2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis.

OBJECTIVE: To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS: We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel. RESULTS: Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended. CONCLUSION: These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.

2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis.

OBJECTIVE: To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS: We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel. RESULTS: Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended. CONCLUSION: These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.

Osteoporosis Management in Ankylosing Spondylitis.

Low bone mineral density (BMD) is increasingly recognized as a common comorbid condition in ankylosing spondylitis (AS). As low BMD increases fracture risk, it is important to identify and treat low BMD in patients with AS who have been shown to be at increased risk for fractures above the population normal. Since low BMD occurs early in disease, we screen during the first year of diagnosis with dual energy x-ray absorptiometry (DXA). If patients are found to have osteoporosis by T-score of less than -2.5 or if their Z-score on DXA is more than two standard deviations below the mean, we initiate therapy with bisphosphonates in males and in females who are not planning any future pregnancies. While reduction in fracture risk with bisphosphonate therapy has not been clearly defined in patients with AS, reduction in vertebral and hip fractures has been well established in primary osteoporosis and thus it is our first line treatment. If there are contraindications to the use of bisphosphonates in the treatment of low BMD, we will consider the use of denosumab. If the patient is not receiving a TNF-alpha inhibitor (TNFi) and has active disease, we also favor early initiation of TNFi due to their positive effects on BMD though the outcome on reduction in vertebral fractures remains unclear. We counsel all patients regarding the importance of adequate intake of vitamin D and calcium per the Institute of Medicine guidelines. All patients should be encouraged to participate in weight-bearing activities with a focus on core strength and gait training.

Measurement and treatment of radiographic progression in ankylosing spondylitis: lessons learned from observational studies and clinical trials.

PURPOSE OF REVIEW: One of the major goals of treatment of ankylosing spondylitis is to prevent or slow the development of spinal new bone formation. Recent observational studies are compared with the results from clinical trials for the effects of tumor necrosis factor-alpha inhibitors (TNFi) and NSAIDs on radiographic measures of spinal damage. RECENT FINDINGS: Data from clinical trials indicate that treatment up to 2 years with TNFi was not associated with a difference in rates of progression of spinal damage, compared with historical controls. These studies were based on open-label extensions, and analyzed as cohort studies. Recent observational studies have suggested that TNFi may reduce radiographic progression. The different conclusions may be related to the longer treatment and observation period of these observational studies, which may have permitted detection of changes in this slowly evolving process. There is emerging evidence from a clinical trial and retrospective studies that continuous NSAID use may slow radiographic progression. SUMMARY: Lack of evidence that TNFi slows radiographic progression in ankylosing spondylitis in data from clinical trials may be because of the design of these studies, and possibly not a true null treatment effect.

Cervical spine involvement early in the course of rheumatoid arthritis.

OBJECTIVES: Cervical spine involvement in rheumatoid arthritis (RA) is considered a feature of long-standing disease. We describe two patients who presented with cervical symptoms as early features of RA. METHODS: We report two RA cases with cervical spine involvement as early features and use MEDLINE to review the literature concerning the frequency and disease duration of this manifestation and its imaging with plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI). RESULTS: An 80-year-old man with cervical myelopathy from a C1-C2 rheumatoid pannus underwent decompression surgery before development of peripheral synovitis from RA. A 63-year-old woman presented with neck pain and polyarthritis at RA diagnosis, with imaging that confirmed a C1-C2 rheumatoid pannus. Onset of cervical spine involvement in RA is generally after 10 years of disease duration, ranging from 3 months to 45 years after peripheral synovitis among patients with seropositive erosive RA. Occurring in 9-88% of RA patients, cervical spine involvement may result in cervical instability due to either mechanical compression or vascular impairment of the spinal cord. Bone erosions and atlanto-axial subluxation on standard radiographs are two major signs of cervical spine involvement in RA. MRI identifies earlier signs of RA and has a higher sensitivity in detecting bone erosions compared to conventional radiography. CONCLUSIONS: Cervical spine involvement in RA is not an uncommon condition but is rare at early disease onset. Symptoms of cervical pain and myelopathy should prompt a thorough neurological examination accompanied by imaging.

Arthritis, occupational class, and the aging US workforce.

OBJECTIVES: The working poor sometimes delay retirement to survive. However, their higher risk of disease and disability threatens both their financial survival and their ability to work through the retirement years. We used the burden of disease attributable to arthritis by occupational class to illustrate the challenges faced by the older poor. METHODS: We merged data from the National Health Interview Survey, Medical Expenditure Panel Survey, and the National Death Index into a single database. We then calculated and compared age- and occupational class-specific quality-adjusted life years (QALYs) between workers with and without arthritis by using unabridged life tables. RESULTS: White-collar workers have a higher overall health-related quality of life than do other workers, and suffer fewer QALYs lost to arthritis at all ages. For instance, whereas 65-year-old white-collar workers without arthritis look forward to 17 QALYs of future life, blue-collar workers with arthritis experience only 11, and are much less likely to remain in the workforce than are those in service, farming, or white-collar jobs. CONCLUSIONS: To meet the needs of the aging workforce, more extensive health and disability insurance will be needed.

Sleep disturbances in adults with arthritis: prevalence, mediators, and subgroups at greatest risk. Data from the 2007 National Health Interview Survey.

OBJECTIVE: To examine the prevalence of sleep disturbances in adults with arthritis in a nationally representative sample, mediators of sleep difficulties, and subgroups of individuals with arthritis at greatest risk. METHODS: Using data on US adults ages≥18 years participating in the 2007 National Health Interview Survey, we computed the prevalence of 3 measures of sleep disturbance (insomnia, excessive daytime sleepiness, and sleep duration<6 hours) among persons with arthritis. We used logistic regression analysis to examine if the association of arthritis and sleep disturbances was independent of sociodemographic characteristics and comorbidities, and to identify potential mediators. We used classification trees to identify subgroups at higher risk. RESULTS: The adjusted prevalence of insomnia was higher among adults with arthritis than those without arthritis (23.1% versus 16.4%; P<0.0001), but was similar to those with other chronic diseases. Adults with arthritis were more likely than those without arthritis to report insomnia (unadjusted odds ratio 2.92, 95% confidence interval 2.68-3.17), but adjustment for sociodemographic characteristics and comorbidities attenuated this association. Joint pain and limitation due to pain mediated the association between arthritis and insomnia. Among adults with arthritis, those with depression and anxiety were at highest risk for sleep disturbance. Results for excessive daytime sleepiness and sleep duration<6 hours were similar. CONCLUSION: Sleep disturbance affects up to 10.2 million US adults with arthritis, and is mediated by joint pain and limitation due to pain. Among individuals with arthritis, those with depression and anxiety are at greatest risk.

Socioeconomic and ethnic differences in disease burden and disparities in physical function in older adults.

OBJECTIVES: We investigated whether a greater burden of disease among poorer individuals and ethnic minorities accounted for socioeconomic and racial disparities in self-reported physical functioning among older adults. METHODS: We used data from adults aged 60 years or older (n = 5556) in the Third National Health and Nutrition Examination Survey, 1988-1994 to test associations between education level, poverty index, and race/ethnicity and limitations in 11 functions. We adjusted for demographic features and measures of disease burden (comorbid conditions, smoking, hemoglobin level, serum albumin level, knee pain, body mass index, and skeletal muscle index). RESULTS: Associations between education and functional limitations were attenuated after adjustment, but those with 0-8 years of education were more likely than those with 13 or more years of education to have limitations in 3 functions. Poverty was associated with a higher likelihood of limitations despite adjustment. The likelihood of limitations among non-Hispanic Blacks and Mexican Americans was similar to that of non-Hispanic Whites after adjustment. CONCLUSIONS: Socioeconomic disparities in functional limitations among older Americans exist independent of disease burden, whereas socioeconomic differences and disease burden account for racial disparities.

Association of measured physical performance and demographic and health characteristics with self-reported physical function: implications for the interpretation of self-reported limitations.

BACKGROUND: Self-reported limitations in physical function often have only weak associations with measured performance on physical tests, suggesting that factors other than performance commonly influence self-reports. We tested if personal or health characteristics influenced self-reported limitations in three tasks, controlling for measured performance on these tasks. METHODS: We used cross-sectional data on adults aged >/= 60 years (N = 5396) from the Third National Health and Nutrition Examination Survey to examine the association between the repeated chair rise test and self-reported difficulty rising from a chair. We then tested if personal characteristics, health indicators, body composition, and performance on unrelated tasks were associated with self-reported limitations in this task. We used the same approach to examine associations between personal and health characteristics and self-reported difficulty walking between rooms, controlling for timed 8-foot walk, and self-reported difficulty getting out of bed, controlling for repeated chair rise test results. RESULTS: In multivariate analyses, participants who performed worse on the repeated chair rise test were more likely to report difficulty with chair rise. However, older age, lower education level, lower serum albumin, comorbidities, knee pain, and being underweight were also significantly associated with self-reported limitations with chair rise. Results were similar for difficulty walking between rooms and getting out of bed. CONCLUSIONS: Self-reports of limitations in physical function are influenced by personal and health characteristics that reflect frailty, and should not be interpreted solely as measured difficulty performing the task.

Sex disparities in self-reported physical functioning: true differences, reporting bias, or incomplete adjustment for confounding?

OBJECTIVES: To determine whether sex disparities in self-reported physical functioning remain after adjusting for potential confounding factors and to assess associations for possible reporting bias. DESIGN: Cross-sectional survey. SETTING: U.S. population of noninstitutionalized older adults. PARTICIPANTS: Women and men aged 60 and older (N=5,396) who participated in the Third National Health and Nutrition Examination Survey. MEASUREMENTS: Degree of self-reported limitation in 11 physical functions. RESULTS: In unadjusted models, women reported more limitations than men in 10 of 11 tasks. In multivariate ordinal logistic regression models that included adjustment for age, race or ethnicity, education level, comorbidities, smoking, hemoglobin, serum albumin, knee pain, body mass index, skeletal muscle index, and physical performance tests, women reported more limitations only in lifting or carrying 10 pounds (adjusted odds ratio=2.03, 95% confidence interval=1.45-2.84). There was no evidence of systematic reporting differences between men and women for limitations in lifting or carrying 10 pounds relative to the degree of limitation predicted by the model. CONCLUSION: Older women have similar degrees of self-reported limitation in physical functioning as older men of the same age, health, and physical abilities.

Changes in the rates of joint surgery among patients with rheumatoid arthritis in California, 1983-2007.

BACKGROUND: Treatment of patients with rheumatoid arthritis (RA) has improved markedly over the past 25 years. OBJECTIVE: To investigate whether rates of joint surgery, a long-term consequence of poorly controlled RA, have changed over this period. METHODS: In this population-based, serial cross-sectional study of patients with RA aged >or=40 years in California, trends in annual rates of total knee arthroplasty, total hip arthroplasty, total ankle arthroplasty or arthrodesis and total wrist arthroplasty or arthrodesis from 1983 to 2007 were examined. RESULTS: Rates of joint surgery peaked in the 1990 s and since have decreased. Among patients aged 40-59 years, rates of knee surgery in 2003-2007 were 19% lower than in 1983-1987 (adjusted rate ratio 0.81; 95% CI 0.74 to 0.87, p<0.0001), while rates of hip surgery in 2003-2007 were 40% lower (p<0.0001). Rates of knee and hip surgery did not decrease in patients aged >or=60 years but increased as observed in the general population. Compared with rates of ankle and wrist surgery in the mid-1980s, rates in the mid-2000s decreased significantly in both age groups. CONCLUSIONS: Rates of joint surgery in RA peaked in the 1990 s and have declined thereafter, suggesting that longterm outcomes of RA are improving.