Nonradiographic Axial Spondyloarthritis

Clinical and Therapeutic Relevance

Nilasha Ghosh; Eric M. Ruderman

Arthritis Res Ther. 2017;19(286)

Conclusion

The classification of spondyloarthritis remains an evolving topic. While there is general agreement on the current ASAS classification of axSpA, there is remaining uncertainty on whether clinical differences among patients meeting these criteria may have relevance for prognosis, disease progression, and response to therapy. Nonradiographic axSpA has emerged as one subclassification, though it appears to be part of the spectrum of axSpA rather than an entity in itself. As such, it currently seems to have more relevance as a regulatory construct than a disease definition. Other aspects of disease, such as gender, duration, and inflammatory burden, some of which may differ in those patients with nr-axSpA, appear to be more relevant to clinical course and treatment response. As these other demographic elements are better understood, particularly with respect to their impact on therapy, the concept of nr-axSpA will almost certainly become less important.

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Abbreviations
AS: Ankylosing spondylitis; ASAS: Assessment of SpondyloArthritis International Society; ASDAS: Ankylosing Spondylitis Disease Activity Score; axSpA: Axial spondyloarthritis; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; BASFI: Bath Ankylosing Spondylitis Functional Index; CRP: C-reactive protein; DESIR: Devenir des Spondylarthropathies Indifférenciées Récentes; DMARD: Disease-modifying antireheumatic drug; ESSG: European Spondyloarthropathy Study Group; GESPIC: German Spondyloarthritis Inception Cohort; HLA: Human leukocyte antigen; HRQOL: Health-related quality of life; hsCRP: High-sensitivity C-reactive protein; IL: Interleukin; mNY: Modified New York; MRI: Magnetic resonance imaging; NHANES: National Health and Nutrition Examination Survey; nr-axSpA: Nonradiographic axial spondyloarthritis; NSAID: Nonsteroidal anti-inflammatory drug; r-axSpA: Radiographic axial spondyloarthritis; SpA: Spondyloarthritis; TNF: Tumor necrosis factor

Acknowledgments
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Table 1. Items in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), scored on a numerical rating scale [17]
How would you describe the overall level of fatigue/tiredness you have experienced?
How would you describe the overall level of ankylosing spondylitis neck, back or hip pain you have had?
How would you describe the overall level of pain/swelling in joints other than neck, back or hips you have had?
How would you describe the overall level of discomfort you have had from any areas tender to touch or pressure?
How would you describe the overall level of morning stiffness you have had from the time you wake up?
How long does your morning stiffness last from the time you wake up?

Table 2. Items in the Bath Ankylosing Spondylitis Functional Index (BASFI), scored on a numerical rating scale [18]
Putting on your socks or tights without help or aids (e.g., sock aid).
Bending forward from the waist to pick up a pen from the floor without an aid.
Reaching up to a high shelf without help or aids (e.g., helping hand).
Getting up out of an armless dining room chair without using your hands or any other help
Getting up off the floor without help from lying on your back.
Standing unsupported for 10 min without discomfort.
Climbing 12 to 15 steps without using a handrail or walking aid. One foot at each step.
Looking over your shoulder without turning your body.
Doing physically demanding activities (e.g., physiotherapy, exercises, gardening or sports).
Doing a full days activities, whether it be at home or at work.

Table 3. Phase 3 trials of tumor necrosis factor (TNF) inhibitors in nonradiographic spondyloarthritis and ankylosing spondylitis
Trial	TNF inhibitor	Dose	Primary endpoint	Comparator	Results
nr-axSpA Trials
ABILITY-1 [27]	Adalimumab	40 mg q 2 weeks	ASAS40 response at week 12	Placebo	ASAS20: 52% vs. 41% ASAS40: 36% vs. 15%
RAPID-axSpA (nr-axSpA subset) [19]	Certolizumab pegol	400 mg q 4 weeks	ASAS20 response at week 12	Placebo	ASAS20: 63% vs. 40% ASAS40: 47% vs. 16%
EMBARK [51]	Etanercept	50 mg q week	ASAS40 response at week 12	Placebo	ASAS20: 52% vs. 36% ASAS40: 33% vs. 15%
GO-AHEAD [26]	Golimumab	50 mg q 4 weeks	ASAS20 response at week 16	Placebo	ASAS20: 72% vs. 40% ASAS40: 57% vs. 23%
AS Trials
ATLAS [56]	Adalimumab	40 mg q 2 weeks	ASAS20 response at week 12	Placebo	ASAS20: 58% vs. 21% ASAS40: 40% vs. 13%
RAPID-axSpA (AS subset) [19]	Certolizumab pegol	400 mg q 4 weeks	ASAS20 response at week 12	Placebo	ASAS20: 64% vs. 37% ASAS40: 50% vs. 19%
Etanercept phase III [57]	Etanercept	50 mg q week	ASAS20 response at week 12	Placebo	ASAS20: 59% vs. 28% ASAS50: 44% vs. 16%
GO-RAISE [53]	Golimumab	50 mg q 4 weeks	ASAS20 response at week 14	Placebo	ASAS20: 59% vs. 22% ASAS40: 44% vs. 15%

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Nonradiographic Axial Spondyloarthritis

Clinical and Therapeutic Relevance

Conclusion

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