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Peripheral Arthritis Can Occur at Any Time During New Axial SpA
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Among patients with recent-onset axial spondyloarthritis, 36% reported developing peripheral arthritis at any time during their disease duration, with these patients demonstrating a greater disease burden than those without peripheral arthritis, according to recent findings in Arthritis Research & Therapy.
“Arthritis and enthesitis are the most common peripheral features in axSpA and can be found predominantly in the lower limbs,” Clementina López-Medina, MD, PhD, of Cochin Hospital, Paris, and colleagues wrote. “The prevalence of peripheral arthritis has been well described in [ankylosing spondylitis] patients, with percentages ranging between 22 and 30%. However, the prevalence of this manifestation in the whole group of axSpA varies between the different cohorts. ... The majority of these data refer only to baseline visits, and very few studies evaluate the time of onset of this clinical feature during follow-up.”
To characterize the prevalence and incidence of peripheral arthritis during 5 years of follow-up from recent-onset axSpA, and to examine the factors linked to their development and measure their impact on treatment and outcomes, López-Medina and colleagues reviewed data from the Devenir des Spondylarthropathies Indifferenciées Récentes (DESIR) cohort. According to the researchers, the DESIR cohort includes 708 patients aged between 18 and 50 years with early inflammatory back pain, recruited from 25 centers across France. Patients with previous treatment with biologics were excluded.
Visits with these patients were scheduled for every 6 months for the first 2 years, and annually thereafter.
The researchers focused on the first 5 years of follow-up from the DESIR cohort. For each visit, they calculated the prevalence and incidence of peripheral arthritis, and used multivariate analysis to analyze the baseline factors associated with the arthritis. In addition, they compared drug use, patient-reported outcomes and sick-leave use between those with and without peripheral arthritis.
According to López-Medina and colleagues, 36% of the 708 included patients demonstrated at least one case of arthritis, including 151 who had the condition prior to the inclusion visit and 104 who developed it during the follow-up period. This corresponds to an incidence rate of 3.7 cases per 100 person-years, the researchers wrote.
The researchers also found that patients with peripheral arthritis were more likely to be aged 33years or older (OR = 1.6; 95% CI, 1.12-2.27), nonsmokers (OR = 1.58; 95% CI, 1.1-2.27) and HLAB27-negative (OR = 1.47; 95% CI, 1.04-2.08). They are also more likely to have presented with at least one case of dactylitis (OR = 8.5; 95% CI, 4.96-14.6) and enthesitis (OR = 2; 95% CI, 1.41-2.84).
In addition, patients with peripheral arthritis demonstrated a significant greater use of TNF inhibitors, conventional synthetic DMARDs and corticosteroids during the follow-up, compared with those without. They also scored higher on BASDAI and BASFI indices, demonstrated poorer quality of life and reported taking more sick days from work.
“In this study, we observed that peripheral arthritis can appear at any time during the disease and has a high burden of disease (deteriorating quality of life and causing days of sick leave),” López-Medina and colleagues wrote. “This finding is the reason why rheumatologists should check systematically this clinical feature during the monitoring of these patients. Other studies are required in order to confirm or not these results and to better understand the underlying pathological process.” – by Jason Laday
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Alan L. Epstein, MD
When thinking about axial spondyloarthritis, we tend to focus on the spinal manifestations, their natural history and their response to treatment. It should be remembered that peripheral arthritis and enthesitis can also be important clinical features in patients with primarily axial spondyloarthritis.
Peripheral arthritis can be seen in 22-30% of patients with ankylosing spondylitis, and in 15-20% of patients with recent onset axial spondyloarthritis at baseline. In cohorts of patients with established axial spondyloarthritis, peripheral arthritis can be seen in 35-40% of patients at baseline, demonstrating an increased prevalence over time.
We have very little clinical information on the development of peripheral arthritis in patients with axial spondyloarthritis and the response of peripheral arthritis to treatment. In the study by Lopez-Medina and colleagues, the researchers found that 21% of the patients had evidence of peripheral arthritis at baseline and an additional 19% developed peripheral arthritis during the five-year follow-up. In 20% of the patients with peripheral arthritis, it preceded the axial symptoms, whereas in 66% of the patients the peripheral symptoms followed the axial ones.
Peripheral arthritis can occur at any time in a patient with primarily axial spondyloarthritis and is associated with a high burden of disease. It is therefore important for the clinician to be vigilant of this clinical feature. We still need more information on the response of the peripheral arthritis to treatment.
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