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Published Clinical Papers 2019

A selection of the latest research findings

Physical activity and sedentary behaviour and their associations with clinical measures in axial spondyloarthritis

Physical activity is key in the management of axial SpA, however, its relationship with clinical measures is unknown. Previous research has mainly focused on subjective methods of measuring physical activity and sedentary behaviour. The aim of this study was to explore the associations between objectively measured physical activity and sedentary behaviour with clinical measures in people with established axial SpA.

Fifty participants were recruited from secondary-care rheumatology outpatient services in Glasgow, UK. Clinical measures collected included the BASDAI, BASFI, BASMI, ASQOL and the Six Minute Walk Test. Results showed that physical activity is associated with better function, exercise capacity and spinal mobility, while sedentary behaviour  is associated with lower exercise capacity and poor quality of life.

Fatigue in Ankylosing Spondylitis Is Associated With Psychological Factors and Brain Gray Matter

The aim of this research was to explore the mechanism of axial SpA (AS) associated fatigue from multiple aspects, including neuropsychological changes. 120 patients and 78 age- and sex-matched healthy individuals were recruited into the study. Fatigue was assessed by the fatigue item of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Multidimensional Assessment of Fatigue (MAF) scale. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). The cortical thickness and subcortical gray matter volume were assessed using a Philips Achieva 3.0 T TX MRI scanner.

 Of the 120 axial SpA (AS) patients, 103 (86%) reported varying degrees of fatigue. Of these, a third (32%) had severe fatigue two thirds (68%) had mild fatigue. The structural equation model suggested axial SpA (AS) activity triggered the occurrence of fatigue by inducing psychological change. Head MRI imaging found that the left thalamus volume in (axial SpA ) AS patients with severe fatigue was significantly larger than that in non-fatigue AS patients and healthy controls.

Characteristics and burden of disease in patients with radiographic and non-radiographic axial spondyloarthritis

This research was based upon a systematic literature review. The researchers conclude patients with radiopgraphic and non-radiographic axial SpA (AS) share a similar clinical presentation except for peripheral involvement, which is more prevalent among those non-radiographic axial SpA. r-axSpA. Except for more impaired mobility in people with radiographic disease, both groups showed a comparable burden of disease, treatment modalities and treatment effect.

Awareness of axial spondyloarthritis among chiropractors and osteopaths: Findings from a UK web-based survey

Chiropractors and osteopaths are important professional partners in the management of axial spondyloarthritis (axSpA). In view of recent advances in diagnosis and treatment, researchers, including Jill Hamilton from NASS  sought to understand their current knowledge and working practices.
A web-based survey was advertised to Chiropractors and Osteopaths via the Royal College of Chiropractors and Institute of Osteopathy.
Of 382 completed responses; 237 chiropractors (62%) and 145 osteopaths (38%); all were familiar with ankylosing spondylitis (AS), however only 63% and 25% were familiar with the terms axSpA and non-radiographic axSpA respectively. Seventy-seven percent were confident with inflammatory back pain. Respondents routinely asked about inflammatory bowel disease (91%), psoriasis (81%), acute anterior uveitis (49%), peripheral arthritis (71%), genitourinary/gut infection (56%), enthesitis (30%), and dactylitis (20%).Eighty-seven percent were aware of the association between axSpA and HLA-B27. Only 29% recognised that axSpA was common in women. Forty percent recommend an x-ray (pelvic in 80%), and if normal 27% would recommend MRI sacroiliac joints and whole spine. Forty-four percent were aware of biologic therapies.Forty-three percent were confident with the process of onward referral to rheumatology via the general practitioner (GP). The principal perceived barrier to onward referral was reluctance by the GP to accept their professional opinion.

Targeting inflammatory pathways in axial spondyloarthritis

The triggers and pathogenesis of axial SpA (AS) are not yet completely understood. However, therapeutic agents targeting TNF and IL17  have proven successful in suppressing many of the clinical symptoms and signs of axial SpA, giving an indication of which pathways are responsible for initiating and maintaining the inflammation. The mechanisms that eventuate in syndesmophytes and ankyloses are less clear. This review addresses these two critical pathways of inflammation, discussing their nature and these factors that may activate or enhance the pathways in patients with axial SpA. In addition, genetic and other markers important to the inflammatory pathways implicated in axSpA are explored, and prognostic biomarkers are discussed. Treatment options available for the management of axial SpA and their associated targets are highlighted.

Use of Complementary and Alternative Medicine in Axial Spondyloarthritis: A Qualitative Exploration of Self-Management

Axial SpA (AS) is often subject to diagnostic delays. Individuals report using complementary and alternative therapies prior to and following diagnosis, though little is known concerning reasons underlying use of such therapies. This study provides detailed insights into the motivation and experiences of complementary and alternative medicine use within a population of individuals with axial SpA.

Individuals with axial SpA recommended greater integration between mainstream and complementary and alternative therapies, valuing informed advice from mainstream healthcare professionals before selecting appropriate complementary and alternative therapies for potential use. Healthcare professionals should be proactive in discussing complementary and alternative therapy use with patients and supply them with details of organisations that can provide good-quality information.

Comorbidity burden in axial spondyloarthritis: a cluster analysis

This research aimed to examine how comorbidities cluster in axial spondyloarthritis (axSpA) and whether these clusters are associated with quality of life, global health and other outcome measures. They discovered comorbidity is common among axSpA patients. The two most common comorbidities were hypertension and depression. Patients in the depression-anxiety and fibromyalgia-IBS clusters reported poorer health and increased axial SpA severity.

Emerging treatment options for spondyloarthritis

This article gives a very brief update on emerging treatment options.

AxSpA patients who also meet criteria for fibromyalgia: identifying distinct patient clusters using data from a UK national register (BSRBR-AS)

Around 1 in 8 patients with axial spondyloarthritis (axial SpA) also meet criteria for fibromyalgia and these patients have considerable unmet need. Identifying effective therapy is important but to what extent fibromyalgia-like symptoms relate to axial SpA disease severity has not been established. The aim of this research was to determine whether distinct clusters of axial SpA patients exist and if so to determine a) whether they differ in terms of prevalence of fibromyalgia and b) the features of patients in clusters with high prevalence.
Researchers found the major feature defining cluster is high axial SpA disease activity although clusters with features of fibromyalgia in the absence of high disease activity also show moderately high prevalence. Management may be most successful with pharmacologic therapy to target inflammation but enhanced by the concurrent use of non-pharmacologic therapy.

Biological treatment of ankylosing spondylitis: a nationwide study of treatment trajectories on a patient level in clinical practice

The aim of this study was to describe 5-year treatment trajectories on a patient level, including subsequent therapy changes and dose reductions, of individual patients with ankylosing spondylitis (AS) starting a first anti TNF. Patients were identified in the nationwide Swedish Rheumatology Quality register and all changes in their treatment during follow-up were recorded.

Researchers conclude that less than half remain on their first anti TNF after 5 years, but most are still on a biologic. While patients remaining on treatment with their first anti TNF appear to be able to reduce the dose over time, a large proportion cycle through several biologics, and a third have no anti-rheumatic treatment after 5 years. This indicates the importance of thorough follow-up programs as well as a need for alternative therapeutic options.

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

This study aimed to compare co-morbidities and biologic therapy 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.
Despite age differences, nr-axSpA patients had similar co-morbidity burdens as those with AS. Both groups received comparable biologic therapy treatment.

Treat-to-target in axial spondyloarthritis: gold standard or fools’ gold?

Treat-to-target (T2T) is an emerging management strategy in axial spondyloarthritis (axSpA). The concept was originally based on evidence from other chronic conditions, such as hypertension, diabetes and hypothyroidism, as well as some rheumatic diseases, such as rheumatoid arthritis and gout.

International groups have recommended a T2T strategy in axSpA and observational evidence suggests that a T2T approach might be beneficial in axSpA. However, data from a prospective randomised study proving the efficacy of a T2T strategy compared to routine care are still lacking. Moreover, the cost-effectiveness of such strategy in clinical practice also needs to be tested. The target will need to be useful and feasible in both clinical practice and clinical trials.

The British Society for Rheumatology biologic DMARD safety guidelines

This guideline provides evidence-based recommendations for the safe use of biologic therapies in adults. It covers the safety aspects of all biologic therapies approved by the National Institute for Health and Care Excellence (NICE) as of June 2016, for the treatment of RA, PsA and axial spondyloarthritis (SpA) including AS. This group of conditions are referred to as inflammatory arthritis (IA) in the guideline. Therapies approved by NICE after June 2016, such as secukinumab (Cosentyx), are not included.

The guideline highlights several specific safety areas including recommendations for screening before a biologic is started, recommendations for monitoring, the implications of other conditions and ageing, vaccinations and the management of biologic therapies in specific situations such as infection, malignancy and surgery.

Factors associated with ASDAS remission in a long-term study of ankylosing spondylitis patients under tumor necrosis factor inhibitors

The objective of this study was to determine the clinical and demographic factors associated with disease remission and drug survival in patients with ankylosing spondylitis (AS) on  anti TNF therapy on an electronic database. Results indicated that that ASDAS-CRP remission is an achievable goal not only for people on their first anti TNF, but also for those on a second anti-TNF. This was particularly notable in younger patients and those with a lower BASDAI at baseline. Non-smokers also seemed to do better.

YouTube as a source of patient information for ankylosing spondylitis exercises

Researchers evaluated the educational quality of 56 YouTube videos offering exercises for people with AS. Of the 56 videos evaluated,  27 were  high quality, 10 were intermediate quality, and 19 were low quality. They conclude YouTube can be considered as an important source of high-quality videos as nearly half of the videos were of high quality. Physicians should inform patients about the importance of video resources during the use of YouTube and should guide patients to the accurate sources of information. Don’t forget NASS have some great exercise videos on YouTube.

Vitamin D serum concentration is not related to the activity of spondyloarthritis – preliminary study

Vitamin D plays an important role in mineral turnover and bone remodelling and there are increasing data about its immunomodulatory potential in different rheumatologic disorders. Deficiency of vitamin D is frequent in people with spondyloarthritis (SpA) and some data suggest its association with increased disease activity and structural damage. However, its exact role in the pathogenesis of SpA and its association with disease activity are still a matter of debate so researchers carried out a preliminary study of 63 patients.

The researchers concluded that their data showed no correlation between the concentration of 25(OH)D in the serum and disease activity in  SpA. However, they noted that this does not exclude the potential role of vitamin D in pathogenesis of SpA. They highlight further studies are required.