Para médicos · reumatologia
Resumos de artigos, podcasts e newsletters sobre Espondiloartrite Axial, para atualização médica.
A newsletter destaca a revisão do índice de dano (SDI) no Lúpus Eritematoso Sistêmico, que busca maior precisão clínica ao remover itens de atividade inflamatória e incluir critérios de gravidade. Além disso, apresenta novos guidelines da EULAR para vasculites e polimialgia reumática, e discute evidências recentes sobre terapias biológicas e inibidores de fosfodiesterase em doenças autoimunes.
A newsletter analisa um estudo populacional que revela alta prevalência de edema ósseo sacroilíaco em indivíduos saudáveis, alertando para a necessidade de contexto clínico no diagnóstico de espondiloartrites. Além disso, discute as divergências entre diretrizes globais para esclerose sistêmica e apresenta avanços em novas terapias biológicas para o lúpus.
BACKGROUND: According to the modified New York criteria (mNYc), moderate-severe sacroiliac joint (SIJ) structural damage on radiography is necessary for classifying radiographic axial spondyloarthritis (r-axSpA). In contrast to radiography, MRI provides no ionizing radiation, higher sensitivity for structural damage, better inter-reader reliability, and is gradually replacing radiography. Therefore, we aimed to develop and validate a high specificity MRI cut-off to the radiographic component of the mNYc (rad-mNYc), defined as MRI findings that correspond to an mNY-positive radiograph. METHODS: based on erosion, backfill and ankylosis in 5/all slices) and ROC curves were calculated. Internal validation by bootstrapping was performed. RESULTS: predicting rad-mNYc (specificity 0.95, sensitivity 0.39, area-under-curve 0.83, accuracy with mNYc 69.2%. Internal validation showed moderate accuracy and high positive predictive value. Cut-offs for sclerosis, erosion, backfill and ankylosis were ≥ 9, ≥12, ≥ 5, and ≥ 1, respectively, with sensitivities all ≤ 0.21 except ankylosis 0.34 and accuracy ~ 60%, except ankylosis 67%. Cut-offs using all MRI-slices performed slightly worse or similarly. CONCLUSIONS: ) was the optimal high specificity MRI cut-off to rad-mNYc positivity, being potentially usable in both research and clinical settings, with different thresholds depending on whether sensitivity or specificity is prioritized.
OBJECTIVE: People with inflammatory arthritis (IA) frequently experience work instability, absenteeism, and reduced productivity, culminating in early job loss. This study evaluated the effectiveness and cost-effectiveness of WORKWELL job retention vocational rehabilitation (JRVR) delivered by occupational therapists, compared to a control group receiving written self-help advice. METHODS: A pragmatic, multi-centre randomised controlled trial was conducted across 18 UK NHS Trusts. Employed adults (n = 249) with IA experiencing moderate to severe work instability, were randomised (1:1) to intervention or control groups. WORKWELL included structured work assessment, individually tailored action plans, and interventions over 2-4 months. Follow-up was at 6, 12, and 36 months. The primary outcome was the Work Limitations Questionnaire-25 (WLQ-25). Analyses used linear mixed-effects regression adjusted for baseline characteristics and occupational skill level. An NHS perspective was used for the within-trial cost-effectiveness analysis. Much of the trial was affected by the COVID-19 pandemic. RESULTS: At 12 months, there was no significant difference in WLQ-25 between groups (adjusted mean difference: -1.8; 95% CI -7.4 to 3.8; p = 0.53), or in most secondary outcomes at 12- or 36-months. However, absenteeism showed a relative reduction of 46% at 12 months (p = 0.08), and employment retention at 36 months was higher in the intervention (93%) vs. control group (85%). The intervention was not cost-effective from an NHS perspective. CONCLUSION: WORKWELL did not lead to improved work productivity compared to self-help advice. Future research should explore more flexible delivery methods, including digital tools, to support sustainable employment for people with IA. A plain-language abstract is available in the supplementary material. TRIAL REGISTRATION: ClinicalTrials.gov; NCT03942783. ISRCTN Registry; ISRCTN61762297.
A newsletter apresenta os destaques do EULAR 2026, focando em novas evidências para o tratamento da Artrite Reumatoide e Espondiloartrite Axial. São discutidos estudos inovadores sobre o uso de tocilizumabe na depressão inflamatória, o efeito da tirzepatida no ácido úrico e a eficácia do upadacitinibe após falha terapêutica. O conteúdo também aborda o papel da IA no suporte a pacientes com esclerose sistêmica e um caso clínico de Doença de Vogt-Koyanagi-Harada.
Objective To examine the independent association of kinesiophobia with meeting physical activity (PA) guideline recommendations in individuals with axial spondyloarthritis (axSpA). Methods This cross-sectional study recruited U.S.-based adults with axSpA via online platforms and support groups between October and December 2020, during the COVID-19 pandemic. Participants completed a digital survey including demographic and clinical information and validated outcome measures for kinesiophobia (TSK-11), disease activity (BASDAI), function (BASFI), quality of life (ASQoL), and PA participation. PA participation was categorized as meeting American College of Sports Medicine (ACSM) guidelines for moderate, vigorous, and strengthening activity. Logistic regression models assessed the association of TSK-11 scores with meeting ACSM PA recommendations, adjusting for age, sex, disease duration, and disease activity. Results 180 participants completed the survey. Overall, 31%, 26%, and 34% met ACSM guidelines for moderate, vigorous, and strengthening activity, respectively. Higher kinesiophobia was significantly associated with reduced odds of meeting PA guidelines across all activity types. In adjusted models, sample sizes ranged from 141 to 142 participants across activity outcomes due to incomplete data; each one-point increase in TSK-11 was associated with 11% lower odds of meeting strengthening activity guidelines (OR = 0.89, 95% CI: 0.83–0.96), 8% lower odds for meeting moderate activity guidelines (OR = 0.92, 95% CI: 0.86–0.99), and 9% lower odds for meeting vigorous activity guidelines (OR = 0.91, 95% CI: 0.84–0.98). No covariates included in the adjusted models (age, sex, disease duration, BASDAI) were significant predictors. Conclusion Kinesiophobia was independently associated with lower odds of meeting PA guidelines among individuals with axSpA, beyond demographic and disease-related factors. These findings underscore the need for routine assessment and targeted intervention strategies to address fear-avoidant behaviors in activity and exercise counseling for
Introduction Spondyloarthritis (SpA) is a major cause of chronic pain and disability worldwide; however, clinical characterization remains limited in Southeast Asia, particularly in low- and middle-income countries. This study aimed to describe the epidemiological and clinical characteristics of SpA in Central Vietnam. Methods We conducted a cross-sectional study of patients diagnosed with SpA according to the Assessment of SpondyloArthritis International Society criteria from 2019 to 2024. Disease activity was evaluated using the Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) and the Patient Global Assessment (PGA). Factors associated with ASDAS-CRP and PGA score were explored using linear regression models. Results Based on an analaysis of 177 patients with SpA, the following results were observed. Most patients (148) had axial SpA, while 29 (16.4%) had peripheral SpA. Males accounted for 66.7% of cases, and 95.5% were diagnosed before the age of 45 years. The mean ASDAS-CRP and PGA scores were 2.8 ± 1.1 and 5.1 ± 2.1, respectively. Overall, 57% of patients exhibited high or very high disease activity. Higher ASDAS-CRP scores were significantly associated with male sex, presence of enthesitis, CRP ≥ 5 mg/L, ESR ≥ 10 mm/h, and absence of anemia. Higher PGA scores were significantly associated with older age at diagnosis, presence of enthesitis, chronic enteritis, CRP ≥ 5 mg/L, and absence of anemia. Conclusion This study highlights a male predominance and a higher proportion of axial over peripheral SpA in Central Vietnam. Most patients presented with moderate to high disease activity. These findings emphasize the need for early diagnosis and management, as well as larger multi-center studies to better define the epidemiology and clinical patterns of SpA in Vietnam. Key Points • Provides the first comprehensive clinical characterization of spondyloarthritis
OBJECTIVE: Although axial spondyloarthritis (axSpA) is an inflammatory disease primarily affecting the spine, studies investigating cervical spine instability (CSI) are limited, and no research has comprehensively evaluated all forms of CSI. This study aimed to determine the frequency and associated factors of CSI in axSpA patients. METHOD: This retrospective cross-sectional study, conducted in a single tertiary rheumatology unit, included adult axSpA patients with inflammatory back pain duration of > 10 years and receiving biological or targeted synthetic therapy. Patients with any concomitant disease that could affect the spine were excluded. CSI lesions were assessed using lateral neutral, full extension, full flexion, and open-mouth anteroposterior cervical radiographs. Radiographs were evaluated by two blinded rheumatologists. RESULTS: In total, 159 axSpA cases (ankylosing spondylitis: 89.3%; non-radiographic axSpA: 10.7%) were included in the study; 57.9% were male, mean age was 47 years, and mean disease duration was 17 years. A total of 33 CSI lesions was detected in 31 patients (19.5%); the most common was anterior atlantoaxial subluxation (54.5%), followed by subaxial (33.3%) and vertical subluxation (6.1%). In univariate logistic regression analysis; disease duration (p = 0.004), age at first symptom (p = 0.02), uveitis (p = 0.049), and sacroiliitis stage (p = 0.039) were associated with CSI. In multivariate analysis, disease duration was identified as a potential independent predictor of CSI (p = 0.027). CONCLUSION: These results highlight the need for increased clinical awareness of CSI in axSpA, and support consideration of cervical imaging in patients with prolonged disease duration, severe sacroiliitis, or uveitis.
Background Several cases of pyoderma gangrenosum, a rare neutrophilic dermatosis, have been reported in patients initiating biological therapies for rheumatic health conditions. Despite this, systematic analysis across available therapies is lacking. This study investigated pyoderma gangrenosum reporting in association with antirheumatic biologics to the US Food and Drug Administration Adverse Event Reporting System (FAERS). Methods Reports from FAERS (2016–second quarter of 2025) were complied, deduplicated, and standardized. Pyoderma gangrenosum cases were classified according to the Medical Dictionary for Regulatory Activities. Proportional reporting ratios (PRRs) and 95% confidence intervals (CIs) were calculated to estimate disproportionality for 20 individual antirheumatic biologics from nine pharmacologic classes. Results During the study period, 13,284,367 adverse events were reported to FAERS, including 1316 pyoderma gangrenosum cases; 868 (65.96%) cases identified an antirheumatic biologic as the primary suspect product. Positive disproportionality signals were detected for 11 study biologics belonging to six pharmacologic classes. All four interleukin (IL)-17 inhibitors exhibited disproportionate pyoderma gangrenosum reporting, with brodalumab (PRR 23.02; 95% CI 8.64–61.36) and bimekizumab (PRR 9.10; 95% CI 4.08–20.29) demonstrating the strongest signals. Positive disproportionality signals were also observed among biologics targeting tumor necrosis factor alpha, IL-6, IL-12/23, IL-23, and CD20. Similar results were obtained in sensitivity analyses. Conclusion Despite its limitations, this hypothesis-generating analysis identified significantly disproportionate pyoderma gangrenosum reporting with several antirheumatic biologics. Clinicians should remain vigilant for these paradoxical reactions in patients undergoing biologic treatment for rheumatic conditions. Key points • Pyoderma gangrenosum has been reported in patients undergoing treatment with biologics for rheumatic indications. • This study analyzed spontaneous postmarketing pyoderma gangrenosum reporting in association with 20 antirheumatic biologics. • Pyoderma gangrenosum disproportionality signals were identified for 11 biologics targeting interleukin (IL)-6, IL-17, IL-12/23, IL-23,
Background The expanding use of biologic and targeted synthetic disease-modifying antirheumatic drugs (bDMARDs and tsDMARDs) has substantially improved outcomes in autoimmune diseases but is accompanied by complex safety concerns. Risk management plans (RMPs) have been introduced to mitigate treatment-related risks; however, real-world adherence to these strategies and their broader clinical impact remain incompletely characterized. Methods We conducted a retrospective observational cohort study of adult patients with autoimmune diseases who received bDMARDs, tsDMARDs, or biosimilars at a tertiary medical center in southern Taiwan between October 2014 and December 2023. Patients were classified into RMP and non-RMP groups based on completion of predefined pre-treatment safety assessments within 6 months prior to therapy initiation, including pulmonary and tuberculosis evaluation, viral hepatitis screening, and documentation of cardiovascular and malignancy risk factors. Clinical outcomes included Pneumocystis jirovecii pneumonia (PJP), major adverse cardiovascular events (MACE), treatment-related respiratory adverse events, and all-cause mortality. Multivariable logistic regression and time-to-event analyses were performed to evaluate associations between RMP implementation and clinical outcomes. Results Among 1,078 patients included, only 348 (32.3%) fulfilled the predefined RMP criteria prior to treatment initiation. Compared with the RMP group, patients without RMP exhibited significantly higher incidences of PJP (11.9% vs. 2.3%), MACE (8.5% vs. 2.6%), treatment-related respiratory adverse events (50.4% vs. 42.8%), and all-cause mortality (7.3% vs. 1.7%) (all p < 0.05). After multivariable adjustment, RMP implementation remained independently associated with lower risks of PJP (adjusted odds ratio [aOR] 0.18, 95% CI 0.15–0.84), MACE (aOR 0.30, 95% CI 0.13–0.71), and all-cause mortality (aOR 0.21, 95% CI 0.07–0.61). Subgroup and time-to-event analyses demonstrated that anti-CD20 therapy was associated with the highest risk of early-onset PJP, MACE, and mortality, with most events occurring within the first three
PURPOSE OF REVIEW: The concept of difficult-to-treat (D2T) disease is increasingly recognized across immune-mediated inflammatory diseases, and was recently introduced in spondyloarthritis (SpA). Several terms, including difficult-to-manage (D2M), complex-to-manage (C2M), and treatment-refractory (TR) describe disease states characterized by persistent symptoms and inadequate response to targeted therapies. This review aims to clarify the emerging constructs of D2M and TR disease in axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA), and their implications for emerging research in this area. RECENT FINDINGS: Recent initiatives from ASAS, EULAR, and GRAPPA have proposed definitions to frame D2T clinical scenarios in axSpA and PsA. These converge on distinguishing treatment-refractory disease, characterized by persistent objective inflammation despite multiple targeted therapies, from broader D2M/C2M states driven by multifactorial contributors including non-inflammatory factors. Emerging data suggest that clinical and biological heterogeneity across disease domains may contribute to these phenotypes. Challenging phenotypic presentations often display overlapping features between axSpA and PsA, supporting the concept of a continuum across the SpA spectrum. SUMMARY: Distinguishing TR disease from broader D2M/C2M states is essential for avoiding inappropriate treatment escalation, and supporting personalized multidisciplinary care. Further research is needed to validate these definitions, determine contributing factors and their prevalence, and clarify the molecular mechanisms underlying treatment refractory disease.
A newsletter discute os desafios práticos e emocionais da maternidade em mulheres com doenças reumáticas, destacando que o cuidado médico deve transcender métricas clínicas como o DAS-28. Além disso, apresenta atualizações científicas sobre novos biomarcadores de inflamação coronariana na artrite reumatoide e a caracterização de fenótipos específicos em pacientes com anticorpos anti-CENP-B e anti-SSA.
Sex and gender shape disease presentation, diagnostic accuracy, treatment response and clinical outcomes in rheumatology, yet these dimensions remain insufficiently embedded in clinical practice. Owing to the markedly unbalanced sex prevalence ratios across many rheumatic diseases, the ‘minority’ sex is consistently under-represented in clinical studies, limiting the interpretation of long-term outcomes and treatment effectiveness. Sex-related differences in pain perception, inflammatory biomarkers and imaging patterns further complicate disease assessment, and treatment allocation and drug persistence also differ between women and men. Gender-related factors — including disparities in care-seeking behaviours, social roles and lifestyle factors — additionally modulate symptom burden and disease trajectories. Evidence remains particularly scarce for transgender, gender-diverse and intersex individuals, who are rarely captured in clinical cohorts, restricting the development of inclusive and generalizable evidence. Embedding sex-aware and gender-aware approaches into diagnostic reasoning, risk assessment and therapeutic decision-making is therefore essential for advancing precision, equity and truly personalized rheumatological care. Such integration enables clinicians to interpret disease signals more accurately, anticipate divergent multimorbidity trajectories and tailor treatment strategies to the biological and sociocultural contexts of each patient.
OBJECTIVE: To compare demographic, clinical, functional, and therapeutic characteristics of patients with axial spondyloarthritis (axSpA) across three Latin American regions using data from the ESPALDA registry between January 2019 and December 2024. METHODS: This cross-sectional study included 418 patients diagnosed with axSpA who fulfilled ASAS classification criteria. Participants were recruited from three regions: Northern (Mexico), Andean (Colombia, Ecuador, Peru, Venezuela), and Southern (Argentina, Chile, Paraguay, Uruguay). Collected data included demographic features, HLA-B27 status, extra-articular manifestations, disease activity, radiographic damage, and treatments. RESULTS: The Northern region showed the highest prevalence of HLA-B27 (81%) and uveitis (36.3%), along with lower frequencies of peripheral involvement and fewer patients with MRI sacroiliitis (12.9%) (all p ≤ 0.003). In contrast, the Southern region reported a later onset of inflammatory back pain (median 39 vs. 22 years; p = 0.01), higher BASFI scores (median 4.6 vs. 2.87; p = 0.004), and a lower response to NSAIDs (59.8% vs. >77%; p = 0.001). Use of biologic DMARDs was lowest in the Northern region (34.4%) compared with the Andean (58.2%) and Southern (53.9%) regions (p ≤ 0.002 for North vs. others). The median diagnostic delay was 40.9 months (IQR 21-120), with no significant regional differences. CONCLUSION: Two clinical phenotypes of axSpA appear to exist in Latin America: a predominantly axial, HLA-B27-positive phenotype in the Northern region, and a second phenotype in the Andean and Southern regions characterized by greater peripheral involvement and, in the South, later symptom onset and worse functional status.
We have reviewed and updated the Canadian Rheumatology Association/Spondyloarthritis Research Consortium of Canada (CRA/SPARCC) living treatment recommendations for the management of axial spondyloarthritis (axSpA). 1,2 Since its initial publication, the panel felt the need to reassess recommendations relating to treatment with interleukin-17 inhibitors (IL-17i).
Summary Background Patient-initiated follow-up (PIFU) is designed to give patients more control over their follow-up care in rheumatology and relies on patients coming forward to schedule appointments and understand how and when to contact their rheumatology team. Additionally, rheumatology teams need to establish suitable criteria and have systems in place to support PIFU. Resources to inform patients with rheumatic disease about PIFU or to support its implementation in rheumatology clinics is scarce. The aim of this study was to co-design resources with patients and clinicians to support the implementation of PIFU across the UK. Methods This co-design study was done across four research centres in the UK: University of Oxford, University of Plymouth, King's College London, and the University of the West of England. The study was overseen by a steering group, who met on a monthly basis. Patients were invited through online advertisements disseminated via patient charities and clinicians were invited via email. Patients aged 18 years or older with a self-reported inflammatory arthritis and clinicians with and without experience in PIFU were included. Online patient-led and clinician-led workshops were conducted to discuss their views and experiences of PIFU, to identify the needs of both groups, and to develop PIFU resources to support its implementation. Findings Between Oct 3, 2023, and April 30, 2024, ten online workshops were conducted (including seven patient-led [61 patients] and three clinician-led workshops [nine clinicians]). Based on discussions from these workshops several patient and clinician PIFU resources were designed. For patients, this included a PIFU video in English (with subtitles available in Welsh, Polish, Urdu, Punjabi, Romanian, and Cantonese), a frequently asked questions document, and an infographic with links to patient organisations. For clinicians,
Abstract Objectives The heterogeneous presentation of axial spondyloarthritis (axSpA) complicates diagnosis and treatment decisions. This study compared patient symptoms, healthcare resource utilisation and physician-patient alignment on disease severity and treatment satisfaction between the United States (US) and five European countries (5EU). Methods Data were drawn from the Adelphi axSpA Disease Specific Programme (DSP)™, a real-world cross-sectional survey conducted in the US and 5EU between March and November 2021. Rheumatologists reported on consecutive patients, including clinical characteristics, disease severity, symptomatic burden, treatment history, healthcare resource utilisation, and treatment satisfaction. Patients reported on disease severity, treatment satisfaction, and other validated patient-reported outcome measures. Physician-patient alignment was quantified using weighted kappa analyses. Results 351 rheumatologists provided data for 2,750 patients (US = 656, 5EU = 2,094), of whom 1,011 (36.8%) self-reported data. Mean [standard deviation (SD)] number of symptoms at diagnosis were similar (US: 6.0 [4.4] vs 5EU: 6.4 [4.3]; p= 0.0657), however mean [SD] at data collection was greater in the US than 5EU (3.3 [3.3] vs 2.3 [2.8] respectively; p&lt; 0.0001). Physician-patient alignment on disease severity at diagnosis (κ = 0.37 vs κ = 0.47), treatment initiation (κ = 0.32 vs κ = 0.42) and data collection (κ = 0.32 vs κ = 0.61), and treatment satisfaction (κ = 0.35 vs κ = 0.42) were lower in US than 5EU. Mean [SD] consultations in the previous 12 months were lower in the US than 5EU (5.2 [3.4] vs 6.5 [5.1]; p= 0.0008), although mean hospitalisations were similar. Conclusion Differences in symptomatic burden and care were observed between regions. Identifying care gaps will aid in implementing targeted improvements in treatment, minimising the risk of health inequalities.
Arthritis &amp;Rheumatology, Volume 78, Issue 3, Page 772-773, March 2026.
Arthritis &amp;Rheumatology, Volume 78, Issue 3, Page 582-591, March 2026.
Objective Axial Spondyloarthritis Disease Activity Score (ASDAS) is a composite score that measures disease activity in axial spondyloarthritis (axSpA) and is based on patient-reported outcomes and objective measures of inflammation. An ASDAS score of < 1.3 indicates inactive disease (ASDAS-ID) in axSpA clinical trials and is considered equivalent to clinical remission. We hypothesized that achieving ASDAS< 1.3 represents a stringent target that may be difficult to attain in randomized clinical trials. We aimed to evaluate the proportion of patients achieving inactive disease compared to low disease activity i.e, ASDAS<2.1 (ASDAS-LDA) with axSpA in clinical trials. Methods A comprehensive literature search was conducted in MEDLINE, Embase, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and the EU Clinical Trials Register to identify eligible studies published from inception through August 2025. Clinical trials reporting ASDAS inactive disease or low disease activity were included. Eligible studies enrolled patients with radiographic or non-radiographic axial spondyloarthritis treated with biologic therapies, including Tumor Necrosis Factor inhibitors (TNF-i), Interleukin-17 inhibitors (IL-17i), or targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) such as Janus Kinase inhibitors (JAK-i). Risk of bias was assessed using the Cochrane Risk of Bias tool, and two independent reviewers screened all records, with disagreements resolved by a senior author. A meta-analysis was performed, and data were synthesized using forest plots to calculate pooled odds ratios with 95% confidence intervals(CI). Study heterogeneity was assessed using the I² statistic. Results A total of 41 unique studies were included; 19 randomized clinical trials (RCTs) were identified with 6171 patients included in the meta-analysis. Additionally, twenty-two open-label extension (OLE) studies were included. Several OLE publications originated from the same parent RCT and therefore did not
Objective To analyze unselected routine care patients with all rheumatic diagnoses for positive anxiety, depression, and/or fibromyalgia screening within a single MDHAQ (multidimensional health assessment questionnaire), and for pain and RAPID3 (routine assessment of patient index data) in patients with positive vs negative screens. Methods Each rheumatology patient with any diagnosis at Rush University is given an MDHAQ at each encounter to provide comprehensive medical history information, completed by most patients in 5-10 minutes and scored by a professional in <30 seconds. Frequencies of positive MDHAQ anxiety, depression, and fibromyalgia screening indices were computed in patients with 15 rheumatic diagnoses in 5 categories: inflammatory, connective tissue, non-inflammatory, bone mineral disorders, and primary fibromyalgia. Median pain 0-10 visual numeric scale (VNS) and 0-30 RAPID3 scores were compared in patients with positive vs negative screens. Results In 1,337 study patients (excluding primary fibromyalgia), 30% had positive screens for anxiety, 24% for depression, and 25% for (non-primary) fibromyalgia, and 44% any of these 3 multimorbidity screens. Positive screens in different rheumatic diagnosis categories ranged from 17%-39% for anxiety, 9%-33% for depression, 7%-31% for (non-primary) fibromyalgia, and 30%-52% for any multimorbidity screen. Median pain was 7.0/10 vs 4.0/10 and median (RAPID3) 17.0/30 vs 8.2/30 in patients with any of 3 positive vs all negative screens (p< 0.001). Conclusion Positive anxiety, depression, and/or fibromyalgia screens in 44% of routine care patients who have significantly higher pain scores agree with extensive research findings, suggesting inclusion of pragmatic screening for clinical decisions at all routine encounters.
Longitudinal DVU-level modeling translates radiographic spinal damage into anatomically resolved, clinically interpretable losses in mobility and function, extending beyond global damage scores in r-axSpA.
A newsletter destaca que adolescentes com vasculite por IgA apresentam maior risco de púrpura persistente e proteinúria, exigindo vigilância renal redobrada. Na espondiloartrite axial, o uso de upadacitinibe mostrou-se superior à troca por outro anti-TNF ou anti-IL-17 após falha terapêutica inicial. O conteúdo também aborda o diagnóstico de eritema ab igne e a identificação de dano miocárdico subclínico no lúpus através de técnicas avançadas de imagem.
Vaccination uptake was relatively low in this vulnerable population. Strategies promoting discussion with the rheumatologist about vaccination and before treatment could play a pivotal role in improving vaccination uptake among patients with AIIRD.
Ankylosing spondylitis (AS) is frequently complicated by osteoporosis and progressive sagittal malalignment and may be accompanied by respiratory limitation. However, in radiographically severe AS, the cross-sectional relationships among sagittal alignment, spinal volumetric bone mineral density (vBMD), and imaging-derived pulmonary metrics remain incompletely characterised. We investigated these associations using quantitative computed tomography (QCT) and CT-based lung volumetry. This retrospective, cross-sectional study included 135 patients with radiographically severe AS (modified New York sacroiliitis grade 3–4) evaluated at a single center between 2021 and 2023. Lumbar trabecular vBMD was measured via QCT, sagittal alignment parameters were assessed on standing radiographs, and pulmonary metrics (TLVin, TLVex, ΔTLV) were derived from paired inspiratory/expiratory chest CT scans. Correlations were adjusted using the Benjamini–Hochberg false discovery rate (FDR). Multivariable linear regression examined associations with sagittal vertical axis (SVA) and pelvic tilt (PT), while multivariable logistic regression was employed to identify independent predictors of osteoporosis (defined as vBMD < 80 mg/cm3). Spinal vBMD and SVA differed significantly between radiographic grades (grade 3 vs 4). In FDR-adjusted correlations, vBMD was inversely associated with age (ρ = −0.58, q < 0.001) and BMI (ρ = −0.28, q = 0.007). Height showed robust associations with alignment (PT: ρ = −0.37, q < 0.001; TK: ρ = −0.39, q < 0.001; SS: ρ = 0.34, q < 0.001) and with TLVin (ρ = 0.33, q < 0.001), while BMI was inversely associated with TLVex (ρ = −0.27, q = 0.011). In prespecified multivariable models, the SVA model explained modest variance (R2 = 0.119) with no independent covariate at p < 0.05; PT was independently associated with height (B = −0.33°/cm, p = 0.001; R2 = 0.248). In the prespecified osteoporosis model, age
Objectives: Ankylosing spondylitis (AS) is an autoimmune disorder marked by chronic inflammation that may accelerate atherosclerosis and increase ischemic heart disease (IHD) risk. This study assessed the association between AS and IHD using nationwide data. Methods: A retrospective historical cohort study was performed using Korean National Health Insurance Service data (2012-2023). AS was defined by the ICD-10 code M45 and the rare disease code V140. After a 3-year washout, IHD was defined as ≥2 visits with codes I20 to I25. Propensity score–matched controls (1:10) were selected, and proportional hazards models were applied. Results: A total of 2869 patients with AS and 28,690 matched controls were followed for a mean of 4.2 years. IHD occurred in 7.08% of patients with AS and 5.05% of controls. The incidence rate ratio (IRR) was 1.42 (95% CI: 1.23-1.65). Subgroup analyses revealed a higher risk among current smokers (IRR, 1.85). The risk increased with longer follow-up periods, especially in older men. Conclusions: AS was significantly associated with elevated IHD risk, particularly among smokers and low-income groups. Early cardiovascular risk management is warranted.
Arthritis comprises a spectrum of immune-mediated joint disorders, with rheumatoid arthritis (RA) representing prototypic autoimmunity and psoriatic arthritis (PsA) and ankylosing spondylitis (AS) spanning an autoinflammation–autoimmunity continuum. Across this spectrum, oxidative stress and inflammatory signaling reinforce each other within synovial/entheseal niches, sustaining immune activation and progressive structural damage. Excess reactive oxygen species (ROS) injure chondrocytes and synoviocytes, activate NF-κB and the NLRP3 inflammasome, and reprogram stromal–immune interactions; inflammatory mediators further increase ROS via NADPH oxidases, mitochondrial dysfunction, and immunometabolic perturbations, sustaining a “ROS–inflammation–ROS” loop. Nuclear factor erythroid 2–related factor 2 (Nrf2) is a redox-responsive transcription factor that, upon release from Keap1, drives antioxidant response element–dependent cytoprotective programs. Beyond antioxidation, Nrf2 can dampen NF-κB-linked transcription and modulate ferroptosis, pyroptosis, and autophagy while shaping macrophage and fibroblast-like synoviocyte states. Collectively, these actions position Nrf2 as a context-dependent redox checkpoint that may constrain inflammatory amplification and tune autoimmune-relevant processes (e.g., inflammatory antigen presentation and effector persistence) largely via microenvironmental remodeling rather than direct TCR/BCR inhibition. Here, we (i) map Nrf2-dependent versus Nrf2-independent nodes in the oxidative stress–inflammation circuit; (ii) compare cell type– and subtype-specific Nrf2 functions across RA, PsA, and AS; (iii) summarize pharmacologic and natural-product Nrf2 activators together with joint-targeted delivery strategies; and (iv) discuss evidence and gaps for Nrf2 in core autoimmune mechanisms, including self-tolerance, antigen handling, and pathogenic immune memory. This synthesis highlights Nrf2 as a mechanistic bridge between redox balance and immune regulation, informing Nrf2-centered therapies for autoimmune and immune-mediated arthritides.
Patients in France wait over 6 years for an axSpA diagnosis. This research may raise awareness of the patient journey to axSpA diagnosis and support development of a primary care flagging strategy to identify patients with suspected axSpA earlier.
Ankylosing spondylitis (AS) represents the archetype of the spondyloarthritis family defined by its strong association with HLA-B*27. While genetic susceptibility has long pointed toward adaptive immunity, the precise cellular pathways linking MHC class I alleles to axial inflammation have remained an enigma. In this article, we review the fundamental molecular and clinical evidence positioning CD8 and CD4 T cells as primary pathogenic drivers of disease in the HLA-B*27 + patients. High-throughput T cell receptor (TCR) sequencing and single-cell RNA sequencing have identified “public” TRAV21/TRBV9 TCRs, that are expanded in the inflamed joints and eyes of patients. These clones initiate disease via molecular mimicry, recognizing both microbial and self-peptides presented by HLA-B*27. The clinical success of seniprutug, a monoclonal antibody selectively targeting TRBV9 + T cells, provided the first proof-of-concept that these specific clonotypes drive clinical disease. Furthermore, high-resolution profiling has identified CD4 Th17 cells as the dominant producers of IL-17 within the synovial niche, providing a cellular basis for the efficacy of IL-17A and IL-17F blockade. AS is a disease characterized by convergent cross-reactive T cell responses. The identification of pathogenic TCR signatures and their candidate cognate antigens has moved diagnostics and management toward precision medicine.
Radiographic axial spondyloarthritis (r-axSpA), non-radiographic axial spondyloarthritis (nr-axSpA), and psoriatic arthritis (PsA) represent distinct yet overlapping entities within the spondyloarthritis (SpA) spectrum. Enthesitis has emerged as a unifying hallmark of these diseases, linking mechanical stress, immune dysregulation, and structural remodeling. Understanding similarities and differences in entheseal pathology among these entities may elucidate shared and divergent mechanisms driving disease pathogenesis and progression. Mechanical stress at entheses activates mechanosensitive pathways leading to inflammatory changes and eventually new bone formation. In both research and clinical practice, enthesitis is assessed though the use of clinical indices and imaging modalities, particularly ultrasound and Magnetic Resonance Imaging (MRI), while modern modalities emerge on. Despite shared inflammatory mechanisms, variations in cytokine profiles, soft tissue and underlying bone involvement drive disease-specific patterns of damage and repair in axial and peripheral sites. Combining standardized multimodal imaging with molecular biomarkers holds promise for refining classification, improving early diagnosis, and guiding targeted therapeutic strategies across the SpA spectrum. In this review we explore enthesitis from various standpoints, including pathophysiology, clinical and imaging approaches under the prism of the similarities and differences between PsA and AxSpA.
Introduction Diagnostic delay in axial spondyloarthritis (axSpA) worsens outcomes and increases costs, yet evidence from low-resource settings is scarce. We aimed to quantify diagnostic delay in Palestine and test the hypothesis that referral pathway and socioeconomic factors are independently associated with prolonged delay. Method We conducted a cross-sectional study (July–November 2024) across rheumatology clinics in the West Bank. Adults fulfilling ASAS criteria for axSpA were enrolled via structured interviews. Diagnostic delay was defined as years from symptom onset to confirmed diagnosis. Non-parametric tests and Spearman correlations explored univariable associations. Prolonged delay was prespecified as ≥ 6 years and evaluated using multivariable logistic regression. Exploratory patient phenotypes were derived with Partitioning Around Medoids clustering. Results Seventy-nine patients were included (73% male; mean age 43.0 ± 12.2 years). Mean diagnostic delay was 6.37 ± 5.8 years (median 5). On univariable analyses, longer delay was associated with older age, lower education, low income, first contact with a general practitioner (GP), HLA-B27 negativity/unknown status, and absence of reduced spinal mobility. In multivariable models, GP first contact independently increased the odds of prolonged delay (OR 3.69, 95% CI 1.04–13.11; p = 0.044), while reduced spinal mobility was associated with shorter diagnostic delay (OR 0.16, 95% CI 0.03–0.70; p = 0.016). Clustering identified three diagnostic phenotypes; the longest delays occurred among patients with low education/income and GP-first referral. Conclusions Palestinian patients with axSpA experience an average diagnostic delay exceeding six years, comparable to global estimates. Referral pathway is the principal modifiable barrier, whereas overt clinical signs (reduced spinal mobility) may trigger earlier recognition. Targeted GP education, streamlined referral protocols, and improved access to HLA-B27 testing are priorities for reducing delay in low-resource settings. Key Points • General practitioner referral
A challenge in diagnosing and monitoring radiographic axial spondyloarthritis (r-axSpA) is the absence of reliable biomarkers. This cross-sectional pilot study aimed to evaluate platelet- and neutrophil-derived substances as potential biomarkers in r-axSpA, given the involvement of these cells in disease pathology. Serum and plasma were collected from 13 male, HLA-B27-positive r-axSpA patients without disease-modifying anti-rheumatic drugs and 13 age- and sex-matched blood donor controls. Concentrations of platelet-derived soluble CD40 ligand (sCD40L) and soluble P-selectin (sP-selectin) and neutrophil-derived human neutrophil lipocalin (HNL), myeloperoxidase (MPO), and galectin-3 were measured using ELISA. Associations between these markers and clinical parameters, including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were assessed by Spearman’s rank correlation. Group differences were analysed using the Wilcoxon signed-rank test. Median concentrations of serum sCD40L (4.2 vs. 2.7 ng/mL; p = 0.001), plasma HNL (23.7 vs. 18.6 mg/L; p = 0.040), serum HNL (74.7 vs. 52.3 mg/L; p = 0.013), and plasma MPO (56.6 vs. 37.3 mg/L; p = 0.027) were significantly higher in r-axSpA patients compared with controls. Plasma HNL correlated positively with CRP and ESR, but not with other clinical parameters. In both patients and controls, serum concentrations of sCD40L, sP-selectin, HNL, and MPO were significantly higher than their plasma counterparts, highlighting differences related to sample processing. Serum sCD40L, serum and plasma HNL, and plasma MPO were elevated in r-axSpA patients compared with controls. These findings warrant validation in larger cohorts to clarify the role of sCD40L, HNL and MPO across a heterogeneous group of patients with early and established r-axSpA.
Background Ankylosing spondylitis (AS) frequently coexists with other autoimmune diseases, leading to increased clinical heterogeneity and diagnostic complexity. Early identification of autoimmune comorbidity in AS remains challenging in routine practice. Methods A multicenter, retrospective, cross-sectional study was conducted, where clinical and laboratory data were collected from three independent tertiary centers between 2012 and 2025. Patients were classified into three groups: AS alone, autoimmune diseases alone, and AS with autoimmune comorbidities. Routinely available variables, including demographic characteristics, systemic inflammatory indices, hematological parameters, and liver and renal function markers, were analyzed. Multiple machine learning algorithms were developed for two clinically relevant classification tasks: AS alone vs. AS with autoimmune comorbidities, and autoimmune diseases alone vs. AS with autoimmune comorbidities. Model performance was evaluated using AUC, calibration, decision curve analysis, and clinical impact curves. SHapley Additive exPlanations (SHAP) were applied to enhance interpretability. Results Among all models, LightGBM consistently demonstrated superior and stable performance across discrimination, calibration, and clinical utility metrics. In distinguishing AS alone from AS with autoimmune comorbidities, key contributors included age, gender, renal function–related markers (eGFR, CysC, BUN, UA), and protein and hepatobiliary indices (ALB, DBIL). In comparisons between autoimmune diseases alone and AS with autoimmune comorbidities, SHAP highlighted metabolic- and synthesis-related features (GLOB, PREALB, CHE, ALP), acid–base balance (HCO 3 ), and inflammatory activity (ESR). These patterns suggest that AS-associated autoimmune comorbidity represents a distinct systemic inflammatory–metabolic phenotype rather than a simple amplification of inflammation. Conclusions Using routinely available clinical data, an explainable machine learning framework enables accurate identification and characterization of autoimmune comorbidity in AS. This approach has practical potential for early risk stratification and clinical decision support in real-world settings.
Axial spondyloarthritis (axSpA) is a chronic inflammatory disease characterized by complex pain mechanisms that extend beyond inflammation. Although inflammatory nociceptive pain — primarily mediated by pro-inflammatory cytokines — represents the classic pathway and therapeutic target, many patients continue to experience pain despite suppression of inflammation. This residual pain often reflects non-inflammatory processes, including nociplastic and neuropathic pain. Central sensitization, a key mechanism of nociplastic pain, contributes to pain amplification and poor response to treatment. Fibromyalgia, considered the typical phenotype of nociplastic pain, can co-occur with axSpA and is associated with increased symptom burden and reduced efficacy of anti-inflammatory therapies. Neuropathic pain, albeit less common, can result from structural complications and requires targeted therapeutic approaches. In addition, biological sex differences further influence pain perception and treatment outcomes: female patients report more widespread pain, show higher rates of central sensitization and have a worse response to biologic therapies than male patients. Current treatment paradigms are effective for inflammation-driven symptoms but often fail to address the broader spectrum of pain phenotypes in axSpA. Future work should include the development of biomarkers to differentiate pain mechanisms, the refinement of assessment tools and the evaluation of multimodal therapies that target both inflammation and pain processes. This evolving understanding necessitates a shift from an inflammation-centric to a mechanism-informed approach to pain management in axSpA.
Introduction Axial spondyloarthritis (axSpA) imposes a multidimensional burden that is not fully explained by inflammation. Central sensitization (CS), pain catastrophizing (PC), and sleep disturbance may amplify symptoms and worsen outcomes. This study aimed to assess the prevalence and impact of CS, PC, and sleep disturbances in axSpA patients and their associations with disease activity, function, and quality of life compared with controls. Methods This cross-sectional study included adults with axSpA (ASAS 2009) and healthy controls recruited from a tertiary clinic (April 2024–April 2025). The assessments included demographics; CSI, PCS, JSS, fibromyalgia (ACR-2016), fibromyalgianess (WPI + SSS); and axSpA outcomes (BASDAI, ASDAS, BASFI, BASMI, ASQoL, CRP, and MASES). Statistical analyses included group comparisons, correlations, and multivariable regressions. Results We enrolled 100 axSpA patients and 50 controls. The median scores were greater in the axSpA patients for the CSI (42 vs. 28), PCS (32 vs. 12.5), and JSS (12 vs. 6) (all p < 0.001). The prevalence was greater for CS (59% vs. 20%), PC (53% vs. 18%), and fibromyalgia (43% vs. 18%). The WPI was strongly correlated with the SSS (r = 0.92). In the axSpA patients, the CSI was correlated with the BASDAI (r = 0.58), ASDAS (r = 0.43), BASFI (r = 0.45), and ASQoL (r = 0.68) (all p ≤ 0.001). The PCS and JSS are also correlated with disease activity, disease function, and ASQoL. Independent predictors were CSI—female sex, higher SSS, and worse ASQoL; PCS—ASQoL; JSS—higher SSS and arthritis, with lower scores in patients on TNF inhibitors or pain-modulating therapy. Conclusion CS, PC, sleep disturbance, and FM/FMness are highly prevalent in axSpA patients and are independently associated with worse outcomes. Incorporating nociplastic and psychosocial dimensions into assessment
Immune-mediated inflammatory arthritides (IMIA), including rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and juvenile idiopathic arthritis, are chronic immune-driven disorders in which long-term malignancy safety has become a key determinant of therapeutic decision-making. Patients with IMIA are not oncologically neutral at baseline; persistent inflammatory burden, smoking exposure, age, and cumulative immunosuppressive treatment all modify cancer susceptibility. Against this background, biologic and targeted synthetic disease-modifying antirheumatic drugs may both reduce inflammation-associated oncogenic pressure and attenuate antitumor immune surveillance. In this narrative review, we synthesize current evidence on tumor safety across major biologic classes and Janus kinase inhibitors, with emphasis on data emerging through early 2026. Overall, most biologic therapies appear broadly reassuring with respect to overall malignancy, although non-melanoma skin cancer remains the most reproducible treatment-associated signal, particularly with tumor necrosis factor inhibitors and possibly abatacept. Rituximab retains a favorable profile in patients with prior lymphoproliferative disease, whereas IL-6 and IL-17/23 pathway inhibitors appear largely neutral or reassuring in currently available datasets. By contrast, JAK inhibitors require greater caution in risk-enriched rheumatoid arthritis populations, especially older patients, smokers, and those with prior malignancy or prolonged treatment exposure. Recent register-based studies have shown that overall cancer incidence with JAK inhibitors is comparable to that with TNF inhibitors, although lung and keratinocyte cancers occur more frequently in certain risk groups; accordingly, updated 2025 EULAR guidance recommends early initiation of targeted therapy after cancer remission and tailoring drug choice to prior cancer type and patient-specific factors. We further examine tumor-type-specific patterns, major modifiers of risk, and practical risk-stratified management strategies. The central clinical message is that malignancy safety in IMIA should be interpreted through an individualized framework that balances inflammatory control against oncologic vulnerability rather
Ankylosing spondylitis (AS) and SAPHO syndrome both involve the spine and sacroiliac joints with bone marrow edema (BME) on MRI, which can lead to spinal structural damage. No previous study has compared BME characteristics between the two diseases. 42 SAPHO and 60 AS patients with spinal or sacroiliac involvement underwent whole-spine and sacroiliac MRI. SPARCC scores for each spinal segment and sacroiliac joints, vertebral unit involvement frequency, and BME range, intensity, depth were compared. Correlation between SPARCC scores of the whole spine and sacroiliac joints and clinical indicators were analyzed in the two groups of patients. SPARCC scores for all spinal segments and sacroiliac joints in AS patients were significantly higher than those in SAPHO syndrome patients (P < 0.01). Defining bone marrow edema as SPARCC score > 0, the positive rate of vertebral units in spinal segments and sacroiliac joints was higher in AS than in SAPHO syndrome (P < 0.05). The incidence of BME in the cervical, thoracic, and sacroiliac joints was higher in AS than in SAPHO syndrome (P<0.001), with no significant difference in the incidence of lumbar spine BME (P > 0.05); the incidence of bilateral sacroiliac joint edema also showed no intergroup difference (P > 0.05). Further analysis of the score composition in SPARCC-positive cases revealed: the extent scores for each spinal segment in AS patients were higher than those in the SAPHO group (P < 0.001), while there were no significant differences in intensity and depth scores between the two groups; in the sacroiliac joints, the extent score was higher in the AS group (P < 0.05), but the intensity score was higher in the SAPHO group (P < 0.05). Correlation analysis in AS and SAPHO patients showed: spinal SPARCC
Background While ankylosing spondylitis (AS) and psoriatic arthritis (PsA) share similar immune dysregulation, their relative risks for inflammatory bowel disease (IBD), including definitive subtypes (Crohn’s disease [CD] and ulcerative colitis [UC]) and possible subtypes (indeterminate colitis [IC] and microscopic colitis [MC]), remain unquantified. We aimed to establish comparative IBD risk gradients among AS, psoriasis (PSO), and PsA cohorts. Methods The study utilized a long-term retrospective cohort design by analyzing an electronic health record database. Propensity score matching (PSM) was used to adjust multiple confounders. Cox proportional hazards models and log rank test were employed to evaluate the risk of IBD development. Results The study included 26,610 patients with AS and 322,317 with PSO (2005–2023). After PSM, 26,569 matched pairs were analyzed. Compared to PSO, AS was associated with a significantly higher risk of definite IBD [hazard ratio (HR) = 2.96, 95% CI: 2.64–3.33], CD (HR = 3.38, 95% CI: 2.90–3.94), UC (HR = 2.43, 95% CI: 2.07–2.85), and IC (HR = 2.45, 95% CI: 1.33–4.51), but not MC. Subgroup analyses confirmed a consistently higher IBD risk in AS across all ages, sexes, races, BMI categories, and comorbidity profiles. Compared to the general population, AS conferred the highest independent risk for definite IBD (HR = 4.22, 95% CI: 3.60–4.94), followed by PsA (HR = 1.52) and PSO (HR = 1.37). AS also showed a 2.60-fold higher definite IBD risk than PsA (95% CI: 2.32–2.92). Conclusions AS is the phenotype most strongly associated with IBD among the studied spectrum. Compared to PSO, AS confers a significantly higher risk of CD, UC, and IC, and it carries a greater burden of definite IBD than PsA or the general population.
Sex differences in axial spondyloarthritis (axSpA) are increasingly recognized, with women often reporting higher disease burden despite similar objective inflammatory markers. This study aimed to compare clinical features, disease activity, function, quality of life, and treatment patterns between men and women with axSpA and identify sex-specific predictors of disease outcomes using data from the Brazilian Registry of Spondyloarthritis (RBE). This was a cross-sectional, observational study based on data from the RBE, a nationwide multicenter cohort including 828 patients (568 men and 260 women) from 17 referral centers across Brazil. Standardized clinical and demographic data were collected using the REDCap platform. Disease activity (ASDAS-CRP, BASDAI), physical function (BASFI), spinal mobility (BASMI), and quality of life (ASQoL) were assessed with validated instruments. Sex-stratified multivariable linear regression models were constructed to identify independent predictors of each outcome. Women presented higher disease activity (median BASDAI 4.5 vs. 3.2; ASDAS-CRP 2.2 vs. 1.9), greater functional limitation (BASFI 5.0 vs. 4.0), and poorer quality of life (ASQoL 9.0 vs. 7.0) compared to men, despite similar CRP levels. Psychological distress was more frequent in women, while men had worse spinal mobility (BASMI 4.0 vs. 3.5) and higher HLA-B27 positivity. Regression models revealed that shoulder and hip pain were relevant predictors of disease activity in both sexes, but psychological factors and work activity more strongly influenced outcomes in women. Men’s disease burden was more associated with structural damage and cardiometabolic comorbidities. This study highlights distinct sex-related clinical patterns in axSpA. Women reported higher symptom burden, functional limitations, and reduced quality of life, largely influenced by subjective symptoms and comorbidities. Conversely, men presented greater structural impairment and different comorbidity profiles. These findings support the need for sex-informed clinical assessments
Systemic autoimmune and chronic inflammatory rheumatic diseases predominantly affect childbearing women. These women are at greater risk for pregnancy complications stemming from both the underlying disease and the treatments required to manage it. This cross-sectional study aimed to assess the prevalence of effective contraceptive use across a wide range of diseases including systemic lupus, systemic sclerosis, Sharp syndrome, Sjögren’s disease, rheumatoid arthritis, and spondyloarthritis. We conducted a questionnaire-based study targeting women aged 18–45 years with any of the aforementioned diseases. The data were collected from July 2023 to July 2024. A standardized self-report questionnaire, specifically developed for this study, was used to assess gynecological follow-up and reproductive health. Additional clinical data were extracted from patients’ electronic medical records. Descriptive statistics were used to analyze contraception use across different risk groups, including those on teratogenic treatments and those at increased maternal or fetal obstetric risk. 143 patients were included; among those not trying to conceive, 63% used effective contraception. This rate is lower than the 72% reported for the general population in France in 2016. Among previously pregnant patients, 33% experienced an unplanned pregnancy, highlighting the impact of contraceptive failure. There was no difference between patients on teratogenic treatments, those with increased maternal or fetal obstetric risk, and other patients. This study emphasizes the urgent need for improved education and gynecological management of young women with rheumatic diseases in France. Specific educational programs and enhanced gynecological follow-ups are necessary to address this critical gap. This study was registered with ClinicalTrials.gov (NCT05961267), first posted on the 24th of July, 2023, and in the European database (ID-RCB 2023-A01207-38).
Case reports (CRs) are essential in physiotherapy, yet reporting remains heterogeneous and insufficiently standardised. The 2013 CAse REport (CARE) guideline improves transparency but lacks physiotherapy-specific detail. This study aimed to develop a consensus-driven extension of the CARE reporting guideline to support structured reporting of physiotherapy CRs, encompassing physiotherapy-specific assessments and interventions. An e-Delphi consensus process study following the ACcurate COnsensus Reporting Document (ACCORD) guidelines. Online. Forty-four international experts in physiotherapy practice, research and education, along with six core committee members. Experts objectively scored items for relevance (5-point Likert scale) and provided open-ended responses for each item of the drafts. Scores and responses were analysed to facilitate iterative refinement of the Physiotherapy CAse REport (PhyCARE) reporting guidelines. Consensus was predetermined at over 70% agreement. Round 1 had the majority of items achieving ≥70% agreement, except two items that did not meet the threshold were revised and replaced with an alternative. Five new items addressing physiotherapy-specific reporting needs were added, and 10 items were relocated. In round 2, all 35 items across 13 domains achieved 84%-100% agreement. The nomenclature of one domain was revised to 'Outcomes and Follow-up'. Following two e-Delphi rounds, consensus was achieved, and suggestions from online meeting, piloting led to item rephrasing, after which the PhyCARE guidelines were finalised. The PhyCARE guidelines have the potential to provide a physiotherapy-specific extension of CARE to support structured, transparent and reproducible reporting of physiotherapy CRs.
Abstract Objectives To evaluate serum tartrate-resistant acid phosphatase 5b (TRACP5b) levels in patients with ankylosing spondylitis (AS) and primary osteoporosis (OP), and to assess its diagnostic value, correlations with bone mineral density (BMD) and disease activity, and its potential as a marker of secondary osteoporosis in AS. Methods In this cross-sectional comparative study, 23 patients with AS, 24 patients with primary OP, and 20 healthy controls were recruited from Assiut University Hospitals. Demographic, clinical, laboratory, and dual-energy X-ray absorptiometry (DXA) data were collected. AS disease activity was assessed using Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Serum TRACP5b was measured by ELIZA. Group differences, correlations, and ROC curve analysis were performed. Results AS patients were predominantly male and younger than OP patients. Primary OP patients had significantly lower DXA T-scores than AS patients (mean difference = 2.36, p < 0.001). TRACP5b levels were higher in AS patients than controls but not significantly different ( p = 0.111). In AS, TRACP5b correlated with age ( r = 0.534, p = 0.009) and disease activity ( r = 0.427, p = 0.042) but not with BMD. ROC analysis showed moderate diagnostic performance for detecting secondary osteoporosis in AS (AUC = 0.653). No significant differences in TRACP5b or BMD were found across AS treatment groups. Conclusion Serum TRACP5b may serve as a supplementary marker of osteoclast activity in AS and shows moderate diagnostic value for secondary osteoporosis, with levels more related to age and disease activity than BMD. Larger studies are needed to confirm its clinical utility. Key Points • Serum TRACP5b levels were higher in patients with AS than in healthy controls, though without consistent statistical significance, reflecting biological variability. • TRACP5b
To explore how appropriate different intervals between monitoring blood tests are considered in relation to the risk of clinically significant adverse drug reactions in adults prescribed conventional synthetic DMARDs (csDMARDs) for ≥1 year for systemic autoimmune rheumatic diseases (SARD). A RAND/UCLA Appropriateness Method consensus study was undertaken. Members of the BSR csDMARD guideline working group who manage adults with SARD participated. Experts rated the extent to which intervals between blood tests were appropriate using Likert-type scales with responses from 1 (totally inappropriate) to 9 (totally appropriate) for nine scenarios with 5-year predicted risk of discontinuing treatment due to abnormal monitoring blood tests from 5% to 25%. Median score and the number that voted 1-3 (inappropriate), 4-6 (unsure) and 7-9 (appropriate) were calculated for every interval in each scenario. Scenarios for which agreement could not be reached in the first round were recirculated, enclosing individual round 1 response and the panel median score. Consensus that an interval was appropriate for a scenario was reached where the median panel score was ≥7 and up to six experts rated 10% over 5 years, respectively. A threshold to aid risk-stratified monitoring during established csDMARD treatment was agreed for adults with SARD.
Spondyloarthritides (SpA) and inflammatory bowel disease (IBD) are immune-mediated diseases with overlap in clinical and immunological features. However, temporal correlation of SpA and IBD in individual patients and risk factors are not well characterized. We conducted a nationwide population-based study between January 1, 1998 and July 31, 2022 to determine SpA prevalence preceding and its incidence following IBD diagnosis. Using cross-linked register data, we identified individuals with IBD diagnosis and matched them to individuals without IBD. Using logistic regression, we determined the odds of SpA preceding IBD diagnosis and using Cox regression, the hazard of new-onset SpA following IBD diagnosis. Of 102,648 individuals included in the study, 17,108 (16.7%) individuals were diagnosed with IBD. The aOR of SpA in the 8-year period preceding IBD, Crohn's disease (CD), or ulcerative colitis (UC) diagnosis, compared to matched individuals, was 1.95 (95% CI 1.78, 2.14), 2.84 (95% CI 2.43, 3.32), and 1.61 (95% CI 1.43, 1.81), respectively. The aHR of SpA following IBD, CD, and UC diagnosis, compared to matched individuals, was 2.51 (95% CI 2.34, 2.70), 3.17 (95% CI 2.81, 3.59), and 2.24 (95% CI 2.05, 2.45), respectively. SpA prevalence demonstrated temporal variability, with increase during the few years around IBD diagnosis. Associations were stronger for axial SpA, and among women and young adults preceding IBD diagnosis. In a population-based cohort, we report that SpA diagnosis is associated with IBD preceding and following its diagnosis. We demonstrate temporal variability and highlight clinical variables associated with SpA in IBD.
Objective Gut microbiota dysbiosis has been implicated in the pathogenesis of autoimmune and immune-mediated arthritis. Biologics may influence gut microbiota composition; however, it is uncertain whether biologics act directly on microbial communities or indirectly through disease modulation and restoration of immune homeostasis. This systematic review explores how biologic therapies modulate gut microbiota in autoimmune arthritis and their potential as biomarkers for treatment response and disease activity. Methods We searched PubMed, Scopus, the Cochrane Library, and the Web of Science (WOS) for studies assessing gut microbiota changes induced by any biologic therapy in immune-mediated or autoimmune arthritis. The outcomes included changes in microbiota and the potential for microbiota as predictive biomarkers for treatment response and disease activity. Results A total of 12 studies were included. Biologic agents, predominantly anti-TNF and IL-17 inhibitors, significantly altered gut microbiota composition and diversity, with most studies showing increased alpha diversity and normalization of beta diversity post-therapy; however, these effects were not uniformly consistent. Treatment restored beneficial shortchain– fatty-acid–producing taxa, including Faecalibacterium prausnitzii , Megamonas , Lachnoclostridium , and Blautia , while reducing inflammatory genera such as Escherichia-Shigella and Klebsiella? . Certain taxa, notably Lachnospiraceae and Megamonas , correlated with clinical improvement and reduced disease activity. Conclusion Biologic therapy modulates gut microbiota composition in autoimmune and immune-mediated arthritis, promoting a shift toward eubiosis. Specific microbial taxa, including Lachnospiraceae , Blautia , and Faecalibacterium prausnitzii , show potential as noninvasive biomarkers for treatment response and disease activity. These findings guide further longitudinal and interventional studies to validate microbial signatures and their clinical applicability.
Abstract Objectives Refractory manifestations of Behçet’s disease (BD) are commonly treated with TNF-α inhibitors; however, a subset of patients do not respond or are intolerant, prompting the need for alternative therapies. This study aimed to assess the real-life use, efficacy, and safety of non-TNF targeted biologic agents in BD. Methods Data were retrieved from the International AIDA Network Registry for BD. Patients who received any biological agent other than TNF-α inhibitors at any point during follow-up were included in the study. Clinical and demographic characteristics, prior treatments, and treatment responses at 3-, 6-, and 12-month follow-ups were collected. Results In total, 65 patients (36 female/29 male) with a mean age of 45.8 ± 13.3 years were included. Anakinra was the most frequently used agent (n = 31), 34.7% of patients with mucocutaneous, 73.3% with musculoskeletal, and 77.7% with ocular involvement showing a partial or complete response. Canakinumab (n = 11) was effective in mucocutaneous, musculoskeletal, and ocular involvement, including some previously unresponsive to anakinra. Tocilizumab (n = 15) showed favorable outcomes in ocular and neurological involvement (complete response in 5 of 6 patients), while 40% experienced worsening or no response in mucocutaneous manifestations. Secukinumab and ixekizumab were effective in patients with mucocutaneous-articular phenotypes, especially those with axial spondyloarthritis. Ustekinumab (n = 3) and rituximab (n = 5) also demonstrated clinical improvement in selected refractory cases. No new major safety concerns were reported across treatment groups. Conclusion Biologics targeting IL-1, IL-6, IL-17, and IL-12/23 pathways may offer therapeutic alternatives in BD patients unresponsive to TNF-α inhibitors. The treatment efficacy varies across phenotypes, highlighting the need for individualized treatment decisions.
Rheumatoid arthritis (RA) and spondyloarthritis (SpA) are chronic inflammatory rheumatic diseases characterised by pain, fatigue, mood disturbances, sleep problems and reduced quality of life. These symptoms are highly variable both between individuals and within individuals across days, reflecting the fluctuating nature of disease activity and daily functioning. Although physical activity is known to alleviate many of these symptoms, individuals with RA and SpA often encounter barriers that limit regular engagement. Capturing the dynamic interplay between symptoms and physical activity therefore requires methods that account for day-to-day and moment-to-moment variability. Ecological momentary assessment (EMA), especially when combined with actigraphy, enables real-time, context-sensitive monitoring of symptoms and physical activity in daily life. However, little is known about the feasibility and acceptability of such protocols in individuals with RA and SpA, for whom participant burden and adherence may represent significant challenges. This pilot study therefore aims to assess the feasibility and acceptability of a 14-day EMA protocol and to explore factors associated with objectively measured physical activity in individuals with RA and SpA. 50 adults diagnosed with RA or SpA will be recruited through rheumatology clinics or via advertisement. Eligible participants must be smartphone users without cognitive or physical impairments affecting participation. After providing consent, participants will complete baseline questionnaires regarding disease activity, quality of life, sleep, pain, fatigue, affective states and will attend a remote session with a member of the research team to learn how to use the mobile app. They will then complete a 14-day EMA protocol, during which data on patient-related outcomes (PROs), including pain, fatigue, sleep quality and affective states (i.e. positive and negative affects) will be assessed four times daily: upon awakening, 11:00, 15:00 and 20:30. Physical
Peripheral manifestations (peripheral arthritis/enthesitis/dactylitis) are frequent in axial spondyloarthritis (axSpA) yet, understudied. We (i) evaluated the assessment/reporting of peripheral manifestations in trials of biological or targeted synthetic DMARDs (b/tsDMARDs) for axSpA and peripheral SpA (pSpA), and (ii) synthesized the efficacy of b/tsDMARDs on these manifestations. Systematic literature review (SLR) of controlled trials evaluating b/tsDMARDs in axSpA/pSpA (excluding psoriatic arthritis). Records were identified through previous SLRs informing ASAS-EULAR recommendations and updated searches. Outcomes included (i) frequency of assessment/reporting of peripheral arthritis/enthesitis/dactylitis and (ii) treatment efficacy of b/tsDMARDs on these peripheral manifestations [standardized mean differences (SMDs) or relative risk]. We included 100 axSpA and four pSpA trials. In axSpA, peripheral arthritis was assessed in 54%, enthesitis in 64% and dactylitis in only 10% of studies. When assessed, results were reported in 69%, 72% and 10% of studies, respectively, and often in all patients (instead of those affected at baseline). Most frequently used instruments were 44-joint count for peripheral arthritis (48%), Maastricht Ankylosing Spondylitis Enthesitis Score for enthesitis (88%) and digit count for dactylitis (40%). Composite indices like DAS were not used. SMDs (range 0.26 to -1.18) indicated mainly small-to-moderate b/tsDMARD effects, typically higher in patients with baseline peripheral involvement. In pSpA, peripheral manifestations were always assessed/reported, with generally moderate effects (SMD range -0.10 to -1.22). Peripheral manifestations are inconsistently assessed and reported in axSpA trials. While b/tsDMARDs have small-to-moderate effects on peripheral manifestations, these may be underestimated due to not being assessed in the population affected at baseline.
Abstract Objectives Promotion of physical activity (PA) in individuals with rheumatic and musculoskeletal diseases (RMDs) is essential for disease management, yet evidence on social, environmental, and system-level determinants remains limited. This study aimed to quantify the prevalence of these determinants and compare them across four European nations. Method A cross-country survey was developed based on a scoping review and semi-structured stakeholder interviews. The survey comprised 27 items across social, environmental, and system domains. Participants rated each item as a facilitator, barrier, or neutral, using a scale from − 10 (barrier) to + 10 (facilitator). Responses were analyzed to assess cross-country differences in demographic characteristics, PA behavior, and determinant ratings. Results A total of 734 individuals with RMDs participated (41.1% RA, 40.7% axSpA, and 18.1% OA) from France (30.5%), Switzerland (34.4%), the Netherlands (17.3%), and Turkey (17.7%). Significant between-country differences were identified in PA behaviors and demographics ( p < 0.05). Overall determinant scores did not differ significantly ( p = 0.101). Key facilitators varied across countries: “knowledge and fitness to perform exercises” was prominent in Switzerland; “scheduled exercises” in the Netherlands and France; and “health professionals” in France and Turkey. Common barriers included “weather conditions”—particularly in Turkey and the Netherlands—“costs of memberships or sport facilities,” especially in France, and work-related duties in Turkey and the Netherlands. Conclusions Despite comparable overall scores, the relevance of social, environmental, and system-level determinants of PA varied across countries These findings highlight the importance of country-specific contextual factors for understanding PA participation and for designing tailored, effective PA promotion strategies in people with RMDs. Key Points • This study provides novel cross-country insights by comparing contextual determinants across four European countries on how cultural norms
Objective As part of a research program examining rheumatology referrals in British Columbia, the Patient SAID study evaluated the ‘SAID tool', which contains validated patient-completed questionnaires for identifying and prioritizing individuals with inflammatory arthritis, supporting its utility and feasibility. This article reports the perspectives of participating patients and rheumatologists regarding the SAID tool. Methods A multi-methods design was used to collect and analyze patient survey and rheumatologist interview data, with an emphasis on implementation relevance. Ninety-two patients who completed the questionnaires in the SAID study also provided feedback on their experience. Semi-structured interviews were conducted with three rheumatologists. Quantitative and qualitative data were analyzed using Excel and NVivo to identify usability, relevance, and barriers or enablers to implementing the tool in primary-to-specialist referral. Results Most patients (85%) found the SAID tool easy to log into and complete (78%). Across diagnostic groups, most (76%) believed it could help their GP assess symptoms, but emphasized the need for more nuanced response options and space for elaboration. Rheumatologists viewed the tool as brief, useful, and potentially valuable for triage, especially if integrated at the referral stage. Key barriers included time constraints, false negatives, and lack of integration with electronic medical records. All supported optional implementation led by motivated patients, provided it complemented, not complicated, existing workflows. Conclusion With targeted modifications and appropriate implementation mechanisms, the SAID tool has the potential to improve the quality of referrals, support triage decision-making, and address current gaps in access to rheumatology care within evolving digital health systems.
This meta-analysis aimed to explore the impact of biologics on the development of cardiovascular events (CEs) in patients with ankylosing spondylitis (AS). We collected literature related to the effects of biologics on CEs in AS patients through computerized searches of Embase, Web of Science, PubMed, and the Cochrane Library, as well as manual searches. The literature retrieval spanned from the inception of these databases up to March 28, 2025. Literature selection and data extraction were performed in accordance with predefined eligibility criteria. The Newcastle-Ottawa Scale and the Cochrane Risk of Bias tool for randomized trials were utilized to evaluate the quality of eligible articles. Data analysis was performed using STATA 15.0. This meta-analysis incorporated 23 eligible articles encompassing 92 623 subjects. The results illustrated that the biologics group had a lower overall CE risk than the non-biologics group (RR = 0.61, 95% CI, 0.44-0.84, p = 0.003). Specifically, the biologics group demonstrated a reduced risk of myocardial infarction (RR = 0.42, 95% CI, 0.27-0.65, p   0.05). There was no statistically significant variation in the occurrence of CEs between the two groups with the use of etanercept, ixekizumab, or golimumab (p > 0.05). Overall, biologic use may mitigate the risk of CEs, particularly impacting IHD and MI. Given the limitations inherent in the current body of research, additional large randomized controlled trials examining other CE subtypes and specific drug effects are needed. Not applicable.
Effective suppression of inflammation in axSpA patients achieving LDA may be associated with a reduction in subclinical atherosclerosis progression.
Objective To evaluate the timeline for resolution of sacroiliac joint (SIJ) inflammation, changes in structural lesions, and their correlation with patient‐reported outcomes (PROs) in youth with axial juvenile spondyloarthritis (axJSpA) initiating tumor necrosis factor inhibitor (TNFi). Methods This prospective, multicenter study included youth aged 8 to 18 years with a clinical diagnosis of axJSpA starting TNFi. Assessments were conducted at baseline and 12 weeks, including clinical evaluation, magnetic resonance imaging (MRI), and PROs. Participants with persistent SIJ inflammation at 12 weeks were reassessed at 24 weeks. Three blinded reviewers evaluated MRIs using Spondyloarthritis Research Consortium of Canada SIJ inflammation scores (SIS) and SIJ structural scores. Results Of 75 enrolled participants, 73 completed baseline visits, and 62 had MRI‐confirmed axJSpA. Fifty‐seven completed a 12‐week follow‐up; 89% (51 of 57) showed SIS improvement, and 63% (36 of 57) achieved inflammation resolution (SIS <2). Median SIS change from baseline to 12 weeks was −8 (interquartile range: −18 to −3). Among those with persistent inflammation at 12 weeks (n = 26), 85% reported at least moderate clinical improvement. At 24 weeks, 56% (14 of 25) had ongoing inflammation. A total of 84% of SIS improvement occurred within the first 12 weeks. In patients with at least two scans, structural lesion scores decreased, increased, or stayed the same from baseline to the 12‐week scan for erosions (58%/25%/18%), sclerosis (21%/9%/70%), fat metaplasia (0%/30%/70%), and backfill (4%/28%/68%). Conclusion Most participants showed early imaging response to TNFi, with most improvement occurring within 12 weeks. Despite residual inflammation persisting in nearly half of patients, most reported symptom improvement, underscoring both the rapid impact of TNFi and the heterogeneity of treatment effects. image
A newsletter analisa o estudo ESTIVAL, que avaliou a estimulação do nervo vago na osteoartrite erosiva, demonstrando melhora funcional e analgésica em pacientes com sinovite exuberante, apesar de um desfecho primário global negativo. Discute também como a ativação do sistema complemento (especialmente C3dg) prediz a progressão radiográfica na espondiloartrite axial independentemente do controle da PCR. Por fim, destaca atualizações sobre o FRAX 2.0 e o manejo da doença relacionada à IgG4.
A newsletter destaca como a aptidão cardiorrespiratória pode atenuar o declínio cognitivo e discute o potencial dos monócitos como marcadores acessíveis para doença pulmonar intersticial na artrite reumatoide. Além disso, correlaciona a inflamação intestinal à progressão radiográfica na espondiloartrite axial e analisa fatores que predizem a evolução da doença mista do tecido conjuntivo para outras patologias autoimunes.
A newsletter aborda o conceito de Gamopatia Monoclonal de Significado Reumatológico (GMSR), enfatizando sua relevância clínica na Crioglobulinemia e no risco de linfoma na Doença de Sjögren. Discute também os resultados de 17 anos do registro REGISPON-3, que revela a instabilidade fenotípica das espondiloartrites e o início tardio de terapias biológicas. Por fim, apresenta avanços no manejo remoto da osteoporose masculina e novos achados imunológicos na dermatomiosite anti-MDA5.
To assess the comparative risk of osteoporosis and fractures associated with biologic disease-modifying antirheumatic drug (bDMARD) exposure in patients with radiographic axial spondyloarthritis (r-axSpA). This nationwide cohort study analyzed 37,708 patients with r-axSpA. The outcomes of interest were osteoporosis, vertebral fracture, and hip fracture, defined based on diagnosis codes. The follow-up period was from the r-axSpA diagnosis date to December 2021. Multivariable time-varying Cox regression models were used to assess the comparative risk of each outcome comparing the following groups: tumor necrosis factor inhibitor (TNFi) vs bDMARD-naïve, interleukin-17 inhibitor (IL-17i) vs bDMARD-naïve, and IL-17i vs TNFi. For comparing IL-17i vs TNFi, the line of bDMARD treatment was matched between the TNFi and IL-17i groups at a 4:1 ratio. Exposure to TNFi (adjusted hazard ratio [aHR] 0.83; 95% CI 0.76-0.90, P < 0.01) and IL-17i (aHR 0.19, 95% CI 0.10-0.38; P < 0.01) was associated with a lower risk of osteoporosis compared with that of the bDMARD-naïve group. Further, IL-17i (aHR 0.23, 95% CI 0.11-0.46; P < 0.01) was associated with a lower risk of osteoporosis than TNFi. Exposure to TNFi (aHR 0.64, 95% CI 0.59-0.70; P < 0.01) was associated with a lower risk of vertebral fracture than that of the bDMARD-naïve group. IL-17i (vs bDMARD-naïve) was associated with a lower risk of vertebral fracture, although this did not reach statistical significance (aHR 0.52, 95% CI 0.25-1.09; P = 0.09). Hip fracture risk did not differ across groups. Exposure to TNFi and IL-17i may be associated with a lower risk of osteoporosis, but not hip fracture, compared with the bDMARD-naïve group. Exposure to TNFi, but not IL-17i, may be associated with a lower risk of vertebral fracture compared with the
Objective To develop and perform preliminary cross-sectional validation of a magnetic resonance imaging (MRI)-based outcome measure for assessing spinal structural damage in spondyloarthritis clinical trials, with a specific focus on MRI-based synthetic computed tomography (sCT) and related MRI-based techniques. Methods Consensus meetings within the Outcome Measures in Rheumatology (OMERACT) MRI in arthritis working group established consensus definitions for spinal new bone formation and scoring rules. Then, low-dose CT and sCT images of twenty patients with axial spondyloarthritis and five healthy controls were independently assessed by seven experienced readers using the agreed-upon definitions for: marginal syndesmophytes, non-marginal syndesmophytes, and osteophytes. sCT images were reconstructed using a deep learning algorithm (BoneMRI v1.8, MRIGuidance B.V., Utrecht, the Netherlands). Sensitivity and specificity of synthetic CT were calculated using low-dose CT as the reference standard, and inter-reader reliability was assessed. Results A total mean of 35.5 lesions was scored on both sCT and ldCT in all participants. sCT demonstrated an overall good sensitivity (0.77) and excellent specificity (≥0.94) with low-dose CT as reference standard. Inter-reader agreement was substantial for both low-dose CT and sCT, with an overall intra-class coefficient of 0.80 (ldCT) and 0.86 (sCT), and corresponding kappa values of 0.68 and 0.70, respectively. Conclusion This OMERACT international multi-reader exercise established consensus definitions for spinal new bone formation and provided preliminary evidence that sCT meets key OMERACT criteria of domain match and feasibility. This MRI technique for generating CT-like images shows promise as a novel method for assessing spinal structural damage in spondyloarthritis clinical trials.
To describe disease activity and treatments received during the postpartum period, breastfeeding rates and their possible impact on rheumatoid arthritis (RA) and spondyloarthritis (SpA) activity. This ancillary study from the French multicentre prospective cohort (GR2-NCT02450396) included pregnant women with RA and SpA with at least one postpartum visit from October 2014 to October 2022. Disease activity, flares, treatments and breastfeeding rates were described. Factors associated with the occurrence of a flare were evaluated by survival analysis. Disease activity was compared according to breastfeeding duration (never, <6 months and ≥6 months). Ninety-four RA and 124 SpA patients were studied. In RA patients, the proportion of patients presenting with at least one flare was significantly higher during the first 6 months postpartum compared with pregnancy (62.0% vs 43.5%; p=0.02). For SpA patients, there was no difference in disease activity at 6 months postpartum compared with pregnancy (40.7% vs 40.7%; p=0.999). Disease activity in postpartum was similar between the different breastfeeding status in both diseases. 13/91 (14.3%) RA patients and 29/123 (23.6%) SpA patients continued a biologic Disease-Modifying Antirheumatic Drug (bDMARD) during the whole pregnancy and the postpartum. 78/91 RA and 94/123 SpA patients delivered without any DMARDs, and among them, 43/78 (55.1%) and 56/94 (59.6%) (re)started a bDMARD postpartum. RA patients were more likely to flare during early postpartum, while SpA patients remained stable. bDMARD continuation during pregnancy was more frequent in SpA patients, and half of the patients restarted bDMARD during postpartum.
Difficult to manage (D2M) axial spondyloarthritis (axSpA) is an evolving clinical concept. We aimed to assess the prevalence, predictors and long-term outcomes of D2M axSpA. Prospective single center cohort study of axSpA patients starting targeted agents (01/01/2007 until 28/02/2024). The ASAS criteria were applied to classify D2M. Baseline parameters were assessed as predictors of D2M development by multivariate logistic regression models. To identify comorbidity clusters and their contribution to D2M, a K-means cluster analysis on binary indicators of most prevalent chronic illnesses was performed. Long-term functional evolution and adverse events' rate were compared between D2M and non-D2M. Out of 434 patients, 50 (11.5%) developed D2M disease. Compared to non-D2M, they had higher disease activity at baseline (p = 0.01) and failed to improve at 6 months (p < 0.0001), while dyslipidemia, osteoarthritis and fibromyalgia were more prevalent (p < 0.0001). Independent predictors for developing D2M axSpA were the presence of fibromyalgia (OR 3.55), osteoporosis (OR 5.67) and dyslipidemia (OR 2.70), while two clusters of comorbidities ("chronic pain syndromes" and "metabolic") significantly contributed to D2M (OR 2.52 and OR 3.30; p = 0.010 and 0.013 respectively). During a total follow-up period of 2312 patient-years, D2M patients developed higher functional impairment and had more serious adverse events and hospitalizations (p = 0.016) compared to non-D2M patients. 11.5% of axSpA patients developed D2M disease and showed adverse long-term outcome compared to non-D2M. While D2M patients had at baseline higher disease's burden, comorbidities mostly related to chronic pain syndromes predicted D2M development, supporting their significance for D2M axSpA evolution.