Miranda van Lunteren

Sacroiliac radiographic progression in recent onset axial spondyloarthritis: the 5-year data of the DESIR cohort

Objective To estimate sacroiliac joint radiographic (X-SIJ) progression in patients with axial spondyloarthritis (axSpA) and to evaluate the effects of inflammation on MRI (MRI-SIJ) on X-SIJ progression. Methods X-SIJ and MRI-SIJ at baseline and after 2 and 5 years in patients with recent onset axSpA from the DESIR cohort were scored by three central readers. Progression was defined as (1) the shift from non-radiographic (nr) to radiographic (r) sacroiliitis (by modified New York (mNY) criteria) or alternative criteria, (2) a change of at least one grade or (3) a change of at least one grade but ignoring a change from grade 0 to 1. The effects of baseline inflammation on MRI-SIJ on 5-year X-SIJ damage (mNY) were tested by generalised estimating equations. Results In 416 patients with pairs of baseline and 5-year X-SIJ present, net progression occurred in 5.1% (1), 13.0% (2) and 10.3% (3) respectively, regarding a shift from nr-axSpA to r-axSpA (1), a change of at least one grade (2) or a change of at least one grade but ignoring a change from grade 0 to 1 (3). Baseline MRI-SIJ predicted structural damage after 5 years in human leukocyte antigen-B27 (HLA-B27) positive (OR 5.39 (95% CI 3.25 to 8.94)) and in HLA-B27 negative (OR 2.16 (95% CI 1.04 to 4.51)) patients. Conclusions Five-year progression of X-SIJ damage in patients with recent onset axSpA is limited but present beyond measurement error. Baseline MRI-SIJ inflammation drives 5-year radiographic changes.

Does body mass index (BMI) influence the Ankylosing Spondylitis Disease Activity Score in axial spondyloarthritis?: Data from the SPACE cohort.

Objective Obesity is associated with elevated C reactive protein (CRP) levels. The Ankylosing Spondylitis Disease Activity Score (ASDAS) combines patient-reported outcomes (PROs) and CRP. We evaluated the effect of body mass index (BMI) on CRP and on ASDAS, and studied if ASDAS can be used in obese axial spondyloarthritis (axSpA) patients to assess disease activity. Methods Baseline data of patients with chronic back pain of short duration included in the SPondyloArthritis Caught Early (SPACE) cohort were used. Collected data included BMI and ASDAS. Patients were classified according to the ASAS axSpA classification criteria and BMI (overweight ≥25 and obese ≥30). Correlation and linear regression analyses were performed to assess the relation between BMI and ASDAS. Linear regression models were performed to assess if age or gender were effect modifiers in the relation between BMI and CRP, and between BMI and ASDAS. Results In total, 428 patients were analysed (n=168 axSpA; n=260 no-axSpA). The mean age was 31.1 years, 36.9% were male, 26.4% were overweight and 13.3% obese, median CRP was 3 mg/L and the mean ASDAS was 2.6. Gender was the only factor modifying the relationship between BMI and CRP as BMI had an influence on CRP only in females (β=0.35; p<0.001). Correlations between BMI and CRP or PROs were generally weak, and only significant for CRP in female patients. BMI was not related to ASDAS in axSpA patients. Conclusions ASDAS is not affected by BMI in axSpA patients. Therefore, based on our data it is not necessary to take BMI in consideration when assessing disease activity using ASDAS in axSpA patients.

Impact of replacing radiographic sacroiliitis by magnetic resonance imaging structural lesions on the classification of patients with axial spondyloarthritis

Objectives To investigate in patients with chronic back pain of a short duration, the utility of adding structural MRI lesions of the SI joints to the imaging criterion of the Assessment of SpondyloArthritis International Society (ASAS) axial SpA (axSpA) criteria and the utility of replacement of radiographic sacroiliitis by structural MRI lesions. Methods MRI STIR (inflammation, MRI-SI), MRI T1-weighted images (structural lesions, MRI-SI-s) and radiographs of the SI joints of patients in the SPondyloArthritis Caught Early-cohort (chronic back pain: ⩾3 months, ⩽2 years; onset <45 years) were scored by two well-calibrated readers. Previously proposed cut-offs for a positive MRI-SI-s were used (based on <5% prevalence in no-SpA patients): erosions ⩾3, fatty lesions ⩾3, fatty lesions and/or erosions (erosions/fatty lesions) ⩾5. Using the definitions of MRI-SI-s, patients were classified according to the ASAS axSpA criteria. Results Twenty-nine of 294 patients were modified New York (mNY) positive and 32 were MRI-SI-s positive (erosions/fatty lesions ⩾5). Agreement between mNY and MRI-SI-s (erosions/fatty lesions ⩾5) was moderate (κ: 0.58). Using the erosions/fatty lesions ⩾5 cut-off, 3/294 additional patients were classified as axSpA (adding MRI). Using this cut-off instead of mNY (replacing mNY), classification did not change in 286 patients (97.3%), but 5 patients (1.7%) would not be classified as axSpA and 3 previously unclassified patients (1.0%) would be classified as axSpA. Similar results were seen for the other cut-offs (erosions ⩾3 and fatty lesions ⩾3). Conclusion Assessment of structural lesions (fatty lesions and erosions) on MRI-SI instead of or in addition to conventional radiographs does not lead to a different ASAS axSpA classification in most of the patients with early disease onset. This suggests that structural lesions (fatty lesions and erosions) can be reliably used in the ASAS axSpA classification of patients, as both addition and replacement of radiographs of the SI joints.

The impact of illness perceptions and coping on the association between back pain and health outcomes in patients suspected of axial spondyloarthritis: data from the SPACE cohort

To investigate whether illness perceptions and coping influence the relationship between back pain and health outcomes in patients suspected of having axial spondyloarthritis (SpA).

Disease activity decrease is associated with improvement in work productivity over 1 year in early axial spondyloarthritis (SPondyloArthritis Caught Early cohort)

Objectives To assess if a change in disease activity is associated with a change in work productivity loss (WPL) over 1 year in early axial SpA (axSpA) patients. Methods Baseline and 1 year data of axSpA patients in the SPondyloArthritis Caught Early cohort were analysed. Linear regression models were built explaining the change in the Ankylosing Spondylitis Disease Activity Score (ASDAS) over time by the change in absenteeism, presenteeism, WPL and activity impairment over time. Effect modification and confounding were tested for age, gender, arm of Assessment of SpondyloArthritis international Society classification criteria, HLA-B27, duration of chronic back pain, profession and medication. Results At baseline, in 105 axSpA patients (48% female, mean age 30.8 years, mean symptom duration 13.6 months, 92% HLA-B27 positive, 24% radiographic sacroiliitis), the mean ASDAS was 2.4 (s.d. 1.0), absenteeism 9% (s.d. 23), presenteeism 33% (s.d. 28), WPL 36% (s.d. 30) and activity impairment 37% (s.d. 25). After 1 year, the mean ASDAS decreased to 2.0 (s.d. 0.8) and absenteeism, presenteeism, WPL and activity impairment improved to 6% (s.d. 22), 26% (s.d. 26), 27% (s.d. 29) and 27% (s.d. 26), respectively. Models showed that if ASDAS decreased 1 unit, absenteeism, presenteeism, WPL and activity impairment improved by 5, 17, 16 and 18%, respectively. The impact of disease activity on work productivity was higher in patients with shorter symptom duration and the impact on absenteeism was higher in patients starting pharmacological treatment. Conclusions In early axSpA patients, work productivity and daily activities are seriously impacted at baseline and 1 year. However, decreasing disease activity is associated with marked improvements in work productivity and daily activities.

The yield of a positive MRI of the spine as imaging criterion in the ASAS classification criteria for axial spondyloarthritis: results from the SPACE and DESIR cohorts

Objectives To assess the prevalence of spinal inflammation on MRI in patients with chronic back pain (CBP) of maximally 3 years duration and to evaluate the yield of adding a positive MRI-spine as imaging criterion to the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial spondyloarthritis (axSpA). Methods Baseline imaging of the sacroiliac joints (X-SI), MRI of the sacroiliac joints (MRI-SI) and MRI-spine were scored by ≥2 experienced central readers per modality in the SPondyloArthritis Caught Early (SPACE) and DEvenir des Spondylarthropathies Indifférenciées Récentes (DESIR) cohorts. Inflammation suggestive of axSpA was assessed in the entire spine. A positive MRI-spine was defined by the presence of ≥5 inflammatory lesions. Alternative less strict definitions were also tested. Results In this study, 541 and 650 patients with CBP from the SPACE and DESIR cohorts were included. Sacroiliitis on X-SI and MRI-SI was found in 40/541 (7%) and 76/541 (14%) patients in SPACE, and in DESIR in 134/650 (21%) and 231/650 (36%) patients, respectively. In SPACE and DESIR, a positive MRI-spine was seen in 4/541 (1%) and 48/650 (7%) patients. Of the patients without sacroiliitis on imaging, 3/447 (1%) (SPACE) and 8/382 (2%) (DESIR) patients had a positive MRI-spine. Adding positive MRI-spine as imaging criterion led to new classification in only one patient in each cohort, as the other patients already fulfilled the clinical arm. Other definitions of a positive MRI-spine yielded similar results. Conclusion In two cohorts of patients with CBP with a maximum symptom duration of 3 years, a positive MRI-spine was rare in patients without sacroiliitis on MRI-SI and X-SI. Addition of MRI-spine as imaging criterion to the ASAS axSpA criteria had a low yield of newly classified patients and is therefore not recommended.

In Early Axial Spondyloarthritis, Increasing Disease Activity Is Associated with Worsening of Health-related Quality of Life over Time

Objective. In early axial spondyloarthritis (axSpA), data are lacking about the relationship between disease activity and health-related quality of life (HRQOL). We assessed and quantified the association between change in Ankylosing Spondylitis Disease Activity Score (ASDAS) and HRQOL over time in early axSpA. Methods. Baseline and 1-year data of patients with axSpA fulfilling the Assessment of Spondyloarthritis international Society (ASAS) classification criteria from the SPondyloArthritis Caught Early (SPACE) cohort were analyzed. Associations between change in ASDAS and in physical (PCS) or mental component summary (MCS) of the Medical Outcomes Study Short Form-36 were tested by linear regression models. Age, sex, ASAS criteria arm, and blue- versus white-collar work were tested for effect modification. Subsequently, these factors and medication were tested for confounding. Results. There were 161 patients with axSpA [53% male, mean (± SD) age 29.7 (± 7.5) yrs, symptom duration 13.6 (± 7.2) months, HLA-B27–positive 91%, radiographic sacroiliitis 22%] who had ASDAS of 2.5 (± 1.0) and 2.0 (± 0.8), PCS of 28.4 (± 14.3) and 36.9 (± 13.1), and MCS of 48.2 (± 13.8) and 49.3 (± 12.0) at baseline and 1 year, respectively. Per unit increase in ASDAS between baseline and 1 year, PCS worsened by 9.5 points. The same level of disease activity had fewer adverse effects on physical HRQOL in women and white-collar workers. Conclusion. To our knowledge, our data are the first to show that in a broad group of patients with early axSpA, increasing ASDAS is associated with worsening of physical HRQOL, but not mental HRQOL, over time.

Imaging of the sacroiliac joints is important for diagnosing early axial spondyloarthritis but not all-decisive

Objectives To evaluate the contribution of the results of sacroiliac imaging to diagnosis and to the level of confidence in diagnosis in patients presenting with chronic back pain (CBP) and suspected of having axial spondyloarthritis (axSpA). Methods. Data from 513 patients from the SPondyloArthritisCaughtEarly cohort with CBP (⩾3 months, ⩽2 years, onset <45 years) were analysed after full diagnostic work-up. Rheumatologists were asked not only to provide a diagnosis before and after the imaging results had been provided to them, but also to provide the level of confidence of this diagnosis on an 11-point numerical scale. Results. Before imaging, 317/513 patients were diagnosed with axSpA. Of these patients, 178/317 (56%) did not have signs of sacroiliitis on either MRI or radiography, which led to the rheumatologist refuting the initial diagnosis of axSpA in 81/178 (46%) patients. Of the 196/513 patients without axSpA before imaging, 35/196 (18%) had signs of sacroiliitis on imaging. Subsequently, 28/35 (80%) patients were diagnosed with axSpA. Overall, imaging was incongruent with the diagnosis before imaging in 213 patients. This led to a change in diagnosis in 109/213 (51%), which corresponds to 21% (109/513) of all patients in the cohort. In general, diagnostic confidence increased by having imaging results available (from 6.2 to 7.4, P < 0.001). Conclusion In patients with CBP suspected of having axSpA, sacroiliac imaging adds to the confidence in the final diagnosis. However, the number of changes in diagnosis suggests that imaging is important but not all-decisive in early axSpA diagnosis.

Which scoring method depicts spinal radiographic damage in early axial spondyloarthritis best? Five-year results from the DESIR cohort

Objective To compare the performance of different spinal radiographic damage scoring methods in patients with early axial spondyloarthritis (axSpA). Methods Five-year spinal radiographs from the DESIR cohort were scored by three readers (averaged) for the calculation of the Stoke AS Spine Score (SASSS), modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), Radiographic AS Spinal Score (RASSS), BASRI-spine and BASRI-total, and following the OMERACT filter, scores were compared according to truth, discrimination (reliability and sensitivity to change) and feasibility. The proportion of patients with a net change > smallest detectable change and >1 was calculated. The proportion of total variance explained by the patient (true variance) was calculated for the change scores as a measure of reliability, using analysis of variance. Results In total 699 patients were included. Five-year net changes > smallest detectable change (>1) were: RASSS 17% (17%), mSASSS 12% (12%), BASRI-spine and BASRI-total 12% (9%), SASSS 11% (11%). The mSASSS and the RASSS performed the best in terms of capturing the signal (positive change) related to noise (negative change). The proportion of variance explained by the patient was highest for the mSASSS and RASSS (85% for both 5-year progression scores vs 50-55% for other methods). The proportion of patient variance in the thoracic segment of the RASSS was unsatisfactory (46% for progression). Conclusion The existing scoring methods to assess spinal radiographic damage performed well in early phases of axSpA. The mSASSS and RASSS captured most change. There was no clear gain in additionally scoring the thoracic spine for the RASSS. The mSASSS remains the most sensitive and valid scoring method in axSpA, including early phases of the disease.

Do ethnicity, degree of family relationship, and the spondyloarthritis subtype in affected relatives influence the association between a positive family history for spondyloarthritis and HLA-B27 carriership? Results from the worldwide ASAS cohort

BackgroundThe Assessment of SpondyloArthritis international Society (ASAS) defines a positive family history (PFH) of spondyloarthritis (SpA) as the presence of ankylosing spondylitis (AS), acute anterior uveitis (AAU), reactive arthritis (ReA), inflammatory bowel disease (IBD), and/or psoriasis in first-degree relatives (FDR) or second-degree relatives (SDR). In two European cohorts, a PFH of AS and AAU, but not other subtypes, was associated with human leukocyte antigen B27 (HLA-B27) carriership in patients suspected of axial SpA (axSpA). Because the importance of ethnicity or degree of family relationship is unknown, we investigated the influence of ethnicity, FDR, or SDR on the association between a PFH and HLA-B27 carriership in patients suspected of axSpA.MethodsBaseline data from the ASAS cohort of patients suspected of axSpA were analyzed. Univariable analyses were performed. Each disease (AS, AAU, psoriasis, IBD, ReA) in a PFH according to the ASAS definition was a determinant in separate models with HLA-B27 carriership as outcome. Analyses were stratified for self-reported ethnicity, FDR, and SDR. Analyses were repeated in multivariable models to investigate independent associations.ResultsA total of 594 patients were analyzed (mean [SD] age 33.7 [11.7] years; 46% male; 52% HLA-B27+; 59% white, 36% Asian, 5% other). A PFH was associated with HLA-B27 carriership in patients with a white (OR, 2.3, 95% CI, 1.4–3.9) or Asian ethnicity (OR, 3.1, 95% CI, 1.6–5.8) and with a PFH in FDR (OR, 2.9, 95% CI, 1.8–4.5), but not with a PFH in SDR (OR, 1.7, 95% CI, 0.7–3.8) or in other ethnicities. A PFH of AS was positively associated with HLA-B27 carriership in all subgroups (white OR, 7.1; 95% CI, 2.9–17.1; Asian OR, 5.7; 95% CI, 2.5–13.2; FDR OR, 7.8; 95% CI, 3.8–16.0; SDR OR, 3.7; 95% CI, 1.2–11.6). A PFH of AAU, ReA, IBD, or psoriasis was never positively associated with HLA-B27 carriership. In the multivariate analysis, similar results were found.ConclusionsIn the ASAS cohort, a PFH of AS, but not of AAU, ReA, IBD, or psoriasis, was associated with HLA-B27 carriership regardless of white or Asian ethnicity or degree of family relationship. This cohort and two European cohorts show that a PFH of AS and possibly a PFH of AAU can be used to identify patients who are more likely to be HLA-B27-positive and therefore may have an increased risk of axSpA.