Diagnostik, Therapie und Verlaufsbeurteilung der axialen Spondyloarthritis

In den letzten zwei Dekaden haben sich im Feld der Spondyloarthritiden wichtige Neuerungen ergeben. Vordergründig sind das Konzept der axialen Spondyloarthritis als Kontinuum mit zwei Untergruppen – der radiographischen axialen Spondyloarthritis und der nicht-röntgenologischen axialen Spondyloarthritis, die Diagnostik der Erkrankung unter Einbezug der MRT zur Erkennung der Frühformen der Erkrankung sowie direkten Visualisierung entzündlicher Prozesse im Bereich der Wirbelsäule sowie der SIG, die Implementation neuer Klassifikationskriterien sowie die Zulassung diverser hocheffektiver Therapien zu nennen. Nichtsdestotrotz bleiben weitere wichtige Fragen bestehen. So ist insbesondere die Ätiologie und Pathogenese der axSpA nicht ausreichend verstanden und somit stehen lediglich effektive Behandlungsansätze, jedoch weiterhin keine Heilungsmöglichkeiten dieser chronischen immunvermittelten Erkrankung zur Verfügung stehen. Ein wichtiger Schritt zu einem besseren Verständnis der Erkrankung könnte in der Entdeckung des Zusammenspiels des gastro-intestinalen Microbioms mit den Spondyloarthritiden bestehen. [135, 136] Dessen Einfluss auf Krankheitsentstehung und Krankheitsaktivität muss jedoch noch weiter erforscht werden, um hieraus möglichen Nutzen ziehen zu können. Auch konnte die Diagnoseverzögerung deutlich verkürzt werden, jedoch ist diese weiterhin mit durchschnittlich 5,7 Jahren in Deutschland [41] inakzeptabel lange und der Fokus zur Frühdiagnose muss beibehalten und nach neuen Möglichkeiten - auch unter Einbezug digitaler Ansätze – gesucht werden. Darüber hinaus erreichen trotz der Zulassung von bDMARDs als neue Therapieoptionen im klinischen Alltag weiterhin weniger als die Hälfte der axSpA Patienten den angestrebten Zustand einer inaktiven Erkrankung. [137, 138] Dies muss als ein klares Signal verstanden werden einerseits die zur Verfügung stehenden Therapien konsequenter einzusetzen und andererseits nach weiteren Therapieoptionen sowie komplementären Maßnahmen zu forschen. Da auf Grund der zum Teil erst kürzlich erfolgten Zulassungen diverser bDMARDs für das gesamte Spektrum der axSpA Langzeiterfahrungen zum Einsatz dieser Medikamente in der Patientengruppe mit axSpA fehlen, ist es von hoher Bedeutung Erfahrungen zu Sicherheit und Wirksamkeit dieser Therapien bei Patienten 84 mit axSpA im „echten Leben“ anhand von Registerdaten und Beobachtungsstudien zu sammeln. Um einen Leitfaden für die optimale Versorgung von axSpA Patienten zu haben stellen die kürzlich veröffentlichten Qualitätsstandards der ASAS [67] einen Meilenstein dar. Jedoch müssen Wege identifiziert werden, wie die hier empfohlenen Maßnahmen auch im Rahmen der klinischen Routine unter dem wirtschaftlichen Druck sowie in Anbetracht der aktuellen Versorgungssituation erreicht werden können. Im Rahmen dieser Habilitationsschrift wurde der aktuelle Stand zu den Themen der Diagnostik, Therapie und Verlaufsbeurteilung bei der axialen Spondyloarthritis erörtert, die eigenen Arbeiten zu dem Thema vorgestellt und deren möglicher Einfluss auf die Versorgungssituation von Betroffenen diskutiert. Darüber hinaus wurden weiterhin bestehende Fragen zur axialen Spondyloarthritis definiert, welche im Rahmen wissenschaftlicher Projekte in der Zukunft bearbeitet werden sollten

The Prevalent Comorbidome at the Onset of Psoriasis Diagnosis

IntroductionPsoriasis (PsO) is currently regarded as a systemic inflammatory disease with a growing burden of post-diagnosis associated comorbidities. To determine the initial burden of comorbiditis we evaluated the comorbidome at PsO onset.MethodsIn a matched case-control study, we extracted data on 57,228 patients and 125 morbidities from the Clalit Health Services Israeli insurance database. PsO cases were matched with control individuals by sex and age at enrolment. As pre-existing comorbidities, we considered all conditions already present in controls at the same age as the matched PsO case at the time of their diagnosis. To test for differences in the odds of comorbidities between the case and control groups, logistic regression analyses were run to calculate the odds ratio (OR) for each comorbidity, after which the comorbidome was graphically represented.ResultsIn this study we enrolled 28,614 PsO patients and 28,614 controls with an average age of 45.3 & PLUSMN; 19.6 years. At the time of diagnosis, PsO patients were more likely to be diagnosed with 2-4 comorbidities (28.8% vs 23.8%) and > 5 (19.6% vs 12.9%,). PsO patients' specific comorbidomes evidenced several pathological cores: autoimmune and inflammatory systemic diseases [i.e., hidradenitis suppurativa (OR 3.55, 95% CI 1.88-7.28) or polymyalgia rheumatica (OR 3.01 95% CI 1.96-4.77)], inflammatory bowel diseases [i.e., Crohn's disease (OR 2.99 95% CI 2.20-4.13)], pulmonary inflammatory diseases [i.e., chronic obstructive pulmonary disease (OR 1.81 95% CI 1.61-2.04)], hepatological diseases [i.e., cirrhosis (OR 2.00 95% CI 1.36-3.00)], endocrine diseases [dysthyroidisms (OR 1.82 95% CI 1.30-2.59)], mental disorders [i.e., depression (OR 1.72 95% CI 1.57-1.87)], and cardiovascular diseases (i.e., hypertension (OR 1.47 95% CI 1.41-1.53)].ConclusionThe PsO-onset comorbidome may help health professionals plan more comprehensive patient management. By screening for these common PsO-linked conditions, early diagnosis and treatment may become more frequent, thus greatly benefiting patients on their medical journey

Long-term safety of COVID vaccination in individuals with idiopathic inflammatory myopathies: results from the COVAD study

Limited evidence on long-term COVID-19 vaccine safety in patients with idiopathic inflammatory myopathies (IIMs) continues to contribute to vaccine hesitancy. We studied delayed-onset vaccine adverse events (AEs) in patients with IIMs, other systemic autoimmune and inflammatory disorders (SAIDs), and healthy controls (HCs), using data from the second COVID-19 Vaccination in Autoimmune Diseases (COVAD) study. A validated self-reporting e-survey was circulated by the COVAD study group (157 collaborators, 106 countries) from Feb-June 2022. We collected data on demographics, comorbidities, IIM/SAID details, COVID-19 history, and vaccination details. Delayed-onset (> 7 day) AEs were analyzed using regression models. A total of 15165 respondents undertook the survey, of whom 8759 responses from vaccinated individuals [median age 46 (35-58) years, 74.4% females, 45.4% Caucasians] were analyzed. Of these, 1390 (15.9%) had IIMs, 50.6% other SAIDs, and 33.5% HCs. Among IIMs, 16.3% and 10.2% patients reported minor and major AEs, respectively, and 0.72% (n = 10) required hospitalization. Notably patients with IIMs experienced fewer minor AEs than other SAIDs, though rashes were expectedly more than HCs [OR 4.0; 95% CI 2.2-7.0, p < 0.001]. IIM patients with active disease, overlap myositis, autoimmune comorbidities, and ChadOx1 nCOV-19 (Oxford/AstraZeneca) recipients reported AEs more often, while those with inclusion body myositis, and BNT162b2 (Pfizer) recipients reported fewer AEs. Vaccination is reassuringly safe in individuals with IIMs, with AEs, hospitalizations comparable to SAIDs, and largely limited to those with autoimmune multimorbidity and active disease. These observations may inform guidelines to identify high-risk patients warranting close monitoring in the post-vaccination period

COVAD survey 2 long-term outcomes: unmet need and protocol

Vaccine hesitancy is considered a major barrier to achieving herd immunity against COVID-19. While multiple alternative and synergistic approaches including heterologous vaccination, booster doses, and antiviral drugs have been developed, equitable vaccine uptake remains the foremost strategy to manage pandemic. Although none of the currently approved vaccines are live-attenuated, several reports of disease flares, waning protection, and acute-onset syndromes have emerged as short-term adverse events after vaccination. Hence, scientific literature falls short when discussing potential long-term effects in vulnerable cohorts. The COVAD-2 survey follows on from the baseline COVAD-1 survey with the aim to collect patient-reported data on the long-term safety and tolerability of COVID-19 vaccines in immune modulation. The e-survey has been extensively pilot-tested and validated with translations into multiple languages. Anticipated results will help improve vaccination efforts and reduce the imminent risks of COVID-19 infection, especially in understudied vulnerable groups

COVID-19 vaccine safety during pregnancy and breastfeeding in women with autoimmune diseases: results from the COVAD study

Objectives: We investigated COVID-19 vaccine safety in pregnant and breastfeeding women with autoimmune diseases (AID) in the COVID-19 Vaccination in Autoimmune Diseases (COVAD) study. Methods: Delayed-onset (>7 days) vaccine-related adverse events (AE), disease flares (DF), and AID-related treatment modifications were analyzed upon diagnosis of AID versus healthy controls (HC) and the pregnancy/breastfeeding status at the time of at least one dose of vaccine. Results: Among the 9201 participants to the self-administered online survey, 6787 (73.8%) were women. Forty pregnant and 52 breastfeeding patients with AID were identified, of whom the majority had received at least one dose of COVID-19 vaccine (100% and 96.2%, respectively). AE were reported significantly more frequently in pregnant than in non-pregnant patients (overall AE 45% vs 26%, p= 0.01; minor AE 40% vs 25.9%, p= 0.03; major AE 17.5% vs 4.6%, p< 0.01), but no difference was found in comparison with pregnant HC. No difference was observed between breastfeeding patients and HC with respect to AE. Post-vaccination DF were reported by 17.5% of pregnant and 20% of breastfeeding patients, and by 18.3% of age- and disease-matched non-pregnant and non-breastfeeding patients (n = 262). All pregnant/breastfeeding patients who experienced a DF were managed with glucocorticoids; 28.6% and 20% of them required initiation or change in immunosuppressants, respectively. Conclusion: This study provides reassuring insights into the safety of COVID-19 vaccines administered to women with AID during the gestational and post-partum periods, helping overcome hesitant attitudes, as the benefits for the mother and the fetus by passive immunization appear to outweigh potential risks