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Diagnosing Axial Spondyloarthropathy. the New Assessment in Spondyloarthritis Positive Disease

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Diagnosing Axial Spondyloarthropathy. the New Assessment in Spondyloarthritis Positive Disease Editorial Ann Rheum Dis: first published as 10.1136/ard.2009.111435 on 12 May 2009. Downloaded from Therefore, while the improved metho- Diagnosing axial dology of this study to define new criteria for IBP are most welcome, whether the spondyloarthropathy. The new new criteria represent a significant advance will, as the authors highlight, depend on further assessment, particu- Assessment in SpondyloArthritis larly validation in the primary care set- ting. international Society criteria: The subsequent two papers focus on the development2 and validation3 of can- didate classification criteria for axial SpA, MRI entering centre stage including patients with and without radiographic sacroiliitis. These patients A N Bennett,2 H Marzo-Ortega,1 P Emery,1 without radiographic sacroiliitis have up 1 to now been mostly labelled as undiffer- D McGonagle, on behalf of the Leeds entiated SpA (uSpA) following The European Spondyloarthropathy Study Spondyloarthropathy Group Group criteria (ESSG).5 However, uSpA does not differentiate between patients In this issue of the Annals of Rheumatic where MRI is of recognised value as a with isolated axial or isolated peripheral Disease the Assessment in diagnostic and outcome tool.8914 disease. The data reported in this issue of SpondyloArthritis international Society Furthermore, with the emerging data on the journal show that it is possible to (ASAS) have published three interrelated the efficacy of tumour necrosis factor robustly classify cases of axial SpA hence papers (see pages 770, 777 and 784)1–3 (TNF)a blocking therapies in early dis- facilitating the conduct of future clinical that could contribute to a new era in the ease10 11 a new horizon has opened trials and observational studies. This is diagnosis and classification of axial spon- whereby AS sufferers can be identified particularly critical in the context of dyloathritis (SpA). The first paper focuses and treated in the early stages of their therapeutics as the newly proposed cri- on a new definition of inflammatory back disease process before structural damage teria might serve as a basis for a judicious pain (IBP), the ‘‘expert’’ criteria, followed has occurred. use of TNF blockers in the non-radio- by two reports on the development of In the first report Sieper et al1 propose graphic stage of axial SpA. This is all the new classification criteria for axial SpA new clinical criteria for IBP. The study more likely given the increasing evidence and their validation in a large multicentre adopted a novel approach in which the that MRI can predict the future develop- 14 15 study. These criteria for axial SpA will be ‘‘experts’’ were blinded to patient diag- ment of AS, that early preradiographic welcomed by the spondyloarthropathy nosis, and the criteria judged for an ability axial patients with SpA have just as much http://ard.bmj.com/ community, since the currently available to discriminate for a ‘‘diagnosis’’ of IBP disease activity and pain as established 7 criteria4–6 do not allow for the diagnosis of (rather than for a diagnosis of SpA, as AS and that early preradiographic axial 12 13 preradiographic axial SpA. The proposed previously performed). This, along SpA responds well to anti-TNF thera- 10 11 new set of criteria includes early (pre- with the robust statistical analysis, pies. radiographic) and established ankylosing performed using logistic regression to A strength of the ASAS papers lies spondylitis (AS), recognising them as a identify which criteria/parameters inde- within the inclusion of international continuum of disease. This is of major pendently contributed specifically to IBP, experts’ opinions on 71 real-life paper on September 26, 2021 by guest. Protected copyright. importance as it is now clear that the are the strong points of the study. patients. Their opinion regarding diagno- burden of early AS is comparable to that However, the need for new criteria to sis, as well as the strength of certainty of of the later stages.7 The benefit of MRI in define IBP might be questioned since it is their opinion were sought with both the diagnosis of early axial SpA is recog- only 3 years after the last set of IBP being subsequently reviewed and accepted or rejected by a five-strong expert panel. nised by the authors and included in the criteria were published by the same core 12 The subsequent validation study3 is a new classification criteria. Indeed, the group. Indeed, the authors point out unique and unprecedented clinical study inclusion of MRI is the most significant that the existing criteria performed 4–6 reasonably well and that there are only in terms of international collaboration change compared to previous criteria small differences between the new and the recruitment of nearly 650 cases. and is in line with clinical experience criteria and the previous 2006 Berlin Although the mean duration of symp- criteria.12 In addition the new IBP criteria toms of the studied cohort was 6.1 years, surprisingly omit the assessment of early the patient population was representative morning stiffness (EMS) of greater than of the clinical spectrum of disease from 1 Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Chapel Allerton 30 min as well as pain in the second half early preradiographic axial involvement to Hospital, Chapeltown Road, Leeds LS7 4SA, UK; of the night, which were present in the radiographically confirmed sacroiliitis. 2 Defence Medical Rehabilitation Centre, Headley Court, previous criteria. These were dropped Given the emerging power of MRI for Epsom, Surrey KT18 6JN, UK because the duration of EMS and timing predicting the development of AS,14 15 this Correspondence to: Professor P Emery, of nocturnal pain were not specifically imaging modality was importantly Musculoskeletal Disease, Leeds Institute of Molecular analysed. Given the central role of EMS included in the assessment of these Medicine, University of Leeds, Clinical Director (Rheumatology), Director-Leeds MSK Biomedical duration in inflammatory rheumatic dis- patients. Research Unit, Chapel Allerton Hospital, Chapel Town eases this approach seems to lack face Of note, in the first classification Road, Leeds LS7 4SA, UK; [email protected] validity. paper,2 raised C-reactive protein (CRP) Ann Rheum Dis June 2009 Vol 68 No 6 765 Editorial Ann Rheum Dis: first published as 10.1136/ard.2009.111435 on 12 May 2009. Downloaded from levels were more frequent in the non-SpA have improved the overall sensitivity and New criteria for inflammatory back pain in patients with chronic back pain a real patient (42.1%) than the SpA population (27.8%), specificity of these criteria. exercise of the Assessment in SpondyloArthritis yet elevated CRP was included in set 1 Importantly the definition of active International Society (ASAS). Ann Rheum Dis and set 2 candidate classification criteria. MRI sacroiliitis is needed for research as 2009;68:784–8. 3 2. Rudwaleit M, Landewe´R, van der Heijde D, Listing However, in the validation paper this well as clinical practice. Variable J, Brandt J, Braun J, et al. The development of observation is reversed with raised CRP ‘‘degrees’’ of active MRI sacroiliitis are Assessment of SpondyloArthritis interntional Society being more common in SpA. Likewise in recognised depending on the intensity (ASAS) classification criteria for axial spondyloarthritis the initial classification2 of the three and/or extent of the MRI signal when (part I): classification of paper patients by expert 819 opinion including uncertainity appraisal. Ann Rheum studied IBP criteria, the new ‘‘expert’’ using fat suppression techniques which Dis 2009;68:770–6. criteria1 performed worse, with only may lead to different clinical and radio- 3. Rudwaleit M, van der Heijde D, Landewe´R, Listing 57.1% compared to 84.4% for the Calin graphic outcomes.14 Indeed, low grade J, Akkoc N, Brandt J, et al. The development of 13 Assessment of SpondyloArthritis International Society criteria and 85.3% for the Rudwaleit/ bone marrow oedema lesions as identified (ASAS) classification criteria for axial spondyloarthritis Berlin criteria.12 Again however this chan- by MRI are not specific for SpA and are (part II): validation and final selection. Ann Rheum Dis ged considerably in the follow-up valida- also evident in degenerative joint disease 2009;68:777–83. and occasionally in healthy people,818and 4. Amor B, Dougados M, Mijiyawa M. Criteria of the tion study. The proposed new classification of spondylarthropathies. Rev Rhum Mal classification criteria for axial SpA has an hence a clarifying definition of active MRI Osteoartic 1990;57:85–9. 82.9% sensitivity and 84.4% specificity sacroiliitis is essential. 5. Dougados M, van der Linden S, Juhlin R, Huitfeldt B, out of a large data set of 649 patients with In summary, these are exciting times in Amor B, Calin A, et al. The European Spondylarthropathy Study Group preliminary criteria a positive likelihood ratio of 5.3 for axial the field of research in SpA. Only a decade for the classification of spondylarthropathy. Arthritis SpA, which increases the post-test prob- ago there was little recognition of early Rheum 1991;34:1218–27. ability of a diagnosis of axial SpA from disease and treatment in early and estab- 6. van der Linden S, Valkenburg HA, Cats A. Evaluation lished AS was woefully inadequate. Now, of diagnostic criteria for ankylosing spondylitis. A 60.2% to 89.0%. Furthermore when proposal for modification of the New York criteria. benchmarked against existing long-stand- we have widespread access to the non- Arthritis Rheum 1984;27:361–8. ing criteria such as the Amor and ESSG ionising radiation of fat suppression MRI 7. Rudwaleit M, Haibel H, Baraliakos X, Listing J, criteria,45they were shown to be superior. that can predict progression to AS as well Marker-Hermann E, Zeidler H, et al.
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