OBJECTIVE:In the United States, axial spondyloarthritis (axSpA) diagnosis is delayed up to 14 years preventing effective management. We convened a multidisciplinary clinician and patient group to develop recommendations for rheumatology referral of adults with chronic back pain. METHODS:Systematic review (SR) and meta-analysis determined predictive values of clinical, laboratory, and imaging axSpA features for diagnosis. In a Delphi exercise, experts reviewed these test characteristics and voted to gain consensus for inclusion or exclusion in the final recommendations. Features that did not gain consensus were evaluated using discrete choice experiments (DCE). Positive likelihood ratios (+LRs) were used to calculate the probability of axSpA to develop the referral strategy. RESULTS:The SR uncovered 28 axSpA features (+LR 0.5-10). There was consensus to include uveitis, elevated erythrocyte sedimentation rate or C-reactive protein, family history of spondyloarthritis, HLA-B27, inflammatory bowel disease, sacroiliitis by imaging, good response to nonsteroidal anti-inflammatory drugs, and psoriasis. DCE allowed exclusion of features with low importance. Experts considered posttest probability of ≥33% appropriate for referral. +LRs were used to generate a scoring system to be used in adults with chronic back pain with onset before age 45 years; a score of ≥3 is considered a threshold for referral to a rheumatologist. CONCLUSIONS:On behalf of the Spondyloarthritis Research and Treatment Network (SPARTAN), we developed data-driven referral recommendations for adults with chronic back pain to a rheumatologist for evaluation of axSpA. Validation is needed to determine if axSpA is diagnosed in 33% of those referred and if this strategy reduces diagnostic delay.

OBJECTIVE:We surveyed physicians in the United States to assess knowledge, awareness, and attitudes toward axial spondyloarthritis (axSpA). The objective was to identify barriers for referral and opportunities for intervention to reduce diagnostic delay of axSpA. METHODS:An online questionnaire was distributed nationwide to nonrheumatology physicians (NRPs) serving patients with chronic back pain (CBP), namely in family/internal medicine, spine surgery/orthopedics, pain management, physical medicine/rehabilitation, and to rheumatologists as the comparator group. RESULTS:Seven hundred fifty physicians completed the survey (response rate 24%). The majority of NRPs were familiar with inflammatory back pain (IBP); 87% could identify > 4 of 8 IBP items, but only 41% routinely assess for IBP in practice. NRPs screen patients for axSpA risk factors ≤ 50% of the time. NRPs order C-reactive protein and HLA-B27 tests significantly less often, and antinuclear antibodies and rheumatoid factor tests significantly more often than rheumatologists in patients with CBP. Only 50% of NRPs correctly answered sacroiliac/pelvic radiograph as the correct initial imaging test, and 37% correctly selected magnetic resonance imaging of the pelvis as the next imaging test. Unfamiliarity with the terms axSpA and nonradiographic axSpA was reported by 11% and 35% of NRPs, respectively, and NRPs less often consider axSpA as a possible diagnosis in patients with CBP. Formal referral guidelines for patients with suspected axSpA were felt to be important by NRPs and rheumatologists alike. CONCLUSION:There is a substantial lack of knowledge and awareness about nomenclature, laboratory testing, and proper imaging of axSpA among NRPs. Unnecessary laboratory tests are commonly ordered by NRPs and rheumatologists. Formal referral guidelines and improved education may help reduce diagnostic delay of axSpA.

Objective:Lack of timely referral of suspected axial spondyloarthritis (axSpA) patients to rheumatologists is an important modifiable reason for diagnostic delay of axSpA. We assessed the usefulness of a self-referral strategy using a clinical feature-based screening questionnaire (SQ) (A-tool). Methods:Finding axSpA (FaxSpA) was single-centre prospective study involving patients with chronic back pain (CBP). The A-tool, consisting of a three-question prescreen and eight-question SQ, was distributed to patients via the patient communication portal and university Facebook page. Patients with affirmative responses on all three prescreen questions, and three or more questions on SQ were eligible for study visit. Enrolled patients underwent history, physical examination, labs (CRP and HLA-B27) and imaging studies (X-ray and MRI of the pelvis). The clinician's judgement was considered the gold standard for diagnosing axSpA. Results:Eighty-six of the 100 enrolled patients completed all the study procedures, and 29 (34%) were diagnosed with axSpA. Seven patients had AS, and 22 had non-radiographic axSpA. Sensitivity and specificity of the individual A-tool questions for diagnosing axSpA ranged from 0.03 to 0.86 and 0.14 to 0.96, respectively. Positive likelihood ratios (+LR) of the individual items in the A-tool ranged from 0.84 to 1.34. There was low to moderate agreement between the patient responses on the online A-tool and the corresponding physician-confirmed responses. Conclusion:A tool-based strategy for self-referral of CBP patients is a simple, practical and feasible approach for early diagnosis of axSpA. We need a larger prospective study to validate our findings.

VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic syndrome) is an adult-onset autoinflammatory disorder caused by somatic mutations in the UBA1 gene. While its clinical spectrum is expanding, the overlap with autoimmune diseases remains poorly characterized. We present the first reported case of VEXAS featuring overlap with Sjögren's disease. An 86-year-old man with myelodysplastic syndrome developed recurrent fevers, a skin rash, chondritis, bilateral anterior uveitis, acute kidney injury, and macrocytic anemia. He had chronic xerostomia, high titer SSA antibodies, and a positive rheumatoid factor, suggestive of Sjögren's disease. Genetic testing confirmed a UBA1 p.Met41Thr mutation. Our literature review revealed VEXAS co-occurring with various autoimmune conditions, including vasculitides, systemic lupus erythematosus, rheumatoid arthritis, spondyloarthritis, myositis, and autoimmune blistering diseases. Sjögren's disease has not previously been associated with VEXAS. This report adds to the growing evidence of VEXAS-associated autoimmunity. Recognition of such overlap may influence early diagnostic consideration and genetic testing in elderly patients with autoimmune features and cytopenias. Further studies are needed to discern whether these autoimmune features represent independent disease processes or manifestations of VEXAS itself.

Objective:To assess the psychosocial impact of axial spondyloarthritis (axSpA). Methods:A literature search was conducted in two stages: stage 1 included all patients with axSpA and stage 2 focused on patients with inadequate response to prior TNF inhibitor treatment. Selection criteria included population (adults with axSpA), outcomes of interest (psychosocial factors potentially impacted by axSpA, e.g. quality of life, mental health and work productivity) and context [disease-related (disease activity, pain) and -unrelated (gender, race, ethnicity, behaviour) factors potentially affecting psychosocial outcomes). Search results were categorized based on the core domains of disease activity, pain, morning stiffness, fatigue, physical function and overall functioning and health in patients with axSpA. Results:A total of 197 articles were included in this review, most of which were observational, with only one randomized controlled trial (RCT). The evidence suggests an association between greater disease burden and poorer psychosocial outcomes as well as a bidirectional relationship between disease components and psychosocial outcomes, both contributing to the overall disease burden. However, while many studies reported on psychosocial outcomes, potential relationships with disease domains or activity were not evaluated. Furthermore, there were inconsistencies across studies in how these outcomes were measured, such as the use of different tools and/or scales. Conclusion:Given the paucity of RCTs examining psychosocial outcomes in axSpA, future research should focus on standardizing assessment of psychosocial impairments experienced by patients and establishing appropriate interventions and management strategies to ensure the holistic treatment of patients with axSpA and to optimize treatment response and outcomes.

Real-world data on ixekizumab utilization in axial spondyloarthritis (axSpA) are limited. We evaluated ixekizumab treatment patterns and health care resource utilization (HCRU) in patients with axSpA using United States Merative L.P. MarketScan® Claims Databases. This retrospective cohort study included adults with axSpA who initiated ixekizumab during the index period (September 2019–December 2021). Index date was the date of the first ixekizumab claim. All patients had continuous medical and pharmacy enrollment during the 12-month pre-index and follow-up periods. Descriptive statistics were used to assess patient demographics (index date); clinical characteristics (pre-index period); treatment patterns (12-month follow-up period); and HCRU (pre-index and 12-month follow-up periods). The study included 177 patients (mean age 45.8 years; females 54.8

Treatment guided by periodic and quantitative data assessment results in better outcomes compared to using clinical gestalt. While validated generic as well as specific disease activity measures for axial spondyloarthritis (axSpA) are available, there is vast scope to improve their actual utilization in routine clinical practice. In this review, we discuss available disease activity measures for axSpA, describe results from the survey conducted among general rheumatologists as well as Spondyloarthritis Research and Treatment Network (SPARTAN) members about disease activity measurement in daily practice, and discuss ways to improve axSpA disease activity using technological advances. We also discuss the definitions of active disease and target for the treatment of axSpA. The 2019 American College of Rheumatology (ACR)/Spondylitis Association of America (SAA)/Spondyloarthritis Research and Treatment Network (SPARTAN) axSpA treatment guidelines conditionally recommend the regular monitoring of disease activity using a validated measure such as Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) or Ankylosing Spondylitis Disease Severity Index (ASDAS). Assessment of Spondyloarthritis International Society (ASAS)-European Alliance of Associations for Rheumatology (EULAR) guidelines recommend ASDAS as the most appropriate instrument for the assessment of disease activity, preferably calculated using C-reactive protein (CRP). ASAS has selected a core set of variables which were updated recently and have been endorsed by the Outcome Measures in Rheumatology Clinical Trials (OMERACT) group in order to bring homogeneity in assessment of axSpA. In a recent study, Patient-Reported Outcomes Measurement Information System (PROMIS®) measures were able to discriminate inactive, moderate, and high–very high ASDAS activity groups. A newly developed semi-objective index P4 (pain, physical function, patient global, and physician global) correlates well with BASDAI and ASDAS in axSpA and can also be used for other rheumatic diseases in busy clinical practices. Regular disease activity monitoring is critical for long-term management of axSpA and shared decision-making. The integration of electronic health records and smart devices provides a great opportunity to capture patient-reported data. Automated capture of electronic patient-reported outcome measures (ePROMs) is a highly efficient way and results in consistent regular monitoring and may improve the long-term outcomes. While currently used measures focus only on musculoskeletal symptoms of axSpA, a composite disease activity measure that can also incorporate extra-articular manifestations may provide a better assessment of disease activity.

Abstract Background Axial spondyloarthritis (axSpA) is a chronic inflammatory disease which mainly affects the spine and sacroiliac joints, causing longstanding back pain, stiffness, and limited mobility. AxSpA is an underrecognized disease in non-rheumatology practices because of its heterogeneous clinical features that may be difficult to identify. Main body Sports medicine practitioners are well positioned to suspect and recognize axSpA among their patients with chronic back pain and refer them to a rheumatologist. Early referral to a rheumatologist is important for timely diagnosis, prompt treatment, and improved long-term outcomes for patients with axSpA. Physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) remain the first-line treatment for and the cornerstone of axSpA management. For patients with inadequate response to or intolerance of NSAIDs, biologic disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic (ts) DMARDs are indicated. These drugs can reduce pain, inflammation, fatigue, and disability and can improve health-related quality of life. The goal of this review is to improve awareness of axSpA among sports medicine practitioners and other non-rheumatologists so that these providers ensure timely referral of patients with suspected axSpA to rheumatologists for appropriate treatment and better outcomes. We also provide an update on current treatment possibilities for axSpA and describe how rheumatologists use treatment guidelines and disease activity measures to identify and optimally treat patients with active axSpA. Conclusion Sports medicine practitioners have an excellent opportunity to identify patients with suspected axSpA and refer them to rheumatologists in a timely manner, as well as monitor symptoms among patients diagnosed with axSpA to identify inadequately controlled disease.

OBJECTIVE:Patients living with rheumatologic diseases on disease-modifying antirheumatic drugs (DMARD) are at an increased risk of developing tuberculosis (TB). Current guidelines recommend screening for latent tuberculosis infection (LTBI) before initiating DMARD. However, data is lacking on the value of yearly screening for LTBI. METHODS:A retrospective chart review was conducted on adult patients (≥ 18 years) with rheumatologic disease on DMARD followed longitudinally in the outpatient rheumatology clinics between 2017-2021. Collected data included patient demographics, rheumatologic diagnosis, medications, TB-related risk factors, interferon gamma release assay (IGRA) results, LTBI diagnosis and treatment. Descriptive statistics were performed. RESULTS:Among 339 patients, 81 (23.9%) were male, 259 (76.4%) were white, and 93 (27.5%) were Latinx. Inflammatory arthritis (84.1%) was the most common rheumatic diagnosis. Common DMARD were JAK inhibitors (19.2%), TNF-alpha inhibitors (18.9%), and IL-17 A inhibitors (18.0%). Only 2 patients at baseline had positive IGRA, and both had a history of treated LTBI. Positive IGRA tests were recorded in 1 (0.7%), 3 (1.8%), 3 (1.3%), and 3 (1.1%) in the years 2018, 2019, 2020, and 2021, respectively. Four patients converted from negative to positive during serial yearly IGRA testing. After reviewing the IGRA test and TB risk factors, only one patient was considered newly diagnosed with LTBI, requiring 4 months of rifampin. CONCLUSION:In a non-endemic area, serial IGRA testing of low-risk patients on DMARD yielded very low rate of newly diagnosed LTBI. A targeted LTBI screening based on TB-related risk factors should be performed prior to IGRA testing rather than universal yearly screening in a non-endemic setting.