Upadacitinib for the treatment of adults with active non-radiographic axial spondyloarthritis (nr-axSpA)

INTRODUCTION

Non-radiographic axial spondyloarthritis (nr-axSpA) is a chronic inflammatory condition with axial and peripheral musculoskeletal involvement, fulfilling criteria of axSpA in the absence of advanced radiographic sacroiliitis. While appropriate treatment is required for chronic pain and disability resulting from disease progression, the limited availability of treatment options becomes evident. Upadacitinib, an oral selective Janus kinase 1 inhibitor, was approved in Europe, the United States, and other countries for management of nr-axSpA with inadequate response to existing therapies.

AREA COVERED

This review summarizes essential drug profiles, efficacy, and safety of upadacitinib for nr-axSpA in conjunction with data pertaining to radiographic axSpA.

EXPERT OPINION

In a phase 3 trial, upadacitinib exhibited efficacy for patients with nr-axSpA, irrespective of prior exposures to biological disease-modifying antirheumatic drugs (bDMARDs). The safety profiles of upadacitinib in nr-axSpA mirrored those in other indications, underscoring its potential as a promising treatment option for nr-axSpA. Concurrently, physicians should be aware of the absence of real-world data, longitudinal efficacy and safety, direct comparative studies between upadacitinib and bDMARDs in nr-axSpA, and evidence for precision medicine to identify patients who may optimally benefit from upadacitinib over bDMARDs. Future research is imperative to facilitate the effective utilization of upadacitinib in daily clinical practice.

Efficacy and safety of golimumab in patients with non-radiographic axial spondyloarthritis: a withdrawal and retreatment study (GO-BACK)

OBJECTIVES

The GO-BACK study was designed to evaluate the efficacy and safety of golimumab (GLM) treatment withdrawal in adults with non-radiographic axial spondyloarthritis (nr-axSpA) who demonstrate inactive disease during a 10-month open-label (OL) GLM run-in.

METHODS

Eligible participants received OL GLM in period 1. In period 2, participants who achieved inactive disease were randomized 1:1:1 to receive double-blind (DB) treatment with monthly placebo (PBO, treatment withdrawal) or continued GLM treatment given monthly (GLM QMT) or every 2 months (GLM Q2MT). Participants who did not have a disease flare continued DB treatment for ∼12 months. Participants with a disease flare discontinued DB treatment and resumed monthly OL GLM. Primary endpoint compared the proportion of participants without a disease flare in the continued GLM treatment groups (QMT or Q2MT) vs PBO in a multiplicity-controlled, step-down fashion. Safety follow-up continued for ∼3 months after last treatment.

RESULTS

A total of 188 patients, out of the 323 enrolled, were eligible for participation in period 2. Both GLM QMT and GLM Q2MT were superior to treatment withdrawal (PBO) in preventing disease flare (P < 0.001), with a treatment-difference vs PBO of 50.4% and 34.4% for the GLM QMT and GLM Q2MT groups, respectively. The time-to-first flare was significantly longer (log-rank P < 0.0001) with GLM treatment compared with PBO. Of 53 participants (in Q2MT or PBO) who had a confirmed disease flare, 51 (96.2%) attained a clinical response within 3 months of restarting OL GLM. Adverse events were consistent with the known GLM safety profile.

CONCLUSION

Among participants with active nr-axSpA who attained inactive disease after 10 months of GLM treatment, continued GLM treatment is well tolerated and provides superior protection against disease flares compared with GLM withdrawal. (EudraCT: 2015-004020-65, registered on 30 March 2022; NCT: 03253796, registered on 18 August 2017.).

JAK Inhibitors for the Treatment of Axial Spondyloarthritis

Axial spondyloarthritis (axSpA) is a chronic disease characterized by inflammation and new bone formation that causes pain and results in functional impairment and long-term disability. Biologic agents targeting TNFα or IL-17 have been the mainstay of treatment for patients with axSpA and an inadequate response to nonsteroidal anti-inflammatory drugs. However, a proportion of axSpA patients do not respond adequately to those drugs either, creating the need to target alternative disease pathways. Janus kinase (JAK) inhibitors (JAKis) are a group of targeted synthetic disease-modifying anti-rheumatic drugs that block the intracellular signalling pathway of several proinflammatory cytokines. Given their efficacy in the management of rheumatoid arthritis and that JAKs mediate the signalling of cytokines involved in the pathogenesis of axSpA as well, JAKis have been successfully tested in a number of clinical trials in axSpA, which has led to the approval of two compounds, tofacitinib and upadacitinib for the treatment of the disease. Data from new clinical trials, long-term extensions of completed trials, and real-life observational studies that continuously emerge will shape the efficacy and safety profile and ultimately the place of JAKis in the treatment of AxSpA.

Real-world experience with secukinumab in the entire axial spondyloarthritis spectrum

Background

Secukinumab is a biologic disease-modifying antirheumatic drug (bDMARD) that has demonstrated efficacy in the treatment of axial spondyloarthritis (axSpA, i.e., ankylosing spondylitis and non-radiographic axSpA) across various clinical trials. However, data of secukinumab in clinical practice is still limited. Here, we aimed to provide real-world data on secukinumab use, effectiveness, and persistence in axSpA.

Patients and methods

Retrospective, multicenter study of patients with a diagnosis of axSpA treated with secukinumab at 12 centers up to June 2021 in the Valencian Community (Spain). Information was gathered on BASDAI measurement, pain, patient and physician global assessment (ptGA, phGA) using a 100-mm visual analog scale (VAS), persistence and other secondary variables by treatment line (first, second, and ≥ third) for up to 24 months.

Results

221 patients were included (69% men; mean age [standard deviation, SD]: 46.7 [12.1] years old). Secukinumab was used as a first-line bDMARD in 38% of patients, as a second-line in 34% and as a ≥ hird-line in 28%. The percentage of patients achieving low disease activity (BASDAI<4) increased from 9% at baseline to 48% at month 6 and was maintained (49%) up to month 24. The greatest improvement in BASDAI was observed in naïve patients (month 6: -2.6; month 24: -3.7), followed by second-line (month 6: -1.9; month 24: -3.1) and ≥ third-line (month 6: -1.3; month 24: -2.3) patients. Reductions in mean pain VAS (-23.3; -31.9), ptGA (-25.1; -31.9) and phGA (-25.1; -31) were also observed at 6 and 24 months. Secukinumab showed an overall 12-months persistence rate of 70% (95% confidence interval [CI]: 63-77%) and a 24-months persistence rate of 58% (95% CI, 51-66%). Patients receiving first-line secukinumab had the highest 24-months persistence rate (p = 0.05).

Conclusion

Secukinumab improved disease activity in axSpA patients, especially in naive, and second-line patients, which was accompanied by high persistence rates up to 24 months.

Brodalumab, an anti-interleukin-17 receptor A monoclonal antibody, in axial spondyloarthritis: 68-week results from a phase 3 study

OBJECTIVE

To evaluate the long-term efficacy and safety of brodalumab, a fully human anti-interleukin-17 receptor A monoclonal antibody, in patients with axial spondyloarthritis (axSpA).

METHODS

Patients receiving subcutaneous brodalumab 210 mg during the 16-week double-blind period of this multicentre, phase 3 study conducted across Japan, Korea and Taiwan continued the same during the 52-week open-label extension, whereas patients receiving placebo switched to brodalumab 210 mg at week 16. Efficacy (Assessment of SpondyloArthritis International Society [ASAS] 40 and ASAS 20 response rates; change from baseline in Ankylosing Spondylitis Disease Activity Score using C-reactive protein [ASDAS-CRP]) and safety were evaluated.

RESULTS

Overall, 145 patients (brodalumab, n = 77; placebo, n = 68) received brodalumab during the open-label extension. ASAS 40 response rates (95% confidence interval [CI]) of 56.3% (44.7%, 67.3%) and 57.4% (44.1%, 70.0%) were achieved in the brodalumab and placebo groups, respectively, at week 68. ASAS 20 response rates (95% CI) achieved at week 68 in both treatment groups were similar (brodalumab, 71.3% [60.0%, 80.8%]; placebo, 78.7% [66.3%, 88.1%]). The least squares mean change (95% CI) in ASDAS-CRP at week 68 suggested a clinically important improvement (change, ≥1.1) in both treatment groups (brodalumab, -1.528 [-1.737, -1.319]; placebo, -1.586 [-1.815, -1.357]). The exposure-adjusted event rates (per 100 patient-years) for treatment-emergent adverse events (TEAEs) and drug-related TEAEs were 255.9 and 147.9, respectively; nasopharyngitis (35.6) and upper respiratory tract infection (14.7) were the most common TEAEs.

CONCLUSION

Brodalumab demonstrated sustained efficacy and a consistent safety profile in patients with axSpA over 68 weeks.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, https://clinicaltrials.gov, NCT02985983.

A comprehensive analysis with a focus on images

BACKGROUND

Non-radiographic axial spondyloarthritis (nr-axSpA) data from South America are scarce, especially regarding image features. Objective To estimate the frequency of nr-axSpA and ankylosing spondylitis (AS) in a cohort of Argentinian patients with chronic low back pain (LBP) and to analyze the difference between both, with focus on magnetic resonance imaging (MRI) lesions, at diagnosis.

METHODS

Patients with LBP and a diagnosis of axSpA who participated in a reuma-check program were included. All patients with a suspicion of SpA were evaluated using blood analytics, HLA-B27, and images (MRI). Sociodemographic data, SpA features, diagnostic dela,y and clinimetrics were assessed by an operator who was blinded to the patient's test results. On MRI, the presence of SpA lesions was assessed and a concordance exercise was carried out between rheumatologists and radiologist.

RESULT

Of 198 LBP patients, 97 had axSpA, 54% of whom were nr-axSpA. A positive MRI was found in 50%. No difference in terms of disease activity, functional impact, laboratory or treatments between nr-axSpA and AS were found. Higher frequencies of male sex and chronic lesions on sacroiliac MRI were found in AS patients. In the logistic regression, an independent association with AS diagnosis was found: male (odds ratio [OR] 4.8), MRI fat replacement (OR 4.6), MRI sclerosis (OR 7.6), and diagnostic delay of more than 2 years (OR 10). The concordance between rheumatologists and radiologists was considered good to very good (κ 0.7-0.8).

CONCLUSION

The frequency of nr-axSpA was 54%. We found a higher frequency of being male, more SpA features, and a longer diagnostic delay in patients with AS. Patients with AS had more structural lesions, with a good concordance between rheumatologist and radiologist.

A Nationwide Questionnaire Survey on the Prevalence of Ankylosing Spondylitis and Non-Radiographic Axial Spondyloarthritis in Japan

OBJECTIVE

This nationwide study aimed to reveal the prevalence of ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-ax SpA), and the positive rate of human leukocyte antigen (HLA) among these patients in Japan.

METHODS

The first survey was conducted in 2221 randomly selected facilities (26.3%) in September, 2018, where the patients with AS/nr-ax SpA were taken care of from January to December, 2017. We estimated the total number of these patients using response and extraction rate. A second survey was conducted in 117 facilities (49.8%) to assess for HLA-B 27 positivity rate and clinical features.

RESULTS

The estimated total number of the patients with AS and nr-ax SpA were 3200 (95% confidence interval [CI]: 2400-3900) and 800 (530-1100), suggesting that the prevalence of AS and nr-ax SpA in general population were 2.6/100,000 (0.0026%) and 0.6/100,000 (0.0006%), respectively. Although 55.5 % (76/137) of patients with AS were HLA-B27 positive, those whose age of onset was estimated to be over 50 years tended to undergo less HLA-B27 testing.

CONCLUSION

This study revealed the lower prevalence of AS/nr-ax SpA in Japan, compared to those in other countries. Further studies are required to reveal the association of HLA-B27 with the clinical features.

Secukinumab in axial spondyloarthritis: a narrative review of clinical evidence

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

A single center experience: physician related diagnostic delay and demographic and clinical differences between patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis

Background. A large number of comparative studies have been conducted for ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA), including disease burden, treatment modalities and patient characteristics. The aim of this study was to compare physician related diagnostic delay time between patients with AS and nr-axSpA. Methods. In our retrospective study we included 266 patients with axSpA. Patients were classified into two subgroups, AS and nr-axSpA. The time from back pain onset until diagnosis of axSpA was defined as the diagnostic delay. The first specialist referred to and the first diagnosis for each patient was noted in detail. Patient characteristics, clinical manifestations and laboratory and imaging results at diagnosis were also compared between subgroups. Results. The diagnostic delay time was significantly longer for AS patients [6 ± 8.14 years vs 1.62 ± 2.54 years]. 40.9% of all patients were initially consulted by specialists in physical therapy and rehabilitation, followed by 29.7% consulted by a neurosurgeon and 19.9% by a rheumatologist. The most common initial diagnosis was fibromyalgia, 52.6% (140), followed by ankylosing spondylitis, 28.9% (77), and lumbar disc hernia, 12.7% (34). Conclusion. The vast majority of patients were initially evaluated by healthcare providers other than rheumatologists and mostly diagnosed with fibromyalgia. Efforts to increase awareness and to educate first healthcare providers may shorten the diagnostic delay time.

Procollagen I N-terminal peptide correlates with inflammation on sacroiliac joint magnetic resonance imaging in ankylosing spondylitis but not in non-radiographic axial spondyloarthritis: A cross-sectional study

OBJECTIVES

To identify disease activity scores and biomarkers that reflect magnetic resonance imaging (MRI)-determined sacroiliac joint (SIJ) inflammation in ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA).

METHODS

Patients who had AS and nr-axSpA were enrolled. All the patients underwent SIJ MRI. SpondyloArthritis Research Consortium of Canada (SPARCC) method was used to score bone marrow edema in the inflammatory lesions on MRI. Radiographic assessment of the spine was performed using modified Stoke Ankylosing Spondylitis Spine Score. Clinical variables, inflammatory markers, serum alkaline phosphatase, osteocalcin (OC), C-terminal telopeptide of type I collagen (CTX-I), and procollagen I N-terminal peptide (PINP) were measured. Correlation analysis between MRI-determined SIJ inflammation scores and disease activity scores and laboratory variables was performed.

RESULTS

Thirty-five patients had AS and 36had nr-axSpA. Significant differences were noted between the AS group and the nr-axSpA group in terms of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Ankylosing Spondylitis Disease Activity Score (ASDAS)-ESR, ASDAS-CRP, PINP, and SPARCC (p < .001, p = .004, p < .001, p < .001, p = .030, p < .001, respectively). MRI-determined SIJ inflammatory scores correlated with Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), OC, CTX-I, and PINP in AS (p = .036, p = .023, p = .002, p = .041, p = .004, respectively) and correlated with ESR, CRP, ASDAS-ESR, ASDAS-CRP, BASDAI, and BASFI in nr-axSpA (p = .003, p = .002, p < .001, p < .001, p = .010, p = .007, respectively). Multivariate analysis showed that PINP exhibited a positive correlation independent of the MRI inflammatory score and that age exhibited a negative correlation independent of the MRI inflammatory score.

CONCLUSIONS

In AS, PINP and age independently correlated with active inflammation on SIJ MRI. PINP may be useful as a marker of objective inflammation in AS.

The first non-radiographic axial spondyloarthrits with COVID-19

BACKGROUND

Case report of a 21-year-old female developing non-radiographic axialspondyloarthritis in the setting of a preceding severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We felt this was a unique case as some cases of psoriatic arthropathy and reactive arthropathy but none, to our knowledge of non-radiographic axial spondyloarthritis.

CASE PRESENTATION

Twenty one-year-old female presented in June 2020 with inflammatory symptoms with general work-up per primary care provider being negative. Upon further work-up per Rheumatology, felt to have inflammatory back pain with X-rays of SI joints showing grade II sclerosis. Further work-up including magnetic resonance imaging was positive demonstrating bone edema and erosions of SI joint. This prompted further investigation and she had had some vague symptoms of SARS-CoV-2 several months prior including loss of smell, fatigue, and malaise. SARS-CoV-2 semiquanitative antibodies where done that where high positive. She was treated with cetrolizumab and had prompt improvement over the course of the next week.

DISCUSSION AND CONCLUSION

Mechanism of SARS-CoV-2 triggering autoimmunity is still unknown at this time. However, it is important that insights be gained into the type of disease that can be triggered by this infection. As the pandemic continues to rage on, Rheumatologist need to be increasing aware that patients presenting with various forms of inflammatory arthritis may be triggered by an antecedent SARS-CoV-2 infection. Following these cases may help to determine how they differ from other forms of inflammatory arthropathy.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sustained clinical response and safety of etanercept in patients with early axial spondyloarthritis: 10-year results of the ESTHER trial

Aims:

Long-term data on TNFi treatment in patients with axSpA is scarce. The objective of this analysis was to assess long-term clinical efficacy of etanercept in early axSpA [including both non-radiographic and radiographic axSpA forms], who participated in the long-term (until year 10) extension of the ESTHER-trial.

Methods:

In the previously reported ESTHER-trial, patients with early active axSpA were randomized to treatment with etanercept (n = 40) or sulfasalazine (n = 36) during the first year. Patients in remission discontinued their therapy and were followed up until the end of year 2; in case of remission-loss, etanercept was (re)-introduced and continued until the end of year 10. If remission was not achieved at year 1, patients continued receiving (or were switched to) etanercept for up to 10 years.

Results:

A total of 19 patients (12 with r-axSpA and 7 with nr-axSpA at baseline) out of the initial 76 patients (= 25%) completed year 10 of the study. In the entire group, a sustained clinical response was seen over 10 years of follow up in the as-observed analysis. Completers were significantly more often male and showed lower values of patient and physician global assessments of disease activity, Ankylosing Spondylitis Disease Activity Score (ASDAS), and Ankylosing Spondylitis Quality of Life questionnaire (ASQoL) scores at baseline as compared with non-completers. When analyzing clinical data of the completers, mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI) values were constantly below 2 and mean ASDAS below 2.1 during follow up with no statistically significant differences between the r-axSpA and nr-axSpA subgroups. A total of 39 serious adverse events were documented over the 10 years, while six of them were seen as possibly associated with the etanercept treatment, which led in five patients to treatment discontinuation.

Conclusion:

A sustained clinical response was observed over the 10 years of the study with comparable response and drop-out rates between r-axSpA and nr-axSpA. Etanercept was well tolerated across the entire treatment period and showed a good safety profile with no new safety signals.

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

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

Osteitis condensans ilii in a patient with ulcerative colitis: a mimic of ankylosing spondylitis or non-radiographic axial spondyloarthritis

Osteitis condensans ilii (OCI) is known as one of the sacroiliitis diseases and the symptoms or radiographic findings of OCI sometimes resembled those of ankylosing spondylitis (AS) of non-radiographic axial spondyloarthritis (nr-axSpA). Bone marrow edoema (BME) around sacroiliac (SI) joints on magnetic resonance imaging (MRI) is one of the key findings in the classification criteria of axial SpA, but BME on MRI was also found in patients with OCI. The usage of SI joint MRI is increasing due to the need of accurate or early diagnosis of axial SpA in accordance with development of new biological treatments. Here was the case of a 38-year-old female patient with ulcerative colitis (UC) complicated with OCI, which was a mimic of AS or nr-axSpA. She had a persistent low back pain with BME around SI joints on MRI. She could meet the ASAS criteria of axial SpA and might be diagnosed with inflammatory bowel disease (IBD) related axial SpA. OCI is not a rare disease as a differential diagnosis for axial SpA especially in young women. We report this case with a literature review of OCI and would like the clinicians to be aware of the disease when diagnosing AS or nr-axSpA with chronic low back pain.

Comparison of comorbidities and treatment between ankylosing spondylitis and non-radiographic axial spondyloarthritis in the United States

OBJECTIVES

This study aimed to compare comorbidities and biologic DMARD (bDMARD) use between AS and non-radiographic axial SpA (nr-axSpA) patients, using a large cohort of patients from routine clinical practice in the United States.

METHODS

We performed a cross-sectional study using electronic medical records from two academic hospitals in the United States. Data were extracted using automated searches (⩾3 ICD codes combined with text searches) and supplemented with manual chart review. Patients were categorized into AS or nr-axSpA according to classification criteria. Disease features, comorbidities (from a list of 39 chronic conditions) and history of bDMARD prescription were compared using descriptive statistics.

RESULTS

Among 965 patients identified, 775 (80%) were classified as having axSpA. The cohort was predominantly male (74%) with a mean age of 52.5 years (s.d. 16.8). AS patients were significantly older (54 vs 46 years), more frequently male (77% vs 64%) and had higher serum inflammatory markers than those with nr-axSpA (median CRP 3.4 vs 2.2 mg/dl). Half of all patients had at least one comorbidity. The mean number of comorbidities was 1.5 (s.d. 2.2) and similar between AS and nr-axSpA groups. A history of bDMARD-use was seen in 55% of patients with no difference between groups. The most commonly prescribed bDMARDs were adalimumab (31%) and etanercept (29%). Ever-prescriptions of individual bDMARDs were similar between AS and nr-axSpA.

CONCLUSION

Despite age differences, nr-axSpA patients had similar comorbidity burdens as those with AS. Both groups received comparable bDMARD treatment in this United States clinic-based cohort.

Ultrasonographic evaluation of Achilles tendon: Is there any difference between ankylosing spondylitis, non-radiographic axial spondyloarthropathy and controls?

PURPOSE

The aim is to evaluate Achilles tendon enthesopathy with ultrasound (US) in ankylosing spondylitis (AS) and non-radiographic axial SpA (nr-axSpA) patients and controls, and compare these groups in terms of associations between disease activity parameters and ultrasonographic Achilles enthesitis signs.

METHODS

A total of 24 AS and 20 nr-axSpA patients fulfilling the Assessment in Spondyloarthritis International Working Group criteria for axSpA and 30 controls were enrolled. Demographic characteristics, erythrocyte sedimentation rate, C-reactive protein (CRP), human leukocyte antigen (HLA)-B27, Bath AS Disease Activity Index, Bath AS Functional Index, Bath AS Metrology Index, Maastricht AS Enthesitis Score (MASES), AS Disease Activity Score-CRP, modified Stoke AS Spine Score (m-SASSS) scores and ultrasonographic findings were noted.

RESULTS

HLA-B27 positivity, extra-articular and peripheral involvement, disease activity, functional status, mean m-SASSS, ultrasonographic gray scale (GS) and total scores were similar between AS and nr-axSpA groups. In GS, tendon echotexture scores were significantly different across all groups (0.812 ± 0.384 in AS, 0.575 ± 0.466 in nr-axSpA, 0.017 ± 0.091 in controls; P < .001). Entheseal calcification scores were similar in AS and nr-axSpA patients, and higher than controls (P = .001). Bone profile scores were similar in patients with AS and nr-axSpA, and higher than controls (P = .010). When the correlations between US findings and disease activity and functional status were considered, power Doppler US (PDUS) and MASES total scores were positively correlated in the AS group (P = .045; r = .41).

CONCLUSION

AS and nr-axSpA patients were found to be similar in various clinical, functional, and US findings indicating that these 2 entities are different phenotypic reflections of the same disease spectrum. The positive correlation between PDUS and MASES scores in AS patients substantiate the performance of MASES in evaluation of entheseal activity.

Taiwan Rheumatology Association consensus recommendations for the management of axial spondyloarthritis

Aim

To establish guidelines for the clinical management of axial spondyloarthritis that take into account local issues and clinical practice concerns for Taiwan.

Method

Overarching principles and recommendations were established by consensus among a panel of rheumatology and rehabilitation experts, based on analysis of the most up‐to‐date clinical evidence and the clinical experience of panelists. All Overarching Principles and Recommendations were graded according to the standards developed by the Oxford Centre for Evidence Based Medicine, and further evaluated and modified using the Delphi method.

Results

The guidelines specifically address issues such as local medical considerations, National Health Insurance reimbursement, and management of extra‐articular manifestations.

Conclusion

It is hoped that this will help to optimize clinical management outcomes for axial spondyloarthritis in Taiwan.

Comparison of ankylosing spondylitis and non-radiographic axial spondyloarthritis in a multi-ethnic Asian population of Singapore

OBJECTIVES

To compare clinical characteristics, disease activity, patient-reported outcomes and associated comorbidities between patients with ankylosing spondylitis (AS) and non-radiographic axial spondyloarthitis (nr-axSpA) in a multi-ethnic Asian population of Singapore.

METHODS

We used data from the PREcision medicine in SPONdyloarthritis for Better Outcomes and Disease Remission (PRESPOND) registry in Singapore General Hospital. All patients fulfilled 2009 Assessment in AS International Working Group classification criteria for axial SpA (axSpA). Of these, all AS patients fulfilled the 1984 modified New York criteria. Baseline characteristics, medications, disease activity, patient-reported outcomes and inflammatory markers were recorded using standardized questionnaires.

RESULTS

Two hundred and sixty-two axSpA patients (82% Chinese, 79% male) were included. Mean age (SD) at diagnosis was 32.4 (13.1) years, which was similar between AS and nr-axSpA patients. AS patients were older (mean age 42.7 [13.5] vs 37.4 [13.8] years, P = 0.02), had longer disease duration (mean disease duration 10.9 [8.7] vs 6.4 [4.8] years, P < 0.01), higher Bath Ankylosing Spondylitis Metrology Index (BASMI) (mean BASMI 3.1 [2.3] vs 1.5 [1.5], P < 0.01), more frequently human leukocyte antigen (HLA)-B27 positive (82% vs 68%, P = 0.03), associated with uveitis (33% vs 17%, P = 0.03), and hypertensive (17% vs 0%, P < 0.01) compared to nr-axSpA, respectively. Nr-axSpA patients had higher Bath Ankylosing Spondylitis Global Score (BAS-G) (mean BAS-G 46.9 [16.8] vs 38.6 [20.6], P < 0.01), Bath Ankylosing Spondylitis Disease Activity Index (mean [SD] 4.2 [1.6] vs 3.5 [1.9], P = 0.02) and AS quality of life (ASQoL) (mean ASQoL 4.9 [4.8] vs 3.5 [4.1], P = 0.04) scores compared to AS patients respectively at baseline. Patient global assessment, Bath Ankylosing Spondylitis Functional Index, AS Disease Activity Score - C-reactive protein (CRP), Health Assessment Questionnaire, Short-Form 36 physical component summary and mental component summary were similar in both groups at baseline, as were medications used and mean erythrocyte sedimentation rate and CRP.

CONCLUSIONS

In our multi-ethnic Asian cohort, patients with AS are more likely to be HLA-B27 positive, have uveitis, hypertensive, and have poorer spinal mobility, while nr-axSpA patients tend to experience poorer well-being and quality of life.

Aberrant expression of microRNAs in peripheral blood mononuclear cells as candidate biomarkers in patients with axial spondyloarthritis

OBJECTIVES

Axial spondyloarthritis (axSpA) is a chronic inflammatory arthritis involving the axial skeleton. Recent evidence suggests that microRNAs (miRNAs) play a critical role in ankylosing spondylitis (AS). In this study, we aimed to investigate whether miR-17-5p, miR-27a, miR-29a and miR-126-3p can be verified as potential biomarkers of axSpA.

METHODS

Peripheral blood mononuclear cell (PBMC) miRNA expression was evaluated by quantitative real-time polymerase chain reaction among 43 patients with AS, 26 patients with non-radiographic axSpA (nr-axSpA) and 39 healthy controls. Detailed clinical histories were recorded and the correlation of miRNAs and clinical features were analyzed.

RESULTS

When compared to controls, both patients with AS and nr-axSpA had significantly higher expression levels of miR-17-5p, miR-27a, miR-29a and miR-126-3p. MiR-27a was negatively correlated with Ankylosing Spondylitis Disease Activity Score as well as C-reactive protein in patients with nr-axSpA (r = -0.51, P < 0.01 and r = -0.42, P = 0.034 respectively). No other clinical features were found to correlate with the four miRNAs in patients with AS. Mir-29a showed highest area under the curve with 0.952 and these four miRNAs may be potential biomarkers in patients with axSpA.

CONCLUSIONS

We reported elevated miR-17-5p, miR-27a, miR-29a and miR-126-3p expression in PBMCs of patients with axSpA, and the expression of these four miRNAs might be used as useful diagnostic markers in axSpA.

Cross-sectional study of patients with axial spondyloarthritis fulfilling imaging arm of ASAS classification criteria: baseline clinical characteristics and subset differences in a single-centre cohort

OBJECTIVE

This study compared demographic, clinical and laboratory characteristics between patients with radiographic and non-radiographic axial spondyloarthritis (axSpA).

METHODS

In this single-centre cross-sectional study, a total of 246 patients with axSpA fulfilling the imaging arm of Assessment of SpondyloArthritis International Society classification criteria were recruited. A total of 140 patients were diagnosed as non-radiographic axial spondyloarthritis (nr-axSpA), and 106 patients had ankylosing spondylitis (AS). Sociodemographic characteristics, disease manifestations, clinical and laboratory disease activity and their differences between subsets were analysed. P values below 0.05 with CI 95% were considered statistically significant.

RESULTS

More nr-axSpA patients were women (61.4%) compared with 24.7% of AS patients. First symptoms developed earlier in AS patients compared with nr-axSpA (23.0 (IQR 17.5-30.0) vs 27.8 (IQR 21.0-33.7) years, p=0.001). Disease manifestations did not differ, but patients with nr-axSpA experienced peripheral arthritis more frequently (35.7% vs 17.0%, p=0.001) with less hip involvement (8.6% vs 18.9%, p=0.022) compared with patients with AS. Patients with AS exhibited worse spinal mobility and physical function compared with nr-axSpA. AS Disease Activity Scores and CRP levels were significantly higher in patients with AS compared with nr-axSpA (2.4 (IQR 1.7-2.8) vs 2.0 (IQR 1.1-2.3), p=0.022 and 7.1 (IQR 2.6-14.9) vs 2.5 (IQR 0.8-8.2) mg/L, p<0.001, respectively).

CONCLUSIONS

Our data demonstrated some known and also novel differences between the two imaging arm fulfilling axSpA subgroups. Non-radiographic patients were mostly women who had experienced shorter disease duration, milder disease activity and better functional status with less hip involvement but more peripheral arthritis compared with patients with AS.

Comparison of Non-radiographic Axial Spondyloarthritis and Ankylosing Spondyltis from a Single Rheumatology Hospital in Morocco

BACKGROUND

According to the new classification criteria developed by The Assessment of SpondyloArthritis International Society, patients with axial spondyloarthritis (axSpA) can be classified in 2 subgroups: Patients with radiographic axial spondyloarthritis: ankylosing spondylitis patients (AS) and those with non-radiographic axial spondyloarthritis (nr-axSpA).

OBJECTIVE

The aim of the present study is to describe and discuss the differences and similarities between the two subgroups.

PATIENTS AND METHODS

A cross-sectional study was conducted in a single rheumatology hospital in Morocco. These included patients diagnosed as having axial spondyloarthritis according to ASAS criteria 2010, during a period of 6 years. The AS and the nr-axSpA subgroups were compared for the various axSpA-related variables.

RESULTS

Of the 277 patients with a diagnosis of axial SpA who were included in this study, 160 had AS and 117 had nr-axSpA. AS and nr-ax-SpA shared a similar age at diagnosis, similar prevalence of low back pain, lumbar stiffness, extra-articular manifestations, BASDAI and BASFI. In the multivariate analysis, AS patients were mainly male with cervical stiffness, enthesitis, coxitis and high level of ESR (erythrocyte sedimentation rate). The females generally had a family history of SpA and arthritis and were associated to the nr-axSpA form in the univariate analysis.

CONCLUSION

This was the first study to characterise patients with AS and nr-axSpA in Morocco. Consistent with other studies published, this study showed that patients with nr-axSpA and patients with AS shared a comparable degree of disease burden.

Radiographic progression in non-radiographic axial spondyloarthritis

INTRODUCTION

Non-radiographic axial spondyloarthritis (nr-axSpA) represents a subtype of axial spondyloarthritis (axSpA) with no significant structural damage in sacroiliac joints and spine. In addition, patients with nr-axSpA demonstrate a substantial burden of illness, and a considerable share of them might progress to radiographic axSpA (r-axSpA) over time. The amount and quality of published data allows crude estimation of progression rate and factors related to a higher risk of progression. Areas covered: This review discusses the available data reporting the rates and predictors of radiographic progression in the sacroiliac joints and in the spine in patients with nr-axSpA as well as predisposing factors for such a progression. Expert commentary: Most of the studies report about 10-40% of patients with nr-axSpA to progress to r-axSpA over a period of 2-10 years. Multiple risk factors for the radiographic sacroiliitis progression are outlined and explored. There are not enough data to presume that any treatment modality may influence progression from nr-axSpA to r-axSpA, with TNFi showing some promising results. Radiographic progression in the spine is in general low in nr-axSpA; thus, long-term studies are required to investigate the natural course of the progression and possible treatment effects.

Spotlight on certolizumab pegol in the treatment of axial spondyloarthritis: efficacy, safety and place in therapy

Certolizumab pegol (CZP) is a pegylated humanized tumor necrosis factor-α inhibitor (TNFi) approved for the treatment of ankylosing spondylitis (AS) in the USA and for AS and non-radiographic axial spondyloarthritis (nr-axSpA) in Europe and in some Latin American countries. CZP lacks Fc region, preventing complement fixation and cytotoxicity mediated by antibody; CZP does not actively cross the placenta, unlike other TNFi. RAPID-axSpA study is a Phase III trial conducted in patients with AS and nr-axSpA as double blind and placebo controlled to week 24, dose blind to week 48 and open label to week 204. Of a total of 325 patients recruited, 107 patients were assigned to placebo and 218 patients to CZP (111 to CZP 200 mg Q2W, 107 to CZP 400 mg Q4W). Improvements in axial involvement, joint involvement, enthesitis and quality of life were reported in patients treated with CZP. Safety profile was like that reported for other TNFi in axSpA patients. In this article, we summarized the pharmacology and we reviewed the efficacy and tolerability of this drug for the treatment of axSpA. Some special considerations of CZP during pregnancy are included. CZP, the latest TNFi to be approved, showed efficacy in all manifestations of AS and nr-axSpA.

Sustained efficacy, safety and patient-reported outcomes of certolizumab pegol in axial spondyloarthritis: 4-year outcomes from RAPID-axSpA

Objective

The aim was to assess the long-term safety and efficacy of certolizumab pegol over 4 years of continuous treatment in patients with axial spondyloarthritis (axSpA), including both AS and non-radiographic (nr-) axSpA.

Methods

RAPID-axSpA was a phase 3 randomized trial, double blind and placebo controlled to week 24, dose blind to week 48 and open label to week 204. Patients had a clinical diagnosis of axSpA, meeting Assessment of SpondyloArthritis international Society (ASAS) criteria, and had active disease. The assessed outcomes included ASAS20, ASAS40, AS DAS (ASDAS), BASDAI, BASFI and BASMI scores, along with selected measures of remission. Further patient-reported outcomes, peripheral arthritis, enthesitis, uveitis and quality-of-life measures are also reported.

Results

Two hundred and eighteen of 325 patients randomized (AS: 121; nr-axSpA: 97) received certolizumab pegol from week 0. Of these, 65% remained in the study at week 204 (AS: 67%; nr-axSpA: 63%). Across all outcomes, for AS and nr-axSpA, sustained improvements were observed to week 204 [week 204 overall axSpA: ASAS20: 54.1% (non-responder imputation); 83.7% (observed case, OC); ASAS40: 44.0% (non-responder imputation); 68.1% (OC); ASDAS inactive disease: 32.1% (last observation carried forward); 31.4% (OC)]. In the safety set (n = 315), there were 292.8 adverse events and 10.4 serious adverse events per 100 patient-years. No deaths were reported.

Conclusion

In the first study to evaluate the efficacy of an anti-TNF across both axSpA subpopulations, improvements in clinical and patient-reported outcomes at 24 and 96 weeks were sustained through 4 years of treatment, with no new safety signals.

Trial registration

ClinicalTrials.gov, http://clinicaltrials.gov, NCT01087762.

Work disability in non-radiographic axial spondyloarthritis patients before and after start of anti-TNF therapy: a population-based regional cohort study from southern Sweden

Objective

The aim was to assess work-loss days before and after commencement of anti-TNF treatment in patients with non-radiographic axial spondylarthritis (nr-axSpA).

Methods

Bionaïve nr-axSpA patients (n = 75), aged 17-62 years, fulfilling the Assessment of SpondyloArthritis international Society criteria for axial spondyloarthritis and starting anti-TNF treatment during 2004-11, were retrieved from the observational South Swedish Arthritis Treatment Group study. Patient information was linked to Swedish Social Insurance Agency data on sick leave and disability pension from 1 year before to 2 years after anti-TNF initiation. Matched population references were included for comparison and to adjust for secular trends.

Results

The nr-axSpA patients had a median age of 35 years and disease duration of 6 years at the start of treatment. During the 2 years after anti-TNF initiation, mean work-loss days (including both sick leave and disability pension) in the nr-axSpA group decreased significantly from 3.4 to 1.9 times more than among the population references. The effect was seen on sick leave, whereas disability pension levels remained similar in both groups throughout.

Conclusion

Anti-TNF therapy in nr-axSpA was associated with a significant and sustained improvement of work disability over 2 years. However, the proportion of work-loss days remained almost twice as high as in the general population at the end of follow-up.

[Ankylosing spondylitis and non-radiographic axial spondyloarthritis: Two stages of disease?]

AIM

To compare the clinical manifestations of ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nrAxSpA).

SUBJECTS AND METHODS

A Moscow early spondyloarthritis cohort has now included 132 patients with axial spondyloarthritis, of whom 69 patients who have been followed up at least 12 months are to be involved in a preliminary analysis. The mean age at the time of inclusion in the study was 28.1±5.5 years; the mean disease duration was 24.7±15.8 months; 63 (91.3%) patients were HLA-B27 positive; 41 and 28 included patients were diagnosed with AS and nrAxSpA, respectively.

RESULTS

Men were significantly more in the AS group than in the nrAxSpA group (58.5 and 32.1%, respectively; p=0.05). The patients of the two groups did not differ in main clinical parameters (the presence of arthritis and enthesitis), disease activity (BASDAI, ASDAS-CRP) and functional status (BASFI). All indicators of inflammatory activity decreased nearly 2-fold in both groups after 12 months of follow up. In 7 (25%) patients with nrAxSpA, radiologically detectable sacroiliitis (SI) developed over 12 months and the diagnosis of AS was verified. Among them, 2 (28.5%) patients had initially active SI detected by magnetic resonance imaging (MRI); 4 (57.1%) had chronic SI, and 1 (14.4%) had no pathological MRI changes.

CONCLUSION

Due to the fact that the clinical manifestations of AS and nrAxSpA are comparable, it can be assumed that the latter is an early stage of AS.

Efficiency of treatment with non-steroidal anti-inflammatory drugs according to current recommendations in patients with radiographic and non-radiographic axial spondyloarthritis

OBJECTIVE

NSAIDs are first-line therapy in axial SpA (axSpA). The proportion of patients responding to NSAIDs and differences between AS and non-radiographic axSpA (nr-axSpA) in this regard have not been studied in detail to date. The aim of this study was to examine the proportion of patients with AS and nr-axSpA responding to NSAIDs according to current treatment recommendations.

METHODS

Consecutive anti-TNF-naïve patients with nr-axSpA and AS (n = 50 each) were included if their BASDAI score was ⩾4 without having received maximal NSAID doses. In case of a BASDAI score ⩾4 1 week later, another NSAID was prescribed. For the next 3 weeks, continuous intake of maximal doses was recommended but patients could reduce doses in case of intolerance or improvement. MRI of the SI joints was performed at baseline and week 4.

RESULTS

All outcomes except for CRP and MRI scores improved significantly after 4 weeks of NSAIDs, with no difference between axSpA subgroups. An Assessment of SpondyloArthritis international Society 40% (ASAS40) response and partial remission rates were 35 and 16% at week 4, respectively. At the same time point, a BASDAI score ⩾4 was still present in 44% of patients, 30% of which had reduced NSAID doses, partly due to intolerance (38%). Only 13% of all patients had continuously taken NSAIDs at the maximal dosage, but there was no difference in the efficacy outcome compared with those who had taken reduced doses.

CONCLUSION

AS and nr-axSpA patients had similar response rates to NSAIDs while objective signs of inflammation did not change over 4 weeks. Only a minority of patients was willing to take maximal doses of NSAIDs, and ⩾40% patients remained candidates for TNF blockers. These results may influence future trial designs.

Etanercept for the treatment of non-radiographic axial spondyloarthritis

Presently, tumor necrosis factor α antagonist therapy is the only effective alternative treatment to nonsteroidal anti-inflammatory drugs for the entire spectrum of axial spondyloarthritis, including non-radiographic and radiographic (=ankylosing spondylitis) forms. Recently, etanercept has been approved by the European Medicines Agency for the treatment of non-radiographic axial spondyloarthritis, increasing the number of available treatment options for this indication. The latest data on etanercept concerning clinical efficacy and safety in short-term and long-term treatment of patients with non-radiographic axial spondyloarthritis who do not respond to the first-line therapy with non-steroidal anti-inflammatory drugs suggests good efficacy and safety profiles similar to that observed previously in ankylosing spondylitis. This article reviews recent data on the efficacy and safety of etanercept and is focused on the treatment of non-radiographic axial spondyloarthritis. This article will also discuss the role of etanercept in the context of current and developing treatment options.

Golimumab for the treatment of axial spondyloarthritis

Axial spondyloarthritis (axSpA) is a chronic, immune-mediated inflammatory disease of the axial skeleton that includes ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA). Patients with AS experience chronic pain due to sacroiliac joint and spinal inflammation, and may develop spinal ankylosing with syndesmophyte formation. Tumor necrosis factor α inhibitors (TNFi) have shown promise in the management of AS and axSpA by targeting the underlying inflammatory process, and providing symptomatic relief. Whether they alter the progression of the disease is uncertain. Golimumab is a fully human IgG1 monoclonal antibody that targets and downregulates the pro-inflammatory cytokine TNF-α. The use of golimumab has been shown to reduce the signs and symptoms of axSpA as well as improve patient function and quality reported outcomes. This review focuses on the biological rationale and the results of clinical trials with golimumab for the treatment of axSpA.

Consensus statement on the investigation and management of non-radiographic axial spondyloarthritis (nr-axSpA)

AIM

Non-radiographic axial spondyloarthritis (nr-axSpA) is axial inflammatory arthritis where plain radiographic damage is not evident. An unknown proportion of these patients will progress to ankylosing spondylitis (AS). The increasing recognition of nr-axSpA has been greatly assisted by the widespread use of magnetic resonance imaging. The aim of this article was to construct a set of consensus statements based on a literature review to guide investigation and promote best management of nr-axSpA.

METHODS

A literature review using Medline was conducted covering the major investigation modalities and treatment options available. A group of rheumatologists and a radiologist with expertise in investigation and management of SpA reviewed the literature and formulated a set of consensus statements. The Grade system encompassing the level of evidence and strength of recommendation was used. The opinion of a patient with nr-axSpA and a nurse experienced in the care of SpA patients was also sought and included.

RESULTS

The literature review found few studies specifically addressing nr-axSpA, or if these patients were included, their results were often not separately reported. Fourteen consensus statements covering investigation and management of nr-axSpA were formulated. The level of agreement was high and ranged from 8.1 to 9.8. Treatment recommendations vary little with established AS, but this is primarily due to the lack of available evidence on the specific treatment of nr-axSpA.

CONCLUSION

The consensus statements aim to improve the diagnosis and management of nr-axSpA. We aim to raise awareness of this condition by the public and doctors and promote appropriate investigation and management.

Evidence for inflammation-induced bone loss in non-radiographic axial spondyloarthritis

OBJECTIVES

Non-radiographic axial SpA (nr-axSpA) comprises those patients who may have clinical and laboratory features of SpA but do not have definite radiographic sacroiliitis. Bone loss (osteopenia or osteoporosis) is well recognized in AS, however, bone status in nr-axSpA is unclear. The aims of this study were to investigate BMD in patients with nr-axSpA and compare them with age- and sex-matched patients with mechanical low back pain (mLBP). The relationship between inflammation on MRI of the lumbar spine and BMD was also assessed in nr-axSpA.

METHODS

Patients with chronic LBP were consecutively recruited. Patients who met the Assessment of SpondyloArthritis International Society (ASAS) criteria for axial SpA but without definite radiographic sacroiliitis were defined as nr-axSpA. Spinal and femoral BMD was assessed with DXA. Lumbar spinal MRI was examined for the presence of bone oedema (BO; inflammatory lesions).

RESULTS

Forty-six patients with nr-axSpA had worse spinal but similar hip BMD, T and Z scores compared with 29 patients with LBP. 25(OH)D3 and parathyroid hormone levels and thyroid function tests were similar between groups. Twenty nr-axSpA patients with inflammation on lumbar MRI had worse spinal and femoral BMD, T and Z scores compared with the patients without inflammation.

CONCLUSION

Patients with nr-axSpA had significant bone loss at the lumbar spine compared with patients with mLBP. Inflammation on MRI is closely associated with low bone mass in patients who are in the very early stage of the disease.