Effects of secukinumab on synovitis and enthesitis in patients with psoriatic arthritis: 52-week clinical and ultrasound results from the randomised, double-blind ULTIMATE trial with open label extension

DEUS Enthesitis Index (DEI): a new tool integrating ultrasound and clinical examination for enthesitis assessment in spondyloarthritis

OBJECTIVES

(1) To develop a composite score, the DEUS (Defining Enthesitis on Ultrasound in Spondyloarthritis) Enthesitis Index (DEI), which integrates ultrasound and clinical examination findings for enthesitis assessment in patients with spondyloarthritis (SpA); (2) to examine the relationships between DEI and clinical features in this population, compared to the clinical examination of the entheses alone.

METHODS

This was a cross-sectional, observational, multicentric study involving 20 rheumatology centres across 11 countries. Ultrasound and clinical examinations were performed bilaterally on the lower limb large entheses (ie, quadriceps tendon, proximal and distal patellar tendons, Achilles tendon and plantar fascia) in 413 patients with SpA, including 224 patients with axial SpA and 189 patients with psoriatic arthritis (PsA). A score of 1.0 for clinical enthesitis and 1.0 for ultrasound enthesitis was assigned for each of the 10 entheses evaluated. The total DEI score, which combines clinical and ultrasound findings, ranged from 0 to 20 per patient. Logistic and gamma regression models based on DEI were compared with those derived solely from clinical enthesitis assessment to evaluate their relative performance in explaining disease-related outcomes.

RESULTS

Among patients with SpA, the median DEI was 1.0 (IQR 0.0-3.0). DEI showed significant associations with SpA disease activity and severity indices in regression analyses, except for the Disease Activity in Psoriatic Arthritis score in patients with PsA. Compared with the clinical examination alone of the same entheses, DEI models exhibited a significantly better fit with C-reactive protein levels and ultrasound-detected structural damage at the enthesis (ie, enthesophytes and bone erosions). By contrast, the clinical examination alone models showed a significantly stronger fit with SpA disease activity indices and patient-reported outcomes compared with the DEI.

CONCLUSIONS

DEI is a novel tool that integrates both ultrasound and clinical examination findings for enthesitis assessment, potentially ensuring a more reliable evaluation of this key domain in SpA.

Minimally invasive ultrasound-guided biopsy of the common extensor tendon enthesis: a cadaveric study to standardise the technique

OBJECTIVE

To develop and validate a minimally invasive ultrasound (US)-guided biopsy technique to collect entheseal tissue from the common extensor tendon (CET) enthesis at the lateral humeral epicondyle.

METHODS

Seven sonographers performed a US examination of the CET on six human cadaveric upper limbs to locate the enthesis using an anatomical landmark-based approach. An adapted mini-arthroscopic system was introduced under US guidance to the target site for sample collection. At the end of the procedure, a dye was injected through the guide needle, followed by dissection, to confirm the sampling location. Histology and immunohistochemistry analyses were performed to assess the quality and representativeness of the samples. The reliability of the procedure among operators was evaluated by analysing the rate of successful sampling.

RESULTS

24 samples were collected. The target site to be biopsied was identified as the insertion of the extensor carpi radialis brevis component of the CET. On dissection, the stain used to verify sampling accuracy was confirmed within the defined target area, with no damage to adjacent structures. Histology and immunohistochemistry indicated that most of the samples exhibited characteristics consistent with entheseal tissue (21 out of 24). All participants identified the CET and successfully completed the procedure, demonstrating reliable sample quality across operators.

CONCLUSION

We developed a landmark-based approach to perform a minimally invasive full controlled US-guided biopsy of the CET enthesis that showed to be feasible and reproducible. We believe that this standardised, minimally invasive technique will widespread a reliable collection of entheseal tissue for future clinical and translational studies.

Primary non-response in inflammatory arthritis treated with biologics and targeted therapies in daily clinical practice

Background

Switching between therapies is a recommended strategy for rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients who experience treatment failure; moreover, data on switching due to primary non-response and subsequent failures are limited.

Objectives

To obtain information from clinical practice regarding failures due to primary non-response in patients on biologic and target synthetic disease-modifying antirheumatic drugs (ts/bDMARDs), assessing the incidence rate (IR) of switching due to primary non-response and risk of subsequent treatment failure by cycling compared to swapping.

Design

A longitudinal retrospective study, spanning from 2007 to 2022, was conducted on patients with RA or PsA treated with ts/bDMARDs at an outpatient rheumatology clinic.

Methods

The main outcomes were as follows: (1) ts/bDMARD failure due to primary non-response and (2) subsequent discontinuation of prescribed ts/bDMARD due to lack of efficacy. The independent variable was switching between classes compared to switching within class. As covariates, clinical, sociodemographic, clinical, and treatments were considered. To estimate ts/bDMARDs switching rates, survival techniques were used, expressing the IR per 100 patients * year with their 95% confidence interval. Cox multivariate regression analyses were run to assess the role of switching between/within class in the subsequent treatment failure.

Results

In total, 327 patients were included. Of these, 50 patients in 77 treatment courses developed primary non-response with an IR of 4.25 (3.4-5.3). The IR was quite similar between RA and PsA, higher in women, and in those who started ts/bDMARDs after 2018. In those with primary non-response, there were 42 subsequent treatment failures with an IR of 26.38 (19.49-35.69). The multivariate model showed that cycling increased the risk of subsequent failure compared to swapping (hazard ratio: 2 (1.1-3.77), p = 0.03).

Conclusion

This study provides support to consider swapping a better alternative rather than cycling after primary non-response.

Relationship Between Ultrasound and Physical Examination in the Assessment of Enthesitis in Patients With Spondyloarthritis: Results From the DEUS Multicenter Study

OBJECTIVE

The study objectives were (i) to explore the agreement between the Outcome Measures in Rheumatology (OMERACT) ultrasound lesions of enthesitis and physical examination in assessing enthesitis in patients with spondyloarthritis (SpA) and (ii) to investigate the prevalence and clinical relevance of subclinical enthesitis in this population.

METHODS

Twenty rheumatology centers participated in this cross-sectional study. Patients with SpA, including axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA), underwent both ultrasound scan and physical examination of large lower limb entheses. The OMERACT ultrasound lesions of enthesitis were considered, along with a recently proposed definition for "active enthesitis" by our group. Subclinical enthesitis was defined as the presence of "active enthesitis" in ≥1 enthesis in patients with SpA without clinical enthesitis (ie, number of positive entheses on physical examination and Leeds Enthesitis Index score = 0).

RESULTS

A total of 4,130 entheses in 413 patients with SpA (224 with axSpA and 189 with PsA) were evaluated through ultrasound and physical examination. Agreement between ultrasound and physical examination ranged from moderate (ie, enthesophytes) to almost perfect (ie, power Doppler and "active enthesitis"). Patellar tendon entheses demonstrated the highest agreement, whereas Achilles tendon insertion showed the lowest. Among 158 (38.3%) of 413 patients with SpA with clinical enthesitis, 108 (68.4%) exhibited no "active enthesitis" on ultrasound. Conversely, of those 255 without clinical enthesitis, 39 (15.3%) showed subclinical enthesitis. Subclinical enthesitis was strongly associated with local structural damage. However, no differences were observed regarding the demographic and clinical profiles of patients with SpA with and without subclinical enthesitis.

CONCLUSION

Our study underscores the need for a comprehensive tool integrating ultrasound and physical examination for assessing enthesitis in patients with SpA.

Synovitis scoring in hand osteoarthritis with ultrasonography: the performance of the Global OMERACT/EULAR Ultrasound Synovitis Score (GLOESS) is comparable to synovial thickening alone

BACKGROUND

Inflammation is increasingly recognised as a treatment target in hand osteoarthritis, and therefore correct measurement of local inflammation is essential. This study aimed to assess ultrasound scoring of synovitis and the additional value of the Global OMERACT/EULAR Ultrasound Synovitis Score (GLOESS) in hand osteoarthritis.

METHODS

Data from the randomised, double-blinded Hand Osteoarthritis Prednisolone Efficacy (HOPE) trial were used. The HOPE trial included patients with painful, inflammatory hand OA, treated with prednisolone or placebo (1:1). Ultrasound was performed in 30 hand joints at weeks 0, 6 and 14. Effusion, synovial thickening and Doppler signal were measured, the GLOESS was calculated from the latter two. Joint tenderness on palpation was assessed semiquantitatively (0-3), soft swelling as present/absent. Changes in ultrasound scores, and their association with change in joint tenderness or soft swelling, were investigated using generalised estimating equations. Effect sizes were calculated.

RESULTS

Of 92 included patients 79% were women, with mean (SD) age 63.9 (8.8) and body mass index 27.2 (4.6). Synovial thickening was the most prevalent. All ultrasound scores were strongly associated with joint tenderness and soft swelling cross-sectionally. There was no association of change in ultrasound scores with change in tenderness, but there was with change in soft tissue swelling. Synovial thickening and the GLOESS responded to treatment (effect size -0.39 (-0.72 to -0.07), -0.39 (-0.71 to -0.07), respectively).

DISCUSSION

Various ultrasound scores were associated with joint tenderness and soft swelling. The GLOESS and synovial thickening were both responsive to treatment, but GLOESS was not superior to synovial thickening alone.

Superior effect of adalimumab versus secukinumab on ultrasound-confirmed synovitis in psoriatic arthritis: comprehensive evidence from musculoskeletal ultrasound and clinical assessments

Background and objectives: Psoriatic arthritis (PsA) is a chronic inflammatory musculoskeletal disorder affecting 30% of psoriatic patients. Effective treatment, especially with biologics like IL-17 and TNF inhibitors, is vital for improving patient outcomes. This study aimed to compare the efficacy of secukinumab and adalimumab in PsA patients through clinical and ultrasonographic evaluations.Materials and methods: We enrolled 116 PsA patients, with 58 patients receiving secukinumab and 58 receiving adalimumab. Regular follow-ups were conducted at weeks 4, 12, 24, and 52. The primary outcome was the proportion of patients achieving at least a 20% improvement in the ACR response (ACR20) at week 12, with additional evaluations for axial arthritis, enthesitis, skin involvement, minimal disease activity, health assessment questionnaire, and ultrasound changes.Results: There was no significant difference in ACR20 response between the two groups at week 12 (OR: 0.59, 95% CI: 0.26-1.37, p = 0.22). However, secukinumab demonstrated superior efficacy in achieving Psoriasis Area and Severity Index (PASI)90 (OR: 2.25, 95%CI: 1.07-4.74, p = 0.03), while adalimumab showed better improvement in ultrasound synovitis count (β: 0.94, 95%CI: 0.09-1.79, p = 0.03) and synovitis PD signal (β: 0.20, 95%CI: 0.03-0.36, p = 0.02).Conclusions: In conclusion, both treatments were highly effective for PsA, with secukinumab being more suitable for severe skin involvement and adalimumab for significant ultrasound-confirmed synovitis.

Imaging in psoriatic arthritis: established methods and emerging techniques

Psoriatic arthritis (PsA) is a heterogeneous, chronic, inflammatory musculoskeletal disease that can lead to peripheral and axial damage and loss of function. A clear difference between PsA and other forms of inflammatory arthritis is the different forms of bone remodeling seen in PSA which incorporates not only increased bone resorption with bone erosions, osteolysis, and loss of bone mineral density but also increased bone formation with periostitis, syndesmophytes, enthesiophytes, and ankylosis. PsA, if diagnosed late, will lead to significant structural damage, the most severe form of which is known as arthritis mutilans, and loss of physical function. Imaging plays a crucial role in diagnosing and monitoring both peripheral and axial conditions associated with PsA. Radiography is currently the main modality used to monitor structural damage in PsA though commonly used scoring systems do not include bony proliferation as a criterion. Besides, radiography is limited in determining the presence and cause of periarticular soft tissue thickening, which may arise from tendinosis, tenosynovitis, synovial proliferation, bursitis, or enthesitis. Recently, much more attention has been paid to determining the imaging characteristics of PsA, which enables more precise identification of disease and severity assessment. Newer imaging technologies also enable variations in normal bone microstructure to be distinguished from disease-related abnormality. This review discusses the current state of innovative imaging modalities in PsA, specifically concentrating on their roles in PsA diagnosis and treatment, improving the early detection of PsA, and identifying patients with skin psoriasis at risk of developing psoriatic arthritis.

Additional Value of Ultrasound in Patients with Psoriatic Arthritis within Treatment Target

Background: In psoriatic arthritis (PsA), musculoskeletal ultrasound is a complementary tool to physical examination, useful even in patients in remission to detect subclinical activity. Objectives: The objective of the study was to assess the ultrasound prevalence of active enthesitis and synovitis in patients who reached the therapeutic target. Methods: This cross-sectional study included patients with at least 6 months of therapy with a targeted synthetic or biological disease-modifying antirheumatic drug who were in treatment target (i.e., DAPSA < 14). Patients underwent bilateral clinical and ultrasound examination of the elbow lateral epicondyle, quadriceps insertion, distal patellar tendon insertion, and Achilles enthesis for assessing enthesitis, and hand and foot joints for assessing synovitis. Enthesitis and synovitis were considered active if the power Doppler signal showed at least a score of one. Results: The study included 51 PsA patients, women (52.9%), with an average age of 55 years. Although the patients were within the DAPSA treatment target, 21.6% had at least one painful enthesis at clinical examination, 19.6% had ultrasound evidence of at least one active enthesitis and 15.7% had ultrasound signs of at least one active synovitis. Conclusions: Among PsA patients thought to be within the therapeutic target, ultrasound detected a non-negligible percentage of active enthesitis and synovitis.

Validation and incorporation of digital entheses into a preliminary GLobal OMERACT Ultrasound DActylitis Score (GLOUDAS) in psoriatic arthritis

OBJECTIVES

The main objective was to generate a GLobal OMERACT Ultrasound DActylitis Score (GLOUDAS) in psoriatic arthritis and to test its reliability. To this end, we assessed the validity, feasibility and applicability of ultrasound assessment of finger entheses to incorporate them into the scoring system.

METHODS

The study consisted of a stepwise process. First, in cadaveric specimens, we identified enthesis sites of the fingers by ultrasound and gross anatomy, and then verified presence of entheseal tissue in histological samples. We then selected the entheses to be incorporated into a dactylitis scoring system through a Delphi consensus process among international experts. Next, we established and defined the ultrasound components of dactylitis and their scoring systems using Delphi methodology. Finally, we tested the interobserver and intraobserver reliability of the consensus- based scoring systemin patients with psoriatic dactylitis.

RESULTS

32 entheses were identified in cadaveric fingers. The presence of entheseal tissues was confirmed in all cadaveric samples. Of these, following the consensus process, 12 entheses were selected for inclusion in GLOUDAS. Ultrasound components of GLOUDAS agreed on through the Delphi process were synovitis, tenosynovitis, enthesitis, subcutaneous tissue inflammation and periextensor tendon inflammation. The scoring system for each component was also agreed on. Interobserver reliability was fair to good (κ 0.39-0.71) and intraobserver reliability good to excellent (κ 0.80-0.88) for dactylitis components. Interobserver and intraobserver agreement for the total B-mode and Doppler mode scores (sum of the scores of the individual abnormalities) were excellent (interobserver intraclass correlation coefficient (ICC) 0.98 for B-mode and 0.99 for Doppler mode; intraobserver ICC 0.98 for both modes).

CONCLUSIONS

We have produced a consensus-driven ultrasound dactylitis scoring system that has shown acceptable interobserver reliability and excellent intraobserver reliability. Through anatomical knowledge, small entheses of the fingers were identified and histologically validated.

Power Doppler signal at the enthesis and bone erosions are the most discriminative OMERACT ultrasound lesions for SpA: results from the DEUS (Defining Enthesitis on Ultrasound in Spondyloarthritis) multicentre study

OBJECTIVES

To assess, in spondyloarthritis (SpA), the discriminative value of the Outcome Measures in Rheumatology (OMERACT) ultrasound lesions of enthesitis and their associations with clinical features in this population.

METHODS

In this multicentre study involving 20 rheumatology centres, clinical and ultrasound examinations of the lower limb large entheses were performed in 413 patients with SpA (axial SpA and psoriatic arthritis) and 282 disease controls (osteoarthritis and fibromyalgia). 'Active enthesitis' was defined as (1) power Doppler (PD) at the enthesis grade ≥1 plus entheseal thickening and/or hypoechoic areas, or (2) PD grade >1 (independent of the presence of entheseal thickening and/or hypoechoic areas).

RESULTS

In the univariate analysis, all OMERACT lesions except enthesophytes/calcifications showed a significant association with SpA. PD (OR=8.77, 95% CI 4.40 to 19.20, p<0.001) and bone erosions (OR=4.75, 95% CI 2.43 to 10.10, p<0.001) retained this association in the multivariate analysis. Among the lower limb entheses, only the Achilles tendon was significantly associated with SpA (OR=1.93, 95% CI 1.30 to 2.88, p<0.001) in the multivariate analyses. Active enthesitis showed a significant association with SpA (OR=9.20, 95% CI 4.21 to 23.20, p<0.001), and unlike the individual OMERACT ultrasound lesions it was consistently associated with most clinical measures of SpA disease activity and severity in the regression analyses.

CONCLUSIONS

This large multicentre study assessed the value of different ultrasound findings of enthesitis in SpA, identifying the most discriminative ultrasound lesions and entheseal sites for SpA. Ultrasound could differentiate between SpA-related enthesitis and other forms of entheseal pathology (ie, mechanical enthesitis), thus improving the assessment of entheseal involvement in SpA.