Evaluation of comorbidities in spondyloartritis

Las Espondiloartritis (EspA) son un grupo de enfermedades inflamatorias crónicas que pueden expresarse en forma de diferentes fenotipos dependiendo de la presencia de afectación axial (EspA axial), artritis periférica (EspA periférica) o ambas (EspA mixta). Además de los síntomas articulares, muchos pacientes pueden mostrar una serie de manifestaciones extra-articulares que dan lugar a la división de varios subtipos, como la Espondilitis Anquilosante (EA), Artritis Psoriásica (APso), asociada a Enfermedad inflamatoria Intestinal, Artritis Reactiva (ARe) y EspA indiferenciada. Estos pacientes presentan, de forma más frecuente que la población general, determinadas comorbilidades, es decir, manifestaciones clínicas que aparecen como consecuencia de una actividad inflamatoria persistente o debido al tratamiento. Dos importantes comorbilidades observadas en estos enfermos son la Enfermedad Cardiovascular y la fatiga, ambas de gran interés debido a su posible implicación en el tratamiento y pronóstico de las EspA. En este trabajo hemos pretendido evaluar la fatiga y la Enfermedad Cardiovascular en pacientes con EspA mediante la realización de dos estudios utilizando dos registros diferentes: REGISPONSER y ASAS-COMOSPA, respectivamente. En relación a la fatiga, los objetivos de este estudio fueron: 1) evaluar este síntoma en los diferentes subtipos de EspA, y 2) definir su asociación con factores relacionados con la enfermedad y el paciente. En relación a las comorbilidades Cardiovasculares, nuestros objetivos fueron: 3) comparar la prevalencia de Enfermedad Cardiovascular y Factores de Riesgo Cardiovascular entre los diferentes fenotipos de EspA; 4) evaluar las diferencias en las características de las EspA y Enfermedad Cardiovascular entre dos áreas geográficas (Norte de Europa vs. Región Mediterránea); y, finalmente, 5) identificar potenciales factores predictivos para la presencia de un alto Índice de Framingham según las características de las EspA y el área geográfica.Spondyloarthritis (SpA) is a chronic inflammatory disease occurring under different phenotypes depending on the presence of axial involvement (axial SpA), peripheral arthritis (peripheral SpA) or both (mixed SpA). In addition to articular symptoms, many SpA patients exhibit an array of extra-articular manifestations, which generate the division into several subtypes, such as Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), associated to Inflammatory Bowel Disease (IBD-associated SpA), Reactive Arthritis (ReA) and undifferentiated SpA. Fequently, these patients present comorbidities, that is to say, clinical manifestations that appear as a consequence of a persistent inflammatory activity or due to the treatment. Two important comorbidities observed in these patients are Cardiovascular disease and fatigue, which are of particular interest due to their role and their possible involvement in the treatment and prognosis of SpA. In this study, we aimed to evaluate fatigue and Cardiovascular disease in SpA patients undertaking two studies and using two different registries: REGISPONSER and ASAS-COMOSPA, respectively. Regarding fatigue, the objectives of this study were: 1) to evaluate this symptom among different subtypes of SpA, and 2) to define its association with disease-related factors and patient’s features. Regarding Cardiovascular comorbidities, we aimed: 3) to compare the prevalence of Cardiovascular disease and Cardiovascular Risk Factors among different phenotypes of SpA; 4) to assess the differences in SpA characteristics and Cardiovascular disease between two geographical areas, i.e. Northern Europe vs. Mediterranean region; and finally, 5) to identify potential predictive factors for high Framingham Risk Score (FRS) regarding disease features in SpA and geographical area

Future challenges and critical approach to metrology in patients with axial spondyloarthritis

Axial spondyloarthritis (axSpA) is a rheumatic inflammatory chronic disease that mainly affects the spine, producing inflammation and structural damage at the vertebral level (erosions, syndesmophytes, and bony bridges). This leads to a reduction of mobility in axSpA patients [1] that requires assessment by rheumatologists to closely monitor patients and analyse the efficacy of prescribed treatments. Several tools are used for the evaluation of these patients [2]; thus, self-assessed patient report outcomes (PRO) questionnairesmay be completed by the patient to evaluate function (Bath Ankylosing Spondylitis Functional Index—BASFI), whereas other toolsmonitor disease activity (Bath Ankylosing Spondylitis Disease Activity Index—BASDAI) and the patient’s quality of life (Assessment of SpondyloArthritis International Society Health Index—ASAS-HI), among others. In addition, other indexes are used to analyse radiographic structural damage (modified Stoke Ankylosing Spondylitis Spinal Score—mSASSS) and activity indexes based on blood tests (Ankylosing Spondylitis Disease Activity Score—ASDAS)

Characterising the axial phenotype of psoriatic arthritis: a study comparing axial psoriatic arthritis and ankylosing spondylitis with psoriasis from the REGISPONSER registry

AimsTo explore the clinical and radiographical characteristics of axial psoriatic arthritis (PsA) and to compare it with ankylosing spondylitis (AS) with psoriasis.MethodsCross-sectional study from the national multicentre registry REGISPONSER where participants fulfilled the European Spondyloarthropathy Study Group spondyloarthritis criteria at entry. Clinical, laboratory and radiographical characteristics between patients classified as axial PsA and AS with psoriasis by their rheumatologist are compared according to HLA-B27 status.ResultsOf 2367 patients on REGISPONSER, n=405 had PsA, of whom 27% (n=109) had axial involvement as per the treating rheumatologist. 30% (n=26/86) of axial PsA were HLA-B27 positive. In the AS group, 9% (127/1422) had a history of psoriasis and were more frequently male, with longer diagnostic delay and more anterior uveitis than those with axial PsA who had more peripheral involvement and nail disease. Patients with HLA-B27-negative axial PsA reported less inflammatory pain and structural damage compared with AS with psoriasis. By contrast, HLA-B27-positive axial PsA shared clinical characteristics similar to AS and psoriasis although with a lower BASRI score. In the multivariable analysis, patients with AS and psoriasis were independently associated with HLA-B27 positivity (OR 3.34, 95% CI 1.42 to 7.85) and lumbar structural damage scored by BASRI (OR 2.14, 95% CI 1.4 to 3.19).ConclusionThe more prevalent axial PsA phenotype is predominantly HLA-B27 negative and presents different clinical and radiological manifestations when compared with AS with psoriasis. There is great heterogeneity in what rheumatologists consider axial PsA from a clinical and imaging perspective, highlighting the need for research into possible genetic drivers and a consensus definition

Characterising the axial phenotype of psoriatic arthritis: a study comparing axial psoriatic arthritis and ankylosing spondylitis with psoriasis from the REGISPONSER registry

Espondilitis anquilosante; Artritis; EpidemiologíaEspondilitis anquilosant; Artritis; EpidemiologiaAnkylosing spondylitis; Arthritis; EpidemiologyAims To explore the clinical and radiographical characteristics of axial psoriatic arthritis (PsA) and to compare it with ankylosing spondylitis (AS) with psoriasis. Methods Cross-sectional study from the national multicentre registry REGISPONSER where participants fulfilled the European Spondyloarthropathy Study Group spondyloarthritis criteria at entry. Clinical, laboratory and radiographical characteristics between patients classified as axial PsA and AS with psoriasis by their rheumatologist are compared according to HLA-B27 status. Results Of 2367 patients on REGISPONSER, n=405 had PsA, of whom 27% (n=109) had axial involvement as per the treating rheumatologist. 30% (n=26/86) of axial PsA were HLA-B27 positive. In the AS group, 9% (127/1422) had a history of psoriasis and were more frequently male, with longer diagnostic delay and more anterior uveitis than those with axial PsA who had more peripheral involvement and nail disease. Patients with HLA-B27-negative axial PsA reported less inflammatory pain and structural damage compared with AS with psoriasis. By contrast, HLA-B27-positive axial PsA shared clinical characteristics similar to AS and psoriasis although with a lower BASRI score. In the multivariable analysis, patients with AS and psoriasis were independently associated with HLA-B27 positivity (OR 3.34, 95% CI 1.42 to 7.85) and lumbar structural damage scored by BASRI (OR 2.14, 95% CI 1.4 to 3.19). Conclusion The more prevalent axial PsA phenotype is predominantly HLA-B27 negative and presents different clinical and radiological manifestations when compared with AS with psoriasis. There is great heterogeneity in what rheumatologists consider axial PsA from a clinical and imaging perspective, highlighting the need for research into possible genetic drivers and a consensus definition.HM-O is supported by the National Institute for Health Research Leeds Biomedical Research Centre. The REGISPONSER registry is funded by an unrestricted grant from the Spanish Society for Rheumatology. There was no specific funding for the current analysis

Clinical and molecular insights into cardiovascular disease in psoriatic patients and the potential protective role of apremilast

Psoriatic disease, encompassing both psoriasis (Pso) and psoriatic arthritis (PsA), is closely intertwined with a significantly elevated risk of developing cardiovascular diseases. This connection is further compounded by a higher prevalence of cardiometabolic comorbidities, including type 2 diabetes, obesity, insulin resistance, arterial hypertension, and dysregulated lipid profiles. These comorbidities exceed the rates seen in the general population and compound the potential for increased mortality among those living with this condition. Recognizing the heightened cardiometabolic risk inherent in psoriatic disease necessitates a fundamental shift in the treatment paradigm. It is no longer sufficient to focus solely on mitigating inflammation. Instead, there is an urgent need to address and effectively manage the metabolic parameters that have a substantial impact on cardiovascular health. Within this context, apremilast emerges as a pivotal treatment option for psoriatic disease. What sets apremilast apart is its dual-action potential, addressing not only inflammation but also the critical metabolic parameters. This comprehensive treatment approach opens up new opportunities to improve the well-being of people living with psoriatic disease. This review delves into the multifaceted aspects involved in the development of cardiovascular disease and its intricate association with psoriatic disease. We then provide an in-depth exploration of the pleiotropic effects of apremilast, highlighting its potential to simultaneously mitigate metabolic complications and inflammation in individuals affected by these conditions

Exploring the unifying concept of Spondyloarthritis: a latent class analysis of the REGISPONSER registry

ObjectivesThe aim of our study is to identify the potential distinct phenotypes within a broad Spondyloarthritis (SpA) population.MethodsWe conducted a cross-sectional study using the REGISPONSER registry with data from 31 specialist centres in Spain including patients with SpA who fulfilled the European Spondyloarthropathy Study Group (ESSG) criteria. A latent class analysis (LCA) was performed to identify the latent classes underlying SpA according to a set of predefined clinical and radiographic features, independently of expert opinion.ResultsIn a population of 2319 SpA patients, a 5 classes LCA model yielded the best fit. Classes named ‘axial with spine involvement’ and ‘axial with isolated SIJ involvement” show a primarily axial SpA phenotype defined by inflammatory back pain and high HLA-B27 prevalence. Patients in class ‘axial + peripheral’ show similar distribution of manifest variables to previous classes but also have a higher likelihood of peripheral involvement (peripheral arthritis/dactylitis) and enthesitis, therefore representing a mixed (axial and peripheral) subtype. Classes ‘Peripheral + psoriasis’ and ‘Axial + peripheral + psoriasis’ are indicative of peripheral SpA (and/or PsA) with high likelihood of psoriasis, peripheral involvement, dactylitis, nail disease, and low HLA-B27 prevalence, while class ‘Axial + peripheral + psoriasis’ also exhibits increased probability of axial involvement both clinically and radiologically.ConclusionThe identification of 5 latent classes in the REGISPONSER registry with significant overlap between axial and peripheral phenotypes is concordant with a unifying concept of SpA. Psoriasis and related features (nail disease and dactylitis) influence the phenotype of both axial and peripheral manifestations.<br/

Assessment of Subclinical Psychotic Symptoms in Patients with Rheumatoid Arthritis and Spondyloarthritis

Inflammatory and autoimmune processes have been associated with the onset of depressive and psychotic symptoms. Rheumatoid arthritis (RA) and spondyloarthritis (SpA) are rheumatic diseases with an inflammatory etiology. A high prevalence of depressive and anxiety-related comorbidity has been reported for both diseases, with no evidence of a greater prevalence of psychosis. The objective of the present study was to evaluate for the first time subclinical psychotic symptoms in patients with RA and SpA. This is a cross-sectional, single-center study including RA and SpA patients, as well as healthy controls. Abnormal psychotic experiences (positive, negative, and depressive symptoms) were evaluated using the Community Assessment of Psychic Experiences (CAPE-42). Functional capacity was evaluated using the Short-Form Health Survey SF-12. We compared the CAPE and SF-12 scores between the three groups. We recruited 385 individuals: 218 with RA, 100 with SpA, and 67 healthy controls. According to the CAPE scale, the frequency of subclinical psychotic symptoms was greater in patients than in healthy controls (RA, 1.90 vs. 1.63, p < 0.001; SpA, 1.88 vs. 1.63, p = 0.001). Distress was also greater in patients than in controls owing to the presence of symptoms. No differences were observed between the three groups for the mental dimension scores in the SF-12 Health Survey (43.75 in RA, 45.54 in SpA, and 43.19 in healthy controls). Our findings point to a greater prevalence of subclinical psychotic symptoms in patients with RA and patients with SpA than in the general population. The results suggest an association between inflammation and depression/subclinical psychotic symptoms

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

To 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 and female patients. This is a post hoc analysis of the COMOrbidities in SPondyloArthritis study. Differences in comorbidities regarding sex were assessed using logistic regression models. Comorbidities were evaluated for their impact on disease outcomes (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS), Bath Ankylosing Spondylitis Functional Index, European health-related quality of life questionnaire) with linear models, which included sex and comorbidity as explanatory variables and their interaction. Age and treatment with biological synthetic disease-modifying antirheumatic drugs were included as confounders. We included 3982 patients with SpA (65% male, mean age 43.6 years). Male and female patients with SpA exhibited similar comorbidity profiles, except for a low prevalence of fibromyalgia in males and a higher prevalence of certain cardiovascular risk factors in males (hypertension, dyslipidaemia, renal impairment and ischaemic heart disease). Comorbidities, especially fibromyalgia, correlated with higher disease activity, decreased physical function and reduced health-related quality of life in both sexes. Some comorbidities exhibited sex-specific associations with disease outcomes. Peptic ulcers and high waist circumference had a greater impact on disease activity in females (with a higher impact in BASDAI than in ASDAS). In contrast, osteoporosis had a more pronounced effect on physical function in male patients. Comorbidities exert distinct influences on disease activity, physical function and health-related quality of life in male and female patients with SpA. Understanding these sex-specific effects is crucial for improving SpA management, emphasising the importance of assessing disease activity using ASDAS when comorbidities are present to mitigate sex-related disparities in disease assessment

Patients with Axial Spondyloarthritis Show an Altered Flexion/Relaxation Phenomenon

Axial spondyloarthritis (axSpA) is a chronic rheumatic disease characterized by the presence of inflammatory back pain. In patients with chronic low back pain, the lumbar flexion relaxation phenomenon measured by surface electromyography (sEMG) differs from that in healthy individuals. However, sEMG activity in axSpA patients has not been studied. The purpose of this study was to analyze the flexion relaxation phenomenon in axSpA patients. A study evaluating 39 axSpA patients and 35 healthy controls was conducted. sEMG activity at the erector spinae muscles was measured during lumbar full flexion movements. sEMG activity was compared between axSpA patients and the controls, as well as between active (BASDAI ≥ 4) and non-active (BASDAI 0.8 for 1/FRR) and criterion validity. ROC analysis showed good discriminant validity for axSpA patients (AUC = 0.835) vs. the control group using 1/FRR. An abnormal flexion/relaxation phenomenon exists in axSpA patients compared with controls. sEMG could be an additional objective tool in the evaluation of patient function and disease activity status

Subclinical Atherosclerosis Measure by Carotid Ultrasound and Inflammatory Activity in Patients with Rheumatoid Arthritis and Spondylarthritis

Objective: To compare the effect of inflammation on subclinical atherosclerosis using carotid ultrasound in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA). Methods: Cross-sectional study including 347 participants (148 RA, 159 SpA, and 40 controls). We measured the carotid intima media thickness (cIMT) and detection of atheromatous plaques using carotid ultrasound. We recorded disease activity (DAS28-CRP/ASDAS-CRP) and traditional cardiovascular risk factors. We performed descriptive, bivariate, and linear multivariate analyses (dependent variable: cIMT) to evaluate the influence of diagnosis on cIMT in all patients. Two additional multivariate analyses were performed by stratifying patients according to their inflammatory activity. Results: cIMT correlated with the mean CRP during the previous 5 years in RA, but not with CRP at the cut-off date. We did not find such differences in patients with SpA. The first multivariate model revealed that increased cIMT was more common in patients with RA than in those with SpA (β coefficient, 0.045; 95% confidence interval (95% CI), 0.0002–0.09; p = 0.048) after adjusting for age, sex, disease course, and differential cardiovascular risk factors (arterial hypertension, smoking, statins, and corticosteroids). The second model revealed no differences in cIMT between the 2 groups of patients classified as remission–low activity (β coefficient, 0.020; 95% CI, −0.03 to 0.080; p = 0.500). However, when only patients with moderate–high disease activity were analysed, the cIMT was 0.112 mm greater in those with RA (95% CI, 0.013–0.212; p = 0.026) than in those with SpA after adjusting for the same variables. Conclusions: Subclinical atherosclerosis measured by carotid ultrasound in patients with RA and SpA is comparable when the disease is well controlled. However, when patients have moderate–high disease activity, cIMT is greater in patients with RA than in those with SpA after adjusting for age, sex, disease course, and cardiovascular risk factors. Our results point to greater involvement of disease activity in subclinical atherosclerosis in patients with RA than in those with SpA