Updates from the ACR Convergence 2023 Review Course, part 5
SAN DIEGO—Led by moderators Noelle Rolle, MBBS, assistant professor in the Division of Rheumatology, associate program director of the Rheumatology Fellowship at the Medical College of Georgia, Augusta University, and Julia Schwartzmann-Morris, MD, associate professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, N.Y., the Review Course at ACR Convergence 2023 delivered on the promise of a thorough, thoughtful discussion of a plethora of subjects in rheumatology.
Alexis Ogdie-Beatty, MD, MSCE, associate professor of medicine, associate professor of epidemiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, gave a presentation on non-radiographic axial spondyloarthritis (nr-axSpA).
It is estimated that about 1% of the U.S. population between ages 20 and 59 has axial spondyloarthritis (axSpA) and that peak incidence of the condition occurs in the second and third decades of life.1 With regard to sex, nr-axSpA has a ratio of about 1:1 in males and females.2
When a rheumatologist is seeing a patient with back pain, it is important to get a sense of whether strong features of inflammatory back pain are present. Some of the features of this type of back pain include onset before age 45 and back pain/stiffness that is worse in the second half of the night and may awaken the patient from sleep.
Elevations in C-reactive protein (CRP) may be seen more commonly than elevations in erythrocyte sedimentation rate (ESR), but both inflammatory markers can be normal in patients with axSpA. Positivity for HLA-B27 can be helpful in raising the pre-test probability of axSpA in a patient with the right clinical symptoms, but it should be noted that fewer patients with nr-axSpA are HLA-B27 positive than patients with radiographic axSpA.
When radiographs of the sacroiliac joints are negative but clinical suspicion of axSpA remains high, magnetic resonance imaging (MRI) of the pelvis or sacrum is often indicated. On this topic, Dr. Ogdie-Beatty stressed that contrast is not needed for this type of MRI. Even MRI testing has its limits: Abnormalities can increase with age, and false positive findings can be seen in athletes, military recruits, and pregnant or recently pregnant patients.
axSpA vs. nr-axSpA
Speaking more broadly on the concept of radiographic vs. non-radiographic axSpA, Dr. Ogdie-Beatty explained that it was originally thought that non-radiographic disease progressed to radiographic disease over time. However, it is unclear if nr-axSpA represents an early stage of radiographic disease or if it is a different entity all together. Based on trends in the epidemiology of the conditions, it is expected that the proportion of patients with nr-axSpA will increase while that of patients with radiographic axSpA will decrease in future years.
In terms of radiographic progression, about 20% of patients with nr-axSpA will show progression over five years. Thus, since the majority of patients do not experience progression, the question is: Do we need to treat all patients with nr-axSpA?
Dr. Ogdie-Beatty stated that it may be helpful to think about which patients are at highest risk of progression. This would include patients who are HLA-B27 positive; have elevated CRP; have imaging findings with low-grade, radiographic changes or MRI changes at baseline; have a history of smoking; and have a history of uveitis.
Progression in patients is slow, thus in some patients it may be worth discussing initial treatment with non-steroidal anti-inflammatory drugs (NSAIDs); if symptoms become more significant, discussion of biologic therapy would be warranted.
Generally speaking, the treatment of radiographic and nr-axSpA is the same, and in both sets of patients, NSAIDs and corticosteroid injections would be potential options.
A significant oversight in the care of many patients with axial disease is the failure to prescribe physical therapy (PT). A great deal of pain can be attributed to mechanical symptoms and will improve with PT. Dr. Ogdie-Beatty routinely recommends exercise, stretching and core strengthening for her patients.
She also highly encourages patients to quit smoking if they are smokers.
In terms of biologic treatment, options include TNFα inhibitor, IL-17 inhibitor and Janus kinase (JAK) inhibitor therapy. These classes of biologics are regarded as similar in efficacy, although selection of therapy may depend on other variables, such as using a TNFα inhibitor in patients with a history of uveitis or inflammatory bowel disease. In terms of preventing radiographic progression, this is hard to demonstrate in studies because progression is slow and most trials may not have sufficient follow-up periods to evaluate this outcome.
In terms of treat-to-target strategies, Dr. Ogdie-Beatty advises that patients and providers work together to select an objective outcome to follow at each visit. For example, outcomes that may be meaningful to patients include the ability to work out at the gym or to have a successful pregnancy.
Even in patients with confirmed axial spondyloarthritis, not all back pain can or should be attributed to this condition. Patients with nr-axSpA may experience a disc herniation or other mechanical causes of back pain.
In addition, about 30% of patients with axSpA have fibromyalgia, and thus, management of such comorbidities is essential.
In many cases, working with physiatry will be helpful, as will addressing mood disorders, such as depression, and using non-opioid pain medications when necessary.
Dr. Ogdie-Beatty concluded by explaining that, if a patient with suspected nr-axSpA fails to respond to multiple types of treatment, it is reasonable to question the underlying diagnosis and ensure that no other condition is driving symptoms.
Jason Liebowitz, MD, is an assistant professor of medicine in the Division of Rheumatology at Columbia University Vagelos College of Physicians and Surgeons, New York.
- Magrey MN, Danve AS, Ermann J, Walsh JA. Recognizing axial spondyloarthritis: A guide for primary care. Mayo Clin Proc. 2020;95(11):2499–2508.
- Marzo-Ortega H. Axial spondyloarthritis: Coming of age. Rheumatology (Oxford). 2020 Oct 1;59(Suppl4):iv1–iv5.