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

The bright Easter bunny sign: a useful aide-memoire on MRI for costotransverse joint inflammation in axial spondyloarthritis

AIM

To assess the significance of the "bright Easter bunny" sign on magnetic resonance imaging (MRI) to indicate inflammatory costotransverse joint (CtJ) lesions to diagnose axial spondyloarthritis (ax-SpA).

MATERIALS AND METHODS

Consecutive cases of patients with ax-SpA from a specialist rheumatology clinic were analysed retrospectively over two cohorts, between 2012-2014 and 2018-2020, to determine newly diagnosed patients under the Assessment of SpondyloArthritis international Society (ASAS) criteria. Biological naive adult patients who underwent spine MRI and sacroiliac imaging with full immunological work-up and a C-reactive protein reading within 3 months of the scan were included. Blinded images were reviewed by experienced musculoskeletal radiologists.

RESULT

From the 1,284 cases that were identified, 40 cases met the inclusion criteria for this study. Seven out of the 40 cases (17.5%) identified inflammatory lesions at the CtJ with five (70%) showing concordance with the bright Easter bunny sign.

CONCLUSION

The bright Easter bunny sign is concordant with inflammatory costotransverse enthesitis. This aide-memoire radiological sign is often on overlooked edge-of-field sections and this emphasises the need to ensure adequate coverage of the CtJ on spine MRI protocols as an important anatomical site of inflammatory change in ax-SpA assessment.

Circulating Calprotectin (cCLP) in autoimmune diseases

BACKGROUND AND AIM

Calprotectin (CLP) is a heterodimeric complex formed by two S100 proteins (S100A8/A9), which plays a pivotal role in innate immunity. Due to its intrinsic cytotoxic and proinflammatory properties, CLP controls cell differentiation, proliferation and NETosis and has been associated with a wide range of rheumatic diseases. Our review summarizes the widespread interest in circulating CLP (cCLP) as a biomarker of neutrophil-related inflammation, in autoimmune rheumatic disease (ARD) and non-ARD.

METHODS

A thorough literature review was performed using PubMed and EMBASE databases searching for circulating calprotectin and synonyms S100A8/A9, myeloid-related protein 8/14 (MRP8/MRP14), calgranulin A/B and L1 protein in addition to specific ARDs and autoimmune non-rheumatic diseases. We selected only English-language articles and excluded abstracts without the main text.

RESULTS

High cCLP serum levels are associated with worse structural outcomes in rheumatoid arthritis and to a lesser extent, in spondyloarthritis. In addition, cCLP can predict disease relapse in some autoimmune diseases including systemic lupus erythematosus (SLE), anti-neutrophil cytoplasmic antibodies-associated vasculitis (AAV) and some severe manifestations of connective tissue diseases, such as glomerulonephritis in SLE, AAV, juvenile idiopathic arthritis, adult-onset Still's disease and lung fibrosis in systemic sclerosis. Therefore, cCLP levels enable the identification of patients who need an accurate and tight follow-up. The clinical usefulness of cCLP as an inflammatory marker has been suggested for inflammatory/autoimmune non-rheumatic diseases, and especially for the monitoring of the inflammatory bowel diseases patients. Currently, there are only a few studies that evaluated the cCLP efficacy as a clinical biomarker in inflammatory/autoimmune non-rheumatic diseases with controversial results. Future studies are warranted to better clarify the role of cCLP in relation to the disease severity in myasthenia gravis, multiple sclerosis, chronic inflammatory demyelinating polyneuropathy, Graves' orbitopathy, autoimmune bullous diseases and uveitis.

CONCLUSION

Our literature review supports a relevant role of cCLP as potential prognostic biomarker mirroring local or systemic inflammation, especially in chronic inflammatory rheumatic diseases.

Nonradiographic axial spondyloarthritis: expanding the spectrum of an old disease: A narrative review

Nonradiographic axial spondyloarthritis (nr-axSpA) represents a distinct phenotype within the spectrum of axial spondyloarthritis (axSpA), which is characterized by a range of clinical manifestations. Despite a high disease burden that is comparable to ankylosing spondylitis (also known as radiographic axSpA), there is an unmet need to recognize and effectively manage patients with active nr-axSpA.A targeted literature search was conducted in OVID (MEDLINE and Embase databases) to identify articles on nr-axSpA, including its definition, demographics, epidemiology, burden, diagnosis, clinical presentation, and treatment guidelines.The lack of adequate epidemiological data and incomplete understanding of nr-axSpA among rheumatologists and nonrheumatologists contributes to delayed referrals and diagnosis. This delay results in a substantial burden on patients, physically and psychologically, and the healthcare system. Targeted therapies, such as biologics, including inhibitors of tumor necrosis factor or interleukin-17A, have been approved and utilized for the management of nr-axSpA, and other novel therapeutics with different mechanisms of action are in development. Raising awareness among US internists regarding the prevalence of nr-axSpA, disease burden, clinical presentation, diagnostic tools, and available treatments is important for improved disease management.Future clinical investigations focusing on the development of markers that aid early diagnosis and predict treatment response may also improve the management of nr-axSpA. This review provides an overview of nr-axSpA with the aim of raising awareness of the disease among US internists, with an overarching goal to contribute toward the improved recognition and timely referral of these patients to rheumatologists for diagnosis and management.

Australian Consensus Statements for the Assessment and Management of Non-radiographic Axial Spondyloarthritis

Background

The understanding of non-radiographic axial spondyloarthritis (nr-axSpA) has accelerated over the last decade, producing a number of practice-changing developments. Diagnosis is challenging. No diagnostic criteria exist, no single finding is diagnostic, and other causes of back pain may act as confounders.

Aim

To update and expand the 2014 consensus statement on the investigation and management of non‐radiographic axial spondyloarthritis (nr-axSpA).

Methods

We created search questions based on our previous statements and four new topics then searched the MEDLINE and Cochrane databases. We assessed relevant publications by full-text review and rated their level of evidence using the GRADE system. We compiled a GRADE evidence summary then produced and voted on consensus statements.

Results

We identified 5145 relevant publications, full-text reviewed 504, and included 176 in the evidence summary. We developed and voted on 22 consensus statements. All had high agreement. Diagnosis of nr-axSpA should be made by experienced clinicians, considering clinical features of spondyloarthritis, blood tests, and imaging. History and examination should also assess alternative causes of back pain and related conditions including non-specific back pain and fibromyalgia. Initial investigations should include CRP, HLA-B27, and AP pelvic radiography. Further imaging by T1 and STIR MRI of the sacroiliac joints is useful if radiography does not show definite changes. MRI provides moderate-to-high sensitivity and high specificity for nr-axSpA. Acute signs of sacroiliitis on MRI are not specific and have been observed in the absence of spondyloarthritis. Initial management should involve NSAIDs and a regular exercise program, while TNF and IL-17 inhibitors can be used for high disease activity unresponsive to these interventions. Goals of treatment include improving the frequent impairment of social and occupational function that occurs in nr-axSpA.

Conclusions

We provide 22 evidence-based consensus statements to provide practical guidance in the assessment and management of nr-axSpA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00416-7.

Clinical Manifestations and Diagnosis of Axial Spondyloarthritis

BACKGROUND

Axial spondyloarthritis (axSpA) is a chronic, rheumatic disease characterized by inflammation of the sacroiliac joint, spine, and entheses. Axial spondyloarthritis affects up to 1.4% of adults in the United States and is associated with decreased quality of life, increased mortality, and substantial health care-related costs, imposing a high burden on patients, their caregivers, and society.

SUMMARY OF WORK

Diagnosing axSpA can be difficult. In this review, we seek to help rheumatologists in recognizing and diagnosing axSpA.

MAJOR CONCLUSIONS

A discussion of challenges associated with diagnosis is presented, including use and interpretation of imaging, reasons for diagnostic delays, differences in disease presentation by sex, and differential diagnoses of axSpA.

FUTURE RESEARCH DIRECTIONS

The early diagnosis of axSpA and advances in available therapeutic options have improved patient care and disease management, but delays in diagnosis and treatment remain common. Additional research and education are critical for recognizing diverse axSpA presentations and optimizing management early in the course of disease.

Secukinumab in axial spondyloarthritis: a narrative review of clinical evidence

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease characterized by inflammation and new bone formation in the axial skeleton. AxSpA is considered a spectrum of disease that includes two subtypes identified by the Assessment in SpondyloArthritis International Society classification criteria, namely, radiographic (r-axSpA usually referred to as ankylosing spondylitis) and non-radiographic axSpA (nr-axSpA). Although the burden of disease appears similar between the two classified subtypes, the degree of inflammation, as assessed by magnetic resonance imaging and C-reactive protein, and the degree of new bone formation are significantly higher in r-axSpA than in nr-axSpA. Nevertheless, axSpA is considered one disease with different courses. International guidelines for the management of axSpA have outlined treatment goals focused on control of signs and symptoms, inflammation, prevention of progressive structural damage, preservation of physical function, normalization of social participation and improvement of quality of life. The pathogenesis of axSpA has not been completely elucidated to date. A strong link between human leukocyte antigen B27 and axSpA, however, has been identified, and the success of anti-tumour necrosis factor and anti-interleukin (IL)-17A therapy has highlighted some of the key pro-inflammatory cytokines involved. The anti-IL-17A monoclonal antibody secukinumab is approved for the treatment of ankylosing spondylitis and nr-axSpA in the European Union and United States. In this narrative review, we discuss data for secukinumab in axSpA from randomized controlled trials, including MEASURE trials in AS and PREVENT in nr-axSpA, and real-world evidence.

Ixekizumab: an IL-17A inhibitor for the treatment of axial Spondylarthritis

INTRODUCTION

Axial spondyloarthritis (axSpA) is an inflammatory arthritis which affects primarily the entheses of the spine and sacroiliac joints with peripheral joint synovitis and extra-articular manifestations. In 2017, the first IL-17A inhibitor (IL-17Ai) secukinumab was approved for the treatment of radiographic axSpA not responding adequately to conventional therapies, and this was followed in 2019 by a second IL-17Ai, ixekizumab. These agents represent the first alternative class of biological treatments after the TNF inhibitor which dominated the therapeutic landscape of axSpA for over a decade.

AREAS COVERED

This review discusses the role of IL-17Ais in the treatment in axSpA focusing on the newest IL-17Ai ixekizumab. It provides a detailed overview of the drug pharmacodynamic, pharmacokinetics, and clinical trial data, including areas of future research needed in the post-marketing era.

EXPERT OPINION

Early trials of ixekizumab for axSpA have shown encouraging results and an acceptable safety profile. Future phase IV trials should focus on direct head-to-head comparisons between ixekizumab and other biologic drugs, and stratify patients according to important disease characteristics known to affect treatment response including sex, HLA-B27 status, presence of MRI bone marrow edema at baseline, disease duration and any extra-articular manifestations.

The Effect of Etanercept in Nonradiographic Axial Spondyloarthritis by Stratified C-Reactive Protein Levels

Objective

Biological agents have shown markedly different response rates by baseline C‐reactive protein (CRP). Here, we determine the response of patients with nonradiographic axial spondyloarthritis (nr‐axSpA) to etanercept stratified by their baseline CRP level.

Methods

The EMBARK trial was a phase 3, randomized, double‐blind, placebo‐controlled study of etanercept in nr‐axSpA. The primary endpoint was Assessment of Spondyloarthritis International Society (ASAS) 40 at Week 12, the conclusion of the double‐blind phase. It recruited patients who met the ASAS criteria for axial spondyloarthritis, and sacroiliac joint magnetic resonance scans were completed on all patients. In this post hoc analysis, we analyzed outcomes by baseline C‐reactive protein (CRP) level of less than 5 mg/L, 5 mg/L to 10 mg/L, and greater than 10 mg/L. The clinical trial outcome data were accessed via the Vivli platform.

Results

In the less than 5 mg/L CRP group treated with etanercept, the ASAS20 response, ASAS40 response, Ankylosing Spondylitis Disease Activity Score‐CRP (ASDAS‐CRP), and ASDAS‐ESR (erythrocyte sedimentation rate) outcomes were 49% (P = 0.84), 26% (P = 0.14), 42% (P = 0.002), and 44% (P = 0.006), respectively. In the 5 to 10 mg/L CRP group treated with etanercept, the ASAS20 response, ASAS40 response, ASDAS‐CRP, and ASDAS‐ESR outcomes were 56% (P = 0.99), 31% (P = 0.40), 56% (P = 0.16), and 50% (P = 0.11), respectively. In the greater than10 mg/L CRP group treated with etanercept, the ASAS20 response, ASAS40 response, ASDAS‐CRP, and ASDAS‐ESR outcomes were 74% (P = 0.02), 68% (P = 0.003), 82% (P = 0.005), and 50% (P = 0.001), respectively.

Conclusion

Although there are reduced ASAS20 and ASAS40 response rates in the groups with baseline CRP less than 10 mg/L, there remain clinically relevant responses when the composite outcome measures ASDAS‐CRP or ASDAS‐ESR were used, and this should be considered when deciding on thresholds for reimbursement.

Imaging in Axial Spondyloarthritis: What is Relevant for Diagnosis in Daily Practice?

PURPOSE OF REVIEW

To explore how imaging may assist diagnosing axial spondyloarthritis in rheumatology practice.

RECENT FINDINGS

A diagnosis of axial spondyloarthritis is based on pattern recognition by synthesizing clinical, laboratory, and imaging findings. In health care settings providing low threshold access to advanced imaging, sacroiliac joint MRI is the preferred imaging modality in clinically suspected axial spondyloarthritis. In daily routine, the optimum protocol to assess suspected inflammatory back pain combines sacroiliac joint and spine MRI fitting a 30-min slot. Contextual assessment of concomitant structural and active MRI lesions is key to enhance diagnostic utility. In women with postpartum back pain suggestive of axial spondyloarthritis, recent reports advocate waiting 6-12 months after delivery before acquiring sacroiliac joint MRI. Major unmet needs are consistent MRI protocols, standardized training modules on how to evaluate axial MRI, and timely dissemination of imaging advances into mainstream practice both in rheumatology and in radiology. In rheumatology practice, MRI has become indispensable to help diagnose early axial spondyloarthritis. However, major gaps in training and knowledge transfer to daily care need to be closed.

Long-term Tolerability and Efficacy of Golimumab in Active Non-Radiographic Axial Spondyloarthritis: Results From Open-Label Extension

OBJECTIVES

We report the open-label extension (OLE) of the GO-AHEAD study evaluating the long-term efficacy and safety of golimumab (GLM) in patients with non-radiographic axial spondyloarthritis (nr-axSpA).

METHODS

Patients (both GLM- and placebo [PBO]-treated in the double-blind phase) received GLM 50 mg every 4 weeks during the OLE (36-week treatment; additional 8-week safety follow-up; GLM/GLM and PBO/GLM groups). All patients who entered and received ≥1 dose of study treatment in the OLE were included in the efficacy and safety analyses. The primary efficacy evaluations were the proportions of patients achieving 20% and 40% improvement in the ASAS criteria (ASAS20 and ASAS40, respectively). Responders analyses were calculated using a non-responder imputation approach.

RESULTS

Of 198 patients randomised, 189/198 (95.5%) entered the OLE; 174/198 patients (87.9%) completed all visits. Although the proportion of responders increased from weeks 16-52 in OLE in both GLM/GLM and PBO/GLM groups, the GLM/GLM group had a higher proportion of responders than the PBO/GLM group throughout the OLE from weeks 16-52 (ASAS20: 71.1% to 83.9% vs 40.0% to 75.0%, respectively; ASAS40: 56.7% to 76.3% vs 23.0% to 59.4%, respectively; ASAS partial remission: 33.0% to 53.8% and 18.0% to 45.8%). In the OLE, the overall incidence of AEs was lower in the GLM/GLM vs PBO/GLM groups (41.9% and 54.2%).

CONCLUSIONS

Sustained improvement in clinical efficacy was observed at 52 weeks in patients with nr-axSpA following GLM treatment. GLM was well tolerated and provided substantial long-term benefits to patients with nr-axSpA. (NCT01453725; registered on: October 18, 2011).

Non-radiographic versus radiographic axSpA: what's in a name?

Axial spondyloarthritis is a heterogeneous inflammatory condition with variable clinical presentations and outcomes. The complexity of its diagnosis and absence of biomarkers hamper the development of diagnostic criteria with the risk of misuse of the available classification criteria in clinical practice and its consequences. Axial spondyloarthritis should be regarded as a continuum in which some patients, but not all, will have a more severe phenotype characterized by progression into new bone formation and joint fusion. Growing understanding of the factors that might drive disease progression and treatment response will allow for better characterization of treatment options and outcome for each affected individual. The aim of this review is to update the current evidence of what is axial spondyloarthritis and to highlight the need to focus on the concept rather than its classification.

Update of imaging in the diagnosis and management of axial spondyloarthritis

Imaging of the spine and sacroiliac joints has acquired a central role in the diagnosis and classification of axial spondyloarthritis (axSpA) in the earliest phases of the disease. New definitions of specific imaging lesions, particularly in magnetic resonance imaging (MRI), have been recently updated and revised by the ASAS MRI working group to reach a standardized understanding and diagnosis of axSpA among rheumatologists. Recognizing the misleading pitfalls of MRI lesions and differential diagnosis also represents an essential issue in clinical practice to avoid false-positive findings and establish the diagnosis of axSpA with careful regard to the clinical context, clinical signs, and biological tests. This review summarizes the current evidence on the different imaging modalities of the sacroiliac joints and the spine with their application in the clinical setting of SpA and their main pitfalls; it also highlights the newest emerging imaging techniques.

Serum calprotectin: a promising biomarker in rheumatoid arthritis and axial spondyloarthritis

Background

Calprotectin (S100A8/S100A9 protein) is known as a damage-associated molecular pattern (DAMP) protein and reflects mainly neutrophil activation. Serum calprotectin levels might be a good alternative to acute-phase protein as a biomarker in inflammatory rheumatic diseases. The aim of this study is to investigate the association of serum calprotectin with disease activity and severity in rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), and psoriatic arthritis (PsA).

Methods

Serum calprotectin was measured in patients with RA, axSpA, and PsA from the prospective Swiss Clinical Quality Management (SCQM) registry. Asymptomatic first-degree relatives of RA patients were used as healthy controls (HC). Outcomes included swollen joint count (SJC), Disease Activity Score (DAS), Health Assessment questionnaire (HAQ), joint radiographs, and ultrasound power Doppler (USPD) score for RA; Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS) and coxitis for axSpA; and SJC and Disease Activity Index for PSoriatic Arthritis (DAPSA) for PsA. Comparison of outcomes by calprotectin quartile levels was performed using Kruskal-Wallis tests for continuous outcomes or trend tests for categorical outcomes.

Results

A total of 1729 subjects [RA = 969, axSpA = 451, PsA = 237, and HC = 72] were included. Median levels of serum calprotectin were higher in each disease group compared to HC (p < 0.01). In RA patients, all clinical outcomes were statistically different between quartiles of serum calprotectin, indicating an association between calprotectin levels and higher disease activity (SJC, DAS, and USPD scores) and severity (joint radiographs and HAQ). In axSpA, an association between calprotectin levels and ASDAS score (p < 0.01) and prevalence of coxitis (p = 0.02) was observed. For PsA patients, SJC and DAPSA did not differ across calprotectin quartiles.

Conclusions

This large study supports the association of serum calprotectin levels with disease activity in both RA and axSpA, but not in PsA.

Clinical practice recommendations for the use of imaging in the diagnosis and management of axial spondyloarthritis in Taiwan

OBJECTIVE

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease bearing challenges in early diagnosis. To improve clinical diagnosis and management of axSpA, recommendations were developed with current axSpA classification criteria and recent advances in medical imaging applications.

METHODS

A systematic literature review was conducted by 10 rheumatologists and radiologists in Taiwan to retrieve research evidence on the utilization of imaging modalities, including conventional radiography (CR), magnetic resonance imaging (MRI), computed tomography (CT), ultrasound (US), quantitative sacroiliac scintigraphy (QSS), and dual-energy X-ray absorptiometry (DXA). The panel of experts proposed six key issues on the role of imaging in early diagnosis of axSpA, monitoring of disease activity and structural changes, predicting treatment effects, and assessing complications such as osteoporosis and spinal fracture. The consensus was established on the basis of research evidence, clinical experiences and expert opinions. For each recommendation statement, the level of evidence was evaluated, the strength of recommendation was graded and the final level of agreement was determined through voting.

RESULTS

In total, four overarching principles and 13 recommendations were formulated. These recommendations outlined different imaging approaches in the diagnosis and management of axSpA disease progression. Considering CT is easy to perform when MRI is less available in Taiwan, the expert panel proposed a concise and practical diagnostic scheme to strengthen the valuable role of MRI and CT in the diagnostic evaluation of axSpA without evident radiographic features.

CONCLUSION

These modified recommendations provide guidance for rheumatologists, radiologists and healthcare professionals on timely diagnosis of axSpA and disease management with appropriate imaging modalities.

Imaging in rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and osteoarthritis: An international viewpoint on the current knowledge and future research priorities

Imaging is increasingly used in the routine management of rheumatic diseases as well as in the clinical trials of these disorders. This viewpoint, authored by a group of international imaging experts following two meetings dedicated to imaging in rheumatology, reports a consensus about the current knowledge and addresses where further research should be focused based on the views of the international imaging experts and discussion of the evidence with attending imaging practitioners. The goal was to maximize the potential of imaging to improve the clinical management of four rheumatic diseases. These rheumatic diseases include rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and osteoarthritis.

The need for comparative data in spondyloarthritis

Spondyloarthritis comprises a group of inflammatory diseases, characterised by inflammation within axial joints and/or peripheral arthritis, enthesitis and dactylitis. An increasing number of biologic treatments, including biosimilars, are available for the treatment of spondyloarthritis. Although there are a growing number of randomised controlled trials assessing treatments in spondyloarthritis, there is a paucity of data from head-to-head studies. Comparative data are required so that clinicians and payers have the level of evidence required to inform clinical decision-making and health economic assessments. In the absence of head-to-head studies, statistical methods such as network meta-analyses and matching-adjusted indirect comparisons (MAICs) are used for assessing comparative effectiveness.Network meta-analysis can be used to compare treatments for trials using a common comparator (e.g. placebo); however, for those without a common comparator or where considerable heterogeneity exists between the study populations, a MAIC that controls for differences in study design and baseline patient characteristics may be used. MAICs, unlike network meta-analyses, are of value for longer-term comparisons beyond the placebo-controlled phase of clinical trials, which is important for chronic diseases requiring long-term treatment, like spondyloarthritis. At present, there are a number of limitations that restrict the effectiveness of MAIC, such as the poor availability of individual patient-level data from trials, which results in patient-level data from one trial being compared with published whole-population data from another. Despite these limitations, drug reimbursement agencies are increasingly accepting MAIC as a means of comparative effectiveness and greater methodological guidance is needed.This report highlights a number of challenges that are specific to conducting comparative studies like MAIC in spondyloarthritis, including disease heterogeneity, the paucity of biomarkers and the duration of studies required for radiographic endpoints in this slow-progressing disease.

Imaging in axial spondyloarthritis: Changing concepts and thresholds

Imaging is key to recognition of axial spondyloarthritis (SpA) because clinical and laboratory examinations have limited diagnostic utility. Only MRI can capture both inflammation and bone remodeling by simultaneous depiction of active and structural lesions and their anatomic location. Bone marrow edema of limited extent on the sacroiliac joint (SIJ) MRI is often nonspecific and should be interpreted along with the clinical context. Contextual interpretation of the SIJ lesion signature viewed simultaneously on fluid- and fat-sensitive MRI sequences enhances confidence in the recognition of disease. A critical re-appraisal of using pelvic radiographs in clinically suspected early spondyloarthritis is warranted because of substantial limitations. In health care settings with low threshold access to advanced imaging, MRI is the preferred modality in early SpA. CT has recently advanced spinal outcome research, but substantial radiation exposure in young patients with spondyloarthritis and limited evidence on its relevance in practice do not advocate its use in daily routine.

A single determination of C-reactive protein does not suffice to declare a patient with a diagnosis of axial spondyloarthritis 'CRP-negative'

BACKGROUND

To be eligible to receive treatment with an anti-tumour necrosis factor (TNF), non-radiographic axial spondyloarthritis (nr-axSpA) patients require either elevated levels of C-reactive protein (CRP) (CRP > upper limit of normal (ULN)) or magnetic resonance imaging assessment showing inflammation of the sacroiliac joints, in addition to meeting criteria for high disease activity. Many axSpA patients are classified as 'CRP-negative', or CRP normal, despite having levels close to the ULN, and are therefore formally ineligible for treatment. The aim of this study was to investigate the likelihood of a CRP test indicating elevated levels in axSpA patients that have previously tested CRP normal.

METHODS

RAPID-axSpA (NCT01087762) enrolled patients who were either magnetic resonance imaging positive or had elevated CRP (> ULN: 7.9 mg/L). CRP data from the double-blind period for placebo-randomised patients until re-randomisation to certolizumab pegol (week 16 for ASAS20 non-responders/week 24 for ASAS20 responders) were analysed. CRP was assessed at screening, baseline, and nine time points to week 24. Linear mixed models were used to investigate time trends, variability, and correlations of CRP data.

RESULTS

Of 106 placebo-randomised patients with baseline CRP assessments, 26 (25%) tested CRP normal at baseline, of whom 13 (50%) had ≥ 1 test indicating elevated CRP to week 16. Of 80/106 (75%) patients with elevated baseline CRP, 25 (31%) had ≥ 1 normal CRP test to week 16. Linear mixed models did not reveal changes in mean CRP across placebo patients from baseline to week 24.

CONCLUSIONS

In axSpA patients with CRP < ULN the CRP test should be repeated after ≥ 4 weeks as there is a substantial chance of finding a positive result for elevated CRP at subsequent testing, thereby allowing the patient access to treatment.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01087762 . Registered on 16 March 2010.

Efficacy and safety of continuing versus withdrawing adalimumab therapy in maintaining remission in patients with non-radiographic axial spondyloarthritis (ABILITY-3): a multicentre, randomised, double-blind study

BACKGROUND

Success of treatment withdrawal in patients with non-radiographic axial spondyloarthritis who are in remission remains unknown. The ABILITY-3 study explored the ability to withdraw adalimumab treatment in patients with non-radiographic axial spondyloarthritis who achieved sustained clinical remission after open-label treatment with adalimumab.

METHODS

ABILITY-3 was a multicentre, two-period study done in 107 sites in 20 countries. We enrolled adult patients (≥18 years) diagnosed with non-radiographic axial spondyloarthritis, fulfilling Assessment of SpondyloArthritis international Society classification criteria but not the modified New York radiologic criterion, who had objective evidence of active inflammation, active disease, and inadequate response to at least two non-steroidal anti-inflammatory drugs. Patients who achieved Ankylosing Spondylitis Disease Activity Score (ASDAS) inactive disease (<1·3) with open-label adalimumab (40 mg subcutaneously every other week for 28 weeks) at weeks 16, 20, 24, and 28 were randomly assigned (1:1) using an interactive voice or web response system to 40-week, double-blind treatment with adalimumab (continuation) or placebo (withdrawal). The primary efficacy endpoint was the proportion of patients who did not experience a flare (defined as ASDAS ≥2·1 at two consecutive visits) during the double-blind period. Patients who flared were rescued with open-label adalimumab. This study is registered with ClinicalTrials.gov, number NCT01808118.

FINDINGS

Between June 27, 2013, and October 22, 2015, 673 patients were enrolled to the study. The trial completed on April 14, 2017. Of 673 enrolled patients, 305 (45%) achieved sustained remission and were randomly assigned to double-blind treatment (152 patients to adalimumab and 153 to placebo). A greater proportion of patients continuing adalimumab than those receiving placebo did not experience a flare (107 [70%] of 152 patients vs 72 [47%] of 153 patients; p<0·0001) up to and including week 68. Among 673 patients receiving adalimumab at any time, 516 (77%) patients reported an adverse event and 28 (4%) experienced a serious adverse event. The most common adverse events in both the adalimumab and placebo groups were nasopharyngitis (25 [16%] vs 20 [13%]), upper respiratory tract infection (20 [13%] vs 12 [8%]), and worsening of axial spondyloarthritis (ten [7%] vs 21 [14%]).

INTERPRETATION

In patients with active non-radiographic axial spondyloarthritis who achieved sustained remission with adalimumab, continued therapy was associated with significantly fewer patients flaring than was treatment withdrawal.

FUNDING

AbbVie.

Prevalence of axial spondyloarthritis in patients with acute anterior uveitis: a cross-sectional study utilising MRI

Objective

Acute anterior uveitis (AAU) is the most common extra-articular manifestation of axial spondyloarthritis (axSpA). In this study, patients presenting with AAU were evaluated clinically and with MRI in order to estimate the prevalence of axSpA.

Methods

Consecutive patients presenting to a university teaching hospital between February 2014 and March 2015 with AAU were invited to participate. Those with a history of chronic back pain (CBP) beginning <45 years were evaluated clinically and with MRI of thoracolumbar spine and sacroiliac joints.

Results

Of 366 patients with AAU, 57 had a pre-existing diagnosis of axSpA; 77 others fulfilled the study eligibility criteria and 73 (95%) completed the study. Seventeen patients (23.3%) were diagnosed with axSpA by an experienced rheumatologist; of these, eight were human leucocyte antigen-B27 negative. Including those with a previous diagnosis, this equates to a minimum axSpA prevalence of 20.2%; one-quarter of patients were previously undiagnosed.

Conclusion

This is the first study to actively search for the presence of axSpA in unselected patients presenting with AAU utilising MRI as an essential part of the assessment. There is a significant burden of undiagnosed axSpA in patients with AAU, but there does not appear to be a simple mechanism for screening. We recommend that ophthalmologists refer all patients with AAU with CBP, onset <45 years, to rheumatology for further evaluation.

[Magnetic resonance imaging (MRI) diagnostics in axial spondyloarthritis]

BACKGROUND

Axial spondyloarthritis (axSpA) is a frequent disorder, which is difficult to diagnose in the early phase. Currently, magnetic resonance imaging (MRI) of the sacroiliac joints and the spine is frequently applied in this phase, when conventional X rays still provide inconclusive results.

OBJECTIVE

To explain the typical pathological results and the role of MRI in diagnosing axSpA.

RESULTS

The use of MRI of the sacroiliac joints plays a central role in the assessment of the Spondyloarthritis International Association Society (ASAS) classification criteria of axSpA. Bone marrow edema is central to the definition of a positive MRI of the sacroiliac joints. In addition, chronic changes in the sacroiliac joints, such as fat depositions and erosion are taken into account in making the diagnosis of axSpA. When the results are not clear, an additional MRI of the area of the spine in which the patient reports the most pronounced complaints can be performed. A bone marrow edema in at least three vertebral edges can be associated with axSpA.

CONCLUSION

The MRI investigation of the sacroiliac joints has evolved into one of the most important methods in diagnosing axSpA.