AB0826 Keep an Eye on the Back: Spondyloarthritis in Patients with Acute Anterior Uveitis

Abstract

BackgroundPatients with acute anterior uveitis (AAU) have an increased risk for concomitant spondyloarthritis (SpA). Different referral strategies have been proposed to identify AAU patients with high probability of SpA, among them an Assessment of SpondyloArthritis international Society(ASAS)-based referral strategy focusing on patients with chronic back pain starting before the age of 45 years and the Dublin Uveitis Evaluation Tool (DUET) also including psoriasis, HLA-B27 and arthralgia (Poddubnyy et al., Haroon et al., both ARD 2015).ObjectivesTo analyse the prevalence of SpA in patients with AAU, to identify parameters associated with SpA presence, and to evaluate referral algorithms.MethodsPatients with non-infectious AAU underwent structured rheumatologic assessment including magnetic resonance imaging of sacroiliac joints allowing a definitive diagnosis/exclusion of concomitant SpA. Fisher’s exact test and Mann–Whitney U test were used to compare AAU patients with and without SpA. Furthermore, logistic regression analyses were performed. Sensitivity, specificity, positive predictive value, positive and negative likelihood ratios were analysed for referral strategies.ResultsThe 189 AAU patients with complete rheumatologic assessment and SIJ imaging were 40.8 years old, and 55% were males. SpA was diagnosed in 106 AAU patients (56%). The majority (93%) had predominantly axial SpA, 7 patients peripheral SpA. In 74 patients (70%), the SpA diagnosis was established for the first time. Pelvic X-rays were available for 88 (89%) of the axSpA patients, 66% of whom were classified as having radiographic axSpA.SpA was equally frequent in patients experiencing the first episode of AAU and in patients with recurrent disease. In our cohort, AAU patients with and without underlying SpA showed no differences in their ophthalmologic examination. In multivariable logistic regression analysis, psoriasis (OR 12.5 [95%CI 1.3-120.2]), HLA-B27 positivity (OR 6.3 [95%CI 2.4-16.4]), elevated CRP (OR 4.8 [95%CI 1.9-12.4]) and male sex (OR 2.1 [95%CI 1.1-4.2]) were associated with SpA presence.Table 1.Parameters associated with the presence of spondyloarthritis in patients with acute anterior uveitis.univariablemultivariableOR95%CIOR95%CIPsoriasis (ever)14.6(1.9; 112.4)12.5(1.3; 120.2)HLA-B27 positivity6.2(2.7; 14.6)6.3(2.4; 16.4)Elevated CRP (≥ 5 mg/l)4.1(1.8; 9.0)4.8(1.9; 12.4)Male sex2.2(1.2; 4.0)2.1(1.1; 4.2)Inflammatory back pain (ASAS definition)2.1(1.2; 3.9)1.9(0.9; 4.0)Any peripheral manifestation (ever)1.9(1.1; 3.5)1.9(0.9; 3.8)Age in years1.0(1.0; 1.0)1.0(1.0; 1.0)Univariable and multivariable logistic regression analyses. ASAS Assessment of SpondyloArthritis international Society; CRP C-reactive protein; OR odds ratio; CI confidence interval.The Dublin Uveitis Evaluation Tool showed higher specificity for SpA recognition than the ASAS referral tool (42% vs. 28%), which had slightly higher sensitivity (78% vs. 80%). However, both referral strategies would have missed more than 20% of SpA patients.ConclusionWe revealed a high prevalence of overall and previously undiagnosed SpA in AAU patients. Therefore, we propose rheumatologic evaluation for all AAU patients with musculoskeletal symptoms. Rheumatologists should consider that SpA in AAU patients might present “atypically” with back pain starting after 45 years and lasting shorter than 3 months.Figure 1.Performance of Referral Strategies in Patients with Acute Anterior Uveitis. Dublin Uveitis Evaluation Tool (DUET) and an ASAS-based referral tool (ASAS). + respective tool fulfilled, - not fulfilled. ASAS Assessment of SpondyloArthritis international Society; AxSpA axial spondyloarthritis, pSpA peripheral spondyloarthritis.AcknowledgementsThe authors would like to thank the rheumatologists S. Lüders, B. Muche and A.-K. Weber for participating in the clinical data acquisition; and A. Langdon and L. Meinke for their support monitoring and coordinating this study. Furthermore, we are grateful to all participating ophthalmologists who included their patients in this study and to all patients. The study was supported by an unrestricted research grant from AbbVie. AbbVie had no role in the study design or in the collection, analysis, or interpretation of the data, the writing of the manuscript, or the decision to submit the manuscript for publication. Dr. Judith Rademacher and Dr. Dominika Pohlmann are participants in the BIH-Charité Clinician Scientist Program funded by the Charité –Universitätsmedizin Berlin and the Berlin Institute of Health.Disclosure of InterestsJudith Rademacher: None declared, Hanna Müllner: None declared, Torsten Diekhoff Speakers bureau: AbbVie, MSD, Novartis, Canon MS, Consultant of: Lilly, Hildrun Haibel Speakers bureau: AbbVie, MSD, Janssen, Roche, Pfizer, Sobi, Consultant of: Janssen, Sobi, Novartis, Sabrina Igel: None declared, Dominika Pohlmann Speakers bureau: Bayer, Consultant of: AbbVie, Celgene, Janssen, Novartis, UCB, Grant/research support from: Bayer, Allergan, Fabian Proft Speakers bureau: AMGEN, AbbVie, BMS, Celgene, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: AbbVie, Celgene, Janssen, Novartis, UCB, Grant/research support from: UCB, Novartis, Lilly, Mikhail Protopopov Consultant of: Novartis, Valeria Rios Rodriguez Consultant of: AbbVie, Falk e.V., Murat Torgutalp: None declared, Uwe Pleyer Shareholder of: stock or stock options from Novartis, BionTec, Speakers bureau: AbbVie, Alimera, Novartis, Grant/research support from: AbbVie, Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer and UCB, Consultant of: AbbVie, Biorad, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, MSD, Novartis, Pfizer, Samsung Bioepis and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, Pfizer