Combination of denosumab and biologic DMARDs in inflammatory muscle-skeletal diseases and connective tissue diseases

Pathogenesis, assessment, and management of bone loss in axial spondyloarthritis

INTRODUCTION

Axial spondyloarthritis (axSpA) presents a complex scenario where both new bone formation in entheseal tissues and significant trabecular bone loss coexist, emphasizing the intricate nature of bone dynamics in this context.

METHODS

A search of the literature was conducted to compose a narrative review exploring the pathogenesis, possible assessment methods, and potential management options for axSpA.

RESULTS

While chronic systemic and local inflammation contribute to bone loss, the mechanisms behind axSpA-associated bone loss exhibit distinct characteristics influenced by factors like mechanical stress and the gut microbiome. These factors directly or indirectly stimulate osteoclast differentiation and activation through the RANK-RANKL axis, while simultaneously impeding osteoblast differentiation via negative regulation of bone anabolic pathways, including the Wnt signaling pathway. This disruption in the balance between bone-resorbing osteoclasts and bone-forming osteoblasts contributes to overall bone loss in axSpA. Early evaluation at diagnosis is prudent for detecting bone changes. While traditional dual x-ray absorptiometry (DXA) has limitations due to potential overestimation from spinal new bone formation, alternative methods like trabecular bone score (TBS), quantitative CT (QCT), and quantitative ultrasound (QUS) show promise. However, their integration into routine clinical practice remains limited. In addition to approved anti-inflammatory drugs, lifestyle adjustments like regular exercise play a key role in preserving bone health. Tailoring interventions based on individual risk profiles holds potential for mitigating bone loss progression.

CONCLUSION

Recognizing the pivotal role of bone loss in axSpA underscores the importance of integrating regular assessments and effective management strategies into clinical practice. Given the multifaceted contributors to bone loss in axSpA, a multidisciplinary approach is essential.

Dual targeted therapy in patients with psoriatic arthritis and spondyloarthritis: a real-world multicenter experience from Spain

Dual targeted therapy (DTT) has emerged as a promising approach in patients with refractory spondyloarthritis (SpA) or psoriatic arthritis (PsA) and extra-musculoskeletal manifestations of both diseases, but its effectiveness/safety ratio still remains unclear. This is a retrospective, real-world multicenter study in refractory SpA and PsA patients with simultaneous use of two biological or synthetic targeted agents. Effectiveness was assessed using Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) and Disease Activity in Psoriatic Arthritis (DAPSA) Score. We identified 39 different DTT combinations in 36 patients (22 SpA; 14 PsA), 25 of them with concomitant inflammatory bowel disease. The most commonly used combinations were TNF inhibitor plus antagonist of the IL12/23 pathway, followed by TNF inhibitor plus IL-17 antagonist. During a median exposure of 14.86 months (IQR 8-20.2), DTT retention rate was 69.4% (n=25/36; 19 SpA, 6 PsA). Major clinical improvement (change in ASDAS-CRP > 2 or improvement > 85% in DAPSA) was achieved in 69.4% of patients (n=25/36 therapeutical combinations; 17/21 SpA, 8/15 PsA), with a 58.3% (n=21/36 combinations; 15/20 SpA, 6/13 PsA) low-activity/remission rate. Of the patients who were receiving glucocorticoids, 55% managed to withdraw them during follow-up. Interestingly, only four serious adverse events in three patients were observed, leading to DTT discontinuation.