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Marques ML, Ramiro S, van Lunteren M, Stal RA, Landewé RB, van de Sande M, Fagerli KM, Berg IJ, van Oosterhout M, Exarchou S, Ramonda R, van der Heijde D, van Gaalen FA. Can rheumatologists unequivocally diagnose axial spondyloarthritis in patients with chronic back pain of less than 2 years duration? Primary outcome of the 2-year SPondyloArthritis Caught Early (SPACE) cohort. Ann Rheum Dis 2024; 83:589-598. [PMID: 38233104 DOI: 10.1136/ard-2023-224959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024]
Abstract
OBJECTIVES To investigate the prevalence of axial spondyloarthritis (axSpA) in patients with chronic back pain (CBP) of less than 2 years (2y) duration referred to the rheumatologist, the development of diagnosis over time, and patient characteristics of those developing definite (d-)axSpA over 2y. METHODS We analysed the 2y data from SPondyloArthritis Caught Early, a European cohort of patients (<45 years) with CBP (≥3 months, ≤2y) of unknown origin. The diagnostic workup comprised evaluation of clinical SpA features, acute phase reactants, HLA-B27, radiographs and MRI (sacroiliac joints and spine), with repeated assessments. At each visit (baseline, 3 months, 1y and 2y), rheumatologists reported a diagnosis of axSpA or non-axSpA with level of confidence (LoC; 0-not confident at all to 10-very confident). MAIN OUTCOME axSpA diagnosis with LoC≥7 (d-axSpA) at 2y. RESULTS In 552 patients with CBP, d-axSpA was diagnosed in 175 (32%) at baseline and 165 (30%) at 2y. Baseline diagnosis remained rather stable: at 2y, baseline d-axSpA was revised in 5% of patients, while 8% 'gained' d-axSpA. Diagnostic uncertainty persisted in 30%. HLA-B27+ and baseline sacroiliitis imaging discriminated best 2y-d-axSpA versus 2y-d-non-axSpA patients. Good response to non-steroidal anti-inflammatory drugs and MRI-sacroiliitis most frequently developed over follow-up in patients with a new d-axSpA diagnosis. Of the patients who developed MRI-sacroiliitis, 7/8 were HLA-B27+ and 5/8 male. CONCLUSION A diagnosis of d-axSpA can be reliably made in nearly one-third of patients with CBP referred to the rheumatologist, but diagnostic uncertainty may persist in 5%-30% after 2y. Repeated assessments yield is modest, but repeating MRI may be worthwhile in male HLA-B27+ patients.
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Affiliation(s)
- Mary Lucy Marques
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
- Rheumatology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Sofia Ramiro
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
- Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, Limburg, Netherlands
| | - Miranda van Lunteren
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Rosalinde Anne Stal
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Robert Bm Landewé
- Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, Limburg, Netherlands
- Department of Rheumatology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Marleen van de Sande
- Department of Rheumatology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Karen Minde Fagerli
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Inger Jorid Berg
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | | | - Sofia Exarchou
- Department of Clinical Sciences Malmö, Rheumatology, Lund University, Lund, Sweden
| | - Roberta Ramonda
- Rheumatology Unit, Padua University Hospital, Padova, Veneto, Italy
| | | | - Floris A van Gaalen
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
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de Hooge M, Diekhoff T, Poddubnyy D. Magnetic resonance imaging in spondyloarthritis: Friend or Foe? Best Pract Res Clin Rheumatol 2023; 37:101874. [PMID: 37953121 DOI: 10.1016/j.berh.2023.101874] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/06/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
Magnetic resonance imaging (MRI) has emerged as a valuable tool for early detection and of axial spondyloarthritis (axSpA). A standardized imaging acquisition protocol, aligned with the current state-of-the-art, is crucial to obtain MRI scans that meet the diagnostic quality requirements. It is important to note that certain lesions, particularly bone marrow edema (BME), can be induced by mechanical stress or be a manifestation of another non-inflammatory disorder and may mimic the characteristic findings of axSpA on MRI. Therefore, a thorough assessment of MRI lesions, considering their localization and presence of highly specific features such as erosions and backfill, becomes imperative. Additionally, the application of additional imaging modalities, when necessary, can contribute to the differentiation of axSpA from other conditions that may exhibit similar MRI findings. This review provides recommendations on how to perform MRI in daily clinical practice and how to interpret finding from the differential diagnostic point of view.
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Affiliation(s)
- Manouk de Hooge
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium.
| | - Torsten Diekhoff
- Department of Radiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany.
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van Gaalen FA, Rudwaleit M. Challenges in the diagnosis of axial spondyloarthritis. Best Pract Res Clin Rheumatol 2023; 37:101871. [PMID: 37714776 DOI: 10.1016/j.berh.2023.101871] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/17/2023]
Abstract
With back pain as one of the most common complaints in the population and with no single disease feature with sufficient sensitivity and specificity to diagnose axial spondyloarthritis (axSpA) on its own, diagnosing axSpA can be challenging. In this article, we discuss clinical, laboratory, and imaging spondyloarthritis features that can be used in diagnosis and explain the general principles underlying an axSpA diagnosis. Moreover, we discuss three pitfalls to avoid when diagnosing axSpA: i) using classification criteria as diagnostic criteria, ii) making a diagnosis by simple counting of spondyloarthritis features, and iii) over-reliance on imaging findings. Finally, we have some advice on how to build diagnostic skills and discuss new developments that may help facilitate the diagnosis of axSpA in the future.
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Affiliation(s)
- Floris A van Gaalen
- Department of Rheumatology, Leiden University Medical Center, the Netherlands.
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Ziade N. Human leucocyte antigen-B27 testing in clinical practice: a global perspective. Curr Opin Rheumatol 2023; 35:235-242. [PMID: 37115941 DOI: 10.1097/bor.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
PURPOSE OF REVIEW The association between human leucocyte antigen (HLA)-B27 and spondyloarthritis (SpA) was described half a century ago. New insights about pathophysiologic pathways and their role in bone formation were reported in recent years and will be discussed in this review. RECENT FINDINGS There is a considerable variation in the association between HLA-B27 and SpA across the globe, with the strongest association reported in populations of Northern European and Asian descent and the lowest in the Middle East and Africa. Other genes are also involved in disease susceptibility, highlighting the importance of newly proposed weighted genetic scores to support the diagnosis. On the global level, the interaction between genetic background and gut dysbiosis seems critical for disease predisposition. As for the individual patient, the presence of HLA-B27 can have a significant influence on SpA diagnosis and disease phenotype. More importantly, new studies suggested a role for HLA-B27 in radiographic damage in the sacroiliac joints and the progression of bone formation in the spine. SUMMARY Findings in recent years have enhanced our understanding of the role of HLA-B27 in the pathophysiology and in disease-related bone formation in SpA, which may pave the way for new therapeutic targets.
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Affiliation(s)
- Nelly Ziade
- Saint-Joseph University
- Hotel-Dieu de France Hospital, Beirut, Lebanon
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Rusman T, van der Weijden M, Nurmohamed MT, van Denderen CJ, Landewé R, Bet PM, Bijl CVD, van der Laken CJ, van der Horst-Bruinsma IE. Does a short course of etanercept influence disease progression and radiographic changes in patients suspected of non-radiographic axial spondyloarthritis? Three -years follow- up of a placebo-controlled trial. Scand J Rheumatol 2023; 52:137-141. [PMID: 35543102 DOI: 10.1080/03009742.2022.2050502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To study the long-term effect of 16 weeks of etanercept treatment on disease activity and radiographic changes in patients with suspected non-radiographic axial spondyloarthritis (nr-axSpA). METHOD Eighty patients with inflammatory back pain and suspected nr-axSpA, with a Bath Ankylosing Disease Activity Index (BASDAI) ≥ 4, received etanercept (n = 40) 25 mg twice weekly or placebo (n = 40) for 16 weeks. They were followed without treatment restrictions after 24 weeks, for up to 3 years. Comparisons were made between patients who received etanercept or placebo in the first period, and changes in BASDAI, Ankylosing Spondylitis Disease Activity Score (ASDAS), Bath Ankylosing Spondylitis Metrology Index (BASMI), function, and radiographic changes in the spine [according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS)] and sacroiliac joints (Bath Ankylosing Spondylitis Radiology Index (BASRI). RESULTS After 3 years of follow-up, 84% of the patients were diagnosed with SpA, predominantly axSpA. Biological treatment was started after 24 weeks in 30% of patients. Disease activity scores after 3 years did not reveal significant differences between the initial randomization groups in mean BASDAI scores (mean difference 0.9, 95% CI -1.1;0.7, p = 0.6) and ASDAS (mean ASDAS 0.3, 95% CI 0.6;3.1, p = 0.5). BASMI and function scores remained stable over 3 years. No differences in radiographic changes of the sacroiliac joints or spine were observed over 3 years between the two groups. CONCLUSION A short course of etanercept in patients with suspected nr-axSpA did not affect disease activity, the chance of biological treatment, or radiographic progression after 3 years of follow-up.
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Affiliation(s)
- T Rusman
- Department of Rheumatology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Mac van der Weijden
- Department of Rheumatology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - M T Nurmohamed
- Department of Rheumatology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Rbm Landewé
- Department of Rheumatology, Amsterdam UMC, AMC, Amsterdam, The Netherlands
| | - P M Bet
- Department of Clinical Pharmacology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Cma van der Bijl
- Department of Rheumatology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - C J van der Laken
- Department of Rheumatology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
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Bittar M, Khan MA, Magrey M. Axial Spondyloarthritis and Diagnostic Challenges: Over-diagnosis, Misdiagnosis, and Under-diagnosis. Curr Rheumatol Rep 2023; 25:47-55. [PMID: 36602692 DOI: 10.1007/s11926-022-01096-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW This article aims to review the challenges in axial spondyloarthritis diagnosis and identify the possible contributing factors. RECENT FINDINGS The inability to reach an accurate diagnosis in a timely fashion can lead to treatment delays and worse disease outcomes. The lack of validated diagnostic criteria and the misuse of the currently available classification criteria could be contributing. There is also significant inter-reader variability in interpreting images, and the radiologic definitions of axial spondyloarthritis continue to be re-defined to improve their positive predictive value. The role of inflammatory back pain features, serologic biomarkers, genetics, and their diagnostic contribution to axial spondyloarthritis continues to be investigated. There is still a significant amount of delay in the diagnosis of axial spondyloarthritis. Appreciating the factors that contribute to this delay is of utmost importance to close the gap. It is similarly important to recognize other conditions that may present with symptoms that mimic axial spondyloarthritis so that misdiagnosis and wrong treatment can be avoided.
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Lindqvist E, Olofsson T, Jöud A, Geijer M, Wallman JK, Mogard E. How good is the agreement between clinical diagnoses and classification criteria fulfilment in axial spondyloarthritis? Results from the SPARTAKUS cohort. Scand J Rheumatol 2022:1-10. [PMID: 35695036 DOI: 10.1080/03009742.2022.2064183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To study the agreement between clinical axial spondyloarthritis (axSpA) diagnoses and fulfilment of the Assessment of SpondyloArthritis international Society (ASAS) axSpA and modified New York (mNY) classification criteria, and to compare disease/health status between axSpA subtypes. METHOD Patients with prevalent, clinical axSpA attending a rheumatology clinic were enrolled in a cross-sectional study. Assessments included physical evaluation, laboratory testing, questionnaires, and appropriate imaging, allowing classification. Standard axSpA outcome measures were compared between patients fulfilling mNY/radiographic versus non-radiographic axSpA (r-axSpA/nr-axSpA) criteria. RESULTS Of 239 consecutively included patients, 141 fulfilled ASAS r-axSpA and/or mNY criteria, while 57 fulfilled nr-axSpA criteria. The agreement between r-axSpA and mNY criteria fulfilment was 94%. The positive predictive value (PPV) of a clinical ankylosing spondylitis (AS) diagnosis for mNY criteria fulfilment was 71%; the PPV of an undifferentiated axSpA (u-axSpA) diagnosis for fulfilment of nr-axSpA criteria was 30% and 40% for mNY criteria. Patients with r-axSpA/AS were older, more often men, and had longer disease duration, more uveitis, and worse spinal mobility than nr-axSpA patients, who had more enthesitis and dactylitis. CONCLUSION We found an overall good concordance between clinical axSpA diagnoses and classification criteria fulfilment, with 83% fulfilling ASAS axSpA and/or mNY criteria. Regarding axSpA subtypes, the concordance was weaker, and although the ICD-10 code for AS correctly identified patients meeting mNY criteria in 71% of cases, one-third of mNY-positive patients lacked an AS diagnosis. Moreover, clinical u-axSpA diagnoses could not serve as a proxy to identify nr-axSpA, highlighting the importance of thorough classification in research on axSpA subtypes.
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Affiliation(s)
- Elisabet Lindqvist
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
| | - Tor Olofsson
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
| | - Anna Jöud
- Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Mats Geijer
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Radiology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan K Wallman
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
| | - Elisabeth Mogard
- Rheumatology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, lägg till a Sweden
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Truong SL, McEwan T, Bird P, Lim I, Saad NF, Schachna L, Taylor AL, Robinson PC. Australian Consensus Statements for the Assessment and Management of Non-radiographic Axial Spondyloarthritis. Rheumatol Ther 2021; 9:1-24. [PMID: 34962620 PMCID: PMC8814294 DOI: 10.1007/s40744-021-00416-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/09/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Steven L Truong
- School of Medicine and Dentistry, Griffith University, Brisbane, QLD, Australia.
- Coast Joint Care, Maroochydore, QLD, Australia.
| | - Tim McEwan
- School of Clinical Medicine, University of Queensland, Herston Rd, Herston, QLD, 4006, Australia
| | - Paul Bird
- St George Hospital Clinical School, University of New South Wales, Sydney, Australia
| | | | - Nivene F Saad
- Metro South Hospital and Health Service, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
| | - Lionel Schachna
- Department of Rheumatology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Andrew L Taylor
- Department of Rheumatology, Medical School, Fiona Stanley Hospital, University of Western Australia, Perth, Australia
| | - Philip C Robinson
- Metro North, Hospital and Health Service, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, University of Queensland, Royal Brisbane and Women's Hospital, Bowen Bridge Road, Herston, QLD, 4006, Australia
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Lorenzin M, Ortolan A, Vio S, Cozzi G, Scapin V, De Conti G, Doria A, Ramonda R. Psoriasis and Imaging Progression in early Axial Spondyloarthritis: Results from a 48-month follow-up (Italian arm of SPACE study). Rheumatology (Oxford) 2021; 61:2375-2387. [PMID: 34605894 DOI: 10.1093/rheumatology/keab728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/13/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To assess the influence of psoriasis on spinal/pelvic radiographic progression and magnetic resonance imaging (MRI) features in early-stage axial spondyloarthritis (axSpA). METHODS Analysis of baseline data from the Italian SPACE cohort, including patients with chronic-back-pain (CBP; duration ≥ 3 months and ≤2 years; onset <45 years) was performed. Patients underwent a diagnostic work-up, including MRI and X-rays of the sacroiliac joints (SIJ), to establish diagnosis of axSpA (ASAS criteria). Clinical features, disease activity and functional indices, imaging were collected at baseline and yearly during 48-months. Spinal and SIJ X-rays and MRIs were scored by 2 readers following SPARCC, mSASSS and mNY-criteria. Characteristics of axSpA patients with/without psoriasis were compared over-time with descriptive statistics; multivariate-logistic-regression model was constructed to assess predictors of spinal/pelvic radiographic progression. RESULTS 88 patients had axSpA (84.1% non-radiographic; 15.9% radiographic); 36.4% had psoriasis. Patients with psoriasis were older; less frequently had HLA-B27+ and radiographic sacroiliitis with unilateral/asymmetric pattern and more signs of spondylitis. Functional and disease activity indices decreased with slightly higher BASDAI and BASFI in axSpA with psoriasis. All patients showed slight spinal/pelvic radiographic progression. Patients without psoriasis showed increased sacroiliitis progression and low-grade spinal progression. More inflammatory corner lesions on cervical/thoracic MRI-spine were observed in patients with psoriasis. Significant downtrend of SPARCC SIJ/spine scores in all patients was found. Psoriasis was a predictor of increased spinal progression (OR = 0.18; 95%CI : 0.04-0.78). CONCLUSIONS Psoriasis was associated with distinct axSpA features, increased spinal radiographic progression and low-grade radiographic sacroiliitis.
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Affiliation(s)
- Mariagrazia Lorenzin
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Augusta Ortolan
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Stefania Vio
- Radiology Unit, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Giacomo Cozzi
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Vanna Scapin
- Radiology Unit, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Giorgio De Conti
- Radiology Unit, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
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Kiil RM, Mistegaard CE, Jurik AG, Christiansen AA, Hendricks O, Schiøttz-Christensen B, Loft AG. Diagnosing axial spondyloarthritis by multidiciplinary team conference at 3.5 years' follow-up in a cohort of patients with disease features according to the ASAS criteria. Scand J Rheumatol 2021; 51:291-299. [PMID: 34263690 DOI: 10.1080/03009742.2021.1933584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES During the past two decades, magnetic resonance imaging (MRI) has increasingly been used diagnostically in axial spondyloarthritis (axSpA), and in 2009 MRI was introduced in the Assessment of SpondyloArthritis Society (ASAS) classification criteria. In clinical practice, there is a risk of overdiagnosis if MRI findings are not related to clinical and biochemical findings. The aim of this study was to provide an estimate of the prevalence of axSpA in a cohort of clinical patients with low back pain and findings suggestive of axSpA according to ASAS through consensus diagnosis at a multi-disciplinary team (MDT) conference, and to describe the performance of the features included in the ASAS criteria. METHOD Consensus diagnoses of axSpA at MDT conferences were retrospectively established at 3.5 years' follow-up in a cohort of 84 patients, initially referred with disease features according to the ASAS criteria. Patients were examined clinically regarding spondyloarthritis features, and biochemical tests and MRI of the sacroiliac joints and entire spine were performed at baseline and after a mean of 3.5 years. RESULTS According to the MDT consensus, 25 patients (30%) of the total cohort had axSpA at follow-up; 40% of individuals who fulfilled the ASAS criteria at baseline had axSpA, and 37% at follow-up; 96% of axSpA patients according to the MDT consensus met the ASAS criteria at baseline and 92% at follow-up. CONCLUSION Approximately one-third of the included patients had axSpA when evaluated at the MDT conference. The ASAS criteria had low predictive value, but high sensitivity at both baseline and follow-up.
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Affiliation(s)
- R M Kiil
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - C E Mistegaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - A G Jurik
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - A A Christiansen
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark
| | - O Hendricks
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark
| | - B Schiøttz-Christensen
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Research Department, Spine Centre of Southern Denmark, Hospital Lillebaelt, Middelfart, Denmark
| | - A G Loft
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
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11
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Capelusnik D, Ramiro S, Schneeberger EE, Citera G. Peripheral arthritis and higher disease activity lead to more functional impairment in axial spondyloarthritis: Longitudinal analysis from ESPAXIA. Semin Arthritis Rheum 2021; 51:553-558. [PMID: 33901989 DOI: 10.1016/j.semarthrit.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/24/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
OBJETIVE The aim of this study was to investigate whether peripheral arthritis together with disease activity independently contribute to functional impairment over time in patients with axSpA and to evaluate if there are contextual factors modifying this relationship. MATERIAL AND METHODS Patients with axial spondyloarthritis from the ESPAXIA cohort were followed-up annually over a mean of 3.7 years. Physical function was assessed by the self-reported questionnaire BASFI, disease activity by ASDAS and peripheral arthritis was also recorded. Generalized estimating equations (GEE) were used to investigate longitudinal association between peripheral arthritis, ASDAS and BASFI as the outcome. Autoregressive models (adjusted for BASFI 1 year earlier) were run to allow for a truly longitudinal interpretation. Interactions between each of ASDAS and peripheral arthritis with contextual factors (age, gender, educational level, smoking, job type) were tested. RESULTS 185 patients (77 % male, mean (SD) age 42 (13) years old and mean disease duration (SD) of 9.4 (9.6) years) were included. ASDAS and peripheral arthritis independently contributed to explaning BASFI over time. Contextual factors did not modify either of the relationships. A true longitudinal relation was proven with the autoregressive GEE model, showing that, adjusted for age, gender, spinal mobility and use of NSAIDs, an increase of one ASDAS unit led to a BASFI 0.48 units higher (ß 0.48 [95%CI 0.39, 0.57]), and the presence of peripheral arthritis, to a BASFI 0.44 units higher (ß 0.44 [95%CI 0.08, 0.8]). CONCLUSION Peripheral arthritis and higher disease activity independently lead to more functional impairment in axSpA over time. Contextual factors do not modify these relationships.
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Affiliation(s)
- Dafne Capelusnik
- Department of Rheumatology, Instituto de Rehabilitación Psicofísica, CABA, Argentina
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Centre, Leiden and Department of Rheumatology, Zuyderland Medical Centre, Heerlen, the Netherlands
| | - Emilce E Schneeberger
- Department of Rheumatology, Instituto de Rehabilitación Psicofísica, CABA, Argentina
| | - Gustavo Citera
- Department of Rheumatology, Instituto de Rehabilitación Psicofísica, Echeverría 955, CABA 1429, Argentina.
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12
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Maksymowych WP, Lambert RG, Baraliakos X, Weber U, Machado P, Pedersen SJ, Hooge MD, Sieper J, Wichuk S, Poddubnyy D, Rudwaleit M, van der Heijde D, Landewe R, Eshed I, Ostergaard M. Data-driven definitions for active and structural MRI lesions in the sacroiliac joint in spondyloarthritis and their predictive utility. Rheumatology (Oxford) 2021; 60:4778-4789. [DOI: 10.1093/rheumatology/keab099] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/15/2021] [Indexed: 12/17/2022] Open
Abstract
Abstract
Objectives
To determine quantitative SI joint MRI lesion cut-offs that optimally define a positive MRI for inflammatory and structural lesions typical of axial SpA (axSpA) and that predict clinical diagnosis.
Methods
The Assessment of SpondyloArthritis international Society (ASAS) MRI group assessed MRIs from the ASAS Classification Cohort in two reading exercises where (A) 169 cases and 7 central readers; (B) 107 cases and 8 central readers. We calculated sensitivity/specificity for the number of SI joint quadrants or slices with bone marrow oedema (BME), erosion, fat lesion, where a majority of central readers had high confidence there was a definite active or structural lesion. Cut-offs with ≥95% specificity were analysed for their predictive utility for follow-up rheumatologist diagnosis of axSpA by calculating positive/negative predictive values (PPVs/NPVs) and selecting cut-offs with PPV ≥ 95%.
Results
Active or structural lesions typical of axSpA on MRI had PPVs ≥ 95% for clinical diagnosis of axSpA. Cut-offs that best reflected a definite active lesion typical of axSpA were either ≥4 SI joint quadrants with BME at any location or at the same location in ≥3 consecutive slices. For definite structural lesion, the optimal cut-offs were any one of ≥3 SI joint quadrants with erosion or ≥5 with fat lesions, erosion at the same location for ≥2 consecutive slices, fat lesions at the same location for ≥3 consecutive slices, or presence of a deep (i.e. >1 cm depth) fat lesion.
Conclusion
We propose cut-offs for definite active and structural lesions typical of axSpA that have high PPVs for a long-term clinical diagnosis of axSpA for application in disease classification and clinical research.
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Affiliation(s)
| | - Robert G Lambert
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
- Medical Imaging Consultants, Edmonton, Canada
| | | | - Ulrich Weber
- Department of Rheumatology, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Pedro M Machado
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust
- Centre for Rheumatology and MRC Centre for Neuromuscular Diseases, University College London, London, UK
| | - Susanne J Pedersen
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Manouk de Hooge
- VIB Inflammation Research Center, Ghent University
- Rheumatology Department, Ghent University Hospital, Ghent, Belgium
| | - Joachim Sieper
- Department of Rheumatology, Charité – Universitätsmedizin Berlin and German Rheumatism Research Centre, Berlin
| | | | - Denis Poddubnyy
- Department of Rheumatology, Charité – Universitätsmedizin Berlin and German Rheumatism Research Centre, Berlin
| | - Martin Rudwaleit
- Klinikum Bielefeld, Bielefeld
- Department of Rheumatology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - Robert Landewe
- Department of Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam
- Atrium Medical Center, Heerlen, the Netherlands
| | - Iris Eshed
- Sheba Medical Center, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Mikkel Ostergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Lorenzin M, Ortolan A, Felicetti M, Vio S, Favero M, Polito P, Lacognata C, Scapin V, Doria A, Ramonda R. Spine and Sacroiliac Joints Lesions on Magnetic Resonance Imaging in Early Axial-Spondyloarthritis During 24-Months Follow-Up (Italian Arm of SPACE Study). Front Immunol 2020; 11:936. [PMID: 32499784 PMCID: PMC7243825 DOI: 10.3389/fimmu.2020.00936] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/22/2020] [Indexed: 01/31/2023] Open
Abstract
Objectives: Our study aimed to identify: (1) the prevalence of spine and pelvis magnetic resonance imaging (MRI-spine and MRI-SIJ) inflammatory and structural lesions in patients (pts) with a diagnosis of axial spondyloarthritis (axSpA); (2) the predictive factors for a severe disease pattern with a higher probability of radiographic progression. Materials and Methods: Seventy-five pts with low back pain (LBP) (≥3 months, ≤2 years, onset ≤45 years) underwent physical examination, questionnaires, laboratory tests, X-rays, MRI-spine, and MRI-SIJ at baseline (T0) and during a 24-months follow-up. Two expert rheumatologists made axSpA diagnosis and classification (according ASAS criteria). MRI-spine, MRI-SIJ and X-rays were scored independently by 2 readers following the SPARCC, mSASSS, and mNY-criteria. According to ASAS criteria, 21 pts fulfilled imaging arm only and 29 clinical arm with/without imaging arm; 25 pts did not fulfill ASAS criteria. Results: At T0 the mean ± SD LBP onset was 28.51 ± 8.05 years, 45.3% pts were male, 38.7% were HLA-B27+; 56% showed bone marrow oedema (BMO) at MRI-spine and 64% at MRI-SIJ. Signs of enthesitis were found in 58% pts in the thoracic spine. Eighteen (24%) pts presented BMO at MRI-spine with a negative MRI-SIJ. The prevalence of BMO lesions and the SPARCC SIJ and spine score decreased during the follow-up in the 2 cohorts meeting ASAS criteria. An early onset of LBP, a lower use of NSAIDs, a BASDAI>4 were identified as predictors of spine structural damage; the high SPARCC SIJ score appeared to be a predictor of SIJ structural damage. A higher mSASSS was predicted by a lower age of onset of LBP. Predictor of higher SPARCC spine was a higher NSAIDs and of higher SPARCC SIJ score the HLA-B27 positivity with increased inflammatory biomarkers. Conclusions: At T0 a significant prevalence of BMO lesions was observed both in SIJ and spine, with predominant involvement of thoracic district. Since positive MRI-spine images were observed in the absence of sacroiliitis, these findings seem to be relevant in the axSpA diagnosis. Early age of disease onset, long duration of LBP, increased inflammatory biomarkers, higher use of NSAIDs, male gender, HLA-B27 positivity, SPARCC SIJ score>2 appeared predictors of radiological damage and activity.
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Affiliation(s)
- Mariagrazia Lorenzin
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Augusta Ortolan
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Mara Felicetti
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Stefania Vio
- Radiology Unit, University of Padova, Padova, Italy
| | - Marta Favero
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Pamela Polito
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | | | - Vanna Scapin
- Radiology Unit, University of Padova, Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
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14
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Abstract
PURPOSE OF REVIEW Axial spondyloarthritis (AxSpA) is a distinct clinical entity with characteristic clinical and radiographic features; however, a multitude of other metabolic, infectious and inflammatory disorders mimic it both clinically and radiographically. RECENT FINDINGS We present in this review article recent updates about the various disease entities and conditions that may mimic AxSpA and how to differentiate among them. The sensitivity and specificity of MRI in diagnosing AxSpA has limitations and needs to be interpreted in the context of the clinical picture. Interestingly, some recent studies have highlighted that a relatively high prevalence of bone marrow edema on pelvic MRIs in healthy volunteers which could even be categorized as having a 'positive MRI' as defined by Assessment of Spondyloarthritis International Society. Another study revealed that a substantial proportion of patients with suspected sacroiliitis were more commonly diagnosed with diseases other than inflammatory sacroiliitis. On the basis of these reports, it is prudent to request MRIs in the appropriate clinical context and interpreted with caution taking into considerations the wide differential diagnosis of such MRI changes. SUMMARY Highlighting the clinical pearls that differentiate disorders suspected of having sacroiliitis will lead to earlier and correct diagnosis and management; however, one must always take into considerations the radiographic and MRI findings in addition to the clinical presentations in order to make the appropriate diagnosis.
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van Lunteren M, van der Heijde D, Sepriano A, Berg IJ, Dougados M, Gossec L, Jacobsson L, Ramonda R, Rudwaleit M, Sieper J, Landewé R, van Gaalen FA. Is a positive family history of spondyloarthritis relevant for diagnosing axial spondyloarthritis once HLA-B27 status is known? Rheumatology (Oxford) 2020; 58:1649-1654. [PMID: 30938446 PMCID: PMC6735817 DOI: 10.1093/rheumatology/kez095] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 02/23/2019] [Indexed: 12/17/2022] Open
Abstract
Objectives A positive family history (PFH) of spondyloarthritis, in particular a PFH of AS or acute anterior uveitis, is associated with HLA-B27 carriership in chronic back pain patients. As it is unknown, the study aimed to investigate if a PFH contributes to diagnosing axial spondyloarthritis (axSpA) once HLA-B27 status is known. Methods In axSpA-suspected patients from the Assessment of SpondyloArthritis international Society (ASAS), DEvenir des Spondyloarthropathies Indifférenciéés Récentes (DESIR) and SPondyloArthritis Caught Early (SPACE) cohorts, logistic regression analyses were performed with HLA-B27 status and PFH according to the ASAS definition (ASAS-PFH) as determinants and clinical axSpA diagnosis as outcome at baseline. Analyses were repeated with a PFH of AS or acute anterior uveitis. Results In total, 1818 patients suspected of axSpA were analysed (ASAS n = 594, DESIR n = 647, and SPACE n = 577). In patients from the ASAS, DESIR and SPACE cohorts, respectively 23%, 39% and 38% had an ASAS-PFH, 52%, 58% and 43% were HLA-B27 positive, and 62%, 47% and 54% were diagnosed with axSpA. HLA-B27 was independently associated with an axSpA diagnosis in each cohort but an ASAS-PFH was not [ASAS cohort: HLA-B27 odds ratio (OR): 6.9 (95% CI: 4.7, 10.2), ASAS-PFH OR: 0.9 (95% CI: 0.6, 1.4); DESIR: HLA-B27 OR: 2.1 (95% CI: 1.5, 2.9), ASAS-PFH OR: 1.0 (95% CI 0.7, 1.3); SPACE: HLA-B27 OR: 10.4 (95% CI: 6.9, 15.7), ASAS-PFH OR: 1.0 (95% CI: 0.7, 1.5)]. Similar negative results were found for PFH of AS and acute anterior uveitis. Conclusion In three independent cohorts with different ethnical backgrounds, ASAS, DESIR and SPACE, a PFH was not associated independently of HLA-B27 with a diagnosis of axSpA. This indicates that in the vast majority of patients presenting with back pain, a PFH does not contribute to the likelihood of an axSpA diagnosis if HLA-B27 status is known.
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Affiliation(s)
- Miranda van Lunteren
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Inger J Berg
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Maxime Dougados
- Rheumatology Department, Paris Descartes University, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris
| | - Laure Gossec
- Rheumatology Department, Sorbonne Université, Paris.,Rheumatology Department, Pitié Salpêtrière Hospital, Paris, France
| | - Lennart Jacobsson
- Department of Rheumatology, University of Gothenburg, Gothenburg, Sweden
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Martin Rudwaleit
- Department of Rheumatology, Charité Campus Benjamin Franklin, Berlin.,Department of Internal Medicine and Rheumatology, Klinikum Bielefeld Rosenhöhe, Bielefeld
| | - Joachim Sieper
- Department of Rheumatology, Charité Campus Benjamin Franklin, Berlin.,German Rheumatism Research Centre, Berlin, Germany
| | - Robert Landewé
- Department of Rheumatology, Amsterdam Rheumatology & Immunology Center, Amsterdam.,Department of Rheumatology, Zuyderland Hospital, Heerlen, the Netherlands
| | - Floris A van Gaalen
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
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17
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Kiltz U, Braun J, Becker A, Chenot JF, Dreimann M, Hammel L, Heiligenhaus A, Hermann KG, Klett R, Krause D, Kreitner KF, Lange U, Lauterbach A, Mau W, Mössner R, Oberschelp U, Philipp S, Pleyer U, Rudwaleit M, Schneider E, Schulte TL, Sieper J, Stallmach A, Swoboda B, Winking M. [Long version on the S3 guidelines for axial spondyloarthritis including Bechterew's disease and early forms, Update 2019 : Evidence-based guidelines of the German Society for Rheumatology (DGRh) and participating medical scientific specialist societies and other organizations]. Z Rheumatol 2020; 78:3-64. [PMID: 31784900 DOI: 10.1007/s00393-019-0670-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- U Kiltz
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Claudiusstr. 45, 44649, Herne, Deutschland.
| | - J Braun
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Claudiusstr. 45, 44649, Herne, Deutschland
| | | | - A Becker
- Allgemeinmedizin, präventive und rehabilitative Medizin, Universität Marburg, Karl-von-Frisch-Str. 4, 35032, Marburg, Deutschland
| | | | - J-F Chenot
- Universitätsmedizin Greifswald, Fleischmann Str. 6, 17485, Greifswald, Deutschland
| | - M Dreimann
- Zentrum für Operative Medizin, Klinik und Poliklinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistraße 52, 20251, Hamburg, Deutschland
| | | | - L Hammel
- Geschäftsstelle des Bundesverbandes der DVMB, Metzgergasse 16, 97421, Schweinfurt, Deutschland
| | | | - A Heiligenhaus
- Augenzentrum und Uveitis-Zentrum, St. Franziskus Hospital, Hohenzollernring 74, 48145, Münster, Deutschland
| | | | - K-G Hermann
- Institut für Radiologie, Charité Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | | | - R Klett
- Praxis Manuelle & Osteopathische Medizin, Fichtenweg 17, 35428, Langgöns, Deutschland
| | | | - D Krause
- , Friedrich-Ebert-Str. 2, 45964, Gladbeck, Deutschland
| | - K-F Kreitner
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - U Lange
- Kerckhoff-Klinik, Rheumazentrum, Osteologie & Physikalische Medizin, Benekestr. 2-8, 61231, Bad Nauheim, Deutschland
| | | | - A Lauterbach
- Schule für Physiotherapie, Orthopädische Universitätsklinik Friedrichsheim, Marienburgstraße 2, 60528, Frankfurt, Deutschland
| | | | - W Mau
- Institut für Rehabilitationsmedizin, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, 06097, Halle (Saale), Deutschland
| | - R Mössner
- Klinik für Dermatologie, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland
| | | | - U Oberschelp
- , Barlachstr. 6, 59368, Werne a.d. L., Deutschland
| | | | - S Philipp
- Praxis für Dermatologie, Bernauer Str. 66, 16515, Oranienburg, Deutschland
| | - U Pleyer
- Campus Virchow-Klinikum, Charité Centrum 16, Klinik f. Augenheilkunde, Charité, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - M Rudwaleit
- Klinikum Bielefeld, An der Rosenhöhe 27, 33647, Bielefeld, Deutschland
| | - E Schneider
- Abt. Fachübergreifende Frührehabilitation und Sportmedizin, St. Antonius Hospital, Dechant-Deckersstr. 8, 52249, Eschweiler, Deutschland
| | - T L Schulte
- Klinik für Orthopädie und Unfallchirurgie, Orthopädische Universitätsklinik, Ruhr-Universität Bochum, Gudrunstr. 65, 44791, Bochum, Deutschland
| | - J Sieper
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Deutschland
| | - A Stallmach
- Klinik für Innere Medizin IV, Universitätsklinikum Jena, Am Klinikum 1, 07743, Jena, Deutschland
| | | | - B Swoboda
- Abteilung für Orthopädie und Rheumatologie, Orthopädische Universitätsklinik, Malteser Waldkrankenhaus St. Marien, 91054, Erlangen, Deutschland
| | | | - M Winking
- Zentrum für Wirbelsäulenchirurgie, Klinikum Osnabrück, Am Finkenhügel 3, 49076, Osnabrück, Deutschland
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Abstract
BACKGROUND Early detection of patients with axial spondylarthritis (axSpA) in primary care is difficult. The combination of various parameters indicative of inflammatory back pain (AWARE criteria) was found to be beneficial in an initial study. OBJECTIVE Review of the criteria for the identification of young patients with axSpA and chronic back pain (≥3 months of back pain). MATERIAL AND METHODS In adult patients with chronic back pain and age at onset of symptoms <45 years, orthopedic surgeons documented various possible axSpA characteristics before referral to the rheumatologist. RESULTS Overall, the data from 1306 patients were recorded. Of these, ultimately 500 patients were also seen by rheumatologists, 199 patients (39.8%) were diagnosed with axSpA while 301 (60.2%) had non-specific back pain. A total of 87 patients had ankylosing spondylitis (44%) and 112 non-radiographic axSpA (56%). The ASAS classification criteria were fulfilled by 226 patients (45.2%). The mean age of axSpA patients was 38 years, 56% were male with a mean duration of back pain of 98 months. The AWARE criteria had a sensitivity and specificity of 69.3% and 40.3% (n = 343), respectively, when ≥4/5 criteria were chosen. Positive imaging for sacroiliitis using magnetic resonance imaging (MRI) or X‑ray was present in 77% of patients and positive HLA-B27 was identified in 59% of axSpA patients. The combination of positive imaging and HLA-B27 had the highest likelihood ratio for diagnosis of axSpA. CONCLUSION Although the study design used here led to a preselection and thus to a bias in the statistical evaluation, the study confirmed the benefit of the AWARE criteria for the early detection of patients with axSpA. In further studies, the 2‑stage approach with initially 3 clinical questions and then an optional HLA-B27 test is currently being investigated further.
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Maksymowych WP. The role of imaging in the diagnosis and management of axial spondyloarthritis. Nat Rev Rheumatol 2019; 15:657-72. [DOI: 10.1038/s41584-019-0309-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2019] [Indexed: 12/15/2022]
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Abstract
Spondyloarthritis (SpA) describes the group of inflammatory diseases characterized by inflammation within axial joints and/or peripheral arthritis, enthesitis, and dactylitis. Disease development is strongly determined by genes and particularly associated with the presence of HLA-B27. Transgenic expression in animal models leads to induction of a SpA-like disease, suggesting a direct effect of HLA-B27 on disease development. Genome-wide association studies in SpA patients have identified further associations between polymorphisms in genes with an immune function, in particular in genes controlling the interleukin (IL)-23/IL-17 signaling pathway. The efficacy of IL-17 inhibitors in SpA patients underscores the impact of this pathway in this disease. Microscopic gut inflammation or chronic inflammatory bowel disease is found in the majority of patients with SpA, suggesting a pathogenic impact of commensal microbiota. In histopathologic examinations of axial manifestations, replacement of the subchondral bone marrow by granulation tissue with bone destructive and reparative properties is found. The mechanisms governing how genetic predisposition and gut inflammation promote inflammatory reactions at sites of mechanical stress is a matter of current research.
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López-Medina C, Dougados M, Ruyssen-Witrand A, Moltó A. Evaluation of concomitant peripheral arthritis in patients with recent onset axial spondyloarthritis: 5-year results from the DESIR cohort. Arthritis Res Ther 2019; 21:139. [PMID: 31171034 PMCID: PMC6554872 DOI: 10.1186/s13075-019-1927-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 05/28/2019] [Indexed: 12/19/2022] Open
Abstract
Background (a) To describe the prevalence and incidence of peripheral arthritis during 5 years of follow-up in recent axial spondyloarthritis (axSpA), (b) to evaluate factors associated with their appearance and (c) to assess their impact on treatment, patient-reported outcomes and sick leave after follow-up. Methods Data from the early axSpA patients from the DESIR cohort (first 5 years of follow-up) were analysed. Prevalence and incidence of peripheral arthritis at each study visit were calculated. A multivariate analysis was performed to evaluate baseline factors associated with the development of the arthritis. The use of drugs, the impact on patient-reported outcomes and days of sick leave were compared in both groups over time. Results Out of the 708 patients included in DESIR, 255 (36.0%) showed at least one episode of arthritis (151 before the inclusion visit and 104 during the follow-up), with an incidence of 3.7 cases per 100 person-years. Patients with peripheral arthritis were more likely (OR, 95%CI) to be aged ≥ 33 years (1.60, 1.12–2.27), non-smokers (1.58, 1.10–2.27) and HLAB27 negative (1.47, 1.04–2.08) and have presented with at least one episode of dactylitis (8.50, 4.96–14.60) and enthesitis (2.00, 1.41–2.84). Patients with peripheral arthritis showed a significant greater use of TNFb, csDMARDs and corticosteroids over follow-up; higher levels on BASDAI (40.46 vs. 34.28) and BASFI (27.89 vs. 22.52); poorer quality of life; and higher number of days of sick leave (17.97 vs. 12.78) over time. Conclusion In recent axSpA, 36% of patients reported peripheral arthritis at any time of the disease, being associated with negative HLAB27, non-smokers and with other peripheral manifestations. Patients with arthritis showed a higher burden of disease.
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Affiliation(s)
- Clementina López-Medina
- Rheumatology Department, Cochin Hospital, 27 rue du Faubourg Saint Jacques, 75014, Paris, France. .,Inserm (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France. .,University of Córdoba, Córdoba, Spain.
| | - Maxime Dougados
- Rheumatology Department, Cochin Hospital, 27 rue du Faubourg Saint Jacques, 75014, Paris, France.,Inserm (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | | | - Anna Moltó
- Rheumatology Department, Cochin Hospital, 27 rue du Faubourg Saint Jacques, 75014, Paris, France.,Inserm (U1153), Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
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Affiliation(s)
- Ernest Seidman
- Research Institute of the McGill University Health Centre, Division of Gastroenterology, 1650 Cedar Ave., C10.145, Montreal, Quebec H3G 1A4, Canada.
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Danve A, Deodhar A. Axial spondyloarthritis in the USA: diagnostic challenges and missed opportunities. Clin Rheumatol 2018; 38:625-634. [DOI: 10.1007/s10067-018-4397-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 12/15/2022]
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24
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Ez-Zaitouni Z, Landewé R, van Lunteren M, Bakker PA, Fagerli KM, Ramonda R, Jacobsson LTH, van der Heijde D, van Gaalen FA. Imaging of the sacroiliac joints is important for diagnosing early axial spondyloarthritis but not all-decisive. Rheumatology (Oxford) 2018; 57:1173-1179. [DOI: 10.1093/rheumatology/key035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 01/30/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Zineb Ez-Zaitouni
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Robert Landewé
- Department of Rheumatology, Amsterdam Rheumatology & Immunology Center (ARC), Amsterdam, the Netherlands
| | - Miranda van Lunteren
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Pauline A Bakker
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Karen M Fagerli
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | | | | | - Floris A van Gaalen
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
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25
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Ez-Zaitouni Z, Landewé RBM, van der Heijde D, van Gaalen FA. Alternative diagnoses in patients with chronic back pain not diagnosed with axial spondyloarthritis: data from the SPACE cohort. Ann Rheum Dis 2017; 77:e34. [PMID: 28830880 DOI: 10.1136/annrheumdis-2017-212175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/02/2017] [Indexed: 11/04/2022]
Affiliation(s)
- Zineb Ez-Zaitouni
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert B M Landewé
- Department of Rheumatology, Amsterdam Rheumatology & Immunology Center (ARC), Amsterdam, The Netherlands
| | | | - Floris A van Gaalen
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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26
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Affiliation(s)
- Jürgen Braun
- Rheumazentrum Ruhrgebiet, Ruhr University Bochum, Claudiusstrasse 45, 44797, Bochum, Germany
| | - Uta Kiltz
- Rheumazentrum Ruhrgebiet, Ruhr University Bochum, Claudiusstrasse 45, 44797, Bochum, Germany
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