Spondyloarthritis, Ankylosing Spondylitis and Psoriatic Arthritis
Spondyloarthritis, Ankylosing Spondylitis and Psoriatic Arthritis
Background Therapeutic targets have been defined for diseases like diabetes, hypertension or rheumatoid arthritis and adhering to them has improved outcomes. Such targets are just emerging for spondyloarthritis (SpA).
Objective To define the treatment target for SpA including ankylosing spondylitis and psoriatic arthritis (PsA) and develop recommendations for achieving the target, including a treat-to-target management strategy.
Methods Based on results of a systematic literature review and expert opinion, a task force of expert physicians and patients developed recommendations which were broadly discussed and voted upon in a Delphi-like process. Level of evidence, grade and strength of the recommendations were derived by respective means. The commonalities between axial SpA, peripheral SpA and PsA were discussed in detail.
Results Although the literature review did not reveal trials comparing a treat-to-target approach with another or no strategy, it provided indirect evidence regarding an optimised approach to therapy that facilitated the development of recommendations. The group agreed on 5 overarching principles and 11 recommendations; 9 of these recommendations related commonly to the whole spectrum of SpA and PsA, and only 2 were designed separately for axial SpA, peripheral SpA and PsA. The main treatment target, which should be based on a shared decision with the patient, was defined as remission, with the alternative target of low disease activity. Follow-up examinations at regular intervals that depend on the patient's status should safeguard the evolution of disease activity towards the targeted goal. Additional recommendations relate to extra-articular and extramusculoskeletal aspects and other important factors, such as comorbidity. While the level of evidence was generally quite low, the mean strength of recommendation was 9–10 (10: maximum agreement) for all recommendations. A research agenda was formulated.
Conclusions The task force defined the treatment target as remission or, alternatively, low disease activity, being aware that the evidence base is not strong and needs to be expanded by future research. These recommendations can inform the various stakeholders about expert opinion that aims for reaching optimal outcomes of SpA.
The approaches to the diagnosis, therapy and follow-up of patients with ankylosing spondylitis (AS) and psoriatic arthritis (PsA) have undergone a number of paradigmatical changes over the last decade. Especially considerations of the disease spectrum of spondyloarthritis (SpA) have recently undergone remarkable changes. In addition to AS, defined by prevalent radiographic structural changes in the sacroiliac joints, non-radiographic axial SpA (axSpA) has been defined based on the absence of such changes but presence of sacroiliitis (as documented by MRI) and/or human leukocyte antigen B27. The term axSpA, therefore, includes radiographic axSpA (AS) and non-radiographic axSpA. On this basis, new classification criteria have been established by Assessment of SpondyloArthritis international Society (ASAS), novel therapies have proven efficacious, MRI has been increasingly established as an imaging tool in SpA and new indices to assess disease activity have been developed. The novel approach to classification has also differentiated the two predominant manifestations of SpA, axial and/or peripheral, and their potential parallel occurrence. The basis for the new classification lies in the sharing of characteristic features of SpA, such as sacroiliitis, spondylitis and enthesitis and common genetic markers and a positive family history. Furthermore, extramusculoskeletal manifestations such as psoriasis in PsA, a preceding gastrointestinal or urogenital infection as in the case of reactive arthritis (ReA), and chronic inflammatory bowel diseases (IBD) like Crohn's disease and ulcerative colitis, play a role in the definition of a clinical syndrome as belonging to the concept of SpA. For the classification of patients with PsA the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria are well established. Since the presence of psoriasis plays a role in both criteria sets, the ASAS and the CASPAR criteria, there is some overlap between the two. There is no international agreement whether and how they can or should be differentiated. Finally, to account for therapeutic developments, management recommendations have recently been presented.
Despite all these advances, a variety of challenges exist when considering the management of patients with SpA, not least because the definition of a clear therapeutic target and strategies to reach such target are not yet optimally defined.
In many areas of medicine, such as diabetes care or cardiology, clear therapeutic targets are available. More recently, a treatment target has also been advocated for rheumatoid arthritis (RA), namely remission or low disease activity, a recommendation based on insights from various clinical trials as revealed by systematic literature reviews (SLRs). Much less information on the value of defining therapeutic targets is currently available for AS or PsA. Therefore, a task force was formed to discuss and develop a consensus on recommendations aimed at defining a treatment target for, and thus at improving the management of axial and peripheral SpA in clinical practice.
Abstract and Introduction
Abstract
Background Therapeutic targets have been defined for diseases like diabetes, hypertension or rheumatoid arthritis and adhering to them has improved outcomes. Such targets are just emerging for spondyloarthritis (SpA).
Objective To define the treatment target for SpA including ankylosing spondylitis and psoriatic arthritis (PsA) and develop recommendations for achieving the target, including a treat-to-target management strategy.
Methods Based on results of a systematic literature review and expert opinion, a task force of expert physicians and patients developed recommendations which were broadly discussed and voted upon in a Delphi-like process. Level of evidence, grade and strength of the recommendations were derived by respective means. The commonalities between axial SpA, peripheral SpA and PsA were discussed in detail.
Results Although the literature review did not reveal trials comparing a treat-to-target approach with another or no strategy, it provided indirect evidence regarding an optimised approach to therapy that facilitated the development of recommendations. The group agreed on 5 overarching principles and 11 recommendations; 9 of these recommendations related commonly to the whole spectrum of SpA and PsA, and only 2 were designed separately for axial SpA, peripheral SpA and PsA. The main treatment target, which should be based on a shared decision with the patient, was defined as remission, with the alternative target of low disease activity. Follow-up examinations at regular intervals that depend on the patient's status should safeguard the evolution of disease activity towards the targeted goal. Additional recommendations relate to extra-articular and extramusculoskeletal aspects and other important factors, such as comorbidity. While the level of evidence was generally quite low, the mean strength of recommendation was 9–10 (10: maximum agreement) for all recommendations. A research agenda was formulated.
Conclusions The task force defined the treatment target as remission or, alternatively, low disease activity, being aware that the evidence base is not strong and needs to be expanded by future research. These recommendations can inform the various stakeholders about expert opinion that aims for reaching optimal outcomes of SpA.
Introduction
The approaches to the diagnosis, therapy and follow-up of patients with ankylosing spondylitis (AS) and psoriatic arthritis (PsA) have undergone a number of paradigmatical changes over the last decade. Especially considerations of the disease spectrum of spondyloarthritis (SpA) have recently undergone remarkable changes. In addition to AS, defined by prevalent radiographic structural changes in the sacroiliac joints, non-radiographic axial SpA (axSpA) has been defined based on the absence of such changes but presence of sacroiliitis (as documented by MRI) and/or human leukocyte antigen B27. The term axSpA, therefore, includes radiographic axSpA (AS) and non-radiographic axSpA. On this basis, new classification criteria have been established by Assessment of SpondyloArthritis international Society (ASAS), novel therapies have proven efficacious, MRI has been increasingly established as an imaging tool in SpA and new indices to assess disease activity have been developed. The novel approach to classification has also differentiated the two predominant manifestations of SpA, axial and/or peripheral, and their potential parallel occurrence. The basis for the new classification lies in the sharing of characteristic features of SpA, such as sacroiliitis, spondylitis and enthesitis and common genetic markers and a positive family history. Furthermore, extramusculoskeletal manifestations such as psoriasis in PsA, a preceding gastrointestinal or urogenital infection as in the case of reactive arthritis (ReA), and chronic inflammatory bowel diseases (IBD) like Crohn's disease and ulcerative colitis, play a role in the definition of a clinical syndrome as belonging to the concept of SpA. For the classification of patients with PsA the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria are well established. Since the presence of psoriasis plays a role in both criteria sets, the ASAS and the CASPAR criteria, there is some overlap between the two. There is no international agreement whether and how they can or should be differentiated. Finally, to account for therapeutic developments, management recommendations have recently been presented.
Despite all these advances, a variety of challenges exist when considering the management of patients with SpA, not least because the definition of a clear therapeutic target and strategies to reach such target are not yet optimally defined.
In many areas of medicine, such as diabetes care or cardiology, clear therapeutic targets are available. More recently, a treatment target has also been advocated for rheumatoid arthritis (RA), namely remission or low disease activity, a recommendation based on insights from various clinical trials as revealed by systematic literature reviews (SLRs). Much less information on the value of defining therapeutic targets is currently available for AS or PsA. Therefore, a task force was formed to discuss and develop a consensus on recommendations aimed at defining a treatment target for, and thus at improving the management of axial and peripheral SpA in clinical practice.
Source...