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Comorbidities in spondyloarthritis (SpA) add to the burden of disease by contributing to disease activity, functional and work disability, and mortality. Thus, awareness of comorbidities in SpA is crucial to improve their screening and management and to ultimately improve outcomes in those affected. Osteoporosis has been reported to be the most prevalent comorbidity in SpA, and its risk is increased in these patients, compared with the general population; the risk of vertebral fractures requires further evaluation. Cardiovascular risk is also increased in this population, both due to an increase of the traditional cardiovascular risk factors in these patients, but also due to the presence of inflammation. The role of non-steroidal anti-inflammatory drugs in this increased risk needs further elucidation, but there is consensus on the need to encourage smoking cessation and to perform periodic evaluation of cardiovascular risk in these patients, particularly in the case of change in treatment course. Concerning the risk of cancer, no increased risk inherent to SpA seems to exist. However, an increased neoplastic risk can occur due to SpA treatments, e.g., P-UVA. Data are sparse on the risk of infections compared with rheumatoid arthritis, but there appears to be no risk in the absence of TNF-inhibitor exposure. Regardless of which comorbidity, a gap exists between recommendations for their management and actual implementation in clinical practice, suggesting that there is still a need for improvement in this area. Systematic screening for these comorbidities should improve both short- and long-term outcomes in SpA patients.

Several factors might explain this interest: poor tolerability (eg, nausea and fatigue) or contraindications (eg, pregnancy) of conventional synthetic DMARDs (csDMARDs) such as MTX; potential sensitisation to bDMARDs that could be prevented by the use of csDMARDs;3 and data from real-life practice that reveal up to 30% of RA patients on monotherapy were treated with bDMARDs.4 Therefore, there is a need to evaluate the efficacy of novel DMARDs used as monotherapy, and this can be envisioned in two very different settings: patients who have never been exposed to csDMARDs and those who are insufficient responders. Upadacitinib was evaluated in patients with active RA while on MTX therapy.5 The trial compared the 12-week efficacy of upadacitinib addition on top of MTX (221 patients treated with 15 mg of upadacitinib and 219 patients treated with 30 mg of upadacitinib) versus the addition of placebo on top of MTX (221 patients) and found that the addition of upadacitinib to MTX at both doses (64% and 66% responders) was superior to the addition of placebo to MTX (36% responders) in reaching the American College of Rheumatology 20% improvement criteria (ACR 20). Zephyr/Science Photo Library MD's department has received grants to do clinical studies and trials from AbbVie, Pfizer, Lilly, Gilead, Roche, BMS, UCB, and Merck; and MD has received personal fees for participating on advisory boards and symposia from AbbVie, Pfizer, Lilly, Gilead, Roche, BMS, UCB, and Merck, outside the area of work commented on here.

The main symptom in patients with axial spondyloarthritis (axSpA) is inflammatory back pain, caused principally by inflammation of the sacroiliac joints and the spine. However, not all back pain in patients with axSpA is related to active inflammation: other types of pain can occur in these patients, and may be related to structural damage (e.g. ankylosis), degenerative changes, vertebral fractures or comorbid fibromyalgia, which are not uncommon in these patients. Structural damage and ankylosis may lead to a biomechanical stress, which can lead to chronic mechanical pain; and degenerative changes of the spine may also exist in patients with axSpA also leading to mechanical pain. Osteoporosis is more prevalent in axSpA patients than in the general population, and vertebral fractures may result in acute bone pain, which can persist for several months. Fibromyalgia, which is also more prevalent in patients with chronic inflammatory diseases (including axSpA), presents with widespread pain which can mimic entheseal pain. A correct diagnosis of the origin of the pain is crucial, since treatments and management may differ considerably. Recognizing these causes of pain may be a challenge in clinical practice, especially for fibromyalgia, which can coexist with axSpA and may have a significant impact on biologic drug response. In this review, we provide an update of the most common causes of pain other than inflammatory back pain in axSpA patients, and we discuss the latest management options for such causes.

Current recommendations for management of patients with axial spondyloarthritis (axSpA) include regular collection of validated disease activity outcomes. This study aimed at evaluating the proportion of patients for whom validated outcome measures were available on their electronic medical reports (EMR), and the factors associated with the presence of such information on the EMR. We performed a cross-sectional monocentric observational study, including patients with an axSpA diagnosis who attended an outpatient visit between February, 2018 and February, 2019. Patients (demographics, disease characteristics, treatment) and physician characteristics (age, gender) and the disease activity outcome measures (BASDAI, CRP and ASDAS, and the items allowing to calculate them) were retrieved from the EMR. The proportion of patients in which disease activity outcome measures were available in the EMR was calculated, and the association between the presence of such outcomes and patients and physician’s characteristics was evaluated. 320 EMR of axSpA patients seen in the outpatient clinic were examined. Among them, 131 (41%) and 123 (38.4%) had a BASDAI + CRP and an ASDAS reported, respectively, but at least one was available in 178 (55.6%) of the EMR. The most frequently reported disease activity items were duration of morning stiffness (n = 230, 72%) and CRP (n = 224, 70%). Only previous participation on a systematic holistic review was independently associated with a reported disease activity outcome. Thus, implementation of recommendations with regard to regularly collecting disease activity outcome measures is not optimal. The participation in educational programs including self-assessment educational programs might be a key to improve such implementation.

Background (a) To describe the prevalence and incidence of peripheral arthritis during 5 years of follow-up in recent axial spondyloarthritis (axSpA), (b) to evaluate factors associated with their appearance and (c) to assess their impact on treatment, patient-reported outcomes and sick leave after follow-up. Methods Data from the early axSpA patients from the DESIR cohort (first 5 years of follow-up) were analysed. Prevalence and incidence of peripheral arthritis at each study visit were calculated. A multivariate analysis was performed to evaluate baseline factors associated with the development of the arthritis. The use of drugs, the impact on patient-reported outcomes and days of sick leave were compared in both groups over time. Results Out of the 708 patients included in DESIR, 255 (36.0%) showed at least one episode of arthritis (151 before the inclusion visit and 104 during the follow-up), with an incidence of 3.7 cases per 100 person-years. Patients with peripheral arthritis were more likely (OR, 95%CI) to be aged ≥ 33 years (1.60, 1.12–2.27), non-smokers (1.58, 1.10–2.27) and HLAB27 negative (1.47, 1.04–2.08) and have presented with at least one episode of dactylitis (8.50, 4.96–14.60) and enthesitis (2.00, 1.41–2.84). Patients with peripheral arthritis showed a significant greater use of TNFb, csDMARDs and corticosteroids over follow-up; higher levels on BASDAI (40.46 vs. 34.28) and BASFI (27.89 vs. 22.52); poorer quality of life; and higher number of days of sick leave (17.97 vs. 12.78) over time. Conclusion In recent axSpA, 36% of patients reported peripheral arthritis at any time of the disease, being associated with negative HLAB27, non-smokers and with other peripheral manifestations. Patients with arthritis showed a higher burden of disease.

Background Fibromyalgia (FM) can coexist with Spondyloarthritis (SpA) leading to diagnostic and treatment dilemmas, especially in the presence of enthesitis. With this study we aimed to estimate the prevalence of FM in SpA and to compare the clinical/disease features and TNF inhibitors (TNFi) in patients with/without FM. Method FM was defined by a score = > 5/6 of the Fibromyalgia Rapid Screening Tool (FiRST). SpA patients (according to the rheumatologist) and consecutively consulting in the day care hospital but also in the outpatient clinic at the rheumatology department of a tertiary care university hospital were included. Demographics, disease characteristics, activity and severity and TNFi treatment were compared in patients with and without FM; retention rate of the first TNFi and associated factors were explored (Kaplan Meier and Cox regression). Results Of the 196 enrolled SpA patients, 42 (21.4 %) were positively screened for FM. No statistically significant differences in the prevalence of FM were found with regard to the fulfillment of the ASAS criteria for peripheral/axial SpA, nor with regard to the fulfillment of the imaging vs. clinical arm of the ASAS criteria. However, patients with coexisting FM presented significantly with more enthesitis, higher disease activity (BASDAI and VAS) and poorer function scores (BASFI). No differences were found with regard to the initiation of TNFi treatment (79.0 % vs. 70.0 %, respectively), but the retention rate of the first TNFi after 2 years was shorter in the group of patients with FM (28.1 % (95 % CI 12.5-44.0) vs. 41.7 % (95 % CI 32.2-51.3), p = 0.01). Conclusion This study confirms that coexistent FM in SpA might impact the patient-reported outcome indices for disease activity and function, and the retention rate of TNFi treatment.

The increasing rates of CO2 due to anthropogenic activities are causing important potential climate threats for the Mediterranean Sea: ocean acidification and warming. In this region, two seagrass species, Posidonia oceanica and Cymodocea nodosa, can play a crucial role in climate change mitigation. Seagrasses can act as carbon sinks, buffer lowering pH values during the day and storing carbon in the sediment underneath their meadows. However, available data documenting these processes are scattered and collected using different methodologies, which makes its interpretation and generalization very challenging. In this study, we analyzed published and unpublished data (collected for this study) on seagrass community metabolism to compare two methodologies, benthic chambers and multiparametric sensors, and evaluate trends through time for these two species. Furthermore, we analyzed seasonal trends of both seagrass species' metabolic rates and their variation between the eastern and western Mediterranean basins. Most evaluated meadows, 80.9 %, were autotrophic. Calculated metabolic rates differ between methodologies, with multiparametric sensors estimating rates almost an order of magnitude higher, 143.22±28.21 (SE) mmol O2 m−2 d−1 for net community production (NCP) compared to an average of 18.75±3.80 (SE) mmol O2 m−2 d−1 for measurements with benthic chambers. However, sensors are not able to differentiate between habitats and only useful to assess seagrass metabolism at a broader community level, whereas benthic chambers are capable of evaluating rates at the species level and confirm that P. oceanica is more productive compared to C. nodosa. We found similar metabolic rates in the eastern and western Mediterranean regions for P. oceanica with the benthic-chamber technique and higher NCP in the west based on sensor measurements.

ObjectivesThe aim of the study is to evaluate the performance of extreme patient-reported outcomes (PRO) against definitions of fibromyalgia (FM) in patients with axial spondyloarthritis (axSpA).MethodsAncillary analysis of the Predict-SpA trial, an observational study of axSpA patients receiving TNF-α inhibitor, was performed. ‘Extreme PRO’ was defined as a score ≥ 8 on three out of the first five Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) questions (scored 0–10). FM was defined by the American College of Rheumatology (ACR) 1990 criteria and the Fibromyalgia Rapid Screening Test (FiRST). Performances of ‘extreme PRO’ for FM were evaluated by the sensitivity, specificity and positive likelihood ratio using the 1990 ACR criteria as gold standard. As secondary analysis, the FiRST was used as the external standard.ResultsThe prevalence of ‘extreme PRO’ in this population was 28.8% at baseline and decreased to 9.9% at 12 weeks. ‘Extreme PRO’ had low sensitivity 12 weeks after TNF initiation (0.18, 95% confidence interval [CI] 0.10–0.27 vs 0.60, 95% CI 0.50–0.71, at baseline), but high specificity (0.92, 95% CI 0.89–0.94 vs 0.78, 95% 0.74–0.82, at baseline), using ACR 1990 criteria as gold standard. Performances when tested against FiRST at 12 weeks showed higher sensitivity (0.27, 95% CI 0.20–0.35) and specificity (0.96, 95% CI 0.94–0.98).ConclusionThe proposed extreme PRO definition showed great specificity for FM recognition in patients with axSpA, suggesting it could be used in observational studies when specific items for FM classification are not available.

ObjectivesThere is a need for effective and safe treatment during pregnancy in women with chronic inflammatory diseases. This study evaluated placental transfer of certolizumab pegol (CZP), an Fc-free anti-tumour necrosis factor drug, from CZP-treated pregnant women to their infants.MethodsCRIB was a pharmacokinetic (PK) study of women ≥30 weeks pregnant receiving commercial CZP for a locally approved indication (last dose ≤35 days prior to delivery). Blood samples were collected from mothers, umbilical cords and infants at delivery, and infants again at weeks 4 and 8 post-delivery. CZP plasma concentrations were measured with a highly sensitive and CZP-specific electrochemiluminescence immunoassay (lower limit of quantification 0.032 μg/mL).ResultsSixteen women entered and completed the study. Maternal CZP plasma levels at delivery were within the expected therapeutic range (median [range] 24.4 [5.0–49.4] μg/mL). Of the 16 infants, 2 were excluded from the per-protocol set: 1 due to missing data at birth and 1 due to implausible PK data. Of the remaining 14 infants, 13 had no quantifiable CZP levels at birth (<0.032 μg/mL), and 1 had a minimal CZP level of 0.042 μg/mL (infant/mother plasma ratio 0.0009); no infants had quantifiable CZP levels at weeks 4 and 8. Of 16 umbilical cord samples, 1 was excluded due to missing data; 3/15 had quantifiable CZP levels (maximum 0.048 μg/mL).ConclusionsThere was no to minimal placental transfer of CZP from mothers to infants, suggesting lack of in utero foetal exposure during the third trimester. These results support continuation of CZP treatment during pregnancy, when considered necessary.Trial registration number NCT02019602; Results.