Imaging has a central role in the diagnosis, management, and follow-up of patients with axial spondyloarthritis (axSpA). For the early diagnosis of axSpA, magnetic resonance imaging is of utmost ...relevance. While no novel imaging techniques were developed during the past decade, improvements to the existing modalities have been introduced. This report provides an overview of the applications and limitations of the existing imaging modalities.
To update and integrate the recommendations for ankylosing spondylitis and the recommendations for the use of tumour necrosis factor inhibitors (TNFi) in axial spondyloarthritis (axSpA) into one set ...applicable to the full spectrum of patients with axSpA. Following the latest version of the European League Against Rheumatism (EULAR) Standardised Operating Procedures, two systematic literature reviews first collected the evidence regarding all treatment options (pharmacological and non-pharmacological) that were published since 2009. After a discussion of the results in the steering group and presentation to the task force, overarching principles and recommendations were formulated, and consensus was obtained by informal voting. A total of 5 overarching principles and 13 recommendations were agreed on. The first three recommendations deal with personalised medicine including treatment target and monitoring. Recommendation 4 covers non-pharmacological management. Recommendation 5 describes the central role of non-steroidal anti-inflammatory drugs (NSAIDs) as first-choice drug treatment. Recommendations 6-8 define the rather modest role of analgesics, and disprove glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) for axSpA patents with predominant axial involvement. Recommendation 9 refers to biological DMARDs (bDMARDs) including TNFi and IL-17 inhibitors (IL-17i) for patients with high disease activity despite the use (or intolerance/contraindication) of at least two NSAIDs. In addition, they should either have an elevated C reactive protein and/or definite inflammation on MRI and/or radiographic evidence of sacroiliitis. Current practice is to start with a TNFi. Switching to another TNFi or an IL-17i is recommended in case TNFi fails (recommendation 10). Tapering, but not stopping a bDMARD, can be considered in patients in sustained remission (recommendation 11). The final two recommendations (12, 13) deal with surgery and spinal fractures. The 2016 Assessment of SpondyloArthritis international Society-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.
Zusammenfassung
Die systemische juvenile idiopathische Arthritis (sJIA) und die adulte Form des Morbus Still („adult-onset Still’s disease“, AOSD) gehören zum Still-Syndrom. Bis auf das Lebensalter ...finden sich viele Gemeinsamkeiten zwischen sJIA und AOSD. Heutzutage wird ein biphasisches Krankheitsmodell angenommen. Initial steht dabei die Autoinflammation im Vordergrund, die v. a. durch die Dysregulation des angeborenen Immunsystem bedingt ist. Im späteren Verlauf kann die Erkrankung zu einer chronisch-artikulären Verlaufsform wechseln, die vorwiegend durch das adaptive Immunsystem und somit durch Autoimmunität hervorgerufen wird. Die Hypothese des „Window of Opportunity“ beruht auf diesem biphasischen Modell und besagt, dass durch eine frühe zielgerichtete Therapie ein Wechsel der Verlaufsformen verhindert werden kann. Eine schwere Komplikation des „Zytokinsturms“ der systemischen Krankheitsphase stellt das Makrophagenaktivierungssyndrom dar. Klinisch bestehen viele Gemeinsamkeiten zwischen sJIA und AOSD. So gehören u. a. rezidivierende Fieberschübe, ein flüchtiges lachsfarbenes Exanthem und Arthralgien bzw. Arthritis zu häufigen Beschwerden in allen Altersgruppen. Die wenigen Unterschiede betreffen v. a. die Therapien und Nebenwirkungsspektren bei Kindern gegenüber Erwachsenen. Die genetischen Komponenten sind beim AOSD etwas weniger stark ausgeprägt als bei der sJIA, aber auch diesbezüglich gibt es fließende Übergänge. Ferner sind beide Erkrankungen durch exogene Faktoren wie mikrobielle Trigger stark beeinflusst. Zukünftige Forschungsaspekte könnten die tiefer gehende Untersuchung dieser Auslöser wie Viren, Bakterien oder eines dysbiotischen humanen Mikrobioms beinhalten.
Die systemische juvenile idiopathische Arthritis (sJIA) und die adulte Form des Morbus Still („adult-onset Stil’s disease“, AOSD) gehören zum Still-Syndrom. Bis auf das Lebensalter finden sich viele ...Gemeinsamkeiten zwischen sJIA und AOSD. Es wird heutzutage ein biphasisches Krankheitsmodell angenommen. Initial steht dabei die Autoinflammation im Vordergrund, welche vor allem durch die Dysregulation des angeborenen Immunsystem bedingt ist. Im späteren Verlauf kann die Erkrankung zu einer chronisch-artikulären Verlaufsform wechseln, welche vorwiegend durch das adaptive Immunsystem und somit durch Autoimmunität hervorgerufen wird. Die „Window-of-Opportunity“-Hypothese beruht auf diesem biphasischen Modell und besagt, dass durch eine frühe zielgerichtete Therapie ein Wechsel der Verlaufsformen verhindert werden kann. Eine schwere Komplikation des „Zytokinsturms“ der systemischen Krankheitsphase stellt das Makrophagenaktivierungssyndrom (MAS) dar. Klinisch bestehen viele Gemeinsamkeiten zwischen sJIA und AOSD. So gehören u.a. rezidivierende Fieberschübe, ein flüchtiges lachsfarbenes Exanthem und Arthralgien/Arthritis zu häufigen Beschwerden in allen Altersgruppen. Die wenigen Unterschiede bestehen vor allem in Bezug auf die Therapien und die Nebenwirkungsspektren bei Kindern versus Erwachsenen. Die genetischen Komponenten sind etwas stärker ausgeprägt bei sJIA im Vergleich zu AOSD, aber auch diesbezüglich gibt es fließende Übergange und beide Erkrankungen sind durch exogene Faktoren wie mikrobielle Trigger stark beeinflusst. Zukünftige Forschungsaspekte könnten die tiefere Untersuchung dieser Auslöser wie Viren, Bakterien oder einem dysbiotischen humanen Mikrobiom beinhalten.
Back pain, most frequently of the inflammatory type, is the leading symptom in patients with axial spondyloarthritis (axSpA). Back pain in these patients is usually either due to axial inflammation ...or structural changes based on new bone formation. However, there are other possible causes of pain in these patients. There is, for example, a strongly increased risk of vertebral fractures, and, especially in patients with longstanding disease, degenerative spinal changes may play an additional role as a cause of pain. Rarely, but rather specifically, patients with ankylosing spondylitis may develop subarachnoidal cysts that often cause neurologic symptoms, in extreme cases a cauda equina syndrome. It is therefore mandatory to always carefully evaluate the origin of back pain in these patients and to consider all possible differential diagnoses. The correct diagnosis is of major importance because treatments may differ considerably. In the monitoring of patients with axSpA it is especially important to consider that pain may have a different origin and it is crucial to notice changes in the nature of the reported back pain. Accordingly, the recently updated Assessment of Spondyloarthritis international Society (ASAS)/European League Against Rheumatism (EULAR) and the treat-to-target recommendations both define improvement of symptoms, a reduction of pain and abrogation of inflammation as important targets in axSpA that can be achieved by pharmacological and nonpharmacological treatments, in rare cases including surgical methods.
Abstract
Background
The Assessments of Spondyloarthritis international Society (ASAS) classification criteria for axial spondyloarthritis (axSpA) have been criticized because of insufficient ...differentiation towards FM. The aim of this study was to compare the performance of currently used classification criteria in patients diagnosed with axSpA or FM.
Methods
Patients were prospectively included if diagnosed with axSpA or FM by the treating rheumatologist and evaluated by an independent examiner for fulfilment of the classification criteria for axSpA (ASAS criteria) and/or FM (1990 ACR classification and 2010 ACR diagnostic criteria). Patients with axSpA were stratified based on classification as non-radiographic axSpA (nr-axSpA) or AS. Symptom severity was assessed by established disease-related questionnaires.
Results
Overall, 300 patients were included, 100 with FM and 200 with axSpA of which 100 each had nr-axSpA and AS. Almost all FM patients fulfilled the 2010 (100%) and 1990 ACR criteria (98%) for FM, but only 2% fulfilled the ASAS criteria. When calculations were based on only the FM patients with available HLA-B27 results (n = 40), the proportion fulfilling the ASAS criteria was 5%. All axSpA patients met the ASAS criteria but also the 2010 (24%) and 1990 (13.5%) FM criteria. More patients with AS (29% and 19%) than with nr-axSpA (19% and 8%) fulfilled the 2010 and 1990 FM criteria, respectively.
Conclusion
FM patients only rarely fulfil classification criteria for axSpA but some axSpA patients also fulfil FM criteria. Since this was more frequent in patients with AS it may be related to the severity and duration of chronic pain in axSpA patients. Assessment instruments evaluated in axSpA are not disease-specific. The phenomenon of central pain sensitization in rheumatic diseases deserves more study.
Still's syndrome includes systemic juvenile idiopathic arthritis (sJIA) and the adult form of Still's disease (adult-onset Still's disease, AOSD). Except for age, there are many similarities between ...sJIA and AOSD. A biphasic disease model is currently put forth. At disease onset, autoinflammation predominates, which is caused by dysregulation of the innate immune system. Later on, the disease can progress to a chronic-articular form, which is predominantly mediated by the adaptive immune system and is consequently due to autoimmunity. The "window-of-opportunity" hypothesis is based on this biphasic model and supports the assumption that an early, targeted therapy with cytokine blockade can prevent disease progression to chronic destructive arthritis. Macrophage activation syndrome (MAS) is a serious complication of the so-called cytokine storm during the systemic phase of the disease. Clinically, there are many similarities between sJIA and AOSD. Recurrent fever, a fleeting, salmon-colored rash, and arthralgia/arthritis are common signs and symptoms of both sJIA and AOSD. The few differences are mainly related to the therapies and their side effects in children versus adults. In addition, the contribution of genetics to pathogenesis is more pronounced in sJIA compared to AOSD, but there are also smooth transitions in this respect and both diseases are heavily influenced by exogenous factors such as microbial triggers. Future research aspects could include additional investigation of these triggers such as viruses, bacteria, or dysbiosis of the human microbiome.
To assess the efficacy and safety of non-biological therapies in patients with axial spondyloarthritis (axSpA) to inform the update of the Assessment of SpondyloArthritis international Society ...(ASAS)/European League Against Rheumatism (EULAR) recommendations for the management of axSpA. A systematic literature review (2009–2016) of all non-pharmacological treatments, non-biological drugs (except targeted synthetic disease-modifying antirheumatic drugs (DMARDs)) and surgical therapies was performed. Randomised controlled trials (RCTs) and clinical controlled trials were assessed for efficacy and safety, while observational studies with a comparator were assessed for safety. All relevant efficacy and safety outcomes were included. Study heterogeneity precluded data pooling. If possible, Cohen's effect size was calculated for non-pharmacological treatments. In total, 45 papers and 2 abstracts were included. Studies on non-pharmacological treatments were very heterogeneous but overall confirmed a benefit for regular exercises, with small improvements in disease activity, function and spinal mobility. New studies on non-steroidal anti-inflammatory drugs (NSAIDs) confirmed their efficacy and new safety signals were not found. NSAIDs used continuously compared with on-demand did not reduce the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) mean change over 2 years in patients with ankylosing spondylitis with normal C reactive protein (CRP; ≤5 mg/L) (1 ‘negative’ RCT (0.9 vs 0.8; p=0.62)), while for patients with high CRP, conflicting results were found (1 ‘positive’ RCT (0.2 vs 1.7; p=0.003), 1 ‘negative’ RCT (1.68 vs 0.96; p=0.28)). No new trials were found for conventional synthetic DMARDs (csDMARDs). Short-term high-dose systemic glucocorticoids showed limited efficacy. Regular exercises may improve several outcomes. Efficacy and safety of NSAIDs in axSpA are confirmed. Glucocorticoids are not proven to be effective in axSpA and new data on csDMARDs are lacking.
Patient assessment in axial spondyloarthritis (axSpA) is multidimensional, and monitoring of disease activity, function and radiographic progression is complex. There is no simple 'gold standard' for ...measuring disease activity in all individual patients, as disease activity in axSpA is the sum of many different aspects and a complexity that cannot be represented by a single variable. Limited spinal mobility is a cardinal sign of ankylosing spondylitis and loss of spinal mobility has been reported to be a prognostic factor and most often evaluated with the Bath Ankylosing Spondylitis Functional Index. Imaging of the spine and assessment of safety aspects plays an important role in the monitoring of patients with axSpA. The timeframe for collecting information regarding disease activity, function and radiographic progression are recommended on an individual basis.
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