A Worthwhile Measurement of Early Vigilance and Therapeutic Monitor in Axial Spondyloarthritis: A Literature Review of Quantitative Sacroiliac Scintigraphy

Background: Back pain a common cause for hospital visits. Nuclear skeletal scintigraphy, at a high sensitivity, provides a functional imaging for detecting bone diseases. Sacroiliitis is an inflammation of the sacroiliac joint. Bone scan with quantitative sacroiliac scintigraphy (QSS) has been a useful inflammation indicator for sacroiliac joints. However, QSS has been ignored in the rehabilitation practice. Objective: To present the background, mechanisms, and current clinical applications of bone scan with QSS in spondyloarthropathy (SpA). Methods: The authors performed a literature review of QSS through database searching of MEDLINE, Embase, CINAHL, HaPI, Cochrane Review, and citation mining. Studies were included if they had QSS in the methodology performed in adult patients with various diseases. Any articles, including the authors’, that can be performed in a clinical setting were enrolled. Articles explicitly referencing QSS were retained for screening. Results: QSS appearance of SpA, including ankylosing spondylitis, may give rise to early detection. The specificity of sacroiliitis based on QSS increases from 73% to 97%. After investigating the relationship between serum C-reactive protein and sacroiliac joint inflammation in patients with SpA, there appeared to be a significant difference between serum C-reactive protein in serum and in sacroiliac ratio (particularly the middle part of the both joints), indicating a systemic inflammatory response to flair-up of SpA, for example, serum C-reactive protein as an indicator of inflammation. Sacroiliitis also occurs in post-streptococcal reactive arthritis. The involvement of sacroiliac joints in the development of post-streptococcal reactive arthritis had been demonstrated a significant correlation between anti-streptolysin O titres and QSS in patients with post-streptococcal reactive arthritis. Lower extremity periostitis acts as a human model in the study of bottom-up processing for periostitis-induced sacroiliac pain. The use of QSS can also monitor sacroiliac joint dysfunction before and after laser therapy. Improvements of the sacroiliac joint after convalescing of foot periostitis have been reported. Conclusions: Bone scan using QSS is a good screening measurement in scintigraphy rehabilitation for early detection of SpA and raises awareness of physicians toward the next step of diagnosis.

Treat to Target in Spondyloarthritis: Myth or Reality?

A treat-to-target (T2T) strategy is a treatment plan in which the clinician treats the patient aggressively enough to reach and maintain explicitly specified and sequentially measured goals. To apply a T2T strategy, some conditions should be met. First, a proactive, clear endpoint should be used and a threshold should be defined. Second, a choice between several effective therapies must be available. Third, the endpoint should be supported by findings from randomised controlled trials supporting early aggressive treatment. Fourth, the strategy should be cost-effective. Finally, it needs to be acceptable by the stakeholders. The objective of this review was to verify if the conditions for applying the T2T strategy were met in psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), using a narrative review. Based on the currently available literature, the conditions for applying the T2T in PsA and axSpA were partially met. First, proactive outcome measures are available; however, there is no clear consensus regarding the optimal one. Second, there is a reasonable choice of approved therapies for both diseases. Third, additional randomised controlled trials demonstrating the effectiveness of a T2T approach are still needed. Fourth, cost-effectiveness studies are needed and should include patients from different healthcare systems. Fifth, the implementation of T2T recommendations in routine care and the adherence to its application in clinical practice should be promoted. In summary, preliminary data suggest that T2T might be beneficial to patients with PsA and axSpA. However, further studies are needed to meet all the criteria before strongly advocating for T2T strategies.

Management of Pregnancy in Rheumatic Disease

Managing patients with rheumatic diseases (RMD) during pregnancy and the postpartum period can be a challenge for both rheumatologists and obstetricians. While disease activity during the course of pregnancy varies with regard to the presence of underlying conditions, maintenance of remission from conception through to delivery increases the chances of an uncomplicated pregnancy. A period of remission of at least 6 months prior to conception increases the chance of a successful conception while decreasing the risk of flares during pregnancy. For this reason, discussion of pregnancy in females with RMDs should begin prior to conception with risk stratification and pregnancy planning. This allows for the transfer to pregnancy-compatible medications, disease stabilisation, determination of autoantibody status, and evaluation of end-organ damage. During pregnancy, where possible, disease activity should be monitored with scores modified to allow use in pregnancy. Prompt recognition and treatment of active disease is essential to minimise the risk to the pregnancy. Systemic lupus erythematosus and axial spondyloarthropathy can present diagnostic dilemmas due to overlap of symptoms of disease activity and normal pregnancy. Patients with end-organ involvement, such as systemic lupus erythematosus or systemic sclerosis, face a higher risk of adverse pregnancy outcomes and disease progression. Close monitoring of patients with RMD should be done by both obstetrics and rheumatology, with regular communication between specialties. Medications should be reviewed at each stage of pregnancy to ensure compliance with the current American College of Rheumatology (ACR) guidelines and the adequate treatment of RMDs.

Axial Spondyloarthritis: Clinical Characteristics, Epidemiology, and General Approaches to Management

Axial spondyloarthritis (axSpA) is a chronic inflammatory condition, with an age of onset almost exclusively under 45 years. Although symptoms are initially centred on the sacroiliac joints and spine, extraspinal manifestations are common and add considerably to the burden of disease. In this narrative review, the authors provide an update on the epidemiology of the disease and briefly summarise the pathophysiology. The authors detail the clinical manifestations of axSpA, including an overview of axial features, peripheral manifestations, and associated comorbidities. The authors outline the current outcome measures used in the assessment of patients. Finally, the authors provide a summary of the general principles of treatment and briefly outline the role of patient education in the management of individuals with axSpA.

The Interplay of Genes with the Gut Microbiota in the Aetiopathogenesis of Spondyloarthropathies and Crohn’s Disease: Implications for Future Therapeutic Targets

The phenotypical overlap between the spondyloarthropathies (SpA) and Crohn’s disease (CD) has long been recognised. More recently, the co-inheritance of these diseases and the existence of a plethora of shared genetic risk loci have been demonstrated by genealogic databases and genome-wide association studies. Now there is mounting evidence to suggest that the interplay between the gut microbiota and host genetics is central to the shared aetiopathogenesis of SpA and CD. The clinical management of patients with both SpA and CD can be challenging. Preliminary studies seeking to understand this interplay have identified novel therapeutic targets and approaches, which may, in the future, significantly advance patient care. This review provides an overview of the role of host genetics and the intestinal microbiota in the shared aetiopathogenesis of SpA and CD, and explores how this interplay can advance the search for new therapeutic targets.

Clinical Manifestations and Diagnosis of Behçet’s Syndrome

Behçet’s syndrome (BS) is a systemic vasculitis with a wide range of clinical presentations and disease courses. It may involve the mucosa, skin, joints, vessels, eyes, and nervous and gastrointestinal systems. These organ involvements may present alone or co-exist in the same patient. Three main clusters of commonly co-existing manifestations were recognised and are currently called disease phenotypes. There is a significant heterogeneity among patients regarding demographic features and clinical expression of the disease that hinders a standardised disease assessment and a generalised use of diagnostic criteria. Additionally, BS is not associated with pathognomonic laboratory or histopathology features; therefore, the diagnosis is mainly based on the clinical manifestations. The purpose of this narrative review of the literature is to provide a description of the most common or typical clinical features of BS, summarise the major phenotypes of BS, and address the diagnosis strategy of this syndrome.

Managing Chronic Pain in Osteoarthritis and Rheumatoid Arthritis

ON DAY 3 of the European Alliance of Associations for Rheumatology (EULAR) 2021 Congress, participants from across the globe accessed the virtual platform to join Jon Lampa, Associate Professor, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden, and his panel as they explored the challenges and opportunities of managing chronic pain in osteoarthritis and rheumatoid arthritis.

Performance of Different Criteria Sets for Inflammatory Back Pain in Radiographic and Nonradiographic Axial Spondyloarthritis

Introduction: It is important to recognise inflammatory back pain (IBP) for early diagnosis of ankylosing spondylitis (AS). The aims of this study were to develop a valid, reliable Bengali IBP tool and to assess the performance of different IBP criteria sets, including Calin, Berlin set 8a and 7b, and new Assessment of SpondyloArthritis International Society (ASAS) expert criteria, in radiographic axial spondyloarthritis (axSpA) and nonradiographic axSpA. Method: This case-control study was performed in three phases. The first phase involved development of an IBP tool by adding the fifth parameter of ASAS expert criteria to the National Health and Nutrition Examination Survey (NHANES) 2009–2010 arthritis questionnaires; the second phase assessed reliability by test-retest statistics among 87 participants at a 5-day interval. Finally, according to the imaging arm of ASAS axSpA classification criteria, 50 patients with axSpA were included as cases while 50 patients with chronic mechanical back pain (MBP) were included as a control. Results: The presence of IBP with SpA versus patients with MBP, detected by Calin criteria, were 76.0% versus 10.0%, by Berlin 8a were 72.0% versus 6.0%, by Berlin 7b were 58.0% versus 12.0%, and by ASAS were 64.0% versus 18.0%, respectively. Results suggested the Calin criteria set has the highest sensitivity (76.0%) and Berlin set 8a has the highest specificity (78.9%) in the differentiation of IBP from MBP. Conclusion: The performance of the new ASAS criteria was analogous to the other existing criteria sets. The highest positive likelihood ratio and odds ratio were found for Berlin set 8a criteria. The Berlin set 8a criteria can still be used in primary care practice at the first screening because of high sensitivity.

Optimising Response to Advanced Therapies in Rheumatoid Arthritis – Using Prehabilitation to Improve Success?

In recent years, a new concept of prehabilitation, enhancing an individual’s functional capacity ahead of a medical intervention, has begun to be explored in the fields of surgery and oncology, with positive results. This article explores applying the principle of prehabilitation to patients with rheumatoid arthritis prior to starting advanced therapies, including biologic disease-modifying antirheumatic drugs and targeted synthetic disease-modifying antirheumatic drugs. In this article, the literature is reviewed and the existing evidence is summarised, and the suggestion is that this approach could improve a patient’s chance of achieving low disease activity or remission. There are a number of opportunities for improving the likelihood of patients with rheumatoid arthritis having a good response to therapy. Research shows that smokers starting TNF inhibitors are less likely to achieve a good response compared to non-smokers. Obese patients are also less likely to achieve a good response with TNF inhibitors; female patients with obesity may be less likely to achieve a good response with tocilizumab and early real-world data suggest there may be a reduced response to JAK inhibitors. Rheumatoid arthritis patients experiencing depression are less likely to respond to TNF inhibitors. Increased physical activity is potentially beneficial for all rheumatoid arthritis patients, although the effect on response to specific drugs has been less widely explored. Prehabilitation approaches could include targeting smoking cessation, improving physical activity, providing psychological support, optimising BMI, and dietary changes. A number of studies have shown that each of these interventions can lead to significant improvements in disease activity scores, with some patients potentially benefitting from more than one intervention. The authors identify principles for delivering prehabilitation in practice and suggest that this is an exciting area for ongoing research.

Bone Health in Rheumatoid Arthritis: What Can Studies of Bone Microarchitecture Tell Us?

Introduction: Rheumatoid arthritis (RA) is associated with changes in skeletal health, including increased risk of fracture. This study used a novel technique, high-resolution quantitative CT (HRpQCT), to assess bone microarchitecture in patients with RA. Methods: There were 59 patients (female: 41; male: 18) with RA recruited. They underwent dual energy X-ray absorptiometry and HRpQCT of the radius and tibia. The questionnaire information included age, sex, BMI, disease duration, comorbidities, medication use, smoking and alcohol consumption, rheumatoid factor (RF) or cyclic citrullinated peptide (CCP) status, and disease activity. HRpQCT results were compared with published estimated age and sex-specific values. Results: There were 55 patients (female: 39; male: 16) who had either radial or tibial scans available. The mean age was 55.8 (standard deviation [SD]: 12.6) years and median disease duration was 11.4 years (interquartile range [IQR]: 6.3–19.4). Mean BMI was 27.2 (SD: 5.8). Forty-nine (90.7%) participants were RF or CCP positive, with disease severity ranked as severe in 33 (61.1%) patients and moderate in 20 (37.0%). Fifteen participants (27.8%) had previously taken steroids and 47 (85.5%) were receiving tumour necrosis factor inhibitor (TNF-i) medication. Radial trabecular number and density were lower than expected, and trabecular separation was greater than expected (p<0.05), though tibial results were similar (p<0.10 for trabecular number and separation). No difference in cortical values reached statistical significance in this sample. Previous use of steroids was associated with greater radial periosteal circumference (p<0.05, adjusted for sex) and use of TNF-i agents was associated with lower radial total and trabecular area (p<0.05, adjusted for sex). Conclusion: Trabecular bone microarchitecture differences were observed among patients with RA. Further studies with larger numbers of participants are needed.