Remission is related to CRP and smoking in early axial spondyloarthritis. The DESIR cohort

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Factors associated with discontinuation of biologics in patients with inflammatory arthritis in remission: data from the BIOBADASER registry

BACKGROUND

The objectives of this study were to assess the discontinuation of biologic therapy in patients who achieve remission and identify predictors of discontinuation of biologics in patients with inflammatory arthritis in remission.

METHODS

An observational retrospective study from the BIOBADASER registry comprising adult patients diagnosed with rheumatoid arthritis (RA), ankylosing spondylitis (AS), or psoriatic arthritis (PsA) and receiving 1 or 2 biological disease-modifying drugs (bDMARDs) between October 1999 and April 2021. Patients were followed yearly after initiation of therapy or until discontinuation of treatment. Reasons for discontinuation were collected. Patients who discontinued bDMARDs because of remission as defined by the attending clinician were studied. Predictors of discontinuation were explored using multivariable regression models.

RESULTS

The study population comprised 3,366 patients taking 1 or 2 bDMARDs. Biologics were discontinued owing to remission by 80 patients (2.4%): 30 with RA (1.7%), 18 with AS (2.4%), and 32 with PsA (3.9%). The factors associated with a higher probability of discontinuation on remission were shorter disease duration (OR: 0.95; 95% CI: 0.91-0.99), no concomitant use of classic DMARDs (OR: 0.56; 95% CI: 0.34-0.92), and shorter usage of the previous bDMARD (before the decision to discontinue biological therapy) (OR: 1.01; 95% CI: 1.01-1.02); in contrast, smoking status (OR: 2.48; 95% CI: 1.21-5.08) was associated with a lower probability. In patients with RA, positive ACPA was associated with a lower probability of discontinuation (OR: 0.11; 95% CI: 0.02-0.53).

CONCLUSIONS

Discontinuation of bDMARDs in patients who achieve remission is uncommon in routine clinical care. Smoking and positive ACPA in RA patients were associated with a lower probability of treatment discontinuation because of clinical remission.

Evaluating remission and low disease activity from the perspective of the patient with axial spondyloarthritis: The cross-sectional ConREspAx study

OBJECTIVES

To evaluate the properties of a single question to determine patient perception of remission and disease activity; to compare this with existing definitions for remission and low disease activity (LDA).

METHODS

Single-center, cross-sectional study in a tertiary care hospital. Patients with axSpA (fulfilling ASAS criteria) were consecutively included. Both the patient's perception of remission and LDA and that of the physician were evaluated with a single question. Agreement between the patients' perception and other current definitions was tested using the prevalence-adjusted and bias-adjusted kappa (PABAK). The sensitivity (S) and specificity (Sp) of current definitions of disease states were tested against the patient's perception as the gold standard.

RESULTS

The study population included 105 axSpA patients (63.8% males; 67.6% with radiographic sacroiliitis). Patients considered themselves to be in remission in 21% of cases and in LDA in 51.4%; physicians considered patients to be in remission in 45.7% of cases and in LDA in 35.2%. The poorest agreement was recorded for the patient's and the physician's perception of remission. The best agreement for patients' perception of remission was for a BASDAI < 2 and normal C-reactive protein values. This definition was also the most sensitive (S=72.7%) and specific (Sp=83.1%) when the patient's perception was taken as the gold standard.

CONCLUSION

In a real-life setting, the evaluation of remission by the patient through a single question was the hardest criterion to achieve, although it did prove to be a feasible, valid, and specific way to assess remission.

Smoking, alcohol consumption and disease-specific outcomes in rheumatic and musculoskeletal diseases (RMDs): systematic reviews informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A EULAR taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). The aim of this paper was to review the literature on the relationship between smoking and alcohol consumption with regard to RMD-specific outcomes.

METHODS

Two systematic reviews were conducted to identify systematic reviews and meta-analyses, published between 2013 and 2018, related to smoking and alcohol consumption in seven RMDs: osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), systemic sclerosis (SSc) and gout. Two additional systematic reviews were performed to identify original longitudinal studies on smoking and alcohol consumption and disease-specific outcomes.

RESULTS

Nine reviews and 65 original studies on smoking as well as two reviews and 14 original studies on alcohol consumption met the inclusion criteria. While most studies were moderate/poor quality, smoking was significantly associated with poorer outcomes: cardiovascular comorbidity; poorer response to RA treatment; higher disease activity and severity in early RA; axSpA radiographic progression. Results were heterogeneous for OA while there was limited evidence for PsA, SSc and gout. Available studies on alcohol mainly focused on RA, reporting a positive association between alcohol intake and radiographic progression. Five studies assessed alcohol consumption in gout, reporting a significant association between the number and type of alcoholic beverages and the occurrence of flares.

CONCLUSION

Current literature supports that smoking has a negative impact on several RMD-specific outcomes and that moderate or high alcohol consumption is associated with increased risk of flares in RA and gout.

Lifestyle Factors and Disease Activity over Time in Early Axial Spondyloarthritis - The SPondyloArthritis Caught Early (SPACE) Cohort

OBJECTIVE

Our aim was to study the importance of baseline Body Mass Index (BMI), smoking and alcohol consumption (AC) for disease activity (DA) over one year in early axial spondyloarthritis (axSpA), stratified by sex.

METHODS

In the SPondyloArthritis Caught Early cohort (patients with chronic back pain for ≥3 months, ≤2 years and onset <45 years), ASDAS was recorded at inclusion, 3 and 12 months. All patients included in the analysis had axSpA based on a high physician's level of confidence at baseline. Differences in ASDAS over 1 year by BMI (normal <25, overweight 25-29.9, obese ≥30 kg/m²), smoking history (never/previous/current) and AC (none, 0.1-2, 3-5, ≥6 units/week) at baseline were estimated using mixed linear regression models.

RESULTS

There were 344 subjects (mean age 30 years; 49% men). In women, obesity was associated with 0.60 (95% CL 0.28, 0.91) higher ASDAS compared to normal BMI. In both sexes, AC tended to be associated with lower DA over one year, with a significant association only in women with the highest AC (mean difference -0.55 (96% CL-1.05, -0.04). Smoking was associated with higher ASDAS over one year compared to never smoking in both sexes, albeit the difference reached statistical significance only in female former smokers. Results were similar in multivariable analysis, adjusted for all lifestyle factors and other confounders.

CONCLUSION

In early axSpA, BMI and smoking are associated with higher DA over one year, and AC with lower DA. The magnitude of the modest associations may differ between men and women.

Factors associated with remission at 5-year follow-up in recent onset axial spondyloarthritis: results from the DESIR cohort

Objective

The factors contributing to long-term remission in axial SpA (axSpA) are unclear. We aimed to characterize individuals with axSpA at the 5-year follow-up to identify baseline factors associated with remission.

Methods

We included all patients from the DESIR cohort (with recent-onset axSpA) with an available Ankylosing Spondylitis Disease Activity Score–CRP (ASDAS-CRP) at 5-year follow-up. Patients in remission (ASDAS-CRP < 1.3) were compared with those with active disease by demographic, clinical, biological and imaging characteristics. A logistic model stratified on TNF inhibitor (TNFi) exposure was used.

Results

Overall, 111/449 patients (25%) were in remission after 5 years. Among those never exposed to TNFi, 31% (77/247) were in remission compared with 17% (34/202) of those exposed to TNFi. Patients in remission after 5 years were more likely to be male, HLA-B27+, have a lower BMI, and a higher education level. Baseline factors associated with 5-year remission in patients never exposed to TNFi included lower BASDAI [adjusted odds ratio (OR_a) 0.9, 95% CI: 0.8, 0.9) and history of peripheral arthritis (OR_a 2.1, 95% CI: 1.2, 5.3). In those exposed to TNFi, remission was associated with higher education level (OR_a 2.9, 95% CI: 1.6, 5.1), lower enthesitis index (OR_a 0.8, 95% CI: 0.7, 0.9), lower BASDAI (OR_a 0.9, 95% CI: 0.9, 0.9) and lower BMI (OR_a 0.8, 95% CI: 0.7, 0.9).

Conclusion

This study highlights the difficulty in achieving 5-year remission in those with recent-onset axSpA, especially for the more active cases, despite the use of TNFi. Socio-economic factors and BMI are implicated in the outcome at 5 years.

Smoking in spondyloarthritis: unravelling the complexities

Tobacco smoking is a major threat to health. There is no doubt about the need to promote and support cessation at every opportunity. Smoking has a clear role in RA, but what evidence is there that the same relationship exists in SpA? In this review, we examine (the less cited) paradoxes and contradictions in the existing axial SpA (axSpA) and PsA literature; for example, smoking appears to be 'protective' for some axSpA manifestations. We also highlight findings from higher quality evidence: smoking is associated with increased risk of PsA and the risk of psoriasis in axSpA. The relationship between smoking and SpA is far from simple. Our aim is to highlight the harms of smoking in SpA and bring attention to inconsistencies in the literature to inform further research.

2018 update of French Society for Rheumatology (SFR) recommendations about the everyday management of patients with spondyloarthritis

OBJECTIVE

To update French Society for Rheumatology recommendations about the management in clinical practice of patients with spondyloarthritis (SpA). SpA is considered across the range of clinical phenotypes (axial, peripheral, and entheseal) and concomitant manifestations. Psoriatic arthritis is included among the SpA phenotypes.

METHODS

According to the standard procedure advocated by the EULAR for developing recommendations, we first reviewed the literature published since the previous version of the recommendations issued in June 2013. A task force used the results to develop practice guidelines, which were then revised and graded using AGREE II.

RESULTS

Four general principles and 15 recommendations were developed. The first four recommendations deal with treatment goals and general considerations (assessment tools and comorbidities). Recommendations 5 and 6 are on non-pharmacological treatments. Recommendation 7 is about nonsteroidal anti-inflammatory drugs, which are the cornerstone of the treatment, and recommendations 8 to 10 are on analgesics, glucocorticoid therapy, and conventional disease-modifying antirheumatic drugs. Biologics are the focus of recommendations 11 through 14, which deal with newly introduced drug classes, including their indications (active disease despite conventional therapy and, for nonradiographic axial SpA, objective evidence of inflammation) and monitoring, and with patient management in the event of treatment failure or disease remission. Finally, recommendation 15 is about surgical treatments.

CONCLUSION

This update incorporates recent data into a smaller number of more simply formulated recommendations, with the goal of facilitating their use for guiding the management of patients with SpA.