Peripheral spondyloarthritis : a neglected entity-state of the art

Peripheral spondyloarthritis (pSpA) refers to a number of seemingly different spondyloarthritis subsets in which psoriatic arthritis (PsA) is the most common, and symptoms of arthritis, enthesitis or dactylitis predominate the clinical presentation. Although formal classification criteria for pSpA have been introduced in 2011, only a minority of epidemiological and clinical studies addressed this clinical entity as a separate disease. Moreover, research on outcome measures and treatment modalities in pSpA has been mainly focused on PsA. Subsequently, all biological treatments are off-label in patients with non-psoriatic pSpA. Its neglected status has important implications for clinical practice since the emerging group of early-diagnosed non-psoriatic pSpA patients remains poorly characterised and lacks specific treatment recommendations. This review summarises what is currently known regarding pSpA in terms of epidemiology, clinical presentation, diagnosis and therapeutic approach

Low incidence of inflammatory bowel disease adverse events in adalimumab clinical trials across nine different diseases

OBJECTIVE: Adalimumab is approved for treatment of Crohn's disease and ulcerative colitis. Thus, we postulated that exacerbation or new-onset of inflammatory bowel disease (IBD) would be rare events in patients treated with adalimumab for non-IBD indications. This analysis evaluated the incidence of IBD adverse events (AEs) across adalimumab trials. METHODS: IBD AE rates in 75 adalimumab clinical trials in rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, pediatric enthesitis-related arthritis, uveitis, hidradenitis suppurativa, adult and pediatric psoriasis, psoriatic arthritis, non-psoriatic arthritis peripheral spondyloarthritis (pSpA), axial spondyloarthritis (axSpA), including non-radiographic axSpA and ankylosing spondylitis, were analyzed. Search terms for IBD AEs (new onset or worsening/flare) included IBD, ulcerative colitis, Crohn's disease, and ulcerative proctitis. RESULTS: This analysis included 24,114 patients, representing 36,508 patient-years (PY) of adalimumab exposure. The overall rate (95% CI) of IBD AEs in adalimumab-treated patients was 0.1 (0.1-0.2)/100 PY (41 events), ranging from no events (psoriatic arthritis, uveitis, and pediatric trials) to 0.8 (0.2-2.2)/100 PY in pSpA; the rate of IBD in axSpA was 0.6 (0.4-1.0)/100 PY. During placebo-controlled trials, the overall IBD rate was 0.1 (0.0-0.3)/100 PY for adalimumab (3 events in 6781 patients; 2752 PY of exposure) and 0.1 (0.0-0.4)/100 PY for placebo (1 event in 3493 patients; 1246 PY of exposure) groups; IBD rates in axSpA were 0.5 (0.1-1.4)/100 PY and 0.6 (0.0-3.1)/100 PY, respectively. CONCLUSION: The rates of IBD AEs in adalimumab clinical trials were generally low across the evaluated diseases, including axSpA; all events occurred in adult patients

Use of imaging in axial spondyloarthritis for diagnosis and assessment of disease remission in the year 2022

Medical imaging remains the cornerstone of diagnostics and follow-up of axial spondyloarthritis (axSpA) patients. With the lack of specific biomarkers allowing monitoring of disease activity and progression, clinicians refer to imaging modalities for accurate evaluation of the axSpA burden. Technological advances and increasing availability of modern imaging techniques such as MRI have enabled faster diagnosis of the disease, hence dramatically changed the diagnostic delay and improved the prognosis and functional outcomes for axSpA patients. Active sacroiliitis as visualized by MRI has been widely accepted as a diagnostic tool, and definitions of inflammatory and structural lesions within the axial skeleton have been developed. Recently, it has been acknowledged that bone marrow edema, suggestive of sacroiliitis, is a common finding among non-SpA patients, and could be attributed to mechanical loading or accumulate with age in healthy individuals. Therefore, it is crucial to distinguish between true pathological and concealing imaging findings, not only for diagnostic but also for disease remission purposes. New imaging modalities, aimed for in vivo visualization of specific molecular processes, could be employed to cross-validate findings from techniques used in daily clinical practice. This review critically evaluates the use of different imaging modalities for diagnosis and assessment of disease remission in axSpA in the year 2022

Ouderen met eindstadium nierlijden : een pleidooi voor een vroegtijdige zorgplanning

Op basis van de toenemende levensverwachting evolueren steeds meer ouderen met chronisch nierlijden naar een eindstadium („end-stage renal disease” – ESRD), dat volgens veel zorgverleners een indicatie vormt voor het opstarten van dialyse. Op oudere leeftijd heeft dialyse echter vaak een negatieve impact op de levenskwaliteit en het zelfstandig functioneren. De prognose van deze patiënten wordt in belangrijke mate bepaald door de aanwezigheid van comorbiditeit, functionele beperkingen en „frailty”. Aangezien het dialysetraject voor patiënten met een uitgesproken geriatrisch profiel vaak leidt tot een snelle en significante daling van de zelfredzaamheid met een onduidelijke impact op de overleving, gaan er steeds meer stemmen op voor het voeren van een actief medisch beleid zonder het opstarten van dialyse in deze patiëntengroep. Deze evolutie benadrukt het belang van een vroegtijdige zorgplanning („advanced care planning” – ACP), kaderend binnen het geheel van de palliatieve en de ondersteunende zorg. ACP is een proces waarbij de patiënt zorgdoelen aanreikt die de basis vormen voor een door de clinicus ontworpen behandelingsstrategie. Een patiëntgerichte aanpak met de toepassing van een gedeelde besluitvorming kan bijgevolg verhinderen dat ouderen met ESRD in behandelingstrajecten terechtkomen die als zeer belastend worden ervaren en weinig tot niets bijdragen tot hun levenskwaliteit. Een inleidende casus illustreert de impact van dialyse op oudere leeftijd en de nood aan ACP bij ouderen met ESRD

Role of anti-domain 1-β2glycoprotein I antibodies in the diagnosis and risk stratification of antiphospholipid syndrome

Background: Laboratory diagnosis of antiphospholipid syndrome (APS) includes lupus anticoagulant (LAC), anticardiolipin (aCL) or anti-beta(2) glycoprotein I (a beta(2)GPI) antibodies. Antibodies targeting domain 1 of beta(2)GPI (aD1) constitute a pathogenic subset of autoantibodies. Objectives: In this cohort study, we determined the clinical performance characteristics, additional diagnostic value and the contribution to APS risk stratification of an automated aD1 assay. Patients/Methods: LAC, aCL, a beta(2)GPI and aD1 IgG were measured in 101 APS patients, 123 patients with autoimmune disorders, 82 diseased controls and 120 healthy controls. aD1 antibodies were detected by QUANTA Flash (R) Beta2GPI-Domain 1 chemiluminescence immunoassay. Results: With a cut-off value of 20.0 CU, the aD1 IgG assay identifies APS patients in a clinically affected patient cohort with a sensitivity of 53.5% and specificity of 98.8%. It implied a high odds ratio (OR) for clinical events (OR, 17.0; 95% confidence interval [CI], 7.1-40.5). aD1 IgG did not add diagnostic value to the formal aPL panel because a beta(2)GPI IgG was nearly as specific but more sensitive for APS (sensitivity 56.4%) with a higher OR for clinical events (36.2; 95% CI, 11.1-117.9). High aD1 titers identify triple- positive patients and patients with thrombosis in a beta(2)GPI-dependent LAC-positive population. Agreement between aD1 IgG and a beta(2)GPI IgG was high (positive and negative agreement 91.7% and 98.4%, respectively). Conclusion: Detection of aD1 IgG correctly classifies patients at risk of thrombosis. However, the contribution of aD1 IgG to APS diagnosis and risk stratification depends upon the solid phase assays used for aCL and a beta(2)GPI detection