American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis.

OBJECTIVE: To provide evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS: A core group led the development of the recommendations, starting with the treatment questions. A literature review group conducted systematic literature reviews of studies that addressed 57 specific treatment questions, based on searches conducted in OVID Medline (1946-2014), PubMed (1966-2014), and the Cochrane Library. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A separate voting group reviewed the evidence and voted on recommendations for each question using the GRADE framework. RESULTS: In patients with active AS, the strong recommendations included use of nonsteroidal antiinflammatory drugs (NSAIDs), use of tumor necrosis factor inhibitors (TNFi) when activity persists despite NSAID treatment, not to use systemic glucocorticoids, use of physical therapy, and use of hip arthroplasty for patients with advanced hip arthritis. Among the conditional recommendations was that no particular TNFi was preferred except in patients with concomitant inflammatory bowel disease or recurrent iritis, in whom TNFi monoclonal antibodies should be used. In patients with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi. Other recommendations for patients with nonradiographic axial SpA were based on indirect evidence and were the same as for patients with AS. CONCLUSION: These recommendations provide guidance for the management of common clinical questions in AS and nonradiographic axial SpA. Additional research on optimal medication management over time, disease monitoring, and preventive care is needed to help establish best practices in these areas.

American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis.

OBJECTIVE: To provide evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS: A core group led the development of the recommendations, starting with the treatment questions. A literature review group conducted systematic literature reviews of studies that addressed 57 specific treatment questions, based on searches conducted in OVID Medline (1946-2014), PubMed (1966-2014), and the Cochrane Library. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A separate voting group reviewed the evidence and voted on recommendations for each question using the GRADE framework. RESULTS: In patients with active AS, the strong recommendations included use of nonsteroidal antiinflammatory drugs (NSAIDs), use of tumor necrosis factor inhibitors (TNFi) when activity persists despite NSAID treatment, not to use systemic glucocorticoids, use of physical therapy, and use of hip arthroplasty for patients with advanced hip arthritis. Among the conditional recommendations was that no particular TNFi was preferred except in patients with concomitant inflammatory bowel disease or recurrent iritis, in whom TNFi monoclonal antibodies should be used. In patients with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi. Other recommendations for patients with nonradiographic axial SpA were based on indirect evidence and were the same as for patients with AS. CONCLUSION: These recommendations provide guidance for the management of common clinical questions in AS and nonradiographic axial SpA. Additional research on optimal medication management over time, disease monitoring, and preventive care is needed to help establish best practices in these areas.

Safety and efficacy of abatacept in eight rheumatoid arthritis patients with chronic hepatitis B.

OBJECTIVE: There are no previous studies on the use of abatacept in patients with chronic hepatitis B. This medical record review assessed the safety and efficacy of abatacept in 8 patients with rheumatoid arthritis (RA) and chronic hepatitis B. METHODS: A retrospective analysis of patients with RA and chronic hepatitis B treated with abatacept was conducted. The primary outcome was the 4-variable Disease Activity Score in 28 joints using the erythrocyte sedimentation rate (DAS28-ESR) at each followup visit along with markers of hepatitis B reactivation, including aspartate aminotransferase, alanine aminotransferase, and hepatitis B viral load. RESULTS: A total of 47 visit data points were recorded. The mean ± SD duration of followup of patients receiving abatacept was 19.1 ± 12.7 months (range 3-33 months). Analysis was limited to 18 months of followup (included 77% of all visits [36 of 47]). Four patients were started on antiviral prophylaxis for hepatitis B with the initiation of abatacept, while 4 patients were not. Among the 4 patients who received antiviral prophylaxis, RA improved as evidenced by a statistically significant decrease in DAS28-ESR scores, and none had reactivation of hepatitis B. In the 4 patients without antiviral prophylaxis, there was no significant decrease in the DAS28-ESR scores and all 4 experienced reactivation of hepatitis B. There were no adverse events other than the hepatitis B reactivation. CONCLUSION: Use of abatacept in patients with RA and chronic hepatitis B appears feasible if antiviral prophylaxis for hepatitis B is given concurrently. In these patients there were no non-hepatitis-related adverse effects. These data are encouraging and should lead to initiation of controlled trials of abatacept in hepatitis B.

Antiphospholipid antibodies in malignancy: are these pathogenic or epiphenomena?

Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by arterial and venous thrombotic events associated with antiphospholipid antibodies. Antiphospholipid syndrome is commonly seen with collagen vascular diseases; however, other entities that can cause APS include chronic viral infections, certain medications, and malignancies. We present an interesting patient with an atypical presentation and course of presumed APS, which lead us to perform an exhaustive search for a secondary cause. The patient was ultimately found to have splenic marginal zone lymphoma. Analysis of the current data in the literature is presented for APS, antiphospholipid antibodies, and malignancy. Based on the literature findings and our experience, we recommend a thorough and repeated evaluation for an underlying malignancy in patients who have an atypical presentation and features of APS.

Leukocytoclastic vasculitis in a patient with type 1 cryoglobulinemia.

Cutaneous manifestations of type 1 cryoglobulinemia are usually related to vascular occlusion by noninflammatory thrombosis; rarely is leukocytoclastic vasculitis seen in type 1 cryoglobulinemia. We report the case of a 64-year-old male who presented with isolated cutaneous leukocytoclastic vasculitis that was initially attributed to essential mixed cryoglobulinemia after thorough diagnostic evaluation. A lack of adequate clinical response to therapy prompted further investigation, including cryoprecipitate electrophoresis and immunofixation, which revealed an IgM kappa monoclonal gammopathy consistent with type 1 cryoglobulinemia. A renewed search for an underlying malignancy led to the discovery of early Waldenstrom's macroglobulinemia. Although leukocytoclastic vasculitis is more characteristic of mixed cryoglobulinemia, it can be a presenting manifestation of type 1 cryoglobulinemia.

Development and validation of a case ascertainment tool for ankylosing spondylitis.

OBJECTIVE: Ankylosing spondylitis (AS) diagnosis is often delayed. The availability of effective biologic agents for treating AS has increased the importance of early diagnosis. We tested questions derived from a comprehensive literature review and an advisory board in a case-control study designed to identify patients with AS from among patients with chronic back pain (CBP). METHODS: Question items were cognitively tested among patients with AS, and then in case-control studies for validation and creation of a scoring algorithm and question item reduction. AS cases were recruited from a known database, and CBP subjects (controls) were recruited from clinics, employers, and from the SpineUniverse Web site. We used individual question items in a multivariate framework to discriminate between people with and without AS. RESULTS: Forty-three questions yielded 24 items for analyses; 12 of these were entered into a multivariate regression model. Individual items yielded odds ratios ranging from 0.07 to 30.31. Question items with a significant positive relationship to AS included male sex, neck or hip pain/stiffness, longer pain duration, decreased pain/stiffness with daily physical activity, pain relief within 48 hours of nonsteroidal antiinflammatory drugs, and diagnosis of iritis. The tool demonstrated a sensitivity of 67.4 and a specificity of 94.6. The tool was developed from clinically and radiologically diagnosed AS cases and therefore is designed to distinguish AS cases among CBP subjects. In addition, approximately 54% of the AS cases in the study were treated with biologic agents, which may impact questionnaire responses. CONCLUSION: This tool can identify undiagnosed patients with AS and, potentially, those at an earlier stage in their disease course.

Arthritis associated with pityriasis rubra pilaris.

Pityriasis rubra pilaris (PRP) is a rare papulosquamous disease of unknown aetiology, with an estimated prevalence of 2.5 per million.1 It is clinically characterised by the presence of follicular hyperkeratotic papules, but the histopathology is usually non-specific. An interesting case of asymmetric, inflammatory arthritis of the hand in a patient who also presented with PRP is presented, along with a review of the few previously reported cases the literature.