.93). Similarly, the RR for THA revision was elevated at 90-days (1.46; CI, 0.97-2.18) and significantly increased at 2-years (1.69; CI, 1.33-2.14) and overall follow-up (1.51; CI, 1.23-1.85).

CONCLUSION

Patients with AS are at increased risk for complications after THA. Altered biomechanics from a rigid, kyphotic spine place increased demand on the hip joints. The elevated perioperative and postoperative risks should be discussed preoperatively, and these patients may require increased preoperative medical optimization as well as possible changes in component selection and position to compensate for altered spinopelvic biomechanics.

The diagnostic value of three sacroiliac joint pain provocation tests for sacroiliitis identified by magnetic resonance imaging

OBJECTIVES

The aim of the current study was to investigate the diagnostic value of three sacroiliac (SI) joint pain provocation tests for sacroiliitis identified by magnetic resonance imaging (MRI) and stratified by gender.

METHOD

Patients without clinical signs of nerve root compression were selected from a cohort of patients with persistent low back pain referred to an outpatient spine clinic. Data from Gaenslen's test, the thigh thrust test, and the long dorsal sacroilia ligament test and sacroiliitis identified by MRI were analysed.

RESULTS

The median age of the 454 included patients was 33 (range 18-40) years and 241 (53%) were women. The prevalence of SI joints with sacroiliitis was 5%. In the whole study group, only the thigh trust test was associated with sacroiliitis, the area under the receiver operating characteristic (ROC) curve (AUC) was 0.58 [95% confidence interval (CI) 0.51-0.65], sensitivity 31% (95% CI 18-47), and specificity 85% (95% CI 82-87). In men, sacroiliitis was associated with all the SI joint tests assessed and multi-test regimens, with the greatest AUC found for at least one positive out of three tests [AUC 0.68 (95% CI 0.56-0.80), sensitivity 56% (95% CI 31-79), and specificity 81% (95% CI 77-85)]. In women, no significant associations were observed between the SI joint tests and sacroiliitis.

CONCLUSIONS

Only in men were the SI joint tests found to be associated with sacroiliitis identified by MRI. Although, the diagnostic value was relatively low, the results indicate that the use of SI joint tests for sacroiliitis may be optimized by gender-separate analyses.

Challenges of diagnosis and management of axial spondyloarthritis in North Africa and the Middle East: An expert consensus

Axial spondyloarthritis (SpA) is a spectrum of inflammatory disease with stages characterized by both nonradiographic and radiographic sacroiliitis. Nonradiographic axial SpA is associated with health-related quality-of-life impairment and may progress to ankylosing spondylitis. Axial SpA has a low prevalence in some countries in North Africa and the Middle East, and pooling of data and resources is needed to increase understanding of the regional picture. Early diagnosis and effective treatment are required to reduce disease burden and prevent progression. Anti-TNF therapy is recommended for patients with persistently high disease activity despite conventional treatment, and has been shown to be effective in patients without radiographic damage. Diagnostic delays can be an obstacle to early treatment and appropriate referral strategies are needed. In some countries, restricted access to magnetic resonance imaging and anti-TNF agents presents a challenge. In this article, a group of experts from North Africa and the Middle East evaluated the diagnosis and management of axial SpA with particular reference to this region.

Randomized controlled trial of adalimumab in patients with nonpsoriatic peripheral spondyloarthritis

OBJECTIVE

To evaluate the efficacy and safety of adalimumab in patients with active nonpsoriatic peripheral spondyloarthritis (SpA).

METHODS

ABILITY-2 is an ongoing phase III, multicenter study of adalimumab treatment. Eligible patients age ≥18 years fulfilled the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for peripheral SpA, did not have a prior diagnosis of psoriasis, psoriatic arthritis (PsA), or ankylosing spondylitis (AS), and had an inadequate response or intolerance to nonsteroidal antiinflammatory drugs (NSAIDs). Patients were randomized 1:1 to receive adalimumab 40 mg every other week or matching placebo for 12 weeks, followed by a 144-week open-label period. The primary end point was the proportion of patients achieving 40% improvement in disease activity according to the Peripheral SpA Response Criteria (PSpARC40) at week 12. This was defined as ≥40% improvement from baseline (≥20-mm absolute improvement on a visual analog scale) in patient's global assessments of disease activity and pain, and ≥40% improvement in at least one of the following features: swollen joint and tender joint counts, total enthesitis count, or dactylitis count. Adverse events were recorded throughout the study.

RESULTS

In total, 165 patients were randomized to a treatment group, of whom 81 were randomized to receive placebo and 84 to receive adalimumab. Baseline demographics and disease characteristics were generally similar between the 2 groups. At week 12, a greater proportion of patients receiving adalimumab achieved a PSpARC40 response compared to patients receiving placebo (39% versus 20%; P = 0.006). Overall, improvement in other outcomes was greater in the adalimumab group compared to the placebo group. The rates of adverse events were similar in both treatment groups.

CONCLUSION

Treatment with adalimumab ameliorated the signs and symptoms of disease and improved physical function in patients with active nonpsoriatic peripheral SpA who exhibited an inadequate response or intolerance to NSAIDs, with a safety profile consistent with that observed in patients with AS, PsA, or other immune-mediated diseases.

Direct and indirect costs associated with ankylosing spondylitis and related disease activity scores in Turkey

This study assessed quality of life, direct and indirect healthcare costs related to ankylosing spondylitis (AS). This study included 650 prevalent AS patients visiting seven centers at tertiary healthcare institutions in Turkey who were interviewed using a standard questionnaire to determine annual direct and indirect healthcare costs. Eligible patients were age ≥18 years with AS for at least 12 months. Direct costs were categorized as inpatient, outpatient and pharmacy, and AS-related consultation. Indirect costs were categorized as workday loss, additional AS-related costs, and caregiver costs. Clinical outcome measures were obtained, including Patients’ Global Disease Activity (Pt-GDA); visual analog scale (Pain-VAS) for pain; Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Functional Index (BASFI), and Metrology Index (BASMI) scores, and EuroQoL 5 dimension (EQ-5D) health status survey scores. Mean (€4,335.20) and median (€5,671.00) annual costs per patient were calculated. Pharmacy costs (€4,032.73) were highest among overall expenditures, followed by additional AS-related consultation (€2,480.38), outpatient (€225.02), and inpatient costs (€29.98). Over half of AS patients (54.8 %) experienced work loss. Related average annual costs were €414.16, based on income level. 10.3 % of AS patients incurred an additional €2,008.07 in 1 year. 6.8 % of patients required caregivers and incurred €778.70 in average annual patient paid costs. Mean Pt-GDA, Pain-VAS, EQ-5D, BASDAI, BASFI, and BASMI scores were 4.4, 40.5, 62.7, 3.6, 3.1, and 2.9, respectively. Direct and indirect AS-related costs are high and represent a considerable economic burden on Turkish AS patients.

Global prevalence of ankylosing spondylitis

OBJECTIVES

For effective health care provision, knowledge of disease prevalence is paramount. There has been no systematic endeavour to establish continent-based AS estimates, however, prevalence is thought to vary by country and background HLA-B27 prevalence. This study aimed to estimate AS prevalence worldwide and to calculate the expected number of cases.

METHODS

A systematic literature search was conducted. Prevalence data were extracted and used to calculate the mean prevalence by continent and the expected number of cases based on country-specific prevalence (or, if missing, the prevalence from neighbouring countries). A second estimate was made using the prevalence from countries with similar HLA-B27 prevalences if a country-specific prevalence estimate was not available.

RESULTS

The mean AS prevalence per 10,000 (from 36 eligible studies) was 23.8 in Europe, 16.7 in Asia, 31.9 in North America, 10.2 in Latin America and 7.4 in Africa. Additional estimates, weighted by study size, were calculated as 18.6, 18.0 and 12.2 for Europe, Asia and Latin America, respectively. There were sufficient studies to estimate the number of cases in Europe and Asia, calculated to be 1.30-1.56 million and 4.63-4.98 million, respectively.

CONCLUSION

This study represents the first systematic attempt to collate estimates of AS prevalence into a single continent-based estimate. In addition, the number of expected cases in Europe and Asia was estimated. Through reviewing the current literature, it is apparent that the continuing conduct of epidemiological studies of AS prevalence is of great importance, particularly as diagnostic capabilities improve and with the recent development of the criteria for axial SpA.

Spondyloarthropathies

Spondyloarthropathies (SpA) are a group of common inflammatory rheumatic disorders characterised by axial and or peripheral arthritis, associated with enthesitis, dactylitis and potential extra-articular manifestations such as uveitis and skin rash. The diseases, which comprise the group, share a common genetic predisposition, the HLA-B27 gene; however, this association varies markedly among the various SpAs and among different ethnic groups. Environmental factors seem to be triggering the diseases in the genetically predisposed individuals. The radiographic hallmark of the group is sacroiliitis, which when present is of help in the diagnosis. Various sets of diagnostic and classification criteria were developed over the years including the European Spondyloarthropathy Study Group (ESSG) criteria which were until recently the most widely used. The new Assessment in SpondyloArthritis international Society (ASAS) international working group has recently proposed a new set of diagnostic criteria that would enable identification of SpA before structural changes develop in the spine. Magnetic resonance imaging (MRI) changes have now been included in the new classification criteria of early axial SpA and are now considered as a major tool in the diagnosis. Until recently, there were no real disease-modifying anti-rheumatic drugs which were able to halt the disease progression. Over the past decade, tumour necrosis factor (TNF)-alfa-blocking agents have been extensively investigated and became the mainstream of therapy providing the patients an effective treatment option.

Health care costs associated with ankylosing spondylitis in Turkey: an analysis from nationwide real-world data

Objectives. To explore health care costs associated with ankylosing spondylitis (AS) in Turkey. Methods. Research-identified data from a system that processes claims for all Turkish health insurance funds were analyzed. Adult prevalent and incident AS patients with two AS visits at least 60 days apart, identified between June 1, 2010 and December 31, 2010, with at least 1 year of continuous health plan enrollment for the baseline and follow-up years were included in the study. Pharmacy, outpatient, and inpatient claims were compiled over the study period for the selected patients. Generalized linear models were used to estimate the expected annual costs, controlling for baseline demographic and clinical characteristics. Results. A total of 2.986 patients were identified, of which 603 were incident cases and 2.383 prevalent cases. The mean ages were 39 and 41 years, respectively, and 44% and 38% were women for incident and prevalent cases. Prevalent patients had higher comorbidity scores (5.01 versus 2.24, P < 0.001) and were more likely to be prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) (77% versus 72%, P < 0.001) or biologics (35% versus 8%, P < 0.006) relative to incident patients. Seventy-seven percent of prevalent patients were prescribed NSAIDs, followed by biologic and disease-modifying antirheumatic drugs (DMARDs). Total annual medical costs for incident AS patients were €2.253 and €4.233 for prevalent patients. Pharmacy costs accounted for a significant portion of total costs (88% for prevalent patient, 77% for incident patient), followed by physician office visit costs. Prior comorbidities and treatment type also significantly contributed to overall costs. Conclusion. Annual expenditures for AS patients in Turkey were comparable relative to European countries. Pharmaceutical expenditures cover a significant portion of the overall costs. Comparative effectiveness studies are necessary to further decrease health care costs of AS treatment.

Initial Diagnosis of Lumbar Disc Herniation Is Associated with a Delay in Diagnosis of Ankylosing Spondylitis

Objective.

There is often a considerable delay in diagnosis of ankylosing spondylitis (AS). In this multicenter study, we analyzed the delay and possible associated factors, including an initial diagnosis of lumbar disc herniation (LDH), which we frequently encounter in daily clinical practice.

Methods.

The study included 393 consecutive patients [258 men (65.6%), mean age 39.3 ± 10.8 yrs] with AS according to the modified New York criteria. Face-to-face interviews were done using a structured questionnaire, addressing all the potentially relevant factors.

Results.

The mean diagnostic delay was 8.1 ± 8.6 years in the whole study population. The shortest delay was observed when rheumatologists were the first physicians consulted (2.9 ± 5.3 yrs). An initial diagnosis of LDH was reported by 33% of the patients. The diagnostic delays in patients with an initial diagnosis of LDH and those without were 9.1 ± 8.5 years and 6.2 ± 7.4 years, respectively (p = 0.002). In a regression model, predictive factors for delay in diagnosis were age at onset of spondyloarthritic symptoms, back pain, education level, prior diagnosis of LDH, and surgical history for LDH.

Conclusion.

These results indicate the need to increase awareness of the concept of axial spondyloarthritis among specialists who might be the first physicians consulted by patients with AS for their back pain. There is also a need to develop strategies for early referral of such patients to rheumatologists.

Advances in the treatment of inflammatory arthritis

The inflammatory arthritides are a diverse group of conditions characterised by joint inflammation which can lead to pain, deformity and disability. Of these diseases, rheumatoid arthritis (RA) and spondyloarthritis are two of the most common. While the clinical and demographic features of these diseases differ, the central role of inflammation in their pathogenesis has allowed the development of highly effective treatment strategies with wide applicability. These strategies include the use of biological agents which target the cytokine tumour necrosis factor (TNF), a key mediator of inflammation. With the advent of effective agents, therapy has become more aggressive, reducing disease activity and allowing, at least in RA, remission in many patients. While the array of available effective treatments is extensive, the use of objective measures of disease activity can guide treatment decisions (treat to target) and lead to improved outcomes.

A systematic critical review on MRI in spondyloarthritis

Introduction

Magnetic resonance imaging (MRI) has been proven capable of showing inflammatory and structural changes in patients with spondyloarthritis (SpA) and has become widely used in the diagnosis of SpA. Despite this, no systematic reviews evaluate the diagnostic utility of MRI for SpA. Therefore, the objective of this systematic review was to determine the evidence for the utility of MRI in the clinical diagnosis of SpA. The aims were to identify which MRI findings are associated with the diagnosis of SpA and to quantify this association.

Methods

MEDLINE and EMBASE were electronically searched. Inclusion criteria were cross-sectional or longitudinal case-control or cohort MRI studies. The studies required a group with either SpA or inflammatory back pain (IBP) and a non-case group without SpA or IBP. Each group required a minimum of 20 participants. The included articles had to report results containing raw numbers suitable for the construction of two-by-two tables or report results by sensitivity and specificity for cross-sectional studies or odds ratios, relative risk ratios, or likelihood ratios for longitudinal studies. Method quality was assessed by using criteria based on the QUADAS tool.

Results

In total, 2,395 articles were identified in MEDLINE and EMBASE before November 2011. All articles were reviewed by title and abstract. Seventy-seven articles were reviewed by full text, and 10 met the inclusion criteria. Two were considered of high quality: one evaluated the sacroiliac joints, and the other, the spine. Because of the small number of high-quality studies, a meta-analysis was not performed. The two high-quality studies found a positive association between MRI findings (bone marrow edema, erosions, fat infiltrations, global assessment of sacroiliitis, and ankylosis) and the diagnosis of IBP and SpA.

Conclusion

In this review, several MRI findings were found to be associated with SpA. However, because of the small number of high-quality studies, the evidence for the utility of MRI in the diagnosis of SpA must be considered limited. Therefore, caution should be taken to ensure that inflammatory and structural MRI findings are not interpreted as being more specific for SpA than is supported by research.

Prevalence of axial spondylarthritis in the United States: estimates from a cross-sectional survey

OBJECTIVE

The US national prevalence of spondylarthritis (SpA) was estimated for 2 published sets of classification criteria: the Amor criteria and the European Spondylarthropathy Study Group (ESSG) criteria. These 2 SpA criteria sets have been the most widely utilized in previous population-based studies of SpA.

METHODS

The US SpA prevalence estimates were based on a representative sample of 5,013 US adults ages 20-69 years who were examined in the US National Health and Nutrition Examination Survey (NHANES) 2009-2010.

RESULTS

The overall age-adjusted prevalence of definite and probable SpA by the Amor criteria was 0.9% (95% confidence interval [95% CI] 0.7-1.1%), corresponding to an estimated 1.7 million persons (95% CI 1.4-2.1 million persons). The age-adjusted prevalence of SpA by the ESSG criteria was 1.4% (95% CI 1.0-1.9%), corresponding to an estimated 2.7 million persons (95% CI 1.9-3.7 million persons). There were no statistically significant sex differences in SpA prevalence. The SpA prevalence among non-Hispanic white persons was 1.0% (95% CI 0.7-1.5%) by the Amor criteria and 1.5% (95% CI 1.0-2.3%) by the ESSG criteria. SpA prevalence could not be reliably estimated in other race/ethnicity subgroups due to sample size imitations.

CONCLUSION

The SpA prevalence estimates are in the range of SpA prevalence estimates reported elsewhere in population-based surveys and it is likely that SpA may affect up to 1% of US adults, a prevalence similar to that reported for rheumatoid arthritis. The current US SpA prevalence estimates may be lower than the true value because the NHANES 2009-2010 data collection did not capture a complete set of the elements specified in the 2 SpA criteria sets.

Clinical significance of inflammatory back pain for diagnosis and screening of patients with axial spondyloarthritis

Inflammatory back pain (IBP) is the leading symptom of patients with spondyloarthritis (SpA), but its value for diagnosis, classification and screening in primary care is not well defined. Although often used since 1977, its clinical significance has not been extensively studied. As shown recently, most but clearly not all patients with axial SpA have IBP. Therefore IBP has not been included in current criteria for axial SpA as a first-line criterion. The value of IBP for diagnosis of SpA increases in the presence of other more or less sensitive and specific features of SpA such as response to exercise and physical therapy and/or treatment with non-steroidal anti-inflammatory agents.