Editorial
New Paradigms in the Diagnosis and Classification of the Spondylarthritis
Nuevos paradigmas en el diagnóstico y la clasificación de las espondiloartritis
Eduardo Collantes-Estevez
Unidad de Gestión Clínica y Servicio de Reumatología, Hospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
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However, the differences between them are substantial and must be known before application. The <span class="elsevierStyleItalic">diagnostic</span> criteria should be applied to individual patients and should be especially sensitive (high sensitivity) to allow identification of patients with the disease even during the early stages. This depends on the prevalence of the disease. In contrast, the purpose of the <span class="elsevierStyleItalic">classification</span> criteria is to differentiate patients with a specific disease from patients with other illness or individuals from the general population, and are used in epidemiological research to create homogeneous groups of patients. These criteria should have high specificity and be applied to patients’ already diagnosed. Their qualities are not dependent on the prevalence and should not be applied “automatically” for diagnosis, especially in populations where the prevalence is low,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> as in general practices, where the prevalence of these is low and high for low back pain of mechanical origin.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the field of SA, two systems of criteria were developed almost simultaneously, the Amor<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and the European Group for the Study of spondylarthopathies criteria (EGSS),<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> which have been very useful thanks to their good quality in terms of sensitivity (90.8% Amor and 83.5% EGSS) and specificity (96.2% Amor and 95.2% EGSS). However, the introduction of diagnostic imaging, especially MRI, which can detect early sacroiliitis, the efficacy of biological drugs in early stages of the disease<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and the need to recognize patients at increasingly early stages evidenced the shortcomings of these criteria for the early recognition (preradiologic) of inflammatory involvement of the sacroiliac joints and there was a need to develop a new system of classification criteria that overcame these limitations, namely ASAS.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Previously, it was necessary to redefine some concepts. First, it issued a new definition of inflammatory back pain.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Secondly, ASAS has proposed dividing patients with SA into 2 subgroups according to the clinical presentation: <span class="elsevierStyleItalic">predominantly axial SA</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> (which would include the SA and initial forms, now called non-radiographic axial SA) and <span class="elsevierStyleItalic">predominantly peripheral SA</span> (including reactive arthritis, psoriatic arthritis, arthritis associated with chronic inflammatory bowel disease and SAInd).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> And thirdly, it coined the term “<span class="elsevierStyleItalic">preradiographic axial spondyloarthropathy</span>” or “<span class="elsevierStyleItalic">non radiographic axial spondyloarthritis (SAax/pRx)</span>” for patients with clinically predominantly axial disease where no structural damage is detected radiographically on the sacroiliac joints and hence could not be diagnosed with SA; although clinically indistinguishable, both (SAaxnRx and SA) represent a unique disease in varying stages.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">With these premises, ASAS has developed and validated new criteria to classify patients according to their clinical expression (axial or peripheral<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14–16</span></a>). In the axial subtype, a patient may qualify if presenting back pain for more than 3 months duration, beginning before 45 years of age and sacroiliitis on X-rays or MRI, defined when at least one of 11 SA specified characteristics are present, or (if without SI criteria) if HLA-B27 is positive and at least two of these characteristics are present. For the peripheral subtype it is required that the presence of arthritis, dactylitis or entesitis be present, or as an entry criterion, one or two of the characteristics defined. The sensitivity and specificity of the new criteria are: for axial SA criteria, 82.9% and 84.4%, respectively, and for peripheral SA criteria, 78.0% and 82.2%.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding the above, the ASAS criteria report predominant symptoms<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and have slightly better qualities, even when modifying these by adding MRI. Nevertheless, some considerations are worthy of note. These classification systems (axial and peripheral) should not be mutually exclusive, as it is common for phenotypic pattern to change along the evolution of the disease process. Moreover, these criteria are apparently restricted to patients younger than 45 years and limit the ability to include some patients with peripheral forms, particularly reactive arthritis or psoriatic arthritis, which often start above this limit. Some authors<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> have highlighted the differences in access to MRI in different countries, which may influence the applicability of the criteria in clinical practice.</p><p id="par0035" class="elsevierStylePara elsevierViewall">ASAS criteria were developed as classification criteria, but, if applied in a scenario in which the prevalence of disease is high (rheumatology clinic seeing patients with suspected SA) they may also be used as diagnostic criteria. In other scenarios, such as in general medicine they are not sufficient enough to be used for diagnosis.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In short, the new ASAS criteria represent a step forward in the goal of better classification of patients with axial and peripheral SA than those previously developed, especially in the early stages of the disease. Another potential target of these criteria is to facilitate the conduct of clinical trials and observational studies in patients with axial preradiographic SA, but probably the most important contribution of these criteria is that they expand the range of therapeutic indications, via the authorization of competent agencies such as the European Drug Agency and the Food and Drug Administration with TNF blocking agents in patients with very early forms of the disease<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and lead us to finally confirm (or not) that the forceful therapeutic approach to SAaxnRx changes the course of the disease or even induces permanent remission.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Collantes-Estevez E. Nuevos paradigmas en el diagnóstico y la clasificación de las espondiloartritis. Reumatol Clin. 2013;9:199–200.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spondyloarthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Dougados" 1 => "D. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 14 | 21 |
| 2024 October | 29 | 37 | 66 |
| 2024 September | 48 | 13 | 61 |
| 2024 August | 59 | 28 | 87 |
| 2024 July | 55 | 27 | 82 |
| 2024 June | 54 | 35 | 89 |
| 2024 May | 61 | 33 | 94 |
| 2024 April | 51 | 22 | 73 |
| 2024 March | 35 | 33 | 68 |
| 2024 February | 35 | 21 | 56 |
| 2024 January | 39 | 21 | 60 |
| 2023 December | 33 | 24 | 57 |
| 2023 November | 33 | 29 | 62 |
| 2023 October | 31 | 25 | 56 |
| 2023 September | 66 | 41 | 107 |
| 2023 August | 44 | 13 | 57 |
| 2023 July | 26 | 27 | 53 |
| 2023 June | 26 | 29 | 55 |
| 2023 May | 62 | 27 | 89 |
| 2023 April | 17 | 5 | 22 |
| 2023 March | 34 | 32 | 66 |
| 2023 February | 47 | 23 | 70 |
| 2023 January | 35 | 16 | 51 |
| 2022 December | 43 | 25 | 68 |
| 2022 November | 51 | 27 | 78 |
| 2022 October | 55 | 26 | 81 |
| 2022 September | 26 | 29 | 55 |
| 2022 August | 55 | 33 | 88 |
| 2022 July | 31 | 32 | 63 |
| 2022 June | 39 | 38 | 77 |
| 2022 May | 40 | 32 | 72 |
| 2022 April | 35 | 37 | 72 |
| 2022 March | 41 | 43 | 84 |
| 2022 February | 29 | 42 | 71 |
| 2022 January | 37 | 29 | 66 |
| 2021 December | 28 | 46 | 74 |
| 2021 November | 40 | 46 | 86 |
| 2021 October | 70 | 47 | 117 |
| 2021 September | 36 | 45 | 81 |
| 2021 August | 22 | 44 | 66 |
| 2021 July | 29 | 38 | 67 |
| 2021 June | 22 | 39 | 61 |
| 2021 May | 35 | 34 | 69 |
| 2021 April | 98 | 107 | 205 |
| 2021 March | 58 | 20 | 78 |
| 2021 February | 39 | 21 | 60 |
| 2021 January | 30 | 19 | 49 |
| 2020 December | 32 | 13 | 45 |
| 2020 November | 26 | 10 | 36 |
| 2020 October | 27 | 9 | 36 |
| 2020 September | 31 | 15 | 46 |
| 2020 August | 21 | 10 | 31 |
| 2020 July | 17 | 15 | 32 |
| 2020 June | 29 | 11 | 40 |
| 2020 May | 28 | 13 | 41 |
| 2020 April | 25 | 8 | 33 |
| 2020 March | 12 | 4 | 16 |
| 2020 February | 1 | 0 | 1 |
| 2019 April | 2 | 0 | 2 |
| 2019 January | 1 | 0 | 1 |
| 2018 May | 4 | 1 | 5 |
| 2018 April | 57 | 10 | 67 |
| 2018 March | 58 | 8 | 66 |
| 2018 February | 80 | 1 | 81 |
| 2018 January | 23 | 8 | 31 |
| 2017 December | 70 | 6 | 76 |
| 2017 November | 30 | 8 | 38 |
| 2017 October | 36 | 4 | 40 |
| 2017 September | 26 | 5 | 31 |
| 2017 August | 40 | 22 | 62 |
| 2017 July | 29 | 13 | 42 |
| 2017 June | 43 | 14 | 57 |
| 2017 May | 47 | 21 | 68 |
| 2017 April | 45 | 12 | 57 |
| 2017 March | 41 | 25 | 66 |
| 2017 February | 25 | 8 | 33 |
| 2017 January | 38 | 12 | 50 |
| 2016 December | 62 | 25 | 87 |
| 2016 November | 40 | 8 | 48 |
| 2016 October | 52 | 16 | 68 |
| 2016 September | 50 | 6 | 56 |
| 2016 August | 50 | 16 | 66 |
| 2016 July | 29 | 10 | 39 |
| 2016 May | 0 | 23 | 23 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 0 | 24 | 24 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 2 | 0 | 2 |
| 2015 July | 25 | 8 | 33 |
| 2015 June | 38 | 21 | 59 |
| 2015 May | 43 | 29 | 72 |
| 2015 April | 30 | 20 | 50 |
| 2015 March | 21 | 17 | 38 |
| 2015 February | 28 | 15 | 43 |
| 2015 January | 37 | 13 | 50 |
| 2014 December | 36 | 11 | 47 |
| 2014 November | 15 | 15 | 30 |
| 2014 October | 34 | 13 | 47 |
| 2014 September | 27 | 21 | 48 |
| 2014 August | 36 | 19 | 55 |
| 2014 July | 36 | 21 | 57 |
| 2014 June | 43 | 14 | 57 |
| 2014 May | 47 | 20 | 67 |
| 2014 April | 47 | 18 | 65 |
| 2014 March | 50 | 18 | 68 |
| 2014 February | 47 | 14 | 61 |
| 2014 January | 30 | 8 | 38 |
| 2013 December | 32 | 11 | 43 |
| 2013 November | 30 | 13 | 43 |
| 2013 October | 49 | 12 | 61 |
| 2013 September | 44 | 14 | 58 |
| 2013 August | 82 | 29 | 111 |
| 2013 July | 37 | 22 | 59 |
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