Axial Spondyloarthritis: from a conceptual framework to clinical practice

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Effectiveness of switching between TNF inhibitors in patients with axial spondyloarthritis : is the reason to switch relevant?

Publication . Manica, Santiago Rodrigues; Sepriano, Alexandre; Pimentel-Santos, Fernando; Gouveia, Nélia; Barcelos, Anabela; Branco, Jaime C.; Bernardes, Miguel; Ferreira, Raquel Miriam; Vieira de Sousa, Elsa Cristina; Barreira, Sofia; Vinagre, Filipe; Roque, Raquel; Santos, Helena; Madeira, Nathalie; Rovisco, João; Daniel, Alexandra; Ramiro, Sofia

Background: To investigate whether the reason to discontinue the first TNF inhibitor (TNFi) affects the response to the second TNFi in axial spondyloarthritis (axSpA). Methods: Patients with axSpA from the Rheumatic Diseases Portuguese Register (ReumaPt), who discontinued their first TNFi and started the second TNFi between June 2008 and May 2018, were included. Response was assessed by the Ankylosing Spondylitis Disease Activity Score (ASDAS) clinically important improvement (ASDAS-CII), major important improvement (ASDAS-MI), low disease activity (ASDAS-LDA), and inactive disease (ASDAS-ID). The reason for discontinuation of the first TNFi was defined, according to ASDAS-CII as primary failure (no response ≤ 6 months), secondary failure (response ≤ 6 months but lost thereafter), adverse events, and others. The association between the reason for discontinuation of the first TNFi and response to the second TNFi over time was assessed in multivariable generalized equation (GEE) models. Results: In total, 193 patients were included. The reason for discontinuation of the first TNFi did not influence the response to the second TNFi, according to the ASDAS-CII. However, a difference was found with more stringent outcomes, e.g., there was a higher likelihood to achieve ASDAS-ID with the second TNFi for patients discontinuing the first TNFi due to secondary failure (OR 7.3 [95%CI 1.9; 27.7]), adverse events (OR 9.1 [2.5; 33.3]), or other reasons (OR 7.7 [1.6; 37.9]) compared to primary failure. Conclusion: Patients with axSpA with secondary failure to their first TNFi, compared to those with primary failure, have a better response to the second TNFi according to stringent outcomes.

2020Artigo científico

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Eligibility criteria for biologic disease-modifying antirheumatic drugs in axial spondyloarthritis : going beyond BASDAI

Publication . Marona, Jose; Sepriano, Alexandre; Rodrigues-Manica, Santiago; Pimentel-Santos, Fernando; Mourão, Ana Filipa; Gouveia, Nélia; Branco, Jaime Cunha; Santos, Helena; Vieira de Sousa, Elsa Cristina; Vinagre, Filipe; Tavares-Costa, João; Rovisco, João; Bernardes, Miguel; Madeira, Nathalie; Machado, Ana Rita; Roque, Raquel; Silva, Joana Leite; Marques, Mary Lucy; Ferreira, Raquel Miriam; Ramiro, Sofia

Objectives: To compare definitions of high disease activity of the Ankylosing Spondylitis Disease Activity Score (ASDAS) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in selecting patients for treatment with biologic disease-modifying antirheumatic drugs (bDMARDs). Methods: Patients from Rheumatic Diseases Portuguese Register (Reuma.pt) with a clinical diagnosis of axial spondyloarthritis (axSpA) were included. Four subgroups (cross-tabulation between ASDAS (≥2.1) and BASDAI (≥4) definitions of high disease activity) were compared regarding baseline characteristics and response to bDMARDs at 3 and 6 months estimated in multivariable regression models. Results: Of the 594 patients included, the majority (82%) had both BASDAI≥4 and ASDAS ≥2.1. The frequency of ASDAS ≥2.1, if BASDAI<4 was much larger than the opposite (ie, ASDAS <2.1, if BASDAI≥4): 62% vs 0.8%. Compared to patients fulfilling both definitions, those with ASDAS ≥2.1 only were more likely to be male (77% vs 51%), human leucocyte antigen B27 positive (79% vs 65%) and have a higher C reactive protein (2.9 (SD 3.5) vs 2.1 (2.9)). Among bDMARD-treated patients (n=359), responses across subgroups were globally overlapping, except for the most ‘stringent’ outcomes. Patients captured only by ASDAS responded better compared to patients fulfilling both definitions (eg, ASDAS inactive disease at 3 months: 61% vs 25% and at 6 months: 42% vs 25%). Conclusion: The ASDAS definition of high disease activity is more inclusive than the BASDAI definition in selecting patients with axSpA for bDMARD treatment. The additionally ‘captured’ patients respond better and have higher likelihood of predictors thereof. These results support using ASDAS≥2.1 as a criterion for treatment decisions.

2020Artigo científico

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Performance of referral strategies for spondyloarthritis : a population-based nationwide study

Publication . Sepriano, Alexandre Rocha; Ramiro, Sofia; Araújo, Filipe C; Machado, Pedro M; Rodrigues, Ana Maria; Gouveia, Nélia; Eusébio, Mónica; Canhao, Helena; Branco, Jaime

Objectives: To evaluate the performance of the referral strategy (RS) for SpA of a nationwide epidemiological study (EpiReumaPt), as compared with previously proposed RSs. Methods: EpiReumaPt was a three-stage national epidemiologic study. In phase one, 10 661 adult participants were randomly selected and screened for rheumatic and musculoskeletal diseases. In the second phase, positive screenings for ⩾1 rheumatic and musculoskeletal disease plus 20% negative screenings were assessed by a rheumatologist. Finally, three rheumatologists revised all the information and defined the final diagnosis. All participants from phase two were included. Thirteen RS were tested against the SpA diagnosis using several metrics, including sensitivity, specificity, the post-test probability of SpA given a positive RS (positive predictive value) and given a negative RS (1 – negative predictive value). Results: From the total 3877 participants, 92 received a SpA diagnosis [weighted national prevalence: 1.6% (95% confidence interval: 1.2, 2.1)]. Modified versions of the Assessment of SpondyloArthritis international Society-RS and EpiReumaPt-RS were the most sensitive (85% and 72%, respectively) and yielded the lowest post-test probabilities of SpA if negative (0.6% and 0.7%, respectively). Considering the national prevalence (pre-test probability) of SpA (1.6%), a negative screening by these two RSs decreased the probability of SpA substantially (Assessment of SpondyloArthritis international Society: −63%; EpiReumaPt: −56%). Other RSs performed less well in reducing disease probability (range: −6.3%; −37.5%). Overall, the probability of SpA given a positive RS was small (positive predictive value range: 2.2%; 7.6%) and the EpiReumaPt RS yielded the best balance between sensitivity and positive predictive value. Conclusion: The proposed EpiReumaPt RS performed the best as a screening tool for SpA in patients from the general population when laboratory and imaging data were not available.

2019Artigo científico

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Entidade financiadora

Fundação para a Ciência e a Tecnologia

Número da atribuição

SFRH/BD/108246/2015