From bench to bedside - is there a role of IL-17 drugs in rheumatoid arthritis?

INTRODUCTION: IL-17 has been described as a pro-inflammatory cytokine that is relevant in the seronegative spondylarthritides with IL-17 targeted therapies being licensed for their treatment.There is evidence to demonstrate that IL-17 is found in RA joints and contributes to the pro-inflammatory cascade. This results in synovial hyperplasia and osteoclastogenesis thus causing joint destruction and bony erosions. AREAS COVERED: This review article summarizes trials that have studied the use of IL-17 targeted therapies in RA patients who have failed conventional synthetic disease-modifying therapy (C-DMARDS) and biologic DMARDS. EXPERT OPINION: The trials that have studied IL-17 inhibitors in RA patients have only shown a modest improvement in disease activity. In several trials, the primary endpoint was not achieved whilst in others, when comparing with existing licensed biologics for RA, did not demonstrate any superiority.Tissue Necrosis Factor-alpha (TNF-α) likely plays more of a pivotal role in the pathogenesis of RA with IL-17 having a synergistic effect. Therefore, in our opinion, IL-17 inhibitors as an independent therapy for RA are less likely to provide a cost-effective benefit. There may be scope to potentially combine it with TNF-α-inhibitors (TNF-i), but this requires further research especially with the potential concerns related to increased immunosuppression.

Is There a Correlation Between Patient-Reported Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) Score and MRI Findings in Axial Spondyloarthropathy in Routine Clinical Practice?

Background The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is the patient-reported outcome (PRO) that is routinely used in clinical practice to monitor and measure disease activity in axial spondyloarthropathy (axSpA). BASDAI scores greater than four are thought to indicate active disease and require better control. Magnetic resonance imaging (MRI) is the most objective measure of disease activity in axSpA with its ability to pick up active inflammation both in the spine and sacroiliac joints. Previous studies have shown conflicting correlations between BASDAI and MRI, and therefore, there is the question of whether BASDAI is the best tool to monitor disease activity when it is subjective and potentially influenced by other patient factors. We, therefore, conducted a retrospective study to investigate the correlation between BASDAI and MRI in axSpA patients. Methodology Data were collected by retrospective analysis of axSpA patients attending University of Leicester (UHL) axSpA services. BASDAI scores were done within a year and closest to the time of MRI spine + sacroiliac joints were collected. The results prior to the initiation of biologic therapy were used. Data of one hundred and forty-nine patients were collected on their MRI results and BASDAI scores. Data were analysed using Statistical Package for the Social Sciences (SPSS) software and Pearson's chi-squared applied to assess the correlation between BASDAI and MRI findings. Results Out of one hundred and forty-nine patients, 61.7% had active sacroiliitis on their MRI, 57.7% had chronic sacroiliitis, 53% had active spinal inflammation, and 17.4% had other MRI findings of active disease. There was a significant correlation between active sacroiliitis and BASDAI (p=0.014), but similar results were not found with other radiological features. A significant correlation was also found with males having higher BASDAI scores compared to females (p=0.027). Conclusion This study demonstrates a statistically significant correlation between BASDAI and active sacroiliitis with those having higher scores more likely to have active disease on their MRI.

Promising Treatment Options for Axial Spondyloarthritis: An Overview of Experimental Pharmacological Agents.

Axial spondyloarthritis (axSpA) is a chronic inflammatory condition that predominantly affects the axial skeleton. All patients receive conservative management measures which include physiotherapy, patient education and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Those with significant active disease will require escalation of their treatment with the use of biologics. Currently, there are five approved TNF inhibitors and two approved IL-17 inhibitors for use in axSpA. However, despite this up to 40% of patients do not respond or are intolerant to current available treatment. This leaves a significant number of patients with uncontrolled disease and unmet need for additional therapies. Though many drug classes have been trialed for axSpA they show poor efficacy; however, over the last few years there are three which demonstrate much greater promise as novel therapies for axSpA, these include dual neutralization of IL-17A and IL-17F, Janus kinase (JAK) inhibitors, and granulocyte-macrophage colony-stimulating factor (GM-CSF) inhibitors. This article reviews the evidence for these novel emerging therapeutic options for axSpA.

The Impact of the Coronavirus (COVID-19) Pandemic on Outpatient Services-An Analysis of Patient Feedback of Virtual Outpatient Clinics in a Tertiary Teaching Center With a Focus on Musculoskeletal and Rheumatology Services.

The pandemic has resulted in many changes to health services, one of these is the shift from face-to-face consultations to virtual ones across all specialities. As the pandemic continues with no end in sight it seems that virtual consultations will continue for the foreseeable future. In this article, we analyze the patient feedback so far to virtual consultations in a large tertiary center and use this opportunity to reflect on this new service. We have a particular interest in musculoskeletal services as this is largely an outpatient-based speciality and the pandemic has consequently resulted in significant changes in practice. We also consider whether virtual clinics is a sustainable service post-COVID-19 and the benefits and disadvantages of this.

Digital health strategies in the war against COVID-19 and beyond.

This editorial explores how technology has helped clinicians during the COVID-19 pandemic, from patient care to education, the changes that have been made and the numerous exciting possibilities of where technology can amalgamate with health care.

Improving physical healthcare provided to psychiatric inpatients at an acute mental health trust.

Psychiatric patients are at high risk of developing physical health complications. This is due to various factors including medications prescribed, life style choices and diagnostic overshadowing. Admission to a psychiatric unit provides a prime opportunity to review a patient's physical healthcare. We noticed prior to the commencement of this project that this opportunity was not always being used in the inpatient unit, with one in four patients at baseline data collection having no physical health checks. This is despite clear guidance laid out in the trust policy 'Physical Examination of Service Users during Admission to Hospital'. We aimed to improve compliance with these checks to 100%. A number of prior audits in this area had failed to sustain improvement. Therefore, we proposed a quality improvement approach involving a series of plan do study act cycles, in order to test and review processes prior to implementation. The first cycle involved simplification of the paper-based documentation used for physical health checks, which resulted in minimal improvement by 5%. The second cycle involved combining this documentation with the history taking proforma resulting in an overall improvement in compliance to 90%. We learnt that a move away from the more widely used audit towards a more holistic approach of quality improvement allowed an informed continuum of change to take place which likely led to sustained improvement. Post implementation data collected at 1 month revealed compliance remained at 90%. Our initial 100% target was perhaps unrealistic, as there are also longstanding underlying cultural issues around physical healthcare in psychiatric patients that are complex to address and beyond the scope of this project.