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CURRENT OPINION Biomarkers in Axial Spondyloarthritis

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CURRENT OPINION Biomarkers in Axial Spondyloarthritis REVIEW CURRENT OPINION Biomarkers in axial spondyloarthritis Walter P. Maksymowych Purpose of review To assess the literature for biomarker validation studies that address key unmet needs related to the evaluation and management of patients with axial spondyloarthritis (SpA). This review focused on biomarkers facilitating early diagnosis and reflecting disease activity, structural damage on radiography, and clinical response to major therapies. Recent findings Early diagnosis may be facilitated by measurement of antibodies to the human leukocyte antigen class II- associated invariant chain peptide (anti-CD74) but sensitivity declines with increasing duration of disease. No disease activity biomarkers have demonstrated consistent superiority over standard C-reactive protein (CRP), and future validation should employ multivariate analysis aimed at demonstrating the added value of any associated biomarkers beyond available clinical parameters of disease activity and the use of magnetic resonance imaging inflammation as the primary endpoint. Several biomarkers reflecting inflammation (CRP and calprotectin), angiogenesis (vasoactive endothelial growth factor), and connective tissue turnover (C2 M, C3 M, and citrullinated metalloproteinase degraded fragment of vimentin ) have recently been shown to reflect radiographic progression in multivariate studies adjusted for baseline severity. Future studies should be prospective and demonstrate that predictive capacity adds to the information provided by known predictors such as CRP and baseline modified Stoke AS Spine Score. Calprotectin is a promising predictor of response to major therapies for axial SpA. Summary Several promising biomarkers addressing major unmet clinical needs require further validation in prospective studies. Keywords axial spondyloarthritis, biomarker, magnetic resonance imaging radiography, validation INTRODUCTION solely on clinical evaluation is, therefore, fraught The identification and validation of soluble bio- with misinterpretation of the true nature of a markers represent a significant opportunity to patient’s symptoms and may lead to inappropriate address several unmet needs in the management treatment with anti-inflammatory agents. The third of patients with axial spondyloarthritis (axSpA). is assessment of prognostic risk, which is necessary The first is diagnosis prior to the unequivocal devel- to determine which patients with undifferentiated opment of radiographic sacroiliitis, especially as arthritis might develop SpA and which patients with the most sensitive imaging modality, magnetic SpA are destined to develop structural joint damage, resonance imaging (MRI) is costly and/or not especially ankylosis in the spine. Radiography lacks widely available. The second is the assessment and sensitivity to change and cannot be used for monitoring of disease activity in routine practice, monitoring in clinical practice. The fourth is assess- which is limited to patient self-reported measures ment of response to therapy and implementation of that lack correlation with MRI parameters of inflam- mation, physical examination findings, which are University of Alberta, Edmonton, Alberta, Canada primarily evident in peripheral joints, and C-reac- Correspondence to Walter P. Maksymowych, Professor of Medicine, tive protein (CRP), which is insensitive. Moreover, University of Alberta, 562 Heritage Medical Research Building, Edmon- symptoms of inflammatory back pain may be diffi- ton, AB T6G 2S2, Canada. Tel: +1 780 407 1573; fax: +780 407 6055; cult to distinguish from mechanical causes and the e-mail: [email protected] two conditions may occur simultaneously in the Curr Opin Rheumatol 2015, 27:343–348 same patient. Monitoring of disease activity based DOI:10.1097/BOR.0000000000000180 1040-8711 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. www.co-rheumatology.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Spondyloarthropathies recruited patients with chronic back pain who KEY POINTS do not yet demonstrate definite radiographic CRP is currently the best-validated biomarker for sacroiliitis. disease activity and radiographic progression. Increasing evidence supports biomarkers reflecting DISEASE ACTIVITY BIOMARKERS inflammation and joint tissue turnover as predictors of Clinical validation of disease activity biomarkers structural damage. suffers from the lack of availability of an appropriate Clinical validation should be undertaken in both gold standard. A consensus position document prospective cohorts and clinical trials using multivariate recommends that a major treatment target should longitudinal analyses of sufficient duration to account be clinical remission as defined by the absence of for the slow progression and variability of disease. clinical and inflammatory evidence of significant MRI inflammation is currently the most appropriate inflammatory disease, and that disease activity endpoint for validation of biomarkers reflecting should be measured using clinical signs and symp- disease activity. toms and acute phase reactants [3&]. However, a Predictive capacity of biomarkers for structural major drawback to this approach is that no clinical progression may be more readily apparent when parameters have been shown to reflect the histopa- combined with known predictors, for example thology of inflammation at the site of disease. More- baseline mSASSS. over, there is only a weak correlation between clinical and MRI parameters of inflammation, prim- arily in early SpA, and inflammation may still be apparent on MRI of the sacroiliac joints and/or spine a personalized treatment strategy. This review aims even in the presence of clinical remission [4–6]. On at summarizing the recent literature that addresses the contrary, MRI parameters of inflammation in clinical validation of diagnostic, disease activity, the sacroiliac joint have been shown to correlate prognostic, and theragnostic biomarkers, and the with histopathological features of inflammation results of biomarker studies that have employed and also predict the development of radiographic these strategies in patients with axial SpA. sacroiliitis [7–9]. A similar relationship has been described between MRI inflammation in the spine and new bone formation [10–13]. Consequently, DIAGNOSTIC BIOMARKERS since MRI inflammation represents our current best Human leukocyte antigen (HLA) B27 is the primary measure of disease activity, clinical validation of biomarker used to identify patients with axial biomarkers reflecting disease activity should be con- SpA with sensitivity of 60–95% and specificity of ducted using MRI as the gold standard. CRP is an 80–90%. One report described a potential role of example of a biomarker that correlates with MRI antibodies to the HLA class II-associated invariant inflammation albeit moderately [14,15]. chain peptide (anti-CD74 antibodies), which were Most of the studies [16–20] assessing disease detected in 85.1% of axSpA (n ¼ 94) versus 7.8% of activity biomarkers have been cross-sectional and non-SpA (n ¼ 51) patients [1&]. Among non-SpA used correlation analysis with acute phase reactants, patients, positivity for anti-CD74 was observed in the Bath AS Disease Activity Index, or the AS Disease two with degenerative spinal disease, one with Activity Score rather than MRI. A major limitation of rheumatoid arthritis, and one with psoriatic arthri- such biomarker analyses is that many biomarkers tis. In a subsequent report analyzing 156 patients correlate with each other, for example CRP with with axial SpA, sensitivity was somewhat less at 69% interleukin-6, and therefore do not indicate what [2&]. However, sensitivity was 97% in patients with is the independent information provided by the duration of symptoms less than 1 year. The rate of biomarker. Instead, studies should employ multi- positivity declined after the first year. In controls, variate longitudinal analysis to determine to what the prevalence of anti-CD74 was 18/40 (45%) in degree biomarkers contribute independently to psoriatic arthritis without axial involvement, 9/80 assessment of disease activity, as assessed by MRI, (11%) in rheumatoid arthritis, 6/40 (15%) in beyond standard clinical and laboratory assess- systemic lupus erythematosus, 1/40 (2.5%) in HIV, ments. There have been no recent studies that have and 1/125 (0.8%) in blood donors. Consequently, employed such a study design. Previous analyses diagnostic potential of this biomarker should be using MRI as gold standard have shown no corre- regarded as preliminary. Addressing the unmet lations between baseline to 12-week change in clinical need will require biomarker analyses in metalloproteinase 3 (MMP3), type II collagen sera obtained from prospective studies that have C-telopeptide, or type I collagen N-telopeptide 344 www.co-rheumatology.com Volume 27 Number 4 July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Biomarkers in axial spondyloarthritis Maksymowych and change in MRI inflammation [21], whereas a CRP in multivariate analyses adjusted for the single multivariate analysis revealed an independ- severity of radiographic damage at baseline assessed ent although weak association of baseline to 2-week using the modified Stoke AS Spine Score (mSASSS). change in interleukin6 (IL6) with baseline to In the German SPondyloarthritis Inception Cohort, 24-week change in MRI inflammation [22], casting time-averaged CRP, defined as mean CRP level more doubt as to the
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