5Disease activity measurements and monitoring in psoriatic arthritis and axial spondyloarthritis
Introduction
Spondyloarthritis (SpA) is a heterogeneous disease that can have either a predominantly axial or peripheral phenotype [1], ∗[2]. The range of clinical manifestations in SpA is broad and includes chronic (typically inflammatory) back pain, arthritis, enthesitis, dactylitis, and extra-articular features such as psoriasis, uveitis, inflammatory bowel disease, and fatigue. These manifestations may occur separately or simultaneously in the same patient or in their family members, and the disease is strongly linked to human leukocyte antigen B27 (HLA-B27) positivity [1], ∗[2].
Measuring and monitoring disease activity are of paramount importance in rheumatology and in medicine in general. Yet quantifying disease activity is a complex and challenging process. Composite scores can be particularly useful to measure disease activity because they integrate several different aspects of disease activity into one single numerical value, resulting in a more precise estimate of disease activity than the individual variables of the composite score. They also have the potential to increase the statistical power of clinical trials and observational studies. Furthermore, they improve the consistency of patient assessment and care across different clinical and research settings, and help patients and doctors better understand the disease and its impact. However, there may be times when measuring a specific disease feature may be more appropriate, because the therapeutic intervention may be directed primarily at a certain clinical manifestation and not necessarily aimed at generating a global change in disease activity [3], [4].
In this review, we focus on disease activity measurements and monitoring in axial SpA and in the most prevalent form of peripheral SpA, psoriatic arthritis (PsA). All the instruments described for axial SpA were initially developed for ankylosing spondylitis (AS) but are currently applied in both radiographic (i.e., AS) and non-radiographic axial SpA. Several concepts addressed in this review relate to the Outcome Measures in Rheumatology (OMERACT) filter [5], a set of criteria that can serve as a guide to develop valid and meaningful indices. The OMERACT filter includes aspects of “truth” (Is the measure truthful? Does it measure what it intends to measure? Is the result unbiased and relevant?), “discrimination” (Does the measure discriminate between situations that are of interest? Does the measure have the ability to detect change?), and “feasibility” (Can the measure be applied easily, given constraints of time, money, and interpretability?) [5].
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Disease activity measurements and monitoring in axial SpA
The Assessment of SpondyloArthritis International Society (ASAS) has proposed several instruments to assess health outcomes in axial SpA. These instruments cover distinct domains and are divided into core sets to be applied in different settings (Table 1) ∗[2], [6]. These core sets include several disease activity variables such as the assessment of spinal pain, patient global assessment of disease activity, the number of swollen joints (with a 44-joint count being recommended), an enthesitis
Disease activity measurements and monitoring in PsA
PsA does not have diagnostic criteria. Currently, a widely used classification criteria for psoriasis is the Classification Criteria for Psoriatic Arthritis (CASPAR) [51]. In Table 4, the components of the CASPAR criteria are mentioned. Compared to RA where the major disease focus is peripheral arthritis, outcome measures need to cover several manifestations of PsA as mentioned in Table 4, thus making their derivation and validation arduous. PsA is a heterogeneous disease, characterized by
Summary
In PsA and axial SpA, several outcome measures are available for various health outcomes of these diseases, which include disease activity, physical function, mobility, and QOL. Several measures have been developed specifically to assess clinical disease activity. The majority of these measures have good evidence to support their use. The field of assessment of psoriatic PsA and axial SpA has rapidly evolved in the last 5 years, including the development of new composite disease activity
Competing interests
None.
Acknowledgments
PM is funded by a postdoctoral research fellowship award from the National Institute for Health Research (NIHR). This publication was supported by researchers at the NIHR University College London Hospitals Biomedical Research Centre. The views expressed are those of the author and not necessarily those of the National Health Service (NHS), the NIHR, or the Department of Health.
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Resources and Strategies for the Optimal Care of Patients With Axial Spondyloarthritis: The CREA Project
2023, Reumatologia ClinicaPredictors of remission in people with axial spondyloarthritis: A systematic literature review
2022, Seminars in Arthritis and RheumatismCitation Excerpt :With the increasing use of biological agents in the treatment of axSpA in recent years, aiming for clinical remission is now a major treatment goal as outlined in current treat-to-target recommendations [2]. However, at present, there is no clear, universally accepted definition of remission in axSpA [3–7]. Two main definitions of clinical remission/inactive disease have been proposed: 1) Assessment in Spondyloarthritis International Society (ASAS) partial remission (PR) [8], defined by a value no greater than 20 on a 0-100 scale in four domains: pain represented by the visual analogue scale (VAS) score (0–100); function represented by the Bath Ankylosing Spondylitis Functional Index (BASFI) score (0–100); inflammation represented either by the mean of the two morning stiffness-related Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) questions (item 5 or 6), [8]; and 2) Ankylosing Spondylitis Disease Activity Score (ASDAS) inactive disease (ID), defined by an ASDAS score<1.3 [9], with ASDAS C-reactive protein (CRP) or ASDAS erythrocyte sedimentation rate (ESR) being calculated using a formula that weights five items: back pain (BASDAI question 2), peripheral joint complaints (BASDAI question 3), duration of morning stiffness (BASDAI question 6), patient global assessment, and CRP (ASDAS-CRP) or ESR level (ASDAS-ESR) [10–12].
Definition of Remission and Disease Activity Assessment in Psoriatic Arthritis: Evidence and Expert-Based Recommendations
2021, Reumatologia ClinicaCitation Excerpt :Finally, it has been recently showed that DAPSA-based remission/low disease activity performs better than MDA to detect patient-defined remission or remission/low disease activity.28 In axial SpA, evidence suggests that the ASDAS better reflects the inflammatory disease processes (both with biomarkers of inflammation and MRI inflammation scores) than BASDAI.29 In line with recent recommendations,2 we considered that ASDAS is preferred, and BASDAI may be used as an alternative.
Dermatologists’ Role in the Early Diagnosis of Psoriatic Arthritis: Expert Recommendations
2020, Actas Dermo-SifiliograficasIs the new ASDAS nomenclature in agreement with therapeutic decision making in patients with axial spondyloarthritis?
2020, Seminars in Arthritis and RheumatismCitation Excerpt :Axial spondyloarthritis (axSpA) is an inflammatory rheumatic disease whose main symptom is inflammatory axial pain. In clinical practice, the recommendation to obtain an adequate axSpA inflammatory assessment is to use composite indexes reflecting different disease manifestations [1]. There are two primarily composite indexes: The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) [2] and the Ankylosing Spondylitis Disease Activity Score (ASDAS) [3] but due to its better instrument properties, the ASDAS is nowadays the recommended index to monitor disease activity in patients with axSpA.
Management of psoriatic arthritis: Early diagnosis, monitoring of disease severity and cutting edge therapies
2017, Journal of AutoimmunityCitation Excerpt :Thus, dermatology and primary care providers should be keenly poised to diagnose PsA in their at-risk patients with cutaneous psoriasis. For these patients, achieving a good long-term clinical outcome depends in part on the physician's ability to make an early diagnosis of PsA and to initiate treatment prior to the onset of significant and permanent joint damage [3,13]. Making an early diagnosis is also critical for testing new PsA therapies while the disease is still evolving and the capacity to prevent or slow joint damage may be assessed.