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      Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force

      1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 1 , 4 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 5 , 27 , 11 , 28 , 29 , 11 , 30 , 31 , 32 , 33 , 34 , 35

      Annals of the Rheumatic Diseases

      BMJ Publishing Group

      Spondyloarthritis, Ankylosing Spondylitis, Psoriatic Arthritis, Treatment, Outcomes Research

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          Abstract

          Therapeutic targets have been defined for axial and peripheral spondyloarthritis (SpA) in 2012, but the evidence for these recommendations was only of indirect nature. These recommendations were re-evaluated in light of new insights. Based on the results of a systematic literature review and expert opinion, a task force of rheumatologists, dermatologists, patients and a health professional developed an update of the 2012 recommendations. These underwent intensive discussions, on site voting and subsequent anonymous electronic voting on levels of agreement with each item. A set of 5 overarching principles and 11 recommendations were developed and voted on. Some items were present in the previous recommendations, while others were significantly changed or newly formulated. The 2017 task force arrived at a single set of recommendations for axial and peripheral SpA, including psoriatic arthritis (PsA). The most exhaustive discussions related to whether PsA should be assessed using unidimensional composite scores for its different domains or multidimensional scores that comprise multiple domains. This question was not resolved and constitutes an important research agenda. There was broad agreement, now better supported by data than in 2012, that remission/inactive disease and, alternatively, low/minimal disease activity are the principal targets for the treatment of PsA. As instruments to assess the patients on the path to the target, the Ankylosing Spondylitis Disease Activity Score (ASDAS) for axial SpA and the Disease Activity index for PSoriatic Arthritis (DAPSA) and Minimal Disease Activity (MDA) for PsA were recommended, although not supported by all. Shared decision-making between the clinician and the patient was seen as pivotal to the process. The task force defined the treatment target for SpA as remission or low disease activity and developed a large research agenda to further advance the field.

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          The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group.

          Long-term microvascular and neurologic complications cause major morbidity and mortality in patients with insulin-dependent diabetes mellitus (IDDM). We examined whether intensive treatment with the goal of maintaining blood glucose concentrations close to the normal range could decrease the frequency and severity of these complications. A total of 1441 patients with IDDM--726 with no retinopathy at base line (the primary-prevention cohort) and 715 with mild retinopathy (the secondary-intervention cohort) were randomly assigned to intensive therapy administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood glucose monitoring or to conventional therapy with one or two daily insulin injections. The patients were followed for a mean of 6.5 years, and the appearance and progression of retinopathy and other complications were assessed regularly. In the primary-prevention cohort, intensive therapy reduced the adjusted mean risk for the development of retinopathy by 76 percent (95 percent confidence interval, 62 to 85 percent), as compared with conventional therapy. In the secondary-intervention cohort, intensive therapy slowed the progression of retinopathy by 54 percent (95 percent confidence interval, 39 to 66 percent) and reduced the development of proliferative or severe nonproliferative retinopathy by 47 percent (95 percent confidence interval, 14 to 67 percent). In the two cohorts combined, intensive therapy reduced the occurrence of microalbuminuria (urinary albumin excretion of > or = 40 mg per 24 hours) by 39 percent (95 percent confidence interval, 21 to 52 percent), that of albuminuria (urinary albumin excretion of > or = 300 mg per 24 hours) by 54 percent (95 percent confidence interval 19 to 74 percent), and that of clinical neuropathy by 60 percent (95 percent confidence interval, 38 to 74 percent). The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia. Intensive therapy effectively delays the onset and slows the progression of diabetic retinopathy, nephropathy, and neuropathy in patients with IDDM.
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            EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update.

            Recent insights in rheumatoid arthritis (RA) necessitated updating the European League Against Rheumatism (EULAR) RA management recommendations. A large international Task Force based decisions on evidence from 3 systematic literature reviews, developing 4 overarching principles and 12 recommendations (vs 3 and 14, respectively, in 2013). The recommendations address conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GC); biological (b) DMARDs (tumour necrosis factor (TNF)-inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, clazakizumab, sarilumab and sirukumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (Janus kinase (Jak) inhibitors tofacitinib, baricitinib). Monotherapy, combination therapy, treatment strategies (treat-to-target) and the targets of sustained clinical remission (as defined by the American College of Rheumatology-(ACR)-EULAR Boolean or index criteria) or low disease activity are discussed. Cost aspects were taken into consideration. As first strategy, the Task Force recommends MTX (rapid escalation to 25 mg/week) plus short-term GC, aiming at >50% improvement within 3 and target attainment within 6 months. If this fails stratification is recommended. Without unfavourable prognostic markers, switching to-or adding-another csDMARDs (plus short-term GC) is suggested. In the presence of unfavourable prognostic markers (autoantibodies, high disease activity, early erosions, failure of 2 csDMARDs), any bDMARD (current practice) or Jak-inhibitor should be added to the csDMARD. If this fails, any other bDMARD or tsDMARD is recommended. If a patient is in sustained remission, bDMARDs can be tapered. For each recommendation, levels of evidence and Task Force agreement are provided, both mostly very high. These recommendations intend informing rheumatologists, patients, national rheumatology societies, hospital officials, social security agencies and regulators about EULAR's most recent consensus on the management of RA, aimed at attaining best outcomes with current therapies.
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              Standardization of Uveitis Nomenclature for Reporting Clinical Data. Results of the First International Workshop

              To begin a process of standardizing the methods for reporting clinical data in the field of uveitis. Consensus workshop. Members of an international working group were surveyed about diagnostic terminology, inflammation grading schema, and outcome measures, and the results used to develop a series of proposals to better standardize the use of these entities. Small groups employed nominal group techniques to achieve consensus on several of these issues. The group affirmed that an anatomic classification of uveitis should be used as a framework for subsequent work on diagnostic criteria for specific uveitic syndromes, and that the classification of uveitis entities should be on the basis of the location of the inflammation and not on the presence of structural complications. Issues regarding the use of the terms "intermediate uveitis," "pars planitis," "panuveitis," and descriptors of the onset and course of the uveitis were addressed. The following were adopted: standardized grading schema for anterior chamber cells, anterior chamber flare, and for vitreous haze; standardized methods of recording structural complications of uveitis; standardized definitions of outcomes, including "inactive" inflammation, "improvement'; and "worsening" of the inflammation, and "corticosteroid sparing," and standardized guidelines for reporting visual acuity outcomes. A process of standardizing the approach to reporting clinical data in uveitis research has begun, and several terms have been standardized.
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                Author and article information

                Journal
                Ann Rheum Dis
                Ann. Rheum. Dis
                annrheumdis
                ard
                Annals of the Rheumatic Diseases
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                0003-4967
                1468-2060
                January 2018
                6 July 2017
                : 77
                : 1
                : 3-17
                Affiliations
                [1 ] departmentDivision of Rheumatology, Department of Medicine 3 , Medical University of Vienna , Vienna, Austria
                [2 ] department2nd Department of Medicine , Hietzing Hospital , Vienna, Austria
                [3 ] Health Consult , Vienna, Austria
                [4 ] Rheumazentrum Ruhrgebiet, Ruhr-University Bochum , Herne, Germany
                [5 ] departmentDepartment of Rheumatology , Paris Descartes University , Paris, France
                [6 ] departmentDepartment of Rheumatology , St Vincent’s University Hospital , Dublin, Ireland
                [7 ] departmentDivision of Rheumatology , University of Toronto , Toronto, Ontario, Canada
                [8 ] departmentDivision of Rheumatology , University of California , San Diego, CA, USA
                [9 ] Amsterdam Rheumatology & Immunology Center , Amsterdam, The Netherlands
                [10 ] departmentDivision of Rheumatology Research , Swedish-Providence St. Joseph Health System, University of Washington , Seattle, WA, USA
                [11 ] departmentDepartment of Gastroenterology , Infectiology and Rheumatology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin , Berlin, Berlin, Germany
                [12 ] departmentSection for Outcomes Research , Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna , Vienna, Austria
                [13 ] departmentDepartment of Medical Humanities , VU University Medical Centre , Amsterdam, The Netherlands
                [14 ] Neil Betteridge Associates , UK
                [15 ] Ghent University Hospital , Ghent, Belgium
                [16 ] departmentDepartment of Orthopaedics , Rheumatology and Musculoskeletal Sciences, University of Oxford , Oxford, UK
                [17 ] Leeds Institute of Rheumatic and Musculoskeletal Medicine , Leeds, UK
                [18 ] departmentDepartment of Medicine , University of California , San Francisco, CA, USA
                [19 ] departmentDepartment of Rheumatology , UPMC Univ Paris 06, GRC-UPMC 08 (EEMOIS); AP-HP, Pitié Salpêtrière Hospital , Paris, France
                [20 ] Institute of Molecular Medicine, University of Leeds , Leeds, UK
                [21 ] Seayn Medical , Voorschoten, The Netherlands
                [22 ] departmentDepartment of Rheumatology , Diakonhjemmet Hospital , Oslo, Norway
                [23 ] University Health Network and University of Toronto , Toronto, Ontario, Canada
                [24 ] University of Glasgow, College of Medical Veterinary and Life Sciences , Glasgow, UK
                [25 ] A.DI.PSO. (Associazione per la Difesa degli Psoriasici)—PE.Pso.POF (Pan European Psoriasis Patients’ Organization Forum) , Rome, Italy
                [26 ] Centre for Rheumatology & MRC Centre for Neuromuscular Diseases, University College London , London, UK
                [27 ] departmentDivision of Rheumatology , Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania , Pennsylvania, PA, USA
                [28 ] German Rheumatism Research Centrer , Berlin, Germany
                [29 ] departmentAllergy, Immunology and Rheumatology Division , University of Rochester Medical Center Rochester , New York, NY, USA
                [30 ] departmentDivision of Internal Medicine and Rheumatology , Klinikum Bielefeld , Bielefeld, Germany
                [31 ] departmentDepartment of Dermatology , Medical University of Vienna , Vienna, Austria
                [32 ] departmentDepartment of Dermatology , Erasmus Medical Center, Erasmus University , Rotterdam, The Netherlands
                [33 ] departmentDepartment of Rheumatology , Klinikum Bielefeld , Bielefeld, Germany
                [34 ] departmentDivision of Rheumatology , University Hospitals Leuven , Leuven, Belgium
                [35 ] departmentDepartment of Rheumatology , Leiden University Medical Center , Leiden, The Netherlands
                Author notes
                [Correspondence to ] Josef S Smolen, Division of Rheumatology, Department of Medicine 3,Medical University of Vienna, Waehringer Guertel 19-20, 1090 Vienna, Austria; josef.smolen@ 123456wienkav.at
                annrheumdis-2017-211734
                10.1136/annrheumdis-2017-211734
                5754738
                28684559
                © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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                Funded by: FundRef http://dx.doi.org/10.13039/100006483, AbbVie;
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