Inequity in biological DMARD prescription for spondyloarthritis across the globe: results from the ASAS-COMOSPA study

The role of social determinants of health on disease outcomes in axial spondyloarthritis: A narrative review

This review provides a narrative exploration of the literature on various social determinants of health that influence outcomes in axial Spondyloarthritis (axSpA). By using the PROGRESS-Plus framework (place of residence, race, occupation, gender/sex, religion, education, socioeconomic status, social capital, age), this review discusses how these factors have been studied and their impact on disease outcomes in axSpA. The findings suggest that various patient-level factors (e.g. female sex, blue-collar jobs, low educational level) and country-level factors (e.g. low-income countries) associate with worse health outcomes in axSpA. These insights highlight the importance of adopting a multifaceted and holistic approach, that also considers social determinants of health, when managing patients with axSpA. This work also identifies unmet needs in this area including the importance of thinking beyond just biological factors, when considering drivers of suboptimal outcomes in axSpA.

Radiomics-based machine learning model to phenotype hip involvement in ankylosing spondylitis: a pilot study

Objectives

Hip involvement is an important reason of disability in patients with ankylosing spondylitis (AS). Unveiling the potential phenotype of hip involvement in AS remains an unmet need to understand its biological mechanisms and improve clinical decision-making. Radiomics, a promising quantitative image analysis method that had been successfully used to describe the phenotype of a wide variety of diseases, while it was less reported in AS. The objective of this study was to investigate the feasibility of radiomics-based approach to profile hip involvement in AS.

Methods

A total of 167 patients with AS was included. Radiomic features were extracted from pelvis MRI after image preprocessing and feature engineering. Then, we performed unsupervised machine learning method to derive radiomics-based phenotypes. The validation and interpretation of derived phenotypes were conducted from the perspectives of clinical backgrounds and MRI characteristics. The association between derived phenotypes and radiographic outcomes was evaluated by multivariable analysis.

Results

1321 robust radiomic features were extracted and four biologically distinct phenotypes were derived. According to patient clinical backgrounds, phenotype I (38, 22.8%) and II (34, 20.4%) were labelled as high-risk while phenotype III (24, 14.4%) and IV (71, 42.5%) were at low risk for hip involvement. Consistently, the high-risk phenotypes were associated with higher prevalence of MRI-detected lesion than the low-risk. Moreover, phenotype I had significant acute inflammation signs than phenotype II, while phenotype IV was enthesitis-predominant. Importantly, the derived phenotypes were highly predictive of radiographic outcomes of patients, as the high-risk phenotypes were 3 times more likely to have radiological hip lesion than the low-risk [27 (58.7%) vs 16 (28.6%); adjusted odds ratio (OR) 2.95 (95% CI 1.10, 7.92)].

Conclusion

We confirmed for the first time, the clinical actionability of profiling hip involvement in AS by radiomics method. Four distinct phenotypes of hip involvement in AS were identified and importantly, the high-risk phenotypes could predict structural damage of hip involvement in AS.

Ten-year clinical outcome of recent-onset axial spondyloarthritis: Results from the DESIR inception Cohort

OBJECTIVES

This study aimed to evaluate the 10-year clinical outcome of patients with recent-onset axial spondyloarthritis (axSpA).

METHODS STUDY DESIGN

The DESIR cohort is an inception cohort of axSpA patients.

METHODS DIAGNOSIS AND MANAGEMENT

The diagnosis and management of patients were based on the decision of the treating rheumatologist.

METHODS STATISTICAL ANALYSIS

Both complete cases and imputed data analyses were conducted.

RESULTS

Of the 708 enrolled patients, 45 were excluded due to a change in the baseline diagnosis, 3 patients died, and 300 were lost to follow-up over the 10years. In the completer population, one patient required bilateral total hip replacement, and 56 patients received a pension due to invalidity. The prevalence of main extra-musculoskeletal features increased from baseline to year 10: psoriasis from 18% to 30%, acute anterior uveitis from 10% to 18%, and inflammatory bowel disease from 5% to 10%. The most frequent comorbidity was hypertension, with an increase from 5% to 15% from baseline to year 10. In the imputed data analysis the estimated proportions of patients with an acceptable status at year 10 were 70% [95% CI: 63; 77] for acceptable PASS, 43% [95% CI: 37; 49] for BASDAI<3, and 48% [95% CI: 41; 56] for ASDAS<2.1.

CONCLUSION

These findings suggest that despite a quite favorable 10-year outcome exists for severe outcomes, a large proportion of patients present with an important disease burden reflected by patient-reported outcomes. This information can be valuable for providing patients with information at the time of diagnosis.

Budget impact analysis and treatment availability with biosimilar TNF inhibitors in rheumatic diseases in Poland: real-world evidence using a nationwide database

OBJECTIVES

Although several years have passed since biologic disease modifying antirheumatic drugs were introduced to the market, considerable disparities in access still remain. Tumour necrosis factor inhibitors (TNFi) have proven to be highly effective and safe for treating patients with rheumatic musculoskeletal diseases (RMDs). The emergence of biosimilars is promising for cost reduction and more equitable, widespread access.

METHODS

A retrospective budget impact analysis based on final drug prices was conducted using 12 687 treatment courses for infliximab, etanercept and adalimumab. Estimated and real-life savings for public payer were calculated from an 8-year perspective of TNFi use. Data on the treatment cost and on the evolution in the number of patients treated was provided.

RESULTS

From a public payer perspective, the estimated total savings amount to over €243 million for TNFi, with over €166 million attributed to treatment cost reduction in RMDs. Real-life savings were calculated as €133 million and €107 million, respectively. The rheumatology sector generated between 68% and 92% of total savings across models, depending on the adopted scenario. The overall decrease in mean annual cost of treatment ranged between 75% and 89% in the study frame. If all budget savings were spent on reimbursement of additional TNFi, a hypothetical total of almost 45 000 patients with RMDs could be treated in 2021.

CONCLUSIONS

This is the first nation-level analysis that shows estimated and real-life direct cost-savings for TNFi biosimilars. Transparent criteria for reinvesting savings should be developed on both a local and an international levels.

Health inequalities and social determinants of health: The role of syndemics in rheumatic disease

A syndemic is the co-existence of two or more health problems (including both social and biological features) that adversely influence each other with negative consequences on disease outcomes and perpetuation of inequalities. The syndemic approach can be applied to better understand the course of rheumatic musculoskeletal diseases (RMD) involving the study of adverse biological pathways and social determinants of health (SDH) all under the same framework. Identifying if a syndemic exists within RMDs may include investigating the synergic interactions between comorbidity (e.g., diabetes, obesity, chronic kidney diseases) and the concomitant of other adverse conditions (e.g., drug non-adherence, substance abuse), along with SDHs such as low household income, unemployment, low education, limited access to health care, as well as racial/ethnic discrimination. For decades, the understanding of RMDs progression has been based on causality, rather than investigating the kaleidoscopic web of connections that can potentially influence a disease course. The co-existence of health burdens in vulnerable populations, including those with RMD, specifically in certain socioeconomic groups, calls for new ways and strategies of thinking to improve our understanding of risk factors and co-morbidities to offer tailored interventions for clinical medicine and public health policy.

Features of medical and social expertise in ankylosing spondylitis and psoriatic arthritis

Ankylosing spondylitis (AS) and psoriatic arthritis (PsA) are the two most common diseases from the group of spondyloarthritis (SpA), which are often accompanied by permanent disability. Maintaining an acceptable quality of life, preventing the development and progression of structural changes in the musculoskeletal system, maintaining/normalizing functional and social activity are the main goals of their therapy. Over the past decades, the introduction of biological disease modifying antirheumatic drugs has made it possible to achieve significant success in the sustainable control of AS and PsA activity. However, the high cost of treatment significantly limits access to innovative drugs. Specifics of drug supply call for prescription of these drugs in the presence of the status of "disabled", which is assigned on the basis of the results of the medical and social examination (MSE). Execution of the necessary medical documentation for the implementation of the MSE is one of the functions of a rheumatologist.The lecture analyzes the main regulatory legal acts of the Russian Federation regulating the issues of establishing disability and discusses peculiarities of medical reports processing when referring patients with AS and PsA to the MSE.

World mortality of ankylosing spondylitis, psoriatic arthritis and inflammatory bowel disease in 2015 and its evolution from 2001 to 2015

OBJECTIVE

There is little epidemiological data on global mortality in spondyloarthritis (SpA) and inflammatory bowel disease. We then determined mortality rates of ankylosing spondylitis (AS), psoriatic arthritis (PsA), Crohn's disease (CD) and ulcerative colitis (UC) both globally and by country, and to describe their evolution between 2001 and 2015.

METHODS

We used mortality data from the World Health Organisation (WHO), which shows the number of deaths classified by age, sex, and cause of death coded by ICD-10. Age-standardized mortality rates (ASMR) were constructed using the 2015 WHO reference population. Temporal trend analyses of ASMR were performed between 2001 and 2015 using joinpoint regression.

RESULTS

Global ASMR was for 0.13 [0.11-0.14] deaths per million inhabitants for AS, 0.04 [0.03-0.05] for PsA, 0.86 [0.82-0.89] for CD and 0.76 [0.73-0.79] for UC. The worldwide trend analysis showed no significant change in ASMR for AS, a statistically significant increase from 2004 to 2015 (mean annual percent change (APC): 5.94%, p<0.001) for PsA, and a statistically significant decrease from 2001 to 2015 for CD (mean APC: -0.82%, p<0.001) and UC (mean APC: -1.29%, p<0.001). Statistically significant geographical disparities were identified.

CONCLUSION

We found significant geographical disparities in SpA and IBD mortality across the world. Further studies seem to be needed to better understand the evolution of mortality over the last twenty years.

The relationship between patients' income and education and their access to pharmacological chronic pain management: A scoping review

Background

Though chronic pain is widespread, affecting about one-fifth of the world's population, its impacts are disproportionately felt across the population according to socioeconomic determinants such as education and income. These factors also influence patients' access to treatment, including pharmacological pain management.

Aim

A scoping review was undertaken to better understand the association of socioeconomic factors with physicians' pain management prescribing patterns for adults living with chronic pain.

Methods

An electronic literature search was conducted using the EMBASE, CINAHL, SCOPUS, and Ovid MEDLINE databases and 31 retrieved articles deemed relevant for analyses were critically appraised.

Results

The available evidence indicates that patients' lower socioeconomic status is associated with a greater likelihood of being prescribed opioids to manage their chronic pain and a decreased likelihood of receiving prescription medications to manage migraines, rheumatoid arthritis, and osteoarthritis.

Conclusions

These results suggest that individuals with lower socioeconomic status do not receive equal prescription medicine opportunities to manage their chronic pain conditions. This is influenced by a variety of intersecting variables, including access to care, the potential unaffordability of certain therapies, patients' health literacy, and prescribing biases. Future research is needed to identify interventions to improve equity of access to therapies for patients with chronic pain living in lower socioeconomic situations as well as to explain the mechanism through which socioeconomic status affects chronic pain treatment choices by health care providers.

Abbreviation

SES: socioeconomic status; RA: rheumatoid arthritis; IV: intravenous; SC: subcutaneous; bDMARDs: biological disease-modifying antirheumatic drugs; DMARDS; disease-modifying antirheumatic drugs; TNFi: tumour necrosis factor inhibitors; NSAIDs: non-steroidal anti-inflammatory drugs.

Spectrum of Spondyloarthritis Among Chinese Populations

PURPOSE OF REVIEW

This review aims to emphasize interesting and important new findings with a focus on the spectrum of spondyloarthritis (SpA) in China.

RECENT FINDINGS

Over the past decade, significant advances have been made in the investigation of SpA epidemiology, the exploration of genetic and environmental risk factors, the identification of clinical features, and the updating of treatment protocols in the Chinese population. The prevalence of ankylosing spondylitis (AS) in China is 0.20-0.42%, and the prevalence of HLA-B27 in AS patients is 88.8-89.4%. HLA-B*2704 is the most common subtype in Chinese AS patients, followed by HLA-B*2705. HLA-A*01, more precisely HLA-A*01:01, may be associated with psoriatic arthritis (PsA). Tumor necrosis factor inhibitors and IL-17A inhibitors have been shown to be effective and safe for AS patients in China. Juvenile-onset AS is relatively rare, accounting for only 9.1% of the AS population. The prevalence of arthritis related to inflammatory bowel disease is 6.9 to 7.2%. A Chinese study showed that the most frequently prescribed medication was methotrexate (66.4%). Biological agents were prescribed in only16.4% of patients with PsA. This review summarizes the latest research in the epidemiology, pathogenesis, clinical manifestations, and management of SpA among Chinese populations. Multiple HLA associations with SpA have also been described, and it is hoped that discoveries of such ethnic-specific risk factor(s) and understanding of their pathological mechanisms may potentially lead to newer targeted therapies for the Chinese populations worldwide.

Malignancy in ankylosing spondylitis: a cross-sectional analysis of a large population database

BACKGROUND

Increased cancer-risk has been reported with rheumatoid arthritis and systemic lupus erythematosus, but the risk is poorly studied in ankylosing spondylitis (AS). Conflicting data in AS have been reported in Asia and Europe, with lack of US population-based studies. Our objective is to study the prevalence of cancer in patients with AS in the US.

METHODS

Using the Explorys database, we performed a cross-sectional study. Data from AS patients and controls were stratified by 2 rheumatology visits, age groups, clinical characteristics, and frequency of cancers. The data were analyzed using a series of chi-square tests of independence as well as logistic regression to test for association between AS and cancer.

RESULTS

1410 AS patients (12.88%) had cancer. Female AS patients had a lower prevalence of cancer compared to controls (OR 0.840, 95% CI [0.769, 0.916]), while male AS patients had no statistically significant difference (OR 1.011, 95% CI [0.929, 1.099]). Among patients with AS, Skin cancers (squamous cell, malignant melanoma, and basal cell) and head and neck cancers were significantly increased.

CONCLUSION

Our study demonstrated that the prevalence of "any-type-cancer" was not increased in AS patients compared to controls with no rheumatic disease. Skin, head, and neck cancers were more frequently seen in AS patients.

Disparities in healthcare in psoriatic arthritis: an analysis of 439 patients from 13 countries

OBJECTIVES

Patient care can vary substantially by country. The objective was to explore differences in psoriatic arthritis (PsA) across countries for disease activity, impact and treatments.

METHODS

A cross-sectional analysis of 13 countries from the Remission/Flare in PsA study (NCT03119805) of consecutive adult patients with definite PsA was performed. Countries were classified into tertiles by gross domestic product (GDP)/capita. Disease activity (Disease Activity in PsA, DAPSA and Minimal Disease Activity, MDA) and their components, disease impact (patient-reported outcomes) and biological disease-modifying antirheumatic drugs (bDMARDs) were analysed per country and compared between the three tertiles of GDP/capita by parametric and non-parametric tests. We also explored the percentage of patients with significant disease activity (DAPSA >14) and no ongoing bDMARD prescription.

RESULTS

In 439 patients (50.6% male, mean age 52.3 years, mean disease duration 10.1 years), disease activity and disease impact were higher in the lowest GDP/capita countries. DAPSA remission and MDA were attained in the lowest tertile in 7.0% and 18.4% patients, vs 29.1% and 49.5% in the middle tertile and 16.8% and 41.3% in the high tertile, respectively (all p<0.001). bDMARDs use was similar in the tertiles (overall mean 61%). The overall rate of patients with DAPSA >14 and no bDMARDs was 18.5%, and was higher in lower GDP/capita countries (p=0.004).

CONCLUSION

PsA patients from countries with the lowest GDP/capita, despite similar use of bDMARDs, were more likely to have high disease activity and worse disease impact. There is a need for more equity in healthcare.

Expert recommendations on early diagnosis and referral of axial spondyloarthritis in the Kingdom of Saudi Arabia

Axial spondyloarthritis is a chronic inflammatory disorder that primarily involves the axial skeleton (sacroiliac joints and spine), causing stiffness, severe pain and fatigue. In some patients, definitive structural damage of sacroiliac joints is visible on imaging and is known as radiographic axial spondyloarthritis. Some patients do not have a clear radiographic damage of the sacroiliac joints, and this subtype is known as non-radiographic axial spondyloarthritis. Early diagnosis is important for reducing the risk of irreversible structural damage and disability. Management of axial spondyloarthritis is challenging in Saudi Arabia because of inadequate disease knowledge and the unavailability of local guidelines. Therefore, this expert consensus is intended to provide recommendations, including the referral pathway, the definition of remission and the treat-to-target approach, to all healthcare professionals for the management of patients with axial spondyloarthritis. A Delphi technique of consensus was developed by involving an expert panel of 10 rheumatologists, 1 dermatologist and 1 general physician. The experts offered consensus-based recommendations based on a review of available scientific evidence and clinical experience for the referral, screening and management of patients with axial spondyloarthritis.

The occurrence of multiple treatment switches in axial spondyloarthritis. Results from five Nordic rheumatology registries

OBJECTIVES

In axial spondyloarthritis (axSpA), switching between multiple biologic or targeted synthetic (b/ts-) DMARDs might indicate difficult-to-treat disease. We aimed to explore the occurrence of multiple switching in routine care axSpA patients using various definitions, and to identify associated clinical characteristics upon start of first b/tsDMARD (baseline).

METHODS

Observational cohort study including patients with axSpA starting a first-ever b/tsDMARD 2009-2018 based on data from five biologic registries (Denmark/Sweden/Finland/Norway/Iceland). Comorbidities and extra-articular manifestations were identified through linkage to national registries. Multi-switching was defined in overlapping categories according to b/tsDMARD treatment history: treatment with ≥3 b/tsDMARDs, ≥4 or ≥ 5 b/tsDMARDs during follow-up. We explored the cumulative incidence of patients becoming multi-switchers with ≥3 b/tsDMARDs stratified by calendar-period (2009-11/2012-13/2014-15/2016-2018). In the subgroup of patients starting a first b/tsDMARD 2009-2015, baseline characteristics associated with multi-switching (within 3 years' follow-up) were explored using multiple logistic regression analyses.

RESULTS

Among 8,398 patients included, 6,056 patients (63% male, median age 42 years) started a first b/tsDMARD 2009-2015, whereof proportions treated with ≥3, ≥4 or ≥ 5 b/tsDMARDs within 3 years' follow-up were 8%, 3%, 1%, respectively.Calendar-period did not affect the cumulative incidence of multi-switching.Baseline characteristics associated with multi-switching (≥3 b/tsDMARDs) were female gender, shorter disease duration, higher patient global score, comorbidities, and having psoriasis but not uveitis.

CONCLUSION

In this large Nordic observational cohort of axSpA patients, multiple switching was frequent with no apparent time-trend. Clinical associated factors included gender, but also previous comorbidities and extraarticular manifestations illustrating the ongoing challenge of treating this patient group.

Opioid use frequency in early axial spondyloarthritis in Finland - a pharmacoepidemic register study

OBJECTIVES

To evaluate opioid use among incident axial spondyloarthritis (axSpA) patients compared to general population.

METHODS

From the national register, we identified all adult patients with axSpA (ICD-10 codes M45-46), who between 2010 and 2014 (index date, ID) were for the first time granted special reimbursement for any disease-modifying anti-rheumatic drugs (DMARDs). Three matched population controls were identified for each patient. Drug purchases were evaluated between 2009-15, and opioid use was analyzed for one year before and after the ID. The Defined Daily Dose (DDD) was used as a tool to assess the opioid consumption before and after the biological (b) DMARD initiation.

RESULTS

We identified 3,577 axSpA patients and 10,573 controls. Of these patients, 97.2% started a conventional synthetic (cs) DMARD during a year after ID and 23.4% switched later to a self-injected bDMARD between the ID and 31 Dec 2015 (median follow-up 3.4 years). Opioids were purchased at least once by 29.8% and 21.7% of the patients in the years before and after the ID, respectively, compared to 8.1% and 7.8% of the controls. The proportion of opioid-using patients was greatest during the last quarter before the ID [relative risk (RR) 4.72 (95% CI 4.14 to 5.39)] compared to controls, and it remained higher [RR 2.84 (2.59 to 3.11)] also after the start of csDMARDs. DDD of opioid consumption decreased from 7.7 to 1.6/1,000 inhabitants after bDMARD initiation.

CONCLUSION

Considerably more axSpA patients than population controls used opioids. The opioid consumption by dose decreased clearly after bDMARD initiation.

Clinical characteristics of non-radiographic versus radiographic axial spondyloarthritis in Asia and non-radiographic axial spondyloarthritis in other regions: results of the cross-sectional ASAS-COMOSPA study

Objectives

To delineate characteristics of non-radiographic axial spondyloarthritis (nr-axSpA) in Asia versus non-Asian regions, and compare radiographic axSpA (r-axSpA) with nr-axSpA within Asia.

Methods

Data were collected from the Assessment of SpondyloArthritis international Society-COMOrbidities in SPondyloArthritis database. Categorising patients by region, we compared clinical characteristics between nr-axSpA from Asia vs elsewhere (Europe, the Americas and Africa). Within Asians, we additionally compared patient characteristics of those with nr-axSpA versus r-axSpA.

Results

Among 3984 SpA cases, 1094 were from Asian countries. Of 780 axSpA patients in Asia, 112 (14.4%) had nr-axSpA, less than in non-Asian countries (486/1997, 24.3%). Nr-axSpA patients in Asia were predominantly male (75.9% vs 47.1%), younger at onset (22.8 vs 27.8 years) and diagnosis (27.2 vs 34.5 years), and experienced less diagnostic delay (1.9 vs 2.9 years) compared with nr-axSpA in non-Asian countries. Nr-axSpA in Asia exhibited higher human leucocyte antigens-B27 prevalence (90.6% vs 61.9%), fewer peripheral SpA features (53.6% vs 66.3%) and similar extra-articular and comorbid disease rates compared with those with nr-axSpA in non-Asian countries. Disease activity, functional impairment and MRI sacroiliitis were less in nr-axSpA in Asia, with higher rates of non-steroidal anti-inflammatory drug response and less methotrexate and biological disease-modifying antirheumatic drugs use. Within Asia, r-axSpA showed higher disease activity and structural damage compared with nr-axSpA, with no differences in other features.

Conclusion

Among axSpA, lower frequency of nr-axSpA was observed in Asia. Our results offer an opportunity to better understand clinical characteristics and optimise diagnostic strategies, such as ensuring access and availability of MRI resources for accurate diagnosis of nr-axSpA in Asia.

Individual and country-level socioeconomic factors and health outcomes in spondyloarthritis: analysis of the ASAS perSpA study

OBJECTIVES

To investigate the association between individual and country-level socioeconomic (SE) factors and health outcomes across spondyloarthritis (SpA) phenotypes.

METHODS

Patients with axial SpA, peripheral SpA or psoriatic arthritis (PsA) from the ASAS-perSpA study (23 countries) were included. The effect of individual (age, gender, education and marital status) and country-level (e.g. Gross Domestic Product [GDP]) SE factors on health outcomes (ASDAS ≥ 2.1, ASDAS, BASFI, fatigue and ASAS-HI) was assessed in mixed-effects models, adjusted for potential confounders. Interactions between SE factors and disease phenotype were tested. A mediation analysis was conducted to explore whether the impact of country-level SE factors on ASDAS was mediated through b/tsDMARD uptake.

RESULTS

In total 4185 patients (61% males, mean age 45) were included (65% axSpA, 25% PsA, 10% pSpA). Female gender (β = 0.14 (95%CI 0.06-0.23)) lower educational level (0.35 (0.25-0.45)) and single marital status (0.09 (0.01-0.17)) were associated with higher ASDAS. Living in lower GDP countries was also associated with higher ASDAS (0.39 (0.16-0.63)) and 7% of this association was mediated by b/tsDMARD uptake. Higher BASFI was similarly associated with female gender, lower education and living alone, without effect of country-level SE factors. Female gender and lower educational level were associated with worse ASAS-HI, while more fatigue was associated with female gender and higher country-level SE factors (lower GDP, -0.46 (-0.89 to -0.04)). No differences across disease phenotype were found.

CONCLUSIONS

Our study shows country-driven variations in health outcomes in SpA, independently influenced by individual and country-level SE factors and without differences across disease phenotypes.

[Development of quality standards for patients with axial spondyloarthritis for use in Germany]

Quality standards (QS) are measurable constructs designed to quantify gaps in care and subsequently to improve quality of care. The Assessment of SpondyloArthritis International Society (ASAS) recently generated and published international QS for the management of patients with axial spondyloarthritis (axSpA) for the first time. The German Society of Rheumatology (DGRh) then decided to translate, review and possibly adopt these standards by a group of experts from different care settings. Against this background, national QS for the management of patients with axSpA for Germany were developed for the first time. The main focus was on feasibility and practical relevance. Ultimately, nine QS were defined with which the quality of care in Germany can and should be measured and improved.

Association between individual and country-level socioeconomic factors and work participation in spondyloarthritis including psoriatic arthritis: Analysis of the ASAS-perSpA study

OBJECTIVE

To examine whether associations between socioeconomic factors and work outcomes in spondyloarthritis (SpA) differ across axial (axSpA), peripheral SpA (pSpA) and psoriatic arthritis (PsA), and whether associations for individual-level socioeconomic factors are modified by country-level factors.

METHODS

Patients with a physician diagnosis of SpA within working age (18-65 years) were included. Associations between individual- (age, gender, education, marital status) and country-level factors (Human Development Index, Health Care Expenditure (HCE), Gross Domestic Product, percentage unemployed) with work outcomes (employment status, absenteeism, presenteeism) were assessed using multivariable mixed-effects models. Associations between individual factors and outcomes were compared according to SpA phenotypes and country-level factors using interaction terms.

RESULTS

A total of 3835 patients (mean age 42 years, 61% males) from 23 countries worldwide were included (66% axSpA, 10% pSpA, 23% PsA). Being employed was associated with gender (male vs. female OR 2.5; 95%CI 1.9-3.2), education (university vs. primary OR 3.7; 2.9-4.7), marital status (married vs. single OR 1.3; 1.04-1.6), and age in a non-linear manner. University (vs primary) education was associated with lower odds of absenteeism (OR 0.7; 0.5-0.96) and presenteeism (OR 0.5; 0.3-0.7). Associations were similar across SpA phenotypes. Higher HCE was associated with more favourable work outcomes, e.g., higher odds of employment (OR 2.5; 1.5-4.1). Gender discrepancy in odds of employment was greater in countries with lower socioeconomic development.

CONCLUSION

Higher educational attainment and higher HCE were associated with more favourable work outcomes, independently of SpA phenotype. The disadvantageous effect of female gender on employment is particularly strong in countries with lower socioeconomic development.

Root Joint Involvement in Spondyloarthritis: A Post-hoc Analysis from the International ASAS-PerSpA Study

OBJECTIVES

Primary objective was to compare the clinical characteristics of spondyloarthritis (SpA) patients with and without root joint disease (RJD+ and RJD-). Secondary objectives were to compare the prevalence of RJD across various SpA subtypes and in different world regions, to compare the SpA axial severity and SpA burden between RJD+ and RJD-.

METHODS

This is a post-hoc analysis of the ASAS-PerSpA study (PERipheral involvement in SpondyloArthritis), which included 4,465 patients with SpA (axial (axSpA), peripheral (pSpA), psoriatic (PsA), inflammatory bowel disease, reactive and juvenile) according to the rheumatologist's diagnosis. RJD was defined as the "ever" presence of hip or shoulder involvement related to SpA, according to the rheumatologist. The patient's characteristics were compared between RJD+ and RJD-. Multivariable stepwise binary logistic regression analyses were conducted to identify factors associated with "RJD", "hip" and "shoulder" involvement.

RESULTS

RJD was significantly associated with the SpA main diagnosis (highest in pSpA), a higher prevalence of HLA-B27 positivity, enthesitis, tender and swollen joints, CRP, cs-DMARDs, loss of lumbar lordosis and occiput-wall distance > 0. RJD was more prevalent in Asia, and occurred in 1,503 patients (33.7%), with more hip (24.2%) than shoulder (13.2%) involvement. Hip involvement had a distinct phenotype, similar to axSpA (including younger age at onset, HLA-B27 positivity), whereas shoulder involvement was associated with features of pSpA (including older age at onset).

CONCLUSION

RJD+ SpA patients had a distinctive clinical phenotype compared with RJD-. Hip involvement, based on the rheumatologist's diagnosis, was more prevalent than shoulder involvement and was clinically distinct.

Immunoglobulin A antibodies to oxidized collagen type II as a potential biomarker for the stratification of spondyloarthritis from rheumatoid arthritis

OBJECTIVES

The discovery of diseased tissue-specific neoantigens offers the opportunity to develop important disease tissue-specific biomarkers that can help in the prediction, diagnosis, and stratification of diseases. This opportunity is specifically significant for autoimmune diseases where diagnostic biomarkers are not available. Inflammatory autoimmune diseases are commonly associated with local generation of large amounts of reactive oxidants. We have previously identified oxidative post-translationally modified (oxPTM) tissue-specific neoantigens in rheumatoid arthritis (RA) and type 1 diabetes that elicit an immune response. In the current study, we studied the presence and clinical significance of antibodies to oxPTM collagen type II (CII) in patients with spondyloarthritis (SpA).

METHOD

Levels of antibodies specific to native CII and oxPTM-CII were assessed by enzyme-linked immunosorbent assay.

RESULTS

Immunoglobulin G (IgG) binding to oxPTM-CII was observed in 52%, 83%, and 28% of serum samples from patients with axial spondyloarthritis (axSpA), RA, and psoriatic arthritis (PsA), respectively. Importantly, while strong IgA anti-oxPTM-CII responses were detected in axSpA and PsA patients, with 47% and 84% respective binders, no IgA anti-oxPTM-CII was detected in RA patients. IgA anti-oxPTM-CII reactivity in axSpA patients treated with biologics was higher and more frequent, with 85% binders compared to 9% binders in patients treated with synthetic disease-modifying anti-rheumatic drugs.

CONCLUSION

Our data imply that SpA and PsA are associated with the presence of antibodies to oxPTM-CII, suggesting that there may be a humoral component that may distinguish patients with SpA from RA. Our approach could be adapted to other diseases, particularly to inflammatory autoimmune diseases.

Patients with axial spondyloarthritis report significant differences between men and women and high impact of the disease: Large websurvey analysis

OBJECTIVE

In axial spondyloarthritis (axSpA), mounting evidence shows female patients to experience a higher disease burden. These differences appear to be particularly large in South America. One explanation could be inequity in treatment access between men and women. The objective was to evaluate gender differences in disease burden and work participation, and the potential influence of treatment, in Latin American patients.

METHODS

A cross sectional online survey among axSpA patients, collecting disease characteristics, treatment, disease burden (BASDAI, BASFI, ASAS Health Index) and work participation (WPAI). Associations between gender and disease burden or work participation were assessed through regression analyses, correcting for treatment.

RESULTS

AxSpA was reported by 472 participants (63% women) and disease activity (BASDAI≥4: 83%), ASASHI (≥moderately impaired: 91%) and work disability (absenteeism: 41%; presenteeism 82%) were high. Biological use was very low (20%), while 34% used opiates. Females had significantly higher BASDAI, ASAS HI, work absenteeism and presenteeism, although were less likely to receive biologics (26% versus 16%, P<0.01). Gender differences disappeared after correction for treatment.

CONCLUSIONS

This web survey in Latin American axSpA patients shows a high disease burden and work impairment. The use of biologics is low, while the use of opiates was alarmingly high. Women used significantly less biologics despite reporting a worse disease state and work disability, which could be due to treatment inequity.

Development of ASAS quality standards to improve the quality of health and care services for patients with axial spondyloarthritis

OBJECTIVES

The Assessment of SpondyloArthritis International Society (ASAS) aimed to develop a set of quality standards (QS) to help improve the quality of healthcare provided to adult patients affected by axial spondyloarthritis (axSpA) worldwide.

METHODS

An ASAS task force developed a set of QS using a stepwise approach. First, key areas for quality improvement were identified, discussed, rated and agreed on. Thereafter, areas were prioritised and statements for the most important key areas were phrased on consensus. Appropriate quality measures were defined to allow quantification of the QS at the community level.

RESULTS

The ASAS task force, consisting of 20 rheumatologists, two physiotherapists and two patients, selected and proposed 34 potential key areas for quality improvement which were then commented by 140 ASAS members and patients. Within that process three new key areas came up, which led to a re-evaluation of all 37 key areas by 120 ASAS members and patients. Five key areas were identified as most important to determine quality of care: referral including rapid access, rheumatology assessment, treatment, education/self-management and comorbidities. Finally, nine QS were agreed on and endorsed by the whole ASAS membership.

CONCLUSIONS

ASAS successfully developed the first set of QS to help improving healthcare for adult patients with axSpA. Even though it may currently not be realistic to achieve the QS in all healthcare systems, they provide high-quality of care framework for patients with axSpA that should be aimed for.

Add-On Effects of Conventional Synthetic Disease-Modifying Anti-Rheumatic Drugs in Ankylosing Spondylitis: Data from a Real-World Registered Study in China

Background

The aim of this study was to investigate the effects of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) on patients with ankylosing spondylitis (AS) using real-world data, and to analyze patients’ choices of csDMARDs and reasons for discontinuation.

Material/Methods

This observational study included 320 patients satisfying the modified New York criteria for AS. Patients were grouped according to medication: Group 1: 122 patients receiving non-steroidal anti-inflammatory drug (NSAID) monotherapy; Group 2: 198 patients receiving csDMARDs and NSAIDs. Patients were followed for 18 months at 6-month intervals. The change in AS Disease Activity Score and C-reactive protein (ASDAS-CRP) at each visit was the primary outcome. Secondary outcomes were based on validated disease activity questionnaires, clinical assessment, and acute-phase biomarkers (CRP and erythrocyte sedimentation rate [ESR]). Inter-group relationships were assessed across the 18-month follow-up period using generalized additive mixed models.

Results

Sulfasalazine and thalidomide were the most commonly used csDMARDs, with cumulative use times of 8.9±4.1 months and 9.1±4.7 months, respectively. In Group 2, 56 patients discontinued or switched csDMARDs during the follow-up period, with lack of efficacy being the primary reason. The ASDAS-CRP was found to decrease significantly in both groups; however, improvements in many parameters (including ASDAS-CRP, disease activity questionnaires and ESR) were greater in Group 2.

Conclusions

Use of csDMARDs can improve disease activity in terms of ASDAS-CRP. The addition of csDMARDs may provide increased benefits compared with NSAID monotherapy, particularly in the reduction of AS disease activity, in the Chinese population.

Racial Differences in Clinical Features and Comorbidities in Ankylosing Spondylitis in the United States

OBJECTIVE

To examine racial differences of clinical features, medication usage, and comorbidities of patients with ankylosing spondylitis (AS) in the United States.

METHODS

In the Explorys database, 28,520 patients with AS were identified. Data were stratified by 2 rheumatology visits, race, sex, clinical characteristics, medication use, and comorbidities. Datasets were recorded as proportions, which were compared using chi-square test (p < 0.05).

RESULTS

Of the 10,990 patients with AS, 8% were African Americans and had elevated erythrocyte sedimentation rate and C-reactive protein, and high frequency of anterior uveitis, hypertension, diabetes, depression, and heart disease.

CONCLUSION

African Americans with AS in the United States have high disease activity and comorbidities compared to whites.

Treatment failure in inflammatory arthritis: time to think about syndemics?

Social determinants of health play a crucial role in health and disease. In current times, it has become increasingly known that biological and non-biological factors are potentially linked and help to drive disease. For example, links between various comorbidities, both physical and mental illnesses, are known to be driven by social, environmental and economic determinants. This contributes to worse disease outcomes. This article discusses the concept of syndemics, which although well-described in some conditions, represents a novel concept in the context of rheumatic and musculoskeletal diseases. Written in the form of a viewpoint, the article focuses on a novel theoretical framework for studying inflammatory arthritis, based on a syndemic approach that takes into account the social context, biocultural disease interaction, and socio-economic characteristics of the setting. Syndemics involving inflammatory arthritis may be most likely in a social context involving limited access to health care, lack of physical activity and obesogenic diets, high rates of alcohol consumption, and high exposure to stressful life events.

Individual-level and country-level socioeconomic determinants of disease outcomes in SpA: multinational, cross-sectional study (ASAS-COMOSPA)

OBJECTIVE

To explore the independent contribution of individual-level and country level socioeconomic status (SES) determinants to disease activity and physical function in patients with spondyloarthritis (SpA).

METHODS

Data from the cross-sectional, multinational (n=22 countries worldwide) COMOSPA (COMOrbidities in SpA) study were used. Contribution of individual SES factors (gender, education) and country of residence to Ankylosing Spondylitis Disease Activity Score (ASDAS) and Bath Ankylosing Spondylitis Functional Index (BASFI) was explored in multilevel regression models, adjusting for clinical and demographic confounders. Next, the additional effects of national macroeconomic indicators (gross domestic product [GDP], Human Development Index, healthcare expenditure and Gini index) were explored. The mediating role of uptake of biologic disease-modifying antirheumatic drugs between education or GDP and ASDAS was explored by testing indirect effects.

RESULTS

In total, 3370 patients with SpA were included: 65% were male, with a mean age of 43 (SD 14), ASDAS of 2.0 (SD 1.1) and BASFI score of 3.1 (SD 2.7). In adjusted models, patients with low education and female patients had an OR of 1.7 (95% CI 1.3 to 2.2) and an OR of 1.7 (95% CI 1.4 to 2.0), respectively, of having ASDAS ≥2.1. They also reported slightly worse function. Large country differences were observed independent of individual SES and clinical confounders. Patients from less SES developed countries have worse ASDAS, while patterns for BASFI were insignificant. Uptake of biologicals did not mediate the relationship between individual-level or country-level SES and disease activity.

CONCLUSIONS

Individual-level and country-level health inequalities exist also among patients with SpA. Women and lower educated persons had worse disease activity and somewhat worse physical function. While patients in less socioeconomically developed countries had higher disease activity, they reported similar physical function.