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In the field of rheumatology, the first disease that successfully applied the standard treatment strategy was rheumatoid arthritis 1. In 2017, an international working group composed of scholars such as Smolen published the "Security Treatment of Central Axial and Peripheral Spine Arthritis (especially Psoriatic Arthritis)" to support the application of standard treatment strategies in patients with central Axial Spine Arthritis (axSpA). However, there are still many challenges in actual promotion and implementation.
At this 2022 ACR annual meeting, Professor Alexis Ogdie from the Center for Clinical Epidemiology and Biostatistics of the University of Pennsylvania shared the standard treatment of axSpA 2 under the title "Axial Spondyloarthritis: Treat to Target".
What is the standard treatment for axSpA?
Meeting the standard treatment starts with setting treatment goals, to objectively monitoring the disease, adjusting treatment to achieve treatment goals, tracking changes in the condition, and then setting treatment goals, it is a cyclical clinical process. The primary goal of treatment is clinical remission, and the alternative goal is low disease activity (LDA). Ankylosing spondylitis disease activity score (ASDAS) is a commonly used tool to evaluate the disease activity of patients with axSpA. It mainly evaluates five aspects: low back pain , overall patient evaluation, peripheral symptoms, morning stiffness, and C-reactive protein (CRP). ASDAS <1.3>
Regarding the standard treatment of axSpA, it was not until recently that there was evidence that ASDAS may be an indicator of axSpA treatment. However, the TICOSPA trial comparing the efficacy of strict control/compliance treatment in patients with axSpA ( reaches ASDAS2.1) with conventional treatment showed that in terms of the main endpoints of improvement of ≥30% in the International Association for Spine Arthritis-Health Index (ASAS-HI), following strict control/compliance treatment was not significantly better than conventional treatment, and only showed significant differences in some secondary endpoints such as ASDAS. The 2022 ASAS/EULAR working group stated that the actual effectiveness of compliance treatment in axSpA is still uncertain.
Professor Alexis Ogdie gave a case for further introduction. A 36-year-old male patient has repeated back pain for several years. His condition has worsened in the past few months and has affected his daily life. After taking ibuprofen on his own, the pain has been relieved, but it still recurs, and there are also symptoms such as morning stiffness and heel pain . The patient's ASDAS-CRP score was 3.1 points, which was in high disease activity. After active treatment, the symptoms were relieved, and the ASDAS-CRP dropped to 2.2 points, but it still did not reach clinical remission. Why did the patient still fail to meet the standards after treatment? Professor
pointed out that the patient also suffered from depression . Studies have shown that depression can affect the treatment response (Figure 1), and other comorbidities, such as hypertension, , obesity, etc., will also affect the treatment effect. Therefore, if only ASDAS is considered as a treatment indicator, there may be an overtreatment of .
Figure 1 Depression affects treatment response
The "AsAS-EULAR Axial Spinal Arthritis Management Recommendations" updated in 2022 pointed out that treatment should be guided by predetermined treatment goals, and emphasized that the strengthening of immunosuppressive treatment is only recommended if the doctor and the patient confirm that the presence of residual inflammation and other factors (other situations of the patient) does not affect intensive treatment. It can be seen that there is still a shortage of using ASDAS as an indicator for meeting the standard treatment. should also consider more factors that affect the condition, such as patient comorbidities . What indicators should be selected as the endpoint of axSpA clinical trial or the target of meeting the standard treatment?
Alexis Ogdie proposed that some patients have progressed slowly in imaging and there are differences in interpretation of imaging examination results, which may not be suitable as a clinical endpoint/treatment indicator for axSpA, and quality of life (QoL) may be a good indicator. This includes the patient's work ability, daily life functions, social ability, comorbidities, sleep, fatigue, emotions, pain and other aspects.
Currently, the main means of axSpA treatment include non-surgical treatment and surgical treatment (Table 1) 3.However, axSpA is characterized by intermittent, chronic progressiveness and complexity. The patient's physical function and quality of life require long-term, regular and multi-dimensional assessment and management of (psychological intervention, fatigue, sleep, social environment, etc.). Therefore, paying attention to the overall condition of the patient may be more important for improving the condition. The professor proposed that in the treatment of standards, physical exercise, healthy diet, smoking cessation, sleep management, comorbidity management and other contents should be included, and a comprehensive and systematic patient management plan for should be formulated.
Table 1 The main methods of axSpA treatment
Alexis Professor Ogdie concluded that at this stage, does not have sufficient evidence for to support the application of standard treatment in patients with axSpA. In addition to ASDAS, other factors that affect the condition should also be evaluated, such as the patient's mental health, social function, etc. When formulating treatment plans, they should be based on the common decisions of the patient and the doctor.
References:
1. Deng Xuerong, Zhang Zhuoli. Accomplishment treatment of central axial and peripheral spondylitis (especially psoriatic arthritis): Recommended by the International Working Group Updated in 2017 [J]. Chinese Journal of Rheumatology, 2017, 21(10):717-718.
2. Alexis Ogdie. ACR convergence 2022. oral presentation at 14th Nov.
3. Xu Weidong. Expert consensus on the diagnosis and treatment of central axial spondylitis (2019 edition) [J]. Chinese Journal of Arthritis Surgery (electronic version), 2019, 13(03):261-266.
4. Rheumatism and Molecular Immunity Branch of the National Health Industry Enterprise Management Association. Chinese Expert Consensus on Comprehensive Evaluation of Physical Function and Healthy Quality of Life in Central Axial Spinal Arthritis [J]. Chinese Journal of Medicine, 2022, 102(35):2755-2762.
