Management Of Spondyloarthritis Research Articles

The impact of nicotine smoking on spondyloarthritis and rheumatoid arthritis.

Nicotine has major side effects on human health through numerous mechanisms, one of which is the alteration of the immune system and its genetic components. Such alteration can be a predisposing factor for autoimmune diseases such as spondyloarthritis (SpA) and rheumatoid arthritis (RA). This review aims to shed light on the effects of nicotine smoking on the pathophysiology, clinical presentation, and management of SpA and RA. This review looked into the studies, excluding case reports and series, which were cited by PubMed/MEDLINE. Patients with established autoimmune conditions may have a different underlying pathophysiology and disease course when exposed to nicotine through cigarette smoking. Through the involvement of several cytokines, endothelial dysfunction, and epigenetic mechanisms, the severity of SpA is more prominent in smokers. The global health status, pain, and fatigue are worse in SpA patients. The evidence on the effect of nicotine smoking on the treatment of SpA is still limited. Nicotine can contribute to RA via the disruption of cellular regulatory activity, inflammatory responses, morphological, physiological, biochemical, and enzymatic responses. As such, smokers with RA have higher disease activity and are more likely to be seropositive through the citrullination of peptides. In addition, these patients are at risk of achieving a suboptimal response to tumor necrosis factor inhibitors. Cigarette smoking can substantially affect the pathophysiology and clinical presentation of patients with SpA and RA. The impact of nicotine on the management of these diseases still needs to be further studied.

Assessing and Optimizing Large Language Models on Spondyloarthritis Multi-Choice Question Answering: Protocol for Enhancement and Assessment.

Spondyloarthritis (SpA), a chronic inflammatory disorder, predominantly impacts the sacroiliac joints and spine, significantly escalating the risk of disability. SpA's complexity, as evidenced by its diverse clinical presentations and symptoms that often mimic other diseases, presents substantial challenges in its accurate diagnosis and differentiation. This complexity becomes even more pronounced in nonspecialist health care environments due to limited resources, resulting in delayed referrals, increased misdiagnosis rates, and exacerbated disability outcomes for patients with SpA. The emergence of large language models (LLMs) in medical diagnostics introduces a revolutionary potential to overcome these diagnostic hurdles. Despite recent advancements in artificial intelligence and LLMs demonstrating effectiveness in diagnosing and treating various diseases, their application in SpA remains underdeveloped. Currently, there is a notable absence of SpA-specific LLMs and an established benchmark for assessing the performance of such models in this particular field. Our objective is to develop a foundational medical model, creating a comprehensive evaluation benchmark tailored to the essential medical knowledge of SpA and its unique diagnostic and treatment protocols. The model, post-pretraining, will be subject to further enhancement through supervised fine-tuning. It is projected to significantly aid physicians in SpA diagnosis and treatment, especially in settings with limited access to specialized care. Furthermore, this initiative is poised to promote early and accurate SpA detection at the primary care level, thereby diminishing the risks associated with delayed or incorrect diagnoses. A rigorous benchmark, comprising 222 meticulously formulated multiple-choice questions on SpA, will be established and developed. These questions will be extensively revised to ensure their suitability for accurately evaluating LLMs' performance in real-world diagnostic and therapeutic scenarios. Our methodology involves selecting and refining top foundational models using public data sets. The best-performing model in our benchmark will undergo further training. Subsequently, more than 80,000 real-world inpatient and outpatient cases from hospitals will enhance LLM training, incorporating techniques such as supervised fine-tuning and low-rank adaptation. We will rigorously assess the models' generated responses for accuracy and evaluate their reasoning processes using the metrics of fluency, relevance, completeness, and medical proficiency. Development of the model is progressing, with significant enhancements anticipated by early 2024. The benchmark, along with the results of evaluations, is expected to be released in the second quarter of 2024. Our trained model aims to capitalize on the capabilities of LLMs in analyzing complex clinical data, thereby enabling precise detection, diagnosis, and treatment of SpA. This innovation is anticipated to play a vital role in diminishing the disabilities arising from delayed or incorrect SpA diagnoses. By promoting this model across diverse health care settings, we anticipate a significant improvement in SpA management, culminating in enhanced patient outcomes and a reduced overall burden of the disease. DERR1-10.2196/57001.

Effect of dietary interventions on nutritional status in patients with rheumatoid arthritis and spondyloarthritis - A systematic review and meta-analysis

Background & AimPatients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) have an increased risk of developing altered body composition, such as low muscle mass, and an increased risk of developing cardiovascular diseases (CVD).Thus, investigating how to improve body composition and CVD risk factors is a relevant topic to improve management of RA and SpA. The aim of this study was to identify dietary interventions that can improve body composition, as well as reduce CVD risk factors in RA and SpA. MethodsWe searched the databases Medline, Embase and Cochrane. Duplicates were removed using Endnote and records were screened through Rayyan. The primary outcomes were muscle mass (kg) and fat mass (kg). Secondary outcomes were body weight (kg), body mass index (BMI: kg/m2), waist circumference (cm) and lipid profile (total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides, mmol/L). ResultsA total of 4965 articles were identified, and 17 articles were included in this review, of which 15 were suitable for meta-analysis. We found a reduction in TC and LDL-C, (Mean difference, [95%CI]: -0.36, [-0.63, -0.10], I2 =43%, and -0.20, [-0.35, -0.05], I2=0% respectively). Otherwise, no other significant effect was seen in either primary or secondary outcomes. The evidence was graded as moderate for TC and low for LDL-C. ConclusionDietary interventions might reduce the levels of blood lipids, and consequently, the risk of cardiovascular diseases. However, body composition did not change significantly after a 2-4 month dietary intervention. Both short intervention period and lack of reliable methods to assess body composition are possible explanations for this finding. Further studies of longer duration are needed.

Sex differential impact of comorbidities in spondyloarthritis: data from COMOSPA study

ObjectivesTo describe and compare the prevalence of comorbidities in female and male patients with spondyloarthritis (SpA) and to assess whether comorbidities had a different impact on disease outcomes in male...

Osteoimmunology of Spondyloarthritis.

The mechanisms underlying the development of bone damage in the context of spondyloarthritis (SpA) are not completely understood. To date, a considerable amount of evidence indicates that several developmental pathways are crucially involved in osteoimmunology. The present review explores the biological mechanisms underlying the relationship between inflammatory dysregulation, structural progression, and osteoporosis in this diverse family of conditions. We summarize the current knowledge of bone biology and balance and the foundations of bone regulation, including bone morphogenetic protein, the Wnt pathway, and Hedgehog signaling, as well as the role of cytokines in the development of bone damage in SpA. Other areas surveyed include the pathobiology of bone damage and systemic bone loss (osteoporosis) in SpA and the effects of pharmacological treatment on focal bone damage. Lastly, we present data relative to a survey of bone metabolic assessment in SpA from Italian bone specialist rheumatology centers. The results confirm that most of the attention to bone health is given to postmenopausal subjects and that the aspect of metabolic bone health may still be underrepresented. In our opinion, it may be the time for a call to action to increase the interest in and focus on the diagnosis and management of SpA.

Implementation of the recommendations for the psychological management of patients with spondyloarthritis and inflammatory bowel disease

ObjectiveTo assess and improve the level of implementation of the recommendations for the psychological management of patients with spondyloarthritis (SpA) and associated inflammatory bowel disease (IBD). MethodsQualitative study. We performed a narrative literature review to identify the recommendations for the psychological management of SpA and associated IBD and to explore their level of implementation. Based on the findings, we developed a national survey to assess: (1) current level of knowledge and implementation of the recommendations; (2) attitudes towards the recommendations; and (3) barriers and facilitators to their implementation. The results of the review and survey were discussed by a multidisciplinary group of 9 expert rheumatologists and gastroenterologists, who defined implementation strategies to increase the uptake of the recommendations. ResultsThe review included 4 articles, 2 of them included direct recommendations on the identification and management of psychological problems in patients with SpA and IBD. None assessed the level of implementation of the recommendations in routine clinical practice. Our survey showed a great lack of awareness and implementation of the recommendations, even though psychological issues are very relevant for health professionals. Lack of time, resources, and knowledge are considered the main barriers to adherence to the recommendations. We propose several implementation strategies related to educational activities, clinical practice, and others to increase the uptake of reported recommendations. ConclusionsFurther research and efforts are required to achieve behaviour changes in clinical practice to improve the identification and management of psychological problems and needs in patients with SpA and IBD.

Ultrasound in the management of patients with psoriatic arthritis: systematic literature review and novel algorithms for pragmatic use.

In 2015, the European Alliance of Associations for Rheumatology (EULAR) published recommendations for the use of imaging for the diagnosis and management of spondyloarthritis in clinical practice. These recommendations included the use of ultrasound in patients with psoriatic arthritis (PsA), but the management was not clearly distinguished from spondyloarthritis. We aimed to systematically review the literature on the role of ultrasound for the management of PsA, and to propose pragmatic algorithms for its use in clinical practice. A group of ten rheumatologists, experienced in imaging and musculoskeletal ultrasound, met with the objectives of formulating key questions for systematic literature review (SLR), appraising the available evidence and then proposing algorithms on the application of ultrasound in suspected or established PsA, based on both literature and experts' opinion following a Delphi process. The SLR included 120 articles, most of which focused on the diagnostic process. The elevated number of articles retrieved suggest the interest of rheumatologist to use ultrasound in the PsA management. After a consensual discussion on literature data and expert opinion, three algorithms were developed to be used in practical situations: suspicion of PsA, management of PsA either with good or insufficient clinical response. The SLR showed the interests in using ultrasound to objectively evaluate PsA for diagnosis and management. We proposed three practical algorithms to guide its use in the clinical management of patients, from the diagnosis to the assessment of treatment response. Further studies are needed to define remission and to assess ultrasound ability to predict disease severity.

Recommendations of the Moroccan Society of Rheumatology (SMR) for Diagnostic Management of Spondyloarthritis (SpA) and Psoriatic Arthritis (PsA).

In 2017, the Moroccan Society of Rheumatology (SMR) issued guidelines for the treatment of severe ankylosing spondylitis. The emergence of new therapeutic classes, the update of international guidelines for axial SpA and psoriatic arthritis, and the diagnostic and therapeutic challenges encountered by rheumatologists has led to the development of recent SMR guidelines for the management of SpA patients. A group-work included rheumatologists, specialists in physical medicine and rehabilitation, and epidemiologists from various sectors was tasked with writing these recommendations based on a literature review, then adapting them to the national context. Thus, 33 recommendations were selected and organized into two sections: diagnostic and therapeutic. The diagnostic section included three general principles and fourteen recommendations. The first, second, and third recommendations concerned the definition and diagnostic criteria for psoriatic arthritis and psoriatic arthritis. In the management of SpA, Recommendation 4 prioritized the importance of opportunity windows. The recommendation5 concerned the diagnostic and prognostic significance of HLAB27. The sixth and seventh recommendations related to imaging of the sacroiliac joints and the spine. The eighth recommendation focuses on the diagnosis and evaluation of perivascular thrombosis activity. The ninth and tenth recommendations concerned the evaluation of SpA activity and psoriatic arthritis. The eleventh and twelfth recommendations concern the evaluation of function and structural progression. The recommendation number thirteen concerned the diagnosis and treatment of coxitis. Recommendation 14 focuses on the most common co-morbidities and extra-rhinitological manifestations observed in SpA.

Monitoring chronic inflammatory musculoskeletal diseases mixing virtual and face-to-face assessments-Results of the digireuma study.

Mobile health technology holds great promise for the clinical management of patients with chronic disease. However, evidence on the implementation of projects involving digital health solutions in rheumatology is scarce. We aimed to study the feasibility of a hybrid (virtual and face-to-face) monitoring strategy for personalized care in rheumatoid arthritis (RA) and spondyloarthritis (SpA). This project included the development of a remote monitoring model and its assessment. After a focus group with patients and rheumatologists, relevant concerns regarding the management of RA and SpA were raised, leading to the development of the Mixed Attention Model (MAM), which combined hybrid (virtual and face-to-face) monitoring. Then, a prospective study using the mobile solution Adhera for Rheumatology was conducted. Over a 3-month follow-up period, patients were given the opportunity to complete disease-specific electronic patient reported outcomes (ePROs) for RA and SpA with a pre-established frequency, as well as flares and changes in medication at any time. Number of interactions and alerts were assessed. The usability of the mobile solution was measured by the Net-Promoter Score (NPS) and through a 5-star Likert scale. Following the MAM development, forty-six patients were recruited to utilize the mobile solution, of whom 22 had RA and 24 SpA. There were 4,019 total interactions in the RA group, and 3,160 in the SpA group. Fifteen patients generated a total of 26 alerts, of which 24 were flares and 2 were medication-related problems; most (69%) were managed remotely. Regarding patient satisfaction, 65% of the respondents were considered to have endorsed Adhera for Rheumatology, yielding a NPS of 57 and an overall rating was 4.3 out of 5 stars. We concluded that the use of the digital health solution is feasible in clinical practice to monitor ePROs for RA and SpA. Next steps involve the implementation of this telemonitoring method in a multicentric setting.

Knowledge of General Practitioner’s toward Spondyloarthritis (SpA): A Qualitative Study

Background: Low back pain (LBP) is one of major health problems experienced by 80-85% of patients in their lifetime. Spondyloarthritis (SpA) has become one of the leading causes of chronic LBP but is often undiagnosed. General practitioners (GP) have an essential role in the early diagnosis of SpA. Aim: To explore the knowledge of GP about SpA from clinical diagnosis and early management and elaborate on each GP’s clinical perspective and practice performance. Methods: A qualitative study that involved 12 GP. All was consented to participate in an in-depth interview with the experts by online meeting with 15-20 minutes duration. Analysis was focused on the definition, classification, clinical manifestation, diagnosis, and early management of SpA in primary care. Results: All GP were interviewed (12 GP, 9 men, and 3 women; mean age 29.42) with average years in clinical practice was 3.8 years. All GP could describe the definition of SpA. Only a few subjects are aware of the subtype of SpA. Most of the GP could mention chronic back pain as the main SpA symptom, some GP mentioned extra-articular manifestation, but incomplete. All GP understood the current treatment in clinical practice. Conclusion: GP is aware of SpA, but not all could completely mention the type and clinical entities. In addition, a limited resource for investigation makes a diagnosis of SpA difficult. Current early treatment has been acceptable in clinical practice. A comprehensive understanding of diagnosis and effective early treatment may reduce delayed diagnosis and improve patients' quality of life.

Real-life data on the comorbidities in spondyloarthritis from our multicenter nationwide registry: BioStar.

Considering that the comorbid situations during the management of Spondyloarthritis (SpA) have been underlined in several recommendations, the main objective of this study was to evaluate the comorbid conditions of Turkish patients with SpA. This cross-sectional observational study was conducted with 1,242 SpA patients (844 males, 398 females; mean age: 43.9±11.0 years; range, 19 to 81 years) diagnosed according to the modified New York criteria for ankylosing spondylitis or the Assessment of SpondyloArthritis International Society (ASAS) criteria. The patient data were collected from the Biologic and targeted Synthetic antirheumatic drugs Registry (BioStar) between February 1, 2019, and December 29, 2020. Clinical and demographic data, including, age, sex, disease duration, body mass index (BMI), pain, patient's global assessment, physician's global assessment, Bath Ankylosing Spondylitis Disease Activity Index, Ankylosing Spondylitis Disease Activity Score, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index, and Maastricht Enthesitis Score, were recorded. Comorbid conditions were recorded by filling out a questionnaire according to the clinical history or medical records. Charlson Comorbidity Index and Rheumatic Disease Comorbidity Index scores were calculated from the gathered comorbidity information. Nine hundred thirteen patients had radiographic axial SpA, 153 had nonradiographic axial SpA, and 176 had peripheral SpA. The most common comorbidities were hypertension (HT) (n=167, 13.4%), diabetes mellitus (DM) (n=83, 6.7%), thyroid disorders (n=64, 5.6%), and depression (n=61, 4.9%). The comorbidities and the calculated comorbidity indices were significantly higher in females, in those with a BMI >25 kg/m2 , and those over 60 years of age. No relationship was found between smoking and alcohol use and comorbidities. A significantly higher prevalence of HT and DM in peripheral SpA patients and a lower prevalence of thyroid disorders in radiographic axial SpA patients were observed. The most commonly reported comorbidities were HT, DM, thyroid disorders, and depression in SpA patients according to the BioStar database. The frequency of comorbidities and composite comorbidity scores were higher among females, older (>60 years) patients, and overweight (BMI >25 kg/m2 ) patients.

Motivators, Barriers, and Opportunity for E-Health to Encourage Physical Activity in Axial Spondyloarthritis: AQualitative Descriptive Study.

Physical activity is fundamental in the management of axial spondyloarthritis (SpA); however, evidence suggests that patients with axial SpA are not adhering to physical activity recommendations. E-health technology (e.g., telephone reminders and mobile text messaging) can increase participation in physical activity. The aims of this study were as follows: 1) to understand perspectives of the importance of physical activity in the management of axial SpA; 2) to describe factors associated with physical activity adherence; and 3) to explore the role of e-health technology to facilitate physical activity in patients with axial SpA. Semistructured interviews were conducted with axial SpA patients attending an urban academic rheumatology clinic. Interviews were audio recorded and transcribed verbatim. Data were analyzed using thematic principles. Systematic labeling of the data set was completed using an inductive approach until saturation of emergent themes. Twelve patient interviews were completed. Most respondents were male (83.3%) with a mean ± SD age of 45.5 ± 12.5 years and a mean ± SD disease duration of 21.5 ± 14.9 years. Participants defined physical as any activity involving physical exertion. The role of physical activity in axial SpA management was well recognized and included symptom relief, pharmacologic synergy, and impact on general health. Motivators included a growth mindset, social support networks, and facility access. Barriers included fear of disease progression, life demands, and environmental restrictions. Feedback, electronic reminders, and virtual support networks were key components of e-health technology to facilitate engagement in physical activity. The results of this study provide a foundation to guide development of patient-centered e-health technology interventions to increase physical activity uptake in patients with axial SpA.

The Italian Society for Rheumatology recommendations for the management of axial spondyloarthritis.

Over the last few years, the landscape of treatments for axial spondyloarthritis (SpA) has been rapidly evolving, urging international scientific societies to draft or update existing clinical practice guidelines (CPGs) on the management of axial SpA. The Italian Society for Rheumatology (SIR) committed to provide revised and adapted evidence- and expert-based recommendations for the management of patients with axial SpA in Italy. A systematic approach to the adaptation of existing CPGs - the ADAPTE methodology - was adopted to obtain updated recommendations suitable for the Italian context. A systematic literature search was performed in Medline and Embase databases to find international CPGs and consensus statements with recommendations for the management of axial SpA published in the previous five years. A working group composed of rheumatologists with proven experience in the management of axial SpA and methodologists identified the key research questions which guided study selection and data extraction. Guideline quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The Italian recommendations were developed by endorsing or adapting and rewording some existing recommendations. The draft of the recommendations was sent to a multidisciplinary group of external reviewers for comment and rating. Six original CPGs were selected and used to create this SIR CPG, which includes a final set of 14 recommendations covering the management of patients with axial SpA across the following domains: assessment, pharmacological and non-pharmacological treatment, and follow-up. The dissemination and implementation of these SIR recommendations are expected to support an evidencebased clinical approach to the management of patients with axial SpA in Italy.

Magnetic Resonance Imaging of Enthesitis in Spondyloarthritis, Including Psoriatic Arthritis-Status and Recent Advances.

Enthesitis, inflammation at the attachment sites of tendons, ligaments, fascia, and joint capsules to bones plays a critical role in the pathogenesis of spondyloarthritis (SpA), including psoriatic arthritis (PsA). Magnetic resonance imaging (MRI) has aided in a better understanding of pathophysiology, early diagnosis, prognostication, therapeutic outcomes, and follow up of enthesitis. The concept of enthesitis as a focal insertional pathology has transformed over the past decade, with the help of MRI, to a more widespread entity involving both bone and surrounding soft tissues. The utility of MRI in the differential diagnosis of suspected enthesitis has recently been explored. With the emergence of the treat-to-target concept, and a domain-based approach in the management of SpA, objective and sensitive monitoring of response to targeted therapy becomes prudent. Properties like high sensitivity, ability to image intra-osseous pathology along with surrounding structures exemplify the utility of MRI technology. Considering the lack of a comprehensive, validated MRI score the Outcome Measures in Rheumatology (OMERACT) MRI in Arthritis Working Group, informed by a systematic literature review, developed the first international, consensus-based MRI-scoring system, combined with MRI definitions of pathologies for enthesitis in patients with spondyloarthritis (SpA) and PsA. An atlas with representative images of each grade of the scoring system was subsequently developed by the group to aid readers interested in using the heel enthesitis MRI scoring system (HEMRIS). The HEMRIS can find utility in clinical trials targeting enthesitis as the primary outcome. MRI also finds value for global assessment of the total burden of enthesitis. The concept of whole-body MRI (WBMRI), enabling visualization of entheses throughout the body using a single image is relatively new. The MRI whole-body score for inflammation in peripheral joints and entheses (MRI-WIPE) is a promising scoring system, which is undergoing further testing in clinical trials and longitudinal cohorts evaluating global measures of inflammation at entheses. This review discusses the role of MRI in diagnosis and monitoring of enthesitis in SpA and PsA, along with recent advances in the field, based on published literature.

P07 Improving patient care in psoriatic arthritis through quality improvement and audit against the National Institute for Health and Care Excellence NG65 guidelines

Abstract Background NICE guidelines (NG65) for diagnosis and management of spondyloarthritis (SpA) in over 16s provide evidence-based recommendations for provision of care and services for patients, with an aim to improving quality of care. There often appears to be misdiagnosis/under diagnosis of psoriatic arthritis (PsA), as well as unmet needs of achieving treatment to target and low disease activity. Our objective was to audit our PsA service against the guidelines to benchmark current service provision compared to the National recommendations, highlighting potential key areas to improve quality of SpA and PsA patient care and enable service development including our new electronic patient pathway. Methods The NICE baseline assessment tool was used to audit 100 patients diagnosed with PsA, attending the outpatient rheumatology clinic between 2017-2019. The mean age was 54, with a 3:2 female to male ratio. 30% of patients included were on a biologic disease modifying anti-rheumatic drug (bDMARD). Data was collected from clinic letters/medical/physiotherapy records. Data was collated to identify areas of compliance of our service against the guidelines, with the key outcomes scrutinised being assessment and diagnosis, imaging, information and support, pharmacological management and long-term condition management. Results 78% of patients with PsA had documentation of meeting the CASPAR or peripheral ASAS Criteria. 83% of patients who had symptomatic hands/feet obtained X-rays, and 82% had imaging of other peripheral or axial sites. 58% of patients with PsA had documented evidence of having received information on PsA. Out of 100% of patients that were started on a conventional synthetic DMARD (csDMARD), 83% that were on monotherapy were escalated to either an additional csDMARD or a bDMARD. Largely by month 3 the csDMARD was switched or the patient started combination therapy, in comparison to those that started a bDMARD which occurred largely around month 6. 100% of patients had access to flare management advice and flare clinic, but only 30% had documented discussions about cardiovascular (CV) and skin cancer risks on anti-TNF therapy. Subsequent action plans for service improvement included: a best practice pathway developed on the electronic patient records (EPR), including the CASPAR and ASAS criteria, the Group for Research and Assessment of Psoriasis (GRAPPA) 6 domains of PsA, CV and skin cancer risk. All patients are seen in the Nurse/therapist led education sessions for information on the disease. Conclusion Performing an audit of patients against the NG65 guidelines ensured that we were using real-world data to benchmark our service, enabling robust action plans to be developed to address low compliance areas. Consequently, the audit allowed us to justify changing and developing the service for improved patient care. Disclosures E.J. Papadopoulos: Other; Paid work with Novartis Pharmaceuticals. A. Chan: Member of speakers’ bureau; Novartis, Celgene, Janssen, Sanofi. Other; Advisory Board for: Novartis, Celgene, Lilly. K. Rigler: Other; aid work for Novartis Pharmaceuticals. A. Kachwaha: None. J. Gunn: None. N. Zabbey: None. E. Walsh: None.

Spondyloarthritis phenotypes: rationale of evaluation in context of personified medicine

The article contents the analysis of different clinical phenotypes in the most common spondyloarthritis (SpA): ankylosing spondylitis (AS), axial spondylarthritis (axSpA) and psoriatic arthritis (PsA). SpA polymorphism has been discussed on the basis of multiple clinical presentations, structural lesions, radiological, immunological and genetic characteristics. Role of pro-inflammatory agents especially IL-17 in structural progression has been pointed out. Recent data regarding the link between HLA-B27 antigen, gender and age specificity and different clinical manifestation of SpA are presented. Current algorithms for SpA management based on evidence of efficacy sDMARD and/or biologics in separate phenotypes of SpA as well as resistance to DMARD are highlighted. Authors have concluded that meticulous analysis of SpA manifestation and patient’s individual profile is critical in rational SpA management according to personified medicine strategy.

Colitis in spondyloarthritis

Inflammatory bowel disease (IBD) is seen in up to 14% of patients with spondyloarthritis (SpA) with a lower prevalence seen in the Asian population. Conversely, SpA is the most common extraintestinal manifestation in IBD, with prevalence ranging from 10% to 39%. Apart from the strong Class I human leukocyte antigen B27 link for both diseases, several new shared genetic risk loci are identified from genome-wide association studies. Demonstrable mucosal inflammation of gut is present in most of the patients with SpA, even in the absence of clinically overt IBD. Mucosal inflammation leads to disruption of the epithelial barrier and activation of antigen-presenting cells and T-helper cells, which then home to synovium to cause inflammation maintaining the gut synovial axis. Several putative gut bacteria are implicated in the pathogenesis of SpA. IBD must be suspected in all patients of SpA presenting with abdominal pain, diarrhea, unexplained weight loss, anemia, or other malabsorption features. Fecal calprotectin is emerging as a noninvasive screening tool for detecting clinically silent IBD in patient with SpA. Several therapeutic targets have emerged in the last few years based on the understanding of the pathogenic mechanism and have considerably changed the management of both IBD and SpA.

"Mobile Health" for the Management of Spondyloarthritis and Its Application in China.

Spondyloarthritis (SpA) is a group of inflammatory diseases characterized by inflammation in the spine, peripheral joints, and entheses that usually start at the prime of one's life and lead to impaired physical function and reduced quality of life. Ankylosing spondylitis (AS) is prototype of SpA. This article reviews the opportunities and challenges of using mobile health (mHealth) in managing SpA, and report some of our experiences using a mHealth solution for management of SpA patients and performing related research in China. The recent rapid development of mobile communications and the common use of intelligent electronic devices have led to the increasing application of mHealth for chronic disease management by healthcare providers and patients alike. This is a promising new technology that can help mitigate limitations in time and space for patient management, promote easier communication between patients and their healthcare providers, reduce medical expenses, and optimize medical services. We have developed a smartphone-based mHealth SpA management system (SpAMS) that also helps the patients to monitor, manage, and share information on their disease with their physician at regular intervals. There is a shift from a paternalistic model of healthcare to more personalized healthcare in which disease management is conducted by the patient together with their healthcare providers. The increasing utility of mHealth is expected to benefit disease management, promote patient-doctor communication, reduce medical expenses, and optimize medical services.

2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis.

To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel. Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended. These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.

2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis.

To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel. Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended. These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.