Induction of Sustained Clinical Remission in Early Axial Spondyloarthritis Following Certolizumab Pegol Treatment: 48-Week Outcomes from C-OPTIMISE

Machine learning vs human experts: sacroiliitis analysis from the RAPID-axSpA and C-OPTIMISE phase 3 axSpA trials

Objective

Diagnosis of axial spondyloarthritis (axSpA) is primarily established through the identification of the presence or absence of radiographic sacroiliitis. However, the reliability of conventional radiographs (X-rays) is undermined by significant interreader variability. A machine learning tool could reduce diagnosis time, thereby minimising interreader variability. The present study aimed to evaluate the performance of a deep learning model for detecting radiographic sacroiliitis in axSpA patients from the RAPID-axSpA (NCT01087762) and C-OPTIMISE (NCT02505542) trials.

Methods

Radiographs from the RAPID-axSpA and C-OPTIMISE cohorts were retrospectively used. The deep learning model was previously trained by using a transfer learning approach on non-medical data. The model's agreement with expert readers was tested on baseline X-rays using central reader data. Sensitivity, specificity, Cohen's κ, positive and negative predictive values and the area under the receiver operating characteristics curve were calculated.

Results

The model's performance was evaluated in the RAPID-axSpA (n = 277) and C-OPTIMISE (n = 739) cohorts. In RAPID-axSpA, the model achieved 82% sensitivity, 81% specificity and a Cohen's κ of 0.61, closely matching central reader performance. In C-OPTIMISE, the model demonstrated 90% sensitivity, 56% specificity and a Cohen's κ of 0.48. The agreement between the model and central readers was 82% (RAPID-axSpA) and 75% (C-OPTIMISE).

Conclusions

The tested deep learning model exhibited accurate radiographic sacroiliitis detection in axSpA patients from diverse clinical trials. The proposed deep learning model could expedite diagnosis, reduce healthcare resource usage and improve patient care pathways.

Approaches and outcomes of adalimumab discontinuation in patients with well-controlled inflammatory arthritis: a systematic search and review

OBJECTIVE

This systematic search and review aimed to evaluate the available literature on discontinuation of adalimumab and other tumor necrosis factor inhibitors (TNFi) for patients with well-controlled chronic inflammatory arthritides.

METHODS

We conducted a publication search on adalimumab discontinuation from 2000-2023 using PubMed, CINAHL, EMBASE, and Cochrane Library. Included studies evaluated adalimumab discontinuation approaches, tapering schemes, and outcomes including successful discontinuation and recapture after flare, in patients with well-controlled disease. Studies included evaluated rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and juvenile idiopathic arthritis (JIA).

RESULTS

Forty-nine studies were included. Studies evaluating adalimumab alone were limited, and many reported TNFi outcomes as a single entity. Studies on rheumatoid arthritis (RA) (32, 8 RCTs) reported flare rates from 33-87%. Flares with medication tapering were slightly lower than with abrupt stop, and successful recapture was generally high (80-100%). Studies on spondyloarthropathy (12, 4 RCTs), focused on tapering, noting lower flare rates in tapering rather than abruptly stopping, and high recapture rates (~ 90%). Studies on JIA (5) were observational and demonstrated modestly lower flare rates with tapering (17-63%) versus abrupt stopping (28-82%). There was notable variability in study design, follow-up duration, specificity for TNFi results, and controlled pediatric studies.

CONCLUSION

The literature evaluating adalimumab and other TNFi discontinuation, flare rates, and recapture success within the inflammatory arthritis population demonstrated less flare when medications were tapered, over abrupt stop in the RA, spondyloarthropathy, and JIA populations. When medications were restarted after flare, recapture of well-controlled disease was generally high in RA and spondyloarthropathy, and generally favorable in JIA.

Rationale and concerns for using JAK inhibitors in axial spondyloarthritis

Axial spondyloarthritis (axSpA) is a chronic illness with limited treatment options. The role of Janus kinase (JAK) inhibition as a therapeutic option has increasingly become a focus of research in recent years as they have brought a new mode of action to the clinical armamentarium. This review assesses the efficacy and safety profile of these drugs in axSpA. The current phase 2 and 3 clinical trials data are summarized across tofacitinib, upadacitinib and filgotinib. Moreover, the safety profiles of these drugs, in the context of emerging safety signals such as during the ORAL surveillance study, are reviewed. In summary, JAK inhibitors offer a novel therapeutic target for axSpA and appear to address some of the unmet needs for patients who have either failed to respond to current treatment options or in whom they are contraindicated. There is a relative lack of evidence in non-radiographic axSpA and longer-term trials are needed to establish true efficacy and safety profile in radiographic axSpA.

Comparison of established and preliminarily proposed ASAS MRI working group cut-offs for inflammatory MRI lesions in the sacroiliac joints in radiographic and non-radiographic axial spondyloarthritis

BACKGROUND

A consensus definition for active sacroiliitis by MRI, mentioned in the Assessment of SpondyloArthritis International Society (ASAS) classification criteria for axial spondyloarthritis (axSpA), was published in 2009 and included a qualitative and quantitative MRI cut-off component. In 2021, updates to the quantitative component were preliminarily proposed. This post hoc analysis of part A of the phase 3 open-label C-OPTIMISE study (NCT02505542) explores the differences by applying the 2009 and preliminary 2021 inflammatory cut-offs on clinical outcomes of axSpA patients treated with certolizumab pegol.

METHODS

Baseline MRI scans were used to classify 657 patients as MRI+ or MRI- according to the quantitative components of the 2009 and preliminary 2021 MRI cut-offs for inflammatory lesions. Clinical outcomes, including ASAS ≥40% improvement (ASAS40), Ankylosing Spondylitis Disease Activity Score and Bath Ankylosing Spondylitis Disease Activity Index, were reported to week 48.

RESULTS

Across all analysed outcomes, 2009 MRI+ and preliminary 2021 MRI+ subgroups showed similar results. Notably, clinical outcomes for the discordant group (2009 MRI+but preliminary 2021 MRI- group; 53/657 [8.1%]) were close to those seen in MRI- patients according to either 2009 or preliminary 2021 inflammatory cut-offs, and notably different from the totality of MRI+ subgroups.

CONCLUSION

This analysis suggests that the preliminary 2021 cut-offs for MRI inflammatory lesions may slightly increase the specificity of the quantitative part of the 2009 MRI inflammatory lesion definition. The effects of the updated MRI cut-offs need to be assessed on the basis of efficacy outcomes and with the inclusion of aspects of structural changes.

TRIAL REGISTRATION NUMBER

NCT02505542.

Long-term clinical outcomes of certolizumab pegol treatment in non-radiographic axial spondyloarthritis stratified by baseline MRI and CRP status

OBJECTIVE

There is a paucity of data on long-term clinical responses in patients with non-radiographic axial spondyloarthritis (nr-axSpA) based on their baseline objective signs of inflammation such as MRI or C-reactive protein (CRP) levels. This study reports clinical outcomes up to 3 years of the C-axSpAnd trial, including safety follow-up extension (SFE) from Weeks 52 to 156, stratified by patients' baseline MRI and CRP status.

METHODS

C-axSpAnd (NCT02552212) was a phase 3, multicentre study that evaluated certolizumab pegol (CZP) in patients with active nr-axSpA who had active sacroiliitis on MRI and/or elevated CRP. In this post hoc analysis, efficacy outcomes are reported to Week 156 of C-axSpAnd for patients stratified according to their MRI and CRP status at Week 0 (MRI+/CRP-, MRI-/CRP+ and MRI+/CRP+).

RESULTS

Across all outcome measures, including major improvement in Ankylosing Spondylitis Disease Activity Score (ASDAS-MI) and Assessment of SpondyloArthritis international Society criteria ≥40% response (ASAS40), outcomes were generally sustained in SFE patients from Week 52 to Week 156. MRI+/CRP+ patients showed numerically higher or comparable responses relative to MRI-/CRP+ and MRI+/CRP- patients at Weeks 52 and 156; however, all three subgroups demonstrated substantial improvements from Week 0 (in CZP-randomised patients, ASDAS-MI at Week 156 [observed case]: MRI+/CRP+: 73.1%, MRI-/CRP+: 52.2%, MRI+/CRP-: 30.4%; ASAS40: MRI+/CRP+: 76.9%, MRI-/CRP+: 62.5%, MRI+/CRP-: 65.2%).

CONCLUSIONS

In patients with nr-axSpA and objective signs of inflammation, long-term clinical outcomes achieved after 1 year were generally sustained at 3 years across MRI+/CRP+, MRI-/CRP+ and MRI+/CRP- subgroups.

Certolizumab Pegol Treatment in Patients with Axial-Spondyloarthritis-Associated Acute Anterior Uveitis: a Narrative Review

Background

Acute anterior uveitis (AAU) affects up to 40% of patients with axial spondyloarthritis (axSpA). An effective treatment for patients with axSpA that reduces the risk of AAU flares while also targeting axial symptoms is therefore highly desirable. Tumor necrosis factor inhibitors (TNFis) have been shown effective for treatment of axSpA and AAU occurrence, with guidelines conditionally recommending treating patients with axSpA and associated AAU with TNFi monoclonal antibodies. To date, most available data on the impact of TNFis on AAU in axSpA are from observational, open-label studies without parallel comparator arms. However, there is a growing body of evidence describing the impact of the TNFi certolizumab pegol (CZP) on the incidence of axSpA-associated AAU.

Objective

Our objective was to collate data pertaining to the impact of CZP in axSpA-associated AAU in patients across the full axSpA spectrum.

Methods

Data were obtained from four industry-supported phase 3 and 4 clinical trials (C-VIEW, C-axSpAnd, C-OPTIMISE, and RAPID-axSpA). To supplement these data, a targeted literature review was performed through searches of MEDLINE, Embase, and reference lists.

Results

Available data from 1467 patients from the C-VIEW, C-axSpAnd, C-OPTIMISE, and RAPID-axSpA trials show CZP to be effective in AAU in patients across the full axSpA spectrum, reducing AAU flares when compared with placebo or pretreatment period. No differences in AAU outcomes were reported when stratified by axSpA subgroup age or sex. The targeted literature review identified six further studies of CZP in spondyloarthritis-associated AAU, only one of which was specific to axSpA.

Conclusion

CZP was effective in reducing AAU incidence in clinical trials with patients with axSpA. The targeted literature review, however, highlighted that there remains a paucity of data beyond these trials. Data from comparative studies would further enhance the body of evidence on the effects of CZP in patients with axSpA who develop AAU.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-022-00486-1.

Treating spondyloarthritis early: does it matter? Results from a systematic literature review

OBJECTIVE

To summarize evidence on the relationship between early treatment (definition based on symptom/disease duration or radiographic damage) and treatment clinical response in patients with SpA.

METHODS

A systematic literature review was conducted in studies on SpA patients treated with NSAIDs or b/tsDMARDs addressing the impact of symptom/disease duration or presence of radiographic damage on treatment response assessed by any disease activity outcome. For categorical outcomes, relative risk, relative risk ratio (RRR) and number needed to treat were calculated, and for continuous outcomes, differences in differences, to compare groups stratified based on symptom/disease duration or the presence of radiographic damage.

RESULTS

From the 8769 articles retrieved, 25 were included and 1 added by hand-search, all in axSpA, most of them with low risk of bias. Twenty-one studies compared groups based on symptom duration (n = 6) or disease duration (n = 15) and 7 studies based on absence/presence of radiographic damage (2 studies used two comparisons). When early axSpA was defined by symptom duration (<5 years) in RCTs, early treatment was associated with better outcomes in patients with nr-axSpA (n = 2, ASAS40 RRR 5.24 (95%CI 1.12-24.41) and 1.52 (0.60-3.87)) but not in r-axSpA (n = 1) [ASAS20 0.96 (0.53-1.73)]. When early axSpA was defined based on disease duration or radiographic damage, no differences were found between groups.

CONCLUSION

Evidence towards better outcomes in early axSpA is very limited and restricted to nr-axSpA and <5 years symptom duration. When early axSpA is defined based on disease duration or radiographic damage, no differences in response to treatment are found.

The impact of gender and sex on diagnosis, treatment outcomes and health-related quality of life in patients with axial spondyloarthritis

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic condition, historically considered a predominantly male disease. However, increasing evidence suggests a more equal prevalence between men and women. Of the limited research conducted to date, it is apparent that gender differences exist in terms of time to diagnosis, treatment outcomes and health-related quality of life (HRQoL). Despite this, women are underrepresented in clinical trials and most studies do not stratify by gender to identify potential differences in terms of disease manifestations and treatment response. In this perspectives article, we reflect on the potential biological and social factors contributing to these differences and propose three key areas of education and research that should be prioritised in order to address the unmet needs of female patients with axSpA, namely: (1) to identify ways to increase awareness of disease occurrence in female patients among healthcare professionals (HCPs), (2) to improve understanding of gender differences in disease manifestation and outcomes, and (3) to conduct gender-stratified clinical trials with a representative sample of female patients.

Achievement rate and predictive factors of the recommended therapeutical target in patients with axial spondyloarthritis who remain on biological therapy: a prospective cohort study in Spain

OBJECTIVES

To determine the frequency of sustained remission (R) or low diseas activity (LDA) in patients with axial spondyloarthritis (axSpA) undergoing long-term biological therapy and to analyse predictive factors for achieving these outcomes.

DESIGN

Prospective, observational cohort study.

SETTING

Spanish hospital.

PARTICIPANTS

Patients with axSpA who initiated biological treatment between 2003 and 2017.

INTERVENTION

Assessment of demographic and clinical characteristics at the beginning of treatment and disease activity every 6 months up to a maximum of 2 years.

MAIN OUTCOME MEASURES

Disease activity was measured by Ankylosing Spondylitis Disease Activity Score (ASDAS) and Bath Ankylosing Spondylitis Disease Activity Index and C reactive protein (BASDAI&CRP). Sustained R was defined as ASDAS<1.3 and/or BASDAI <2 and normal CRP while sustained LDA was defined as ASDAS <2.1 and/or BASDAI <4 and normal CRP on at least three consecutive visits.

RESULTS

In total 186 patients (66.1% men and 75.3% with radiographic sacroiliitis) were included. Overall, 76.8% of patients achieved ASDAS R/LDA (R53.2%/LDA23.6%) in at least one visit. Forty per cent (R17.6%/LDA22.4%) of the patients fulfilled the sustained ASDAS R/LDA state, whereas only 30.8% maintained this status (R14.8%/LDA15.9%) according to BASDAI&CRP. In the multivariate analysis, male sex (OR=4.01), younger age at the beginning of biological therapy (OR=0.96) and an HLA*B27 positive status (OR=4.30) were associated with achieving sustained ASDAS R/LDA.

CONCLUSIONS

In clinical practice, around one-third of patients on biological disease-modifying antirheumatic drugs achieve a sustained R/LDA status, but these rates drop to less than one in five when targeting remission, preventing the use of the latter as a feasible target. Male sex, HLA*B27 positivity and younger age at the beginning of biological therapy are the main predictors for achieving sustained R/LDA.

Where we are in treat to target era? Predictive factors for remission and drug switching in patients with axial spondyloarthritis: a real-life evidence from BioStaR nationwide registry

OBJECTIVES

Factors associated with disease activity of axial spondyloarthritis (axSpA) and switching of biologic disease-modifying anti-rheumatic drugs have not been clearly defined. We aimed to evaluate clinical characteristics of patients with axSpA, factors related to remission in treat to target era and predictive factors for biologic disease-modifying anti-rheumatic drug switching.

METHOD

A multicenter, observational cross-sectional study was performed between February 2019 and August 2019. We included all consecutive patients ≥ 18 years with axSpA. Demographic and clinical variables were prospectively recorded. Clinical tools included Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Metrology Index (BASMI), and Maastricht Ankylosing Spondylitis Enthesitis Score (MASES).

RESULTS

There were 969 patients with a mean age of 43.4 ± 10.8 years. There were 143 patients (14.8%) with remission and 223 (23.1%) patients with low disease activity. Male sex (p = 0.021), positive family history (p = 0.036), and human leukocyte antigen-B27 (p = 0.011) were predictors of remission by ASDAS-CRP. There were 654 patients (67.5%) who did not switch to another drug. The highest BASMI and MASES scores were calculated in patients with very high disease activity (p < 0.05). In patients with drug switching, the disease duration was significantly higher (p < 0.001) and the age at diagnosis was significantly lower (p = 0.016). There were significantly more patients with uveitis and higher scores of MASES and BASMI in patients who switch to another biologic disease-modifying anti-rheumatic drugs (p = 0.003, p = 0.009, and p = 0.004, respectively).

CONCLUSIONS

In patients with axSpA, male sex, younger age, and HLA-B27 positivity are associated with remission, while longer disease duration and accompanied uveitis appear to be related with drug switching.

CLINICAL TRIAL REGISTRATION NUMBER AND DATE

NCT04139954/25.10.2019.

Certolizumab Pegol Treatment in Axial Spondyloarthritis Mitigates Fat Lesion Development: 4-Year Post-Hoc MRI Results from a Phase 3 Study

OBJECTIVES

Fat lesions (FLs) on MRI T1 sequences are considered early indicators of structural spinal progression in axial spondyloarthritis (axSpA) patients. In this post-hoc analysis from RAPID-axSpA, we assess whether TNFi treatment over 4 years impacts FLs in spinal vertebral edges (VEs) of patients with axSpA.

METHODS

In RAPID-axSpA (NCT01087762), a 4-year, phase 3 randomised trial, participants were randomised to certolizumab pegol (CZP; 400 mg loading dose at Weeks 0/2/4 then 200/400 mg every 2/4 weeks) or placebo (PBO) at baseline; PBO-randomised participants switched to CZP at week 16/24 (denoted PBO-randomised/CZP). Spinal MRI scans were taken at Weeks 0, 12, 48, 96 and 204. Changes in proportions of VEs with FLs are reported as odds ratios (OR) between timepoints.

RESULTS

Overall, 136 participants (CZP: 89, PBO-randomised/CZP: 47) had a baseline and ≥1 post-baseline MRI. The OR (95% CI) vs baseline of FLs was higher in PBO-randomised/CZP vs CZP-randomised participants at Weeks 48 (3.35 [2.16-5.19] vs 1.45 [1.07-1.97]), 96 (2.62 [1.77-3.88] vs 1.84 [1.36-2.48]) and 204 (2.55 [1.59-4.06] vs 1.71 [1.23-2.37]). Across 204 weeks, FLs increased more in VEs with baseline inflammation (week 204 OR: 4.84 [2.56-9.18]) than those without (OR: 1.15 [0.78-1.71]). VEs in which inflammation was resolved by week 12 had lower FL prevalence at Weeks 48, 96 and 204 compared with VEs with unresolved inflammation.

CONCLUSIONS

Early and sustained suppression of inflammation mitigates the risk of long-term fat lesion development in the spine in study participants with axSpA evaluated over 4 years.

Value-Based Healthcare in Rheumatology: Axial Spondyloarthritis and Beyond

PURPOSE OF REVIEW

This review examines axial spondyloarthritis (axSpA) and the wider field of rheumatology through a value-based healthcare (VBHC) lens. VBHC is focused on ensuring patients receive high quality care to improve outcomes and reduce unnecessary costs.

RECENT FINDINGS

There are many opportunities to apply the principles of VBHC in axSpA. These include the appropriate utilization of diagnostic investigations, such as HLA-B27 and magnetic resonance imaging, assessing outcomes meaningful to patients, and optimizing care pathways. Multidisciplinary care may improve value, and reduced specialist review and medication tapering may be appropriate. Increasing the value of the care we provide to patients can occur across domains and directly and indirectly improves patient outcomes. Taking the time to integrate principles of VBHC into our practice will allow us to justifiably gain and maintain access to diagnostic and therapeutic advances for the benefit of all our patients.

Similar biologic drug response regardless of radiographic status in axial spondyloarthritis: data from the BSRBR-AS registry

OBJECTIVES

To describe the baseline characteristics, bDMARD response and drug survival of axSpA patients in the British Society for Rheumatology Biologics Register in Ankylosing Spondylitis (BSRBR-AS) according to radiographic status.

METHODS

BSRBR-AS is a national prospective cohort including axSpA participants classified according to the ASAS criteria. In this analysis, baseline data of patients starting bDMARDs were compared. Ankylosing Spondylitis Disease Activity Scores (ASDAS) for low disease status, clinically important improvement (CII) and major improvement (MI) at one year were used to assess treatment response. Cox proportional hazard analysis was performed after adjusting for clinically relevant cofounders.

RESULTS

1,145 axSpA patients were included. Higher male prevalence, older age and longer disease duration was seen in the r-axSpA subgroup. Based on a complete case analysis (290 patients), two thirds of patients achieved ASDAS low disease state at one year regardless of radiographic status (nr-axSpA: 64.2% vs r-axSpA: 66.1). No statistically significant differences were seen between the subgroups in attaining ASDAS CII (nr-axSpA: 50.7% vs r-axSpA: 44.7%) or MI (nr-axSpA: 20% vs r-axSpA: 18.7%). Drug survival probability curves were similar for both subgroups and hazard ratio for nr-axSpA/axSpA was 0.94 (95% CI 0.69-1.28) when adjusted for sex, age, baseline ASDAS-CRP, smoking status, disease duration, HLA-B27 and prescribed biologic.

CONCLUSIONS

Although there appeared to be some differences in the baseline characteristics when exploring this cohort according to radiographic status which are likely related to the natural history of the disease, the level of biologic response and drug survival was comparable between nr-axSpA and r-axSpA.

Head-to-Head Comparison of Etanercept vs. Adalimumab in the Treatment of Ankylosing Spondylitis: An Open-Label Randomized Controlled Crossover Clinical Trial

Background: Anti-tumor necrosis factor biological agents had been proved to have a dramatic effect in ankylosing spondylitis (AS). We aimed to determine the efficacy and safety of crossover effects of adalimumab vs. etanercept in AS patients. Methods: A randomized, open-label crossover study was done in patients with active AS. Patients were randomized into two sequence groups, etanercept first (treatment arm) vs. adalimumab first (control arm) 8 weeks and then switched over for another 8 weeks. The primary endpoints were the difference of the Bath AS activity index and AS disease activity score (ASDAS)crp at week 16. Secondary endpoints were ASDASesr, ASAS20, and ASAS40 response rates and the proportion of patients achieving ASDAS inactive disease and low disease activity at weeks 8 and 16. Patient global assessment and preference was grading on a numerical scale. Results: A total of 21 patients were screened, and 19 of them were randomly allocated into the treatment arm (n = 9) and control arm (n = 9). At baseline, age, sex, Bath AS activity index, and ASDAS of both arms were comparable (p > 0.05). Both arms showed dramatic improvement, whereas no significance was observed between the changes of ASDAScrp (0.90 ± 1.39 vs. 1.24 ± 1.40 at week 8, p = 0.612; 1.02 ± 1.22 vs. 1.26 ± 1.44 at week 16, p = 0.707, respectively). ASAS20 and ASAS40 response rates were also comparable at week 8 (33 vs. 44%, p = 1.000; 22 vs. 22%, p = 1.000) and week 16 (22 vs. 22%, p = 1.000; 22 vs. 22%, p = 1.000), respectively. Both arms were well-tolerated without a serious adverse event. Adalimumab was relatively more favorable by patients in both arms, with a total mean grading score of 0.4 (-5-5, p = 0.218). Conclusion: Etanercept and adalimumab can both dramatically improve disease activity in 16 weeks. Crossover administration of etanercept and adalimumab revealed comparable efficacy and safety. Trial Registration: The protocol was approved by the Institutional Review Board with the register CS08019 from Chung Shan Medical University Hospital (CSMUH), Taichung, Taiwan and registered at ClinicalTrials.gov Protocol Registration and Results System: NCT02489760.