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CME Rheumatology 26: Bone Marrow Edema of the Sacro-Iliac Joint = Spondyloarthritis? What the General Practicioner Should Know

Low back pain is the leading symptom of a family of inflammatory rheumatic diseases grouped under the umbrella term "spondyloarthritides". This paper discusses the main clinical, laboratory, and imaging features of spondyloarthritides in the diagnostic context of low back pain. It also highlights the current therapeutic principles of axial spondyloarthritis.

This review article presents the innovations in the update of the S3 guidelines on axial spondylarthritis. The total of eight new recommendations address the areas of the consideration of differential diagnoses, coordination of comorbidity management, including a vaccination strategy, treatment targets, safety of nonsteroidal anti-inflammatory drugs (NSAID), treatment response to biological disease-modifying antirheumatic drugs (bDMARD) and discontinuation strategies when remission has been achieved. In this article the authors deal particularly with the areas of early diagnosis and referral as well as exercise therapy and drug treatment.Die vorliegende Übersicht stellt die Neuerungen des Updates der S3-Leitlinie zur axialen Spondyloarthritis vor. Die insgesamt 8 neuen Empfehlungen adressieren die Bereiche der Beachtung von Differenzialdiagnosen, Koordination des Komorbiditätenmanagements einschließlich einer Impfstrategie, Therapieziele, der NSAR(nichtsteroidale Antirheumatika)-Sicherheit, Therapieansprechen von b(„biological“)DMARD („disease-modifying antirheumatic drugs“) und Absetzstrategien bei Erreichen einer Remission. Die Autoren gehen in dem Beitrag insbesondere auf die Bereiche Frühdiagnose und Überweisung sowie Bewegungstherapie und medikamentöse Therapie ein.

Axial spondylarthritis in adulthood (SpAA) is frequently initially manifested as a sacroiliitis, whereas this not true for enthesitis-related arthritis (EAA), which begins in childhood and adolescence. Classically, EAA begins with peripheral arthritis and only a part transitions into a juvenile SpA (jSpA) or SpAA. The criteria used for classification of SpAA and EAA are currently being validated and revised. For the first time imaging is included for EAA. For both diseases nonsteroidal anti-inflammatory drugs (NSAID) are initially used therapeutically, followed by biologicals or synthetic targeted disease-modifying drugs in refractory courses. Steroids should be avoided in long-term treatment. For optimal transition and further care in adulthood, a close cooperation between internistic and pediatric rheumatologists is necessary.Während sich die axiale Spondyloarthritis im Erwachsenenalter (SpAE) initial häufig mit einer Sakroiliitis manifestiert gilt dies nicht für die Enthesitis-assoziierte Arthritis (EAA) mit Beginn im Kindes-und Jugendalter. Klassischerweise beginnt die EAA mit peripherer Arthritis, und nur ein Teil geht in eine jSpA (juvenile Spondyloarthritis)/SpAE über. Die zur Klassifikation der SpAE und der EAA verwendeten Kriterien werden aktuell validiert bzw. neu überarbeitet. Dabei ist für die EAA erstmals auch die Bildgebung inkludiert. Therapeutisch werden bei beiden Erkrankungen initial NSAR (nichtsteroidale Antirheumatika) eingesetzt, gefolgt von Biologika bzw. synthetischen zielgerichteten krankheitsmodifizierenden Medikamenten bei refraktären Verläufen. Steroide sollten in der Langzeitbehandlung vermieden werden. Zur optimalen Transition und Weiterbetreuung im Erwachsenenalter ist eine enge Kooperation zwischen internistischen und pädiatrischen Rheumatologen notwendig.

This article presents how, based on the availability of new imaging methods and medications, objectives regarding the rheumatic disease axial spondyloarthritis (axSpA) have developed over the course of more than two decades into a rheumatologic research group. During recent years, cooperation with the Study of Health in Pomerania (SHIP) cohort has given rise to new fundamental aspects. This involved intensive cooperation between the Ruhr University Bochum (Rheumazentrum Ruhrgebiet) and the Greifswald University Hospital (Community Medicine research collective). The design of the SHIP cohort was published 10 years ago and the cohort approach presented in the Bundesgesundheitsblatt, which also described central methodologic questions in detail. In 2014, a cooperation project between the Ruhr Rheumatology Center/Ruhr University Bochum and the SHIP Department of Clinical and Epidemiologic Research (Klinisch-Epidemiologische Forschung, KEF; SHIP-KEF) was established, which has already resulted in publication of interesting results in high-ranking journals. In order to stress the potential of such corporations, important contents thereof are presented herein, with a focus on MRI and consideration of historical aspects.In diesem Artikel wird dargestellt, wie sich Fragestellungen hinsichtlich der rheumatischen Erkrankung axiale Spondyloarthritis (axSpA) in Zusammenhang mit der Verfügbarkeit neuer bildgebender Verfahren und neuer Medikamente über mehr als zwei Jahrzehnte in einer rheumatologischen Forschungsgruppe entwickelt haben. Insbesondere in den letzten Jahren ergaben sich durch die Kooperation mit der SHIP („Study of Health in Pomerania“)-Kohorte neue grundlegende Aspekte. Dabei bestand eine intensive Kooperation zwischen der Ruhr-Universität Bochum (Rheumazentrum Ruhrgebiet) und der Universitätsmedizin Greifswald (Forschungsverbund „Community Medicine“). Das Design der SHIP-Kohorte ist schon vor 10 Jahren veröffentlicht worden und der Kohortenansatz wurde im Bundesgesundheitsblatt dargestellt, wobei zentrale methodische Fragen ausführlich erörtert wurden. Im Jahr 2014 wurde ein Kooperationsprojekt des Rheumazentrums Ruhrgebiet/Ruhr-Universität Bochum mit der Abteilung Klinisch-Epidemiologische Forschung (KEF) von SHIP vereinbart, aus dem bereits interessante Ergebnisse hochrangig publiziert wurden. Um das Potenzial solcher Kooperationen zu betonen, werden wesentliche Inhalte mit Fokus auf die Magnetresonanztomographie (MRT) im Folgenden, auch unter historischen Aspekten, dargestellt.

Quality standards (QS) are measurable constructs designed to quantify gaps in care and subsequently to improve quality of care. The Assessment of SpondyloArthritis International Society (ASAS) recently generated and published international QS for the management of patients with axial spondyloarthritis (axSpA) for the first time. The German Society of Rheumatology (DGRh) then decided to translate, review and possibly adopt these standards by a group of experts from different care settings. Against this background, national QS for the management of patients with axSpA for Germany were developed for the first time. The main focus was on feasibility and practical relevance. Ultimately, nine QS were defined with which the quality of care in Germany can and should be measured and improved.Qualitätsstandards (QS) sind messbare Konstrukte, die helfen sollen, Versorgungslücken quantitativ zu erfassen, um langfristig die Versorgungsqualität zu verbessern. Die Assessment of SpondyloArthritis International Society (ASAS) hat kürzlich erstmals internationale QS für das Management von Patient*innen mit axialer Spondyloarthritis (axSpA) konsentiert und veröffentlicht. Die Deutsche Gesellschaft für Rheumatologie (DGRh) hat daraufhin beschlossen, diese Standards durch eine Gruppe von Expert*innen aus unterschiedlichen Versorgungsbereichen zu übersetzen, zu prüfen und ggf. zu übernehmen. Vor diesem Hintergrund wurden erstmals nationale QS für das Management von Patient*innen mit axSpA für Deutschland entwickelt. Hierbei wurde v. a. auf Machbarkeit und Praxisrelevanz geachtet. Letztlich wurden 9 QS definiert, mit denen die Qualität der Versorgung in Deutschland gemessen und verbessert werden kann bzw. soll.

Spondylarthritis (SpA) is one of the most frequent extraintestinal manifestations of chronic inflammatory bowel disease (IBD). Several arthritogenic enterobacterial infections can induce sequelae such as reactive SpA. Studies on the gut-synovium axis in view of genetic, immunological, clinical and therapeutic aspects has made enterogenic SpA a model disease of all forms of SpA. The same applies for investigating IBD, as subclinical gut inflammation seen in SpA patients has provided significant evidence for a better understanding of mucosa-associated early immune events in Crohn's disease (CD). This article summarizes the pathognomonic clinical features, diagnostic steps, differential diagnosis and current pathogenetic models of enterogenic SpA. Knowledge of pathogenetic contexts leads to concrete treatment recommendations. These vary individually depending on the underlying IBD, on the inflammatory intestinal or rheumatic activity and on the rheumatological manifestation pattern.Spondyloarthritiden (SpA) gehören zu den häufigsten extraintestinalen Manifestationen der chronisch entzündlichen Darmerkrankungen (CED). Auch bestimmte arthritogene Enterobakterien können als Folgeerkrankung der Gastroenteritis eine reaktive enteropathische SpA auslösen. Die Erforschung der „Darm-Synovium-Achse“ unter genetischen, immunologischen, klinischen und therapeutischen Gesichtspunkten hat die enteropathische SpA zu einer Modellerkrankung der SpAs gemacht. Ähnliches gilt für die Erforschung der CED, da die subklinischen Darmentzündungen bei Patienten mit SpA dazu beigetragen haben, die Mukosa-assoziierten frühen Immunphänomene des Morbus Crohn (CD) besser zu verstehen. Dieser Beitrag stellt neben den pathognomonischen klinischen Bildern, der Diagnostik und Differenzialdiagnostik die aktuellen pathogenetischen Modelle der enteropathischen SpAs vor. Aus dem Wissen um pathogenetische Zusammenhänge ergeben sich konkrete Empfehlungen zur Therapie, wobei individuell nach der zugrunde liegenden Darmerkrankung, nach der entzündlichen intestinalen oder rheumatischen Aktivität und nach dem rheumatologischen Befallsmuster unterschieden wird.

Physical therapy has always been a pillar of the treatment of inflammatory rheumatic diseases in addition to targeted drug treatment; nevertheless, it is only established in the treatment guidelines for a few diseases. Within the last two decades the discovery of myokines has uncovered the physiological correlations of the anti-inflammatory effect of physical activity. For rheumatoid arthritis and spondylarthritis, several randomized controlled trials provide sufficient evidence to make well-founded recommendations. For connective tissue diseases (CTD) the data situation is clearly sparser but nevertheless shows that the positive effects of physical activity prevail. In the following article the authors present the most important clinical studies on sport and inflammatory rheumatic diseases and from these derive possible therapeutic recommendations.Die physikalische Therapie stellt neben einer gezielten medikamentösen Therapie seit jeher eine Säule der Behandlung entzündlich rheumatischer Erkrankungen dar, ist aber bisher nur bei wenigen Erkrankungen in den Behandlungsleitlinien etabliert. Innerhalb der letzten 2 Jahrzehnte konnten durch die Entdeckung der Myokine die physiologischen Zusammenhänge von antiinflammatorischer Wirkung und sportlicher Betätigung aufgedeckt werden. Für die rheumatoide Arthritis und die Spondyloarthritiden liefern mehrere randomisiert kontrollierte Studien eine ausreichende Evidenz, um fundierte Empfehlungen geben zu können. Für die Kollagenosen ist die Datenlage deutlich spärlicher, zeigt aber dennoch, dass die positiven Effekte durch Bewegungstherapie überwiegen. In dem folgenden Beitrag stellen die Autoren die wichtigsten Studien zum Thema Sport bei entzündlich rheumatischen Erkrankungen vor und leiten daraus mögliche therapeutische Empfehlungen ab.

New data for the diagnosis of axial spondyloarthritis on the specificity of active inflammatory changes in sacroiliac joints were generated recently and are reviewed here. A new magnetic resonance imaging sequence to improve the detection of erosions is discussed. Tumor necrosis factor (TNF) and Interleukin-17 (IL-17) inhibitors are now approved as therapy for both radiographic and non-radiographic forms of axial spondyloarthritis. Janus kinase inhibitors delivered promising results in Phase II/III studies. For the inhibition of structural progression new data are discussed on slowing structural progression in the spine under TNF and IL-17 inhibitors.Neue Daten zur Spezifität der aktiven entzündlichen Veränderungen in den Sakroiliakalgelenken wurden generiert. Eine neue MRT-Sequenz für die Verbesserung der Detektion von Erosionen wurde untersucht.TNF und Interleukin-17 (IL-17)-Blocker sind nun für sowohl röntgenologische als auch nichtröntgenologische Formen der axialen Spondyloarthritis zugelassen. Januskinase-Inhibitoren lieferten vielversprechende Ergebnisse in den Phase-II/III-Studien.Neue Daten zur Verlangsamung der strukturellen Progression in der Wirbelsäule unter TNF- und IL-17-Inhibitoren.

CME Sonography 93/Answers: Ultrasound of the Enthesis - Not Every Enthesitis Signals a Spondyloarthritis

To summarize, the currently available imaging procedures have various possibilities to visualize or sometimes to predict the osteogenesis pathognomonic for axial spondylarthritis (axSpA). The individual imaging techniques of X‑rays, computed tomography (CT) and magnetic resonance imaging (MRI) all have strengths and weaknesses in the diagnostics of axSpA. The generally easily available X‑ray imaging rapidly provides information on the condition of large sections of the skeleton. In particular, it can depict the chronic stages with various structural alterations of the sacroiliac joint and syndesmophytes and ankylosis of the spine. The CT technique, which principally has the same contrast as X‑rays, also shows pathological ossifications but without superimpositions, with better resolution of details and a higher dimensionality. The MRI technique has a superior soft tissue contrast so that acute inflammatory stages, such as bone marrow edema and erosion of the edges of vertebrae of the spine (shiny corners, Romanus lesions) or erosions and bone marrow edema of the sacroiliac joint are easily visible. Bony reconstruction processes can be visualized better in X‑ray imaging and particularly in CT, which increases the evidential value of X‑ray, CT and MRI techniques. The positions of conventional radiography and MRI are well-established in the diagnostic algorithm; however, low-dose CT of the spine is still in the experimental stage but the initial results look promising.

In two research projects, rheumatological patient education programmes were updated. The first step was to develop an expert consented framework for all rheumatological patient education programmes. From this, curricula and working materials for rheumatoid arthritis (RA) and axial spondyloarthritis (AS) were derived and two exemplary patient education manuals developed. A randomized controlled trail was designed for the five-hour RA basic education program. Finally, existing train-the-trainer training courses were adapted for these patient education programmes.

From Axial Spondyloarthritis to Osteoporosis - Spectrum of Skeletal Involvement in Inflammatory Bowel Diseases

Drug treatment in patients with axial spondylarthritis (axSpA) aims to modify symptoms and complaints and currently includes the substance groups of nonsteroidal anti-inflammatory drugs (NSAID) and biologicals (disease-modifying antirheumatic drugs, bDMARDS). Treatment with NSAIDs is the first line treatment according to international and national recommendations. Patients with persisting high disease activity despite continuous standard treatment with NSAIDs, should be treated with biologicals. In Germany treatment with tumor necosis factor (TNF) inhibitors or interleukin 17 inhibitor (secukinumab) are currently approved for treating patients with ankylosing spondylitis (AS). Treatment of patients with non-radiographic axSpA (nr-axSpA) is restricted to TNF inhibitors (except infliximab) in Germany. The efficacy and safety are documented for both substance groups; however, due to the longer time since approval longitudinal data for TNF inhibitors are more robust and the data contain information about switching within a substance group. Although overall retention rates of TNF inhibitors are similar despite the difference in formation of antidrug antibodies, data from cohorts provide information about long-term loss of efficacy, switching and also discontinuation strategies. In the meantime, various biosimilars have been approved for infliximab, etanercept and adalimumab. Conventional basic treatment (csDMARDs) and in particular intra-articular administration of glucocorticoids can only be prescribed for axSpA patients with peripheral arthritis.

Although the pathogenesis of spondylarthritis (SpA) has been the subject of intensive research in recent years, the consequences for treatment are relatively minor. Basic research studies indicated a potentially important role of the cytokines tumor necrosis factor (TNF) alpha and interleukin (IL)-17 for the pathogenesis of SpA but their outstanding role could then only be demonstrated by their inhibition in clinical studies, while other promising targets, such as IL‑23 and IL‑6 could not be shown to be relevant (at least against axial manifestations) in clinical studies. The intestinal microbiota probably plays an important role in the pathogenesis but not yet for the treatment of SpA. Ultimately, early effective and long-term suppression of inflammation is currently the best method to prevent ankylosis in the long run.

Axial spondylarthritis (axSpA) is a chronic inflammatory disease of the spine that can be associated with loss of physical function, mobility and upright postural impairment. Established tools for the assessment of function that are largely based on subjective perception are semiquantitatively recorded by standardized questionnaires (Bath ankylosing spondylitis functional index, BASFI), while measurement of spinal mobility of patients with axSpA is based on physical examination of various movement regions particularly the axial skeleton (Bath ankylosing spondylitis metrology index, BASMI). Recently, a performance test has been added to assess the range of motion and speed of certain tasks (AS performance-based improved test, ASPI); however, since these tests have limited reliability and reproducibility, more objective tests would be desirable. In this study the spinal mobility of patients with axSpA was quantified using the Epionics SPINE device (ES) and data were evaluated using the outcome measures in rheumatology (OMERACT) criteria. The ES automatically measures various patterns of spinal movements using electronic sensors, which also assess the range and speed of carrying out movements. Patients with back pain from other causes and persons without back pain served as controls. The measurement results obtained with ES differed between the groups and correlated with BASMI values (r = 0.53-0.82, all p = 0.03). Patients with radiographically detectable axSpA had more limited and slower mobility than those with non-radiographically detectable axSpA. Overall, the results presented here suggest that ES measurements represent a valid and objective measurement procedure of spinal mobility for axSpA patients.Die axiale Spondyloarthritis (axSpA) ist eine chronisch entzündliche Erkrankung der Wirbelsäule, die langfristig mit einem Verlust körperlicher Funktionen, der Beweglichkeit und der aufrechten Haltung einhergehen kann. Bisher gängige Methoden zur Messung der Beweglichkeit basieren zum einen auf subjektiver Patientenwahrnehmung, wobei verschiedene Funktionen durch standardisierte Fragebögen (BASFI) semiquantitativ erfasst werden, und zum anderen werden im Rahmen einer körperlichen Untersuchung verschiedene Bewegungsbereiche v. a. des Achsenskeletts vermessen (BASMI). Vor Kurzem kam der erste Test hinzu, mit dem die Durchführung und Geschwindigkeit bestimmter Aufgaben erfasst werden kann (ASPI). Da diese Tests nur begrenzt verlässlich und reproduzierbar sind, wäre ein objektiverer Test wünschenswert. In der hier berichteten Studie wurde die Mobilität der Wirbelsäule (WS) von Patienten mit axSpA mit dem Epionics SPINE-Gerät (ES) quantitativ untersucht und anhand der OMERACT(outcome measures in rheumatology)-Kriterien evaluiert. Das Gerät misst verschiedene Bewegungsmuster der Wirbelsäule anhand elektronischer Sensoren automatisiert, das schließt die Geschwindigkeit der Bewegungsdurchführung ein. Als Kontrollen dienten Patienten mit Rückenschmerzen anderer Genese und Menschen ohne Rückenschmerzen. Die mit ES erhobenen Messungen unterschieden sich zwischen den Gruppen und korrelierten mit den BASMI-Werten (r =0,53–0,82, alle p = 0,03). Röntgenologische axSpA-Patienten hatten zudem eine eingeschränktere und langsamere Beweglichkeit als die mit nr-axSpA. Insgesamt sprechen die Ergebnisse dieser Arbeit dafür, dass Messungen mit dem ES ein valides und objektives Messverfahren der Wirbelsäulenbeweglichkeit für axSpA-Patienten darstellen.

Early detection of patients with axial spondylarthritis (axSpA) in primary care is difficult. The combination of various parameters indicative of inflammatory back pain (AWARE criteria) was found to be beneficial in an initial study.Review of the criteria for the identification of young patients with axSpA and chronic back pain (≥3 months of back pain).In adult patients with chronic back pain and age at onset of symptoms45 years, orthopedic surgeons documented various possible axSpA characteristics before referral to the rheumatologist.Overall, the data from 1306 patients were recorded. Of these, ultimately 500 patients were also seen by rheumatologists, 199 patients (39.8%) were diagnosed with axSpA while 301 (60.2%) had non-specific back pain. A total of 87 patients had ankylosing spondylitis (44%) and 112 non-radiographic axSpA (56%). The ASAS classification criteria were fulfilled by 226 patients (45.2%). The mean age of axSpA patients was 38 years, 56% were male with a mean duration of back pain of 98 months. The AWARE criteria had a sensitivity and specificity of 69.3% and 40.3% (n = 343), respectively, when ≥4/5 criteria were chosen. Positive imaging for sacroiliitis using magnetic resonance imaging (MRI) or X‑ray was present in 77% of patients and positive HLA-B27 was identified in 59% of axSpA patients. The combination of positive imaging and HLA-B27 had the highest likelihood ratio for diagnosis of axSpA.Although the study design used here led to a preselection and thus to a bias in the statistical evaluation, the study confirmed the benefit of the AWARE criteria for the early detection of patients with axSpA. In further studies, the 2‑stage approach with initially 3 clinical questions and then an optional HLA-B27 test is currently being investigated further.

Tumour necrosis factor-alpha inhibitors (TNFi) are an effective but expensive treatment option in axial spondylarthritis (axSpA) patients who fail to achieve disease control under conventional treatment.The aim of this study was to assess the cost of illness in axSpA patients treated with and without TNFi.Using German health insurance data, patients with axSpA who newly received TNFi between 2011 and 2015 were identified and matched by age and sex to a reference group of patients with axSpA without TNFi treatment. Costs for services performed in an outpatient setting, inpatient care, pharmacotherapy and for productivity loss due to absence from paid work were analyzed over a 2-year period. In patients treated with TNFi , the 2‑year period included 1 year before and 1 year after the initiation of TNFi.Data from 1455 axSpA patients who received TNFi treatment were included in the analyses. Costs for services performed in an outpatient setting, inpatient care, pharmacotherapy (excluding TNFi) as well as productivity loss significantly decreased after initiation of TNFi. Mean total costs increased from € 6075 in the year prior to TNFi initiation to € 27,871 in the year after TNFi initiation. Excluding costs for TNFi, total costs decreased by 22% to € 4761. Mean total costs among the reference group of 1455 age and sex-matched axSpA patients who did not receive TNFi remained stable over 2 years: € 3939 in the first year vs. € 3832 in the second year.Initiation of TNFi treatment led to a sharp increase in the total costs of axSpA patients. Part of this increase was offset by a decrease of costs for services performed in an outpatient setting, inpatient care, pharmacotherapy (excluding TNFi) as well as productivity loss. In patients who did not receive TNFi, the costs remained stable over 2 years.

In Germany, the numbers of patients with spondylarthritides (SpA) and rheumatoid arthritis (RA) have increased. This rise was possibly promoted by the introduction of new classification criteria (CC) that enable an earlier recognition and the inclusion of less severe cases. The study explores how the new CC for axial SpA (axSpA) are incorporated into the clinical practice, compared with the CC for RA and systemic lupus erythematosus (SLE). In addition, the study investigated whether the new entity of non-radiographic axSpA (nr-axSpA) is accepted and used in Germany.In 2016, an online survey was performed among all rheumatologists registered in the German Society of Rheumatology (DGRh). In addition, 150 rheumatologists were invited to the survey at the national meeting of the DGRh in 2016.Among 119 participating rheumatologists, 99% were familiar with the new CC for SpA and 82% applied them in practice (RA 99% and 80%, SLE 50% and 56%). 78% differentiated between radiographic and nr-axSpA and 80% believed that a significant proportion of patients with nr-axSpA will never develop radiographic changes. 91% agreed that the new CC facilitated an earlier treatment start and 58% that the CC enabled more patients to receive biologicals. 50% shared the opinion that the criterion "chronic back pain" could lead to the classification of too many patients as having axSpA. It deemed possible to 65% that patients with nr-axSpA would be treated with biologicals in whom the diagnosis of axSpA could not be confirmed later on. 81% voted against the initiation of TNF inhibitors in nr-axSpA patients with normal CRP levels and normal MRI. 67% interpreted the MRI themselves and 30% stated that the MRI is evaluated according to validated standards by the radiologists. Among all axSpA criteria, HLA B27 and inflammatory back pain received the highest significance and the response to NSAID the lowest.The new CC and the entity of nr-axSpA are accepted by German rheumatologists. A relevant proportion saw weaknesses of the new CC in the differentiation between nr-axSpA and non-specific chronic back pain. In practise, the interpretation of the CC with respect to the start of biologics is relatively strict, especially in cases with normal CRP and MRI. A ranking of axSpA criteria is commonly applied, although this was not initially intended in the CC.

The objective of the research consortium PROCLAIR was to gain population level knowledge on the treatment of patients with rheumatoid arthritis (RA), axial spondylarthritis (axSpA) and osteoarthritis (OA) in Germany.A main question of the consortium was whether it is possible to identify groups of people who were exposed to a particular risk of undersupply or oversupply of treatment. In addition, the study investigated the validity of claims data for these diseases as a basis for further studies.Cross-sectional surveys were carried out among insurees of the BARMER statutory health insurance fund whose claims data included RA, axSpA and OA diagnoses. The questionnaire data were linked with the claims data of the insured persons if they agreed.In all three diseases risk groups for care deficits could be identified. Persons with RA who are not treated by a specialist have less access to drug treatment. Physical therapy is prescribed for all three diagnoses at a low level, even for people undergoing joint replacement surgery. A connection between depressive symptoms and disease activity or function in axSpA was shown. In addition to the results relevant to care, the PROCLAIR network has also made contributions to critically assess the quality of health insurance data.The combination of billing data with survey data enables a comprehensive description of the treatment of musculoskeletal diseases. Particularly relevant factors are the specialization of the physician, sociodemographic parameters of the patients and the region of residence. In particular, access to treatment cannot be investigated in randomized clinical trials.

The prevalence of spondyloarthritis (SpA) in Germany is approximately 1-1.4% and includes predominantly axial SpA (axSpA) and predominantly peripheral SpA. Ankylosing spondylitis (AS) belongs to the group of axial SpA but also exhibits peripheral manifestations. Psoriatic arthritis (PsA) can show purely peripheral or also axial manifestations. The total prevalence of SpA in Germany is approximately 1‑1.4%, the prevalence of AS is ca. 0.5% and PsA 0.2-1.4%. Patients with AS are mainly treated by internal medical rheumatologists but in many places also basically treated by general practitioners and orthopedists. Patients with PsA are mainly diagnosed and treated by rheumatologists and dermatologists working in private practice or in clinical settings. Besides the control of inflammatory activity and prevention or slowing down of the characteristic disease progression, including irreversible structural changes, the main objectives of patients as well as treating physicians are particularly freedom from pain and a quality of life comparable to non-affected persons. Decisive for successful treatment are an early diagnosis and initiation of adequate therapy as well as regular monitoring of disease activity including treatment adjustment taking the needs of the patient into consideration; however, it is unknown how often this is actually successful in routine daily practice in Germany.The aim of the SpA Loop research project was to display the current medical care situation of patients with AS and PsA treated in private practices and hospitals for rheumatology in Germany focusing on patient/physician profiles as well as the diagnostics and treatment.The instrument for the survey was a standardized questionnaire with 29 multiple choice and perception questions that was distributed to medical specialists in the field of internal medicine and rheumatology.A high accordance between rheumatologists in private practice and in hospitals was observed with respect to the presentation and perception of the current medical care situation for patients with AS and PsA in Germany. Differences were only occasionally found.The results of this research project reflect the current status of the medical care situation of AS and PsA patients in Germany. They provide information on which areas of the medical care situation can selectively be improved as well as on interesting aspects and points of discussion with respect to the patient population treated.