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      Characteristics of patients with axial spondyloarthritis by geographic regions: PROOF multicountry observational study baseline results


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          To compare demographic and clinical characteristics of patients with axial SpA (axSpA) across geographic regions.


          Patients With Axial Spondyloarthritis: Multicountry Registry of Clinical Characteristics (PROOF) is an observational study that enrolled recently diagnosed (≤1 year) axSpA patients fulfilling the Assessment of SpondyloArthritis international Society classification criteria from rheumatology clinical practices in 29 countries across six geographic regions. Demographics and disease-related parameters were collected. Here we present baseline data for patients who were classified as radiographic axSpA (r-axSpA) or non-radiographic axSpA (nr-axSpA) confirmed by central reading.


          Of the 2170 patients enrolled, 1553 were classified based on central evaluation of sacroiliac radiographs [r-axSpA: 1023 (66%); nr-axSpA: 530 (34%)]. Patients with nr-axSpA had a significantly higher occurrence of enthesitis (40% vs 33%), psoriasis (10% vs 5%) and IBD (4% vs 2%) vs r-axSpA patients. Significant differences in axSpA characteristics were observed between geographic regions. The highest occurrence of peripheral arthritis (60%), enthesitis (52%) and dactylitis (12%) was in Latin America, and the lowest was in Canada (9%, 9% and 2%, respectively). The occurrence of uveitis and psoriasis was highest in Canada (18% and 14%, respectively) and lowest in China (6% and <1%, respectively). IBD was highest in Arabia (21%), and no cases were observed in China. In multivariable analysis adjusted for factors potentially affecting peripheral and extramusculoskeletal manifestations, geographic regions still exhibited significant differences in frequencies of uveitis ( P < 0.01), psoriasis ( P < 0.0001) and peripheral arthritis ( P < 0.0001).


          The multinational PROOF study of axSpA patients showed significant regional differences in peripheral and extramusculoskeletal manifestations of SpA, which could be considered in management guidelines and clinical trials.

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          Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria.

          The New York and the Rome diagnostic criteria for ankylosing spondylitis (AS) and the clinical history screening test for AS were evaluated in relatives of AS patients and in population control subjects. The New York criterion of pain in the (dorso) lumbar spine lacks specificity, and the chest expansion criterion is too insensitive. The Rome criterion of low back pain for more than 3 months is very useful. Our study showed the clinical history screening test for AS to be moderately sensitive, but it might be better in clinical practice. As a modification of the New York criteria, substitution of the Rome pain criterion for the New York pain criterion is proposed.
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            2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis

            To update and integrate the recommendations for ankylosing spondylitis and the recommendations for the use of tumour necrosis factor inhibitors (TNFi) in axial spondyloarthritis (axSpA) into one set applicable to the full spectrum of patients with axSpA. Following the latest version of the European League Against Rheumatism (EULAR) Standardised Operating Procedures, two systematic literature reviews first collected the evidence regarding all treatment options (pharmacological and non-pharmacological) that were published since 2009. After a discussion of the results in the steering group and presentation to the task force, overarching principles and recommendations were formulated, and consensus was obtained by informal voting. A total of 5 overarching principles and 13 recommendations were agreed on. The first three recommendations deal with personalised medicine including treatment target and monitoring. Recommendation 4 covers non-pharmacological management. Recommendation 5 describes the central role of non-steroidal anti-inflammatory drugs (NSAIDs) as first-choice drug treatment. Recommendations 6–8 define the rather modest role of analgesics, and disprove glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) for axSpA patents with predominant axial involvement. Recommendation 9 refers to biological DMARDs (bDMARDs) including TNFi and IL-17 inhibitors (IL-17i) for patients with high disease activity despite the use (or intolerance/contraindication) of at least two NSAIDs. In addition, they should either have an elevated C reactive protein and/or definite inflammation on MRI and/or radiographic evidence of sacroiliitis. Current practice is to start with a TNFi. Switching to another TNFi or an IL-17i is recommended in case TNFi fails (recommendation 10). Tapering, but not stopping a bDMARD, can be considered in patients in sustained remission (recommendation 11). The final two recommendations (12, 13) deal with surgery and spinal fractures. The 2016 Assessment of SpondyloArthritis international Society-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.
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              Axial spondyloarthritis.

              The term axial spondyloarthritis covers both patients with non-radiographic and radiographic axial spondyloarthritis, which is also termed ankylosing spondylitis. The disease usually starts in the third decade of life with a male to female ratio of two to one for radiographic axial spondyloarthritis and of one to one for non-radiographic axial spondyloarthritis. More than 90% heritabilty has been estimated, the highest genetic association being with HLA-B27. The pathogenic role of HLA-B27 is still not clear although various hypotheses are available. On the basis of evidence from trials the cytokines tumour necrosis factor (TNF)-α and interleukin-17 appear to have a relevant role in pathogenesis. The mechanisms of interaction between inflammation and new bone formation is still not completely understood but clarification will be important for the prevention of long-term structural damage of the bone. The development of new criteria for classification and for screening of patients with axial spondyloarthritis have been crucial for the early indentification and treatment of such patients, with MRI being the most important existing imaging method. Non-steroidal anti-inflammatory drugs and TNF blockers are effective therapies. Blockade of interleukin-17 is a new and relevant treatment option.

                Author and article information

                Rheumatology (Oxford)
                Rheumatology (Oxford)
                Rheumatology (Oxford, England)
                Oxford University Press
                August 2022
                13 December 2021
                13 December 2021
                : 61
                : 8
                : 3299-3308
                Division of Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin
                Epidemiology Unit, German Rheumatism Research Centre , Berlin, Germany
                Division of Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin
                Department of Internal Medicine, Division of Rheumatology, Izmir Katip Celebi University , Izmir, Turkey
                Servicio de Reumatología, Hospital Universitario Infanta Sofía, Universidad Europea , Madrid, Spain
                Division of Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin
                Global Medical Affairs Rheumatology, AbbVie Inc. , Ljubljana, Slovenia
                Global Medical Affairs, AbbVie Inc. , Baar, Switzerland
                Schroeder Arthritis Institute, University Health Network, University of Toronto , Toronto, ON, Canada
                Author notes

                At the time of the study.

                Correspondence to: Denis Poddubnyy, Division of Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin, Hindenburgdamm 30, 12203, Berlin, Germany. E-mail: denis.poddubnyy@ 123456charite.de
                © The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Rheumatology.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                Page count
                Pages: 10
                Funded by: AbbVie, DOI 10.13039/100006483;
                Clinical Science

                axial spondyloarthritis,radiographic,non-radiographic,characteristics,demographics
                axial spondyloarthritis, radiographic, non-radiographic, characteristics, demographics


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