Drug-survival profiling of second-line biologic therapy in rheumatoid arthritis: Choice of another tumour necrosis factor inhibitor or a biologic of different mode of action?

OBJECTIVES: To assess the best choice of second-line therapy between tumour necrosis factor-inhibitor (TNFi) and biologics of different-mode-of-action (BDMA-rituximab/tocilizumab/abatacept) in rheumatoid arthritis (RA) by evaluating drug-survival following discontinuation of the first-line TNFi. METHODS: This retrospective drug-survival study was performed across two different hospitals by conventional-statistics and machine-learning approach. RESULTS: From a total of 435 patients, 213 (48.9%; TNFi = 122, BDMA = 91) discontinued their second-line biologic {median drug-survival: TNFi, 27 months [95% confidence interval (95%CI) 22-32] vs BDMA, 37 months (95%CI 32-52)}. As a second-line biologic, BDMA was likely to reduce the risk of treatment-discontinuation [hazard-ratio (HR) 0.63, 95%CI 0.48-0.83] compared to TNFi, but only in seropositive-patients (HR 0.52, 95%CI 0.38-0.73), not in seronegative-RA. Drug-survival benefit of BDMA over TNFi was not observed if the seropositive-patients were previously exposed to monoclonal-TNFi (HR 0.77, 95%CI 0.49-1.22) versus soluble-TNFi (etanercept/biosimilars) or if the first-line TNFi was terminated within 23.9 months of initiation (HR 0.97, 95%CI 0.56-1.68). CONCLUSIONS: BDMA, as a second-line biologic, is more likely to be sustained in seropositive-patients, particularly without prior exposure to monoclonal-TNFi. The drug-survival benefit of BDMA was not observed in seronegative-patients or if the first-line TNFi was stopped within 2 years.

The JAK inhibitor baricitinib inhibits oncostatin M induction of proinflammatory mediators in ex-vivo synovial derived cells.

OBJECTIVES: To investigate the ex vivo effect of the JAK1/2 inhibitor baricitinib on expression of pro-inflammatory mediators in rheumatoid arthritis (RA) fibroblast like synoviocytes (FLS) stimulated with TNFα, IL-1ß and oncostatin M (OSM), and in RA synovial membrane cells (SMCs). METHODS: RA and osteoarthritis (OA) SMCs, were isolated from arthroplasty specimens of RA (n=8) and OA (n=8) patients, respectively, using enzymatic digestion followed by cell propagation to obtain RA (n=5) and OA (n=3) FLS. Normal FLS and normal human foreskin fibroblasts (HSF) were purchased from commercial sources. Fibroblasts were stimulated with cytokines with or without baricitinib. RA SMCs were cultured in the presence of baricitinib without stimulation. JAK/STAT activation and levels of mRNA and proteins of the various inflammatory cytokines (IL-6, IL-8, MCP-1, RANTES and IP-10) were determined by qPCR, ELISA and MSD. RESULTS: Baricitinib inhibited OSM-induced JAK signalling in RA synovial fibroblasts and effectively suppressed subsequent expression of the proinflammatory mediators IL-6, MCP-1 and IP-10. However, baricitinib was not effective in altering levels of spontaneously released TNFα, IL-6 and IL-8 in RA SMC. Although both TNFα and IL-1ß signal independently of the JAK/STAT pathway, in HSF, but not in RA FLS, baricitinib significantly inhibited TNFα- and IL-1ß-induced MCP-1 and IP-10 protein levels in a dose dependent manner. Furthermore, baricitinib did not inhibit TNFα- and IL-1ß-induced expression of IL-6, IL-8 and MCP-1 in RA FLS. CONCLUSIONS: These findings are consistent with known signalling pathways employed by OSM, TNFα and IL-1ß, but our data suggest that in HSF, baricitinib may have anti-inflammatory effects via downstream modulation of cytokines and chemokines produced in response to TNFα or IL-1ß.

Spondyloarthritis in African Populations Compared to Europeans Living in the United Kingdom.

BACKGROUND: With the aim to study Spondyloarthritis in patients originating from Africa and compare the disease with the way it is manifested in Europeans, data was analysed from 62 African patients and compared with 56 Europeans living in the same geographical area (north East London, United Kingdom) and treated under the same health system (NHS). Data analysed were demographic, social and clinical characteristics. RESULTS: Comparisons showed differences in prevalence of psoriasis (more in Caucasians), uveitis (more in Africans), smoking (more in Europeans), and significantly fewer patients of African origin declared family history of SpA. African patients have less disease activity (but not significantly better measured by BASDAI), and statistically significant better functional ability (BASFI) compared to Europeans. No difference has been noted in gender distribution, age of disease onset, disease duration, delay in diagnosis, disease associations with IBD, night pain, or overall wellbeing. CONCLUSIONS: SpA is different in Africans in that it shows to be milder in terms of disease activity and functional ability with more uveitis less psoriasis and less family history of SpAs.

The Semantics of 'Hip Pain' and its Impact on Clinical Practice in Patient-Reported Outcome Measures (PROMs) of Disease: Results from a Clinical and Radiological Evaluation Cohort.

INTRODUCTION: The item 'hip pain' is widely used in questionnaires related to Spondyloarthritis and/or Ankylosing spondylitis (AS), either in clinics with patients being physically present or remotely, as the hip joint is known to affect AS in particular. Patients in clinics often claim to have hip pain. However, by stating "hip" they are referring to variable structures located in the hip region not necessarily related to hip joint itself. OBJECTIVE: To assess which structure(s) patients mean when referring to hip pain. METHODS: A diagram used as a proforma for patients to indicate the site of 'hip pain' following a detailed history and examination was used. Radiological imaging was utilised for those patients with multiple sites or clinically unclear causes of "hip" pain. RESULTS: From 54 patients 7 different anatomical sites described which were: Trochanter, (27.2%), hip joint (20.8%), iliac crests (anterior superior [6.9%], posterior superior [8.3%], and anterior inferior [4.1%]), lumbar spine (8.3%), sacroiliac joint (6.9%). More than 1 sites in the same patient: (17.5%). Diagnoses were: Trochanteric bursitis (27%), osteoarthritis of hip and spine, (25%), enthesitis (22%), sacroiliitis (6.7%), synovitis (5%), fibromyalgia (3.4%), and hip dislocation (1.6%). More than 1 diagnosis in same patient: 9.3%. CONCLUSION: 'hip pain' as an item used in questionnaires must be interpreted with caution.

CNS Vasculitis in Anti-Synthetase Syndrome.

A 52-year-old woman known to have anti-synthetase syndrome (ASS) with positive anti-alanyl-tRNA synthetase antibody (anti-PL 12) for 4 years presented with headache and progressive deterioration of cognitive functions manifested predominantly by episodes of confusion and dyslexia. Clinical, laboratory and radiological evaluation as well as response to treatment was indicative of vasculitis of the central nervous system (CNS). CNS vasculitis is one of the rare manifestations of inflammatory myositis and no case has been reported to suggest CNS vasculitis in ASS.

Safety of Ixekizumab in Patients With Psoriatic Arthritis: Results From a Pooled Analysis of Three Clinical Trials.

OBJECTIVE: To evaluate ixekizumab safety in adults with psoriatic arthritis (PsA). METHODS: Safety data from 2 integrated data sets are presented: 1) 24-week, double-blind, placebo-controlled period of SPIRIT-P1 and SPIRIT-P2; and 2) all ixekizumab-treated patients of SPIRIT-P1 and SPIRIT-P2 plus SPIRIT-P3 open-label period. We report adverse event (AE) frequency and exposure-adjusted incidence rates per 100 patient-years at 12-week intervals to week 96. RESULTS: The placebo-controlled period had 678 patients (safety population): 224 placebo, 229 ixekizumab every 4 weeks, and 225 ixekizumab every 2 weeks. Overall, 1,118 patients received ixekizumab (total exposure 1,373.4 patient-years). In the placebo-controlled period, the frequencies of ixekizumab-treated patients experiencing ≥1 treatment-emergent AE (TEAE) and those experiencing serious AEs were 68.1% (56.7% placebo) and 4.4% (2.7% placebo), respectively. Injection site reactions (ISRs) were very common (21.4% ixekizumab [4.5% placebo]), with ISR discontinuation rates of 1.1% (ixekizumab) and 0.4% (placebo). Through week 96, the incidence rates of ISRs decreased with increasing ixekizumab exposure. The frequencies of AEs of special interest were 32.8% (ixekizumab) and 27.7% (placebo); for serious infections, the frequencies were 1.3% and 0%, respectively; Candida infections, 2.6% and 0.4%; confirmed major adverse cardiac events, 0% and 0%; malignancy, 0.4% and 0%; hypersensitivities, 5.3% and 1.8%; and depression-related, 1.8% and 1.3%. The frequency of Crohn's disease and ulcerative colitis (investigator-reported) was 0% in both groups, and the frequencies of sponsor-determined inflammatory bowel disease were 0.2% in the ixekizumab group and 0% in the placebo group. Overall, no active tuberculosis, invasive Candida infections, anaphylaxis, or suicide/self-injury behaviors were reported. CONCLUSION: The PsA ixekizumab safety integrated data set reached 1,373.4 patient-years total exposure. Ixekizumab-treated patients had higher rates of overall TEAEs, serious infections, mucocutaneous Candida, hypersensitivities (non-anaphylactic), and ISRs than placebo-treated patients. No unexpected safety outcomes were reported.

Effect of rituximab on a salivary gland ultrasound score in primary Sjögren's syndrome: results of the TRACTISS randomised double-blind multicentre substudy.

OBJECTIVES: To compare the effects of rituximab versus placebo on salivary gland ultrasound (SGUS) in primary Sjögren's syndrome (PSS) in a multicentre, multiobserver phase III trial substudy. METHODS: Subjects consenting to SGUS were randomised to rituximab or placebo given at weeks 0, 2, 24 and 26, and scanned at baseline and weeks 16 and 48. Sonographers completed a 0-11 total ultrasound score (TUS) comprising domains of echogenicity, homogeneity, glandular definition, glands involved and hypoechoic foci size. Baseline-adjusted TUS values were analysed over time, modelling change from baseline at each time point. For each TUS domain, we fitted a repeated-measures logistic regression model to model the odds of a response in the rituximab arm (≥1-point improvement) as a function of the baseline score, age category, disease duration and time point. RESULTS: 52 patients (n=26 rituximab and n=26 placebo) from nine centres completed baseline and one or more follow-up visits. Estimated between-group differences (rituximab-placebo) in baseline-adjusted TUS were -1.2 (95% CI -2.1 to -0.3; P=0.0099) and -1.2 (95% CI -2.0 to -0.5; P=0.0023) at weeks 16 and 48. Glandular definition improved in the rituximab arm with an OR of 6.8 (95% CI 1.1 to 43.0; P=0.043) at week 16 and 10.3 (95% CI 1.0 to 105.9; P=0.050) at week 48. CONCLUSIONS: We demonstrated statistically significant improvement in TUS after rituximab compared with placebo. This encourages further research into both B cell depletion therapies in PSS and SGUS as an imaging biomarker. TRIAL REGISTRATION NUMBER: 65360827, 2010-021430-64; Results.

Real-life experience of using conventional disease-modifying anti-rheumatic drugs (DMARDs) in psoriatic arthritis (PsA). Retrospective analysis of the efficacy of methotrexate, sulfasalazine, and leflunomide in PsA in comparison to spondyloarthritides other than PsA and literature review of the use of conventional DMARDs in PsA.

OBJECTIVE: With the aim of assessing the response to treatment with conventional disease-modifying anti-rheumatic drugs (DMARDs) used in patients with psoriatic arthritis (PsA), data on methotrexate, sulfasalazine (SSZ), and leflunomide were analyzed from baseline and subsequent follow-up (FU) questionnaires completed by patients with either PsA or other spondyloarthritides (SpAs). MATERIAL AND METHODS: A single-center real-life retrospective analysis was performed by obtaining clinical data via questionnaires administered before and after treatment. The indices used were erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Function Index (BASFI), wellbeing (WB), and treatment effect (TxE). The indices measured at baseline were compared with those measured on one occasion in a FU visit at least 1 year later. RESULTS: A total of 73 patients, 51 with PsA (mean age 49.8±12.8 years; male-to-female ratio [M:F]=18:33) and 22 with other SpAs (mean age 50.6±16 years; M:F=2:20), were studied. BASDAI, BASFI, and WB displayed consistent improvements during FU assessments in both PsA patients and controls in comparison to baseline values. SSZ exhibited better efficacy as confirmed by TxE in both PsA patients and controls. ESR and CRP displayed no differences in either the PsA or the SpA group between the cases before and after treatment. CONCLUSION: Real-life retrospective analysis of three DMARDs used in PsA (and SpAs other than PsA) demonstrated that all three DMARDs that were used brought about improvements in BASDAI, BASFI, TxE, and WB. However, the greatest improvements at FU were seen with SSZ use in both PsA and control cohorts.

Randomized Controlled Trial of Rituximab and Cost-Effectiveness Analysis in Treating Fatigue and Oral Dryness in Primary Sjögren's Syndrome.

OBJECTIVE: To investigate whether rituximab, an anti-B cell therapy, improves symptoms of fatigue and oral dryness in patients with primary Sjögren's syndrome (SS). METHODS: We conducted a multicenter, randomized, double-blind, placebo-controlled, parallel-group trial that included health economic analysis. Anti-Ro-positive patients with primary SS, symptomatic fatigue, and oral dryness were recruited from 25 UK rheumatology clinics from August 2011 to January 2014. Patients were centrally randomized to receive either intravenous (IV) placebo (250 ml saline) or IV rituximab (1,000 mg in 250 ml saline) in 2 courses at weeks 0, 2, 24, and 26, with pre- and postinfusion medication including corticosteroids. The primary end point was the proportion of patients achieving a 30% reduction in either fatigue or oral dryness at 48 weeks, as measured by visual analog scale. Other outcome measures included salivary and lacrimal flow rates, quality of life, scores on the European League Against Rheumatism (EULAR) Sjögren's Syndrome Patient Reported Index and EULAR Sjögren's Syndrome Disease Activity Index, symptoms of ocular and overall dryness, pain, globally assessed disease activity, and cost-effectiveness. RESULTS: All 133 patients who were randomized to receive placebo (n = 66) or rituximab (n = 67) were included in the primary analysis. Among patients with complete data, 21 of 56 placebo-treated patients and 24 of 61 rituximab-treated patients achieved the primary end point. After multiple imputation of missing outcomes, response rates in the placebo and rituximab groups were 36.8% and 39.8%, respectively (adjusted odds ratio 1.13 [95% confidence interval 0.50, 2.55]). There were no significant improvements in any outcome measure except for unstimulated salivary flow. The mean ± SD costs per patient for rituximab and placebo were £10,752 ± 264.75 and £2,672 ± 241.71, respectively. There were slightly more adverse events (AEs) reported in total for rituximab, but there was no difference in serious AEs (10 in each group). CONCLUSION: The results of this study indicate that rituximab is neither clinically effective nor cost-effective in this patient population.

Genetic diagnostic profiling in axial spondyloarthritis: a real world study.

OBJECTIVES: Spondyloarthritis (SpA) is often diagnosed late in the course of the disease and improved methods for early diagnosis are required. We have tested the ability of genetic profiling to diagnose axial SpA (axSpA) as a whole group, or ankylosing spondylitis (AS) alone, in a cohort of chronic back pain patients. METHODS: 282 patients were recruited from centres in the United Kingdom, Germany, Taiwan, Canada, Columbia and Turkey as part of the ASAS classification criteria for axSpA study (ASAS cohort). Subjects were classified according to the ASAS axSpA criteria, and the modified New York Criteria for AS. Patients were genotyped for ~200,000 immune-mediated disease SNPs using the Illumina Immunochip. RESULTS: We first established the predictive accuracy of genetic data comparing 9,638 healthy controls and 4,428 AS cases from the homogenous International Genetics of AS (IGAS) Consortium Immunochip study which showed excellent predictive power (AUC=0.91). Genetic risk scores had lower predictive power (AUC=0.83) comparing ASAS cohort axSpA cases meeting the ASAS imaging criteria with IGAS controls. Comparing genetic risk scores showed moderate discriminatory capacity between IGAS AS and ASAS imaging positive cases (AUC 0.67±0.05), indicating that significant differences in genetic makeup exist between the cohorts. CONCLUSIONS: In a clinical setting of referred back pain patients suspected to have axial SpA we were unable to use genetic data to construct a predictive model better than that based on existing clinical data. Potential confounding factors include significant heterogeneity in the ASAS cohort, possibly reflecting the disease heterogeneity of axSpA, or differences between centres in ascertainment or classification performance.

Predictive validity of the ASAS classification criteria for axial and peripheral spondyloarthritis after follow-up in the ASAS cohort: a final analysis.

OBJECTIVE: To establish the predictive validity of the Assessment of SpondyloArthritis international Society (ASAS) spondyloarthritis (SpA) classification criteria. METHODS: 22 centres (N=909 patients) from the initial 29 ASAS centres (N=975) participated in the ASAS-cohort follow-up study. Patients had either chronic (>3 months) back pain of unknown origin and age of onset below 45 years (N=658) or peripheral arthritis and/or enthesitis and/or dactylitis (N=251). At follow-up, information was obtained at a clinic visit or by telephone. The positive predictive value (PPV) of the baseline classification by the ASAS criteria was calculated using rheumatologist's diagnosis at follow-up as external standard. RESULTS: In total, 564 patients were assessed at follow-up (345 visits; 219 telephone) with a mean follow-up of 4.4 years (range: 1.9; 6.8) and 70.2% received a SpA diagnosis by the rheumatologist. 335 patients fulfilled the axial SpA (axSpA) or peripheral SpA (pSpA) criteria at baseline and of these, 309 were diagnosed SpA after follow-up (PPV SpA criteria: 92.2%). The PPV of the axSpA and pSpA criteria was 93.3% and 89.5%, respectively. The PPV for the 'clinical arm only' was 88.0% and for the 'clinical arm'±'imaging arm' 96.0%, for the 'imaging arm only' 86.2% and for the 'imaging arm'+/-'clinical arm' 94.7%. A series of sensitivity analyses yielded similar results (range: 85.1-98.2%). CONCLUSIONS: The PPV of the axSpA and pSpA criteria to forecast an expert's diagnosis of 'SpA' after more than 4 years is excellent. The 'imaging arm' and 'clinical arm' of the axSpA criteria have similar predictive validity and are truly complementary.

Comparison between the intermalleolar distance measured on the couch and on the floor in axial spondyloarthritis.

The aim of this study was to assess whether axial spondyloarthritis (axial SpA) patients' supine position on the couch (OC) or on the floor (OF) affects intermalleolar distance (IMD) measurement and its Bath Ankylosing Spondylitis Metrology Index (BASMI) scoring, using all three versions of BASMI index. OC- and OF-IMDs were obtained for 43 axial SpA patients (M:F = 19:24). Age, gender, height, weight, body mass index (BMI), disease type and disease duration were also collected. Statistical analyses and correlations were performed as appropriate. Mean IMD measurements obtained with individuals in the two distinct measuring positions were not significantly different in the patients studied. Furthermore, there was a significant correlation between OC-IMD and OF-IMD values. There was no significant relationship between IMD and patient age, gender, height, weight, BMI, or disease duration. However, looking at disease type, IMDs of patients with ankylosing spondylitis (AS) were ~30 % greater than those with psoriatic arthritis (PsA) in our study population (p < 0.05). There were no significant differences between the measured patient characteristics that accounted for the greater IMDs of those diagnosed with AS. IMD measurements and resultant BASMI scores were the same whether the patient was positioned OC or OF in our axial SpA cohort. Unexpectedly, IMD measurements were significantly greater (~30 %) in AS patients than in axial PsA patients.

Drug therapies for peripheral joint disease in psoriatic arthritis: a systematic review.

In 2009, GRAPPA published their first evidence-based recommendations for the treatment of psoriasis and psoriatic arthritis (PsA). Since then, new information has been published and drugs developed. We summarize evidence for the efficacy of available treatments for peripheral joint involvement in PsA. We performed a systematic review of current literature on the efficacy of different therapies, management, and therapeutic strategies for peripheral arthritis involvement in PsA, in order to provide information for the development of the new GRAPPA treatment recommendations.

Cross-sectional study assessing family members of psoriatic arthritis patients affected by the same disease: differences between Caucasian, South Asian and Afro-Caribbean populations living in the same geographic region.

AIM: To determine the likelihood of an individual developing psoriatic arthritis (PsA) if they have a relative diagnosed with this disease, and to compare rates among different ethnic groups living in the same geographic region. METHOD: Family histories of patients with PsA were assessed using a semi-structured questionnaire. RESULTS: Data on family members of patients with SpA were collected for 151 patients (46.6%) of the total cohort of 324. A total of 146 patients in the SpA cohort had PsA (45%) and 88 of these patients (60.2%) also had relatives with PsA. Psoriatic arthritis was seen more commonly in Caucasians (n = 88, 58.3%) than in South Asians (n = 28, 18.5%; P < 0.001) or African/Afro-Caribbean (n = 11, 7.3%; P < 0.002) individuals. Caucasians more commonly had relatives affected by the disease (49/78, 62.8%) than in South Asians (16/33, 48.4%; P < 0.034). CONCLUSIONS: Psoriatic arthritis was more common in Caucasian than in South Asian patients. The relatives of Caucasian patients were also more likely to have PsA compared with South Asian patients. Among South Asian patients, the relatives of Pakistani patients were significantly more likely to have PsA compared with other South Asian populations. Patients with a relative with PsA were three times more likely to develop PsA, with an increased likelihood for Pakistani individuals (by a factor of 5.29) compared with other South Asians (2.88) and Caucasians (4.32).

Medical students' attitude towards rheumatology training at foundation years' level in the UK and rationale behind the students' choice: results from a national survey.

The aims are to assess whether medical students are interested in rheumatology as a training post during post-medical-school and prior to specialty training that is covered by foundation years (FY) training in the UK, to determine the time spent in the undergraduate training in rheumatology and whether the desire for musculoskeletal (MsK) medicine training (rheumatology and orthopaedics taken together) is enhanced during FY training and to analyse the rationale behind their choice for rheumatology alone or combined with orthopaedics. An online questionnaire was distributed to all 31 UK medical schools, addressed to fourth-, fifth- and sixth-year medical students. The questionnaire was completed by 256 students from 11 of 31 medical schools existed in the UK in 2009. Most respondents (n = 156; 60.9 %) received 3 weeks (96 h) exposure to rheumatology, whilst one-fifth (n = 53; 20.7 %) had received no exposure in rheumatology. A total of 122 students of the 256 that responded (47.6 %) would like to do rheumatology as part of their training and 116 (45.3 %) would like to have more posts available in rheumatology. However, when asked to choose 6 specialties, out of 21, which would be most useful for post-university training, rheumatology was amongst the bottom three, attracting only 9.4 % of respondent students. A total of 68 of 256 (26.5 %) students, however, expressed a desire for MsK medicine: 44/256 (17.1 %) for orthopaedics and 24/256 (9.4 %) for rheumatology. From a total of 49 of 256 (19.1 %) open-ended responses obtained, 25 (51 %) were from those medical students willing to have exposure in MsK medicine: 15 of 44 (34 %) willing to have orthopaedics and 10 of 24 (41.6 %) willing to have rheumatology. Analysis of the responses revealed that it is mostly the specialty choice that guides towards specialty training. One in five of the medical students responded to had received (actual or perceived) no exposure to rheumatology during their undergraduate years. Career choice that derived mostly from undergraduate exposure is the driving force behind medical students' choice for foundation year training.

The development of candidate composite disease activity and responder indices for psoriatic arthritis (GRACE project).

OBJECTIVE: To develop new composite disease activity indices for psoriatic arthritis (PsA). METHODS: Data from routine clinic visits at multiple centres were collected in a systematic manner. Data included all domains identified as important in randomised controlled trials in PsA. Decisions to change treatment were used as surrogates for high disease activity. New indices were developed by multiple linear regression (psoriatic arthritis disease activity score: PASDAS) and empirically, utilising physician-defined cut-offs for disease activity (arithmetic mean of desirability functions: AMDF). These were compared with existing composite measures: Composite Psoriatic arthritis Disease Activity Index (CPDAI), Disease Activity for PSoriatic Arthritis (DAPSA), and Disease Activity Score for rheumatoid arthritis (DAS28). RESULTS: 161/503 (32%) subjects had treatment changes. Although all measures performed well, compared with existing indices, PASDAS was better able to discriminate between high and low disease activity (area under receiver operating curves (ROC)) curve with 95% CI: PASDAS 0.773 (0.723, 0.822); AMDF 0.730 (0.680, 0.780); CPDAI 0.719 (0.668, 0.770); DAPSA 0.710 (0.654, 0.766); DAS28 0.736 (0.680, 0.792). All measures were able to discriminate between disease activity states in patients with oligoarthritis, although area under the receiver operating curves (AUC) were generally smaller. In patients with severe skin disease (psoriasis area and severity index>10) both nonparametric and AUC curve statistics were nonsignificant for all measures. CONCLUSIONS: Two new composite measures to assess disease activity in PsA have been developed. Further testing in other datasets, including comparison with existing measures, is required to validate these instruments.

Phenotypic and clinical differences between Caucasian and South Asian patients with psoriatic arthritis living in North East London.

To test for demographic and clinical differences between Caucasian and South Asian patients with psoriatic arthritis (PsA) living in the same environment and for differences between sexes. The demographic characteristics of patients attending outpatient clinics were obtained using a semi-structured questionnaire. Clinical parameters included disease activity (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), erythrocyte sedimentation rate (ESR), C-reactive protein), function (Bath Ankylosing Spondylitis Functional Index (BASFI)) and visual analogue scale (VAS) scores for well-being and night pain (10 cm, where 10 = worst possible response). The first symptom experienced at disease onset and the main symptoms during the disease course were recorded in the questionnaire. A total of 217 patents were assessed of whom 151 were Caucasians and 66 were Asians. South Asian patients were significantly younger [(mean) 45.9 years [(SD)(±11.4)] for Asians and 53.1 years (±14.2) for Caucasians (p < 0.005)] and were diagnosed at an earlier age [40.7 years (±11.7) for Asians and 46.7 years (±15.8) for Caucasians (p < 0.05)] compared to Caucasians patients. Asian females with PsA had worse disease in terms of activity (ESR = 23.9 mmHg/h; BASDAI = 6.7), function (BASFI = 5.5), night pain (7.1 on VAS) and well-being (6.6 on VAS) compared with Asian males (13.2 mmHg/h, 5.3, 3.6, 4.1, 4.6, respectively) or Caucasian males and females (15.8 mmHg/h, 5.9, 5.3, 5.4, 5.4; 18.9 mmHg/h, 6.1, 6.1, 5.3, 5.8, respectively). There were no significant differences in symptoms at disease onset or the main symptoms during the disease course between Caucasian and Asian patients, although there was a trend towards more frequent enthesitis in Asian females during the course of disease suggested by pain with pressure compared to Asian males. South Asian patients may develop PsA earlier in life than Caucasian patients do, but their clinical characteristics are generally similar. Asian females with PsA have worse disease activity, function, night pain and well-being than Asian males and Caucasian males and females.

Clinical overlap between fibromyalgia tender points and enthesitis sites in patients with spondyloarthritis who present with inflammatory back pain.

OBJECTIVES: To assess the extent of coexistence of inflammatory back pain (IBP) with fibromyalgia (FM) features in patients with spondyloarthritis (SpA), and to assess the degree of overlap of FM tender points (TeP) and enthesitis sites (ES) in patients with SpA. METHODS: We evaluated 61 consecutive patients who presented with IBP. Anterior and posterior anatomic diagrams were used as an aid to record assessments of TeP typically seen in FM and ES. RESULTS: Of the patients assessed (n=61), 60 patients (97.9%) fulfilled criteria for IBP (male: female=17:43 (28.3%:71.7%); mean age=47.9 years (SD=11.5) and were included in the analysis. Of those who returned the questionnaire (n=47 (78.3%), 76.6% had onset of symptoms at ≤40 years (mean age=33.5±12.5 years), 87.2% had back pain of ≥3 months duration, 91.5% had morning stiffness (mean duration=70±66 minutes), and 60% showed improvement of pain with exercise. Eating disorders were reported by 21.3% of subjects, and stress was identified as a disease trigger by 40.4% of the respondents. Other symptoms related to FM were reported by 68.1% of the interviewed subjects. Of the 60 patients assessed, 18 (30%) fulfilled the clinical criteria for FM (at least 11 out of 18 TeP). Using regression analysis, a significant correlation was identified between FM TeP and ES. CONCLUSIONS: One third of patients with IBP fulfilled the criteria for FM. There is a significant degree of overlap between FM TeP and ES in patients with IBP.