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Introduction: Sacroiliac bone marrow edema is an important factor in the diagnosis and management of axial spondyloarthritis (axSpA). The aim of this meta-analysis is to assess the effect of the different bDMARDs and tsDMARDs on the SPARCC score at 12-16 and 48-52 weeks., Methods: A systematic review, performed on PubMed (including Medline), Cochrane (CENTRAL) and DOAJ databases, included randomized controlled studies evaluating the sacroiliac joint (SIJ) SPARCC score at 12-16 or 48-52 weeks in patients with axSpA meeting the ASAS 2009 criteria or the modified New York criteria. We included studies evaluating the effects of the different treatments on the SPARCC score of SIJ in axial spondyloarthritis in comparison to a control group., Results: Eighteen studies were included in the meta-analysis. Nine studies evaluated the effect of TNFα inhibitors (TNFi), three for IL-17 inhibitors, and four for JAK inhibitors. At 12 and 16 weeks, SIJ SPARCC score was significantly improved by TNFi (WMD: - 3.29 [95% CI - 4.25; - 2, 34]), by IL-17 inhibitors (WMD: - 4.66 [95% CI - 6.22; - 3.09]), and by JAK inhibitors (JAKi) (WMD: - 3.06 [95% CI - 3.24; - 2.89]). There was no difference between the molecule subgroups. At 48-52 weeks, TNFα inhibitors reduced more SIJ SPARCC, but not significantly (WMD: - 2.26 [95% CI - 4.94; 0.42]), than placebo groups who began a TNFi treatment with delay., Conclusion: Our meta-analysis shows a comparable improvement of the SIJ SPARCC score regarding TNFi, JAKi, and IL-17 inhibitors at three months and suggests the presence of an opportunity window. Key Points • Anti-TNF Ab, anti-IL17 Ab, and JAK inhibitor treatments reduce the sacroiliac joint SPARCC scores. • There is no difference between the different treatments in the reduction of the sacroiliac joint SPARCC score after 3 months in axial spondyloarthritis., (© 2023. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Objectives: To determine the cumulative incidence and identify the factors associated with difficult-to-treat axial spondyloarthritis (D2T-axSpA) in French patients newly benefiting from the French 'long-term illness' (LTI) social security scheme for axial spondyloarthritis (axSpA)., Methods: This national cohort study was based on the French National Medico-Administrative Database, SNDS, which contains data on hospitalisation, LTI and outpatient care consumption. All French patients newly receiving LTI benefits for ankylosing spondylitis (AS) between 2010 and 2013 were included in the study. In France, LTI is required to access biological/targeted synthetic DMARDs (b/tsDMARDs). The follow-up period ended on 31 December 2018. So-called D2T-axSpA was defined as the failure of three b/tsDMARDs or of two b/tsDMARDs with different modes of action. Comorbidities and extra-musculoskeletal manifestations were identified using previously described algorithms. Characteristics were compared between patients with D2T-axSpA and patients with non-D2T-axSpA who had received at least one b/tsDMARD with bivariate and multivariate analysis using logistic regression. Incidence rates of major cardiovascular event (MACE) and death were compared using competitive risk analysis., Results: 22 932 patients were included. 10 798 (47.08%) patients received at least one bDMARD. None received tsDMARD. During follow-up, 2115 patients were classified as having D2T-axSpA, representing 19.59% of patients who received at least one bDMARD. In multivariate analysis, D2T-axSpA was significantly associated with female gender, peripheral involvement, psoriasis, hypertension and depression (p<0.001 for each case). There was no difference in the incidence of MACE (p=0.92) or death (p=0.87)., Conclusion: D2T-axSpA affects one in five patients exposed to bDMARDs in this national cohort. D2T-axSpA is more common in women and patients with peripheral involvement and/or comorbidities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Diagnosis of axial spondyloarthritis (axSpA) is nowadays commonly made with the help of pelvic radiography or magnetic resonance imaging (MRI). However, there is an important inter-observer variability in radiography, and MRI is subject to possible false positives and is not the best modality for studying structural lesions. Conversely, pelvic computed tomography (CT) has excellent specificity and appears to be more effective than radiography for the diagnosis of ankylosing spondylitis (AS). However, its findings in patients over 50 years of age have not yet been studied. The objectives of this study were to describe the CT characteristics of sacro-iliac joints (SIJ) and the presence of intra-articular gas in patients with AS aged over 50 years and to compare them with controls of the same age and sex. This two-center, cross-sectional, observational study was performed using the medical records of the rheumatology departments of two University Hospitals. We included patients with a clinical diagnosis of axSpA, who had both definite radiographic sacroiliitis according to the modified New York criteria and met the ASAS 2009 criteria for axSpA (that is, AS), and who had undergone any CT scan including the whole SIJ. Each patient was matched for age and sex to a control randomly selected on the Picture Archiving and Communication System (PACS), symptomatic or asymptomatic, and without spondyloarthritis. For each individual, CT scans were interpreted blindly by two independent rheumatologists and scored for joint space narrowing (JSN), erosions, sclerosis, intra-articular gas, and diffuse idiopathic skeletal hyperostosis (DISH). Ninety patients and 90 controls were included in the study. The rates of positive JSN, erosion, and sclerosis scores were higher in the AS group (91% vs. 21%, p < 0.0001; 31% vs. 2%, p < 0.0001; 27% vs. 13%, p = 0.03, respectively), but the rates of intra-articular gas and DISH were higher in the control group (24% vs. 68%, p < 0.0001; 7% vs. 33%, p < 0.0001, respectively). 58% of patients had complete bilateral ankylosis. A total of 83 (92.2%) patients had a CT scan considered positive for AS, compared with only seven controls (7.8%). Sclerosis and erosions were predominantly on the anterosuperior part and iliac side of the joint in controls and were more diffuse in patients with AS. CT findings in patients with AS over 50 years of age are mostly represented by changes in the joint space; patients with AS have more erosions and sclerosis changes, but less intra-articular gas than controls., (© 2023. Springer Nature Limited.)

Objective: The objective was to determine sex differences in disease outcomes in recent axial spondyloarthritis (SpA) over time., Methods: We analyzed the first 6 years of follow-up of the prospective French multicenter DESIR cohort. Patients analyzed had <3 years of disease, were naive to disease-modifying antirheumatic drugs, and fulfilled the Assessment of SpondyloArthritis international Society classification criteria for axial SpA. Disease activity (Ankylosing Spondylitis Disease Activity Score [ASDAS] using the C-reactive protein [CRP] level), patient global assessment (PtGA), CRP level, and radiographic sacroiliitis were compared between men and women (self-reported sex) by linear and logistic mixed-effects models. Models were created for trajectories of disease activity over 6 years in men and women, using k-means., Results: Of 494 patients analyzed (mean ± SD age 31.9 ± 7.5 years, symptoms duration 20.7 ± 11.7 months), 50.4% were men. Over 6 years of follow-up, both men and women showed clear improvements in ASDAS-CRP, PtGA, and CRP level. Women had higher ASDAS-CRP and PtGA over time compared to men (both P < 0.0001) with overall similar CRP levels (P = 0.089), whereas structural damage increased more in men (P < 0.0001). One-third of both men (33%) and women (34%) belonged to persistent high/very high disease activity trajectories, but ASDAS-CRP was globally higher in women in these trajectories., Conclusion: In early axial SpA, clinical outcomes (disease activity and symptoms) were worse in women than men over 6 years of follow-up, whereas CRP was similar and structural damage was more frequent in men. Although similarly distributed, disease activity scores were higher in women in high/very high disease activity trajectories. Sex appears to be an important contextual factor in axial SpA., (© 2023 American College of Rheumatology.)

Objective: To develop and validate a patient knowledge questionnaire regarding axial spondyloarthritis (axSpA)., Methods: Knowledge considered essential for patients with axSpA was identified through Delphi rounds among rheumatologists, healthcare professionals (HCPs), and patients, then reformulated to develop the knowledge questionnaire. Cross-sectional validation was performed in 14 rheumatology departments to assess internal validity (Kuder-Richardson coefficient), external validity, acceptability, reproducibility (Lin concordance correlation coefficient), and sensitivity to change (knowledge score before vs after patient education sessions and effect size)., Results: The Spondyloarthritis Knowledge Questionnaire (SPAKE) is a self-administered 42-item questionnaire with a 32-item short form, both scored 0 to 100, assessing knowledge of disease, comorbidities, pharmacological treatments, nonpharmacological treatments, self-care, and adaptive skills. In the validation study (130 patients; 67 [51.5%] male, mean age 43.5 [SD 12.9] yrs), the mean (SD) score of the long-form questionnaire was 71.6 (15.4), with higher scores (better knowledge) in nonpharmacological treatments and adaptive skills and lower scores in cardiovascular comorbidity and pharmacological treatments. Acceptability was good, with no missing data; the internal validity coefficient was 0.85. Reproducibility was good (0.81, 95% CI 0.72-0.89). SPAKE showed good sensitivity to change; scores were 69.2 (15.3) then 82.7 (14.0) after patient education sessions (Hedges effect size = 0.92, 95% CI 0.52-1.31)., Conclusion: SPAKE is a knowledge questionnaire for patients with axSpA, developed with the involvement of HCPs and patients and reflecting current recommendations for the management of axSpA. SPAKE will be useful in assessing knowledge acquisition and self-management strategies in routine care and research., (Copyright © 2023 by the Journal of Rheumatology.)

Objective: There is little epidemiological data on global mortality in spondyloarthritis (SpA) and inflammatory bowel disease. We then determined mortality rates of ankylosing spondylitis (AS), psoriatic arthritis (PsA), Crohn's disease (CD) and ulcerative colitis (UC) both globally and by country, and to describe their evolution between 2001 and 2015., Methods: We used mortality data from the World Health Organisation (WHO), which shows the number of deaths classified by age, sex, and cause of death coded by ICD-10. Age-standardized mortality rates (ASMR) were constructed using the 2015 WHO reference population. Temporal trend analyses of ASMR were performed between 2001 and 2015 using joinpoint regression., Results: Global ASMR was for 0.13 [0.11-0.14] deaths per million inhabitants for AS, 0.04 [0.03-0.05] for PsA, 0.86 [0.82-0.89] for CD and 0.76 [0.73-0.79] for UC. The worldwide trend analysis showed no significant change in ASMR for AS, a statistically significant increase from 2004 to 2015 (mean annual percent change (APC): 5.94%, p<0.001) for PsA, and a statistically significant decrease from 2001 to 2015 for CD (mean APC: -0.82%, p<0.001) and UC (mean APC: -1.29%, p<0.001). Statistically significant geographical disparities were identified., Conclusion: We found significant geographical disparities in SpA and IBD mortality across the world. Further studies seem to be needed to better understand the evolution of mortality over the last twenty years., (Copyright © 2022 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.)

Objectives: The optimal treatment target in axial spondyloarthritis (axSpA) is remission; however, a consensual definition of remission is lacking. Our objective was to explore rheumatologists' perception of remission using vignette cases and a priority exercise., Methods: A cross-sectional survey of rheumatologists' perceptions of remission in axSpA was performed in 2020 using (i) 36 vignette cases, with a single clinical picture and three varying parameters [axial pain (ranging from 2 to 5 on a 0-10 scale)], fatigue (2-8), and morning stiffness (<15 min, 30 min or 1 h), assessed as remission yes/no; and (ii) prioritization of elements to consider for remission from a list of 12 items: BASDAI, ASDAS, elements of BASDAI and ASDAS including CRP, NSAID use, extra-articular manifestations (EAMs), and other explanations of symptoms, e.g. fibromyalgia. Analyses were descriptive., Results: Overall, 200 French rheumatologists participated in 2400 vignette evaluations. Of these, 463 (19%) were classified as remission. The six vignette cases representing 56% of all remission cases had <15 min duration of morning stiffness and axial pain ≤3/10, regardless of fatigue levels. Prioritized items for remission were: morning stiffness (75%), EAMs (75%), NSAID use (71%), axial pain (68%) and CRP (66%)., Conclusions: When conceptualizing remission in axSpA, rheumatologists took into account morning stiffness and axial pain as expected; the link between remission and fatigue was much weaker. Furthermore, rheumatologists also included EAMs and NSAID use in the concept of remission. Consensus is needed for definition of remission in axSpA., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: Update the French Society for Rheumatology (SFR) recommendations on the everyday management of patients with spondyloarthritis, including psoriatic arthritis., Methods: Following standardized procedures, a systematic literature review was done by four supervised rheumatology residents based on questions defined by a task force of 16 attending rheumatologists. The findings were reviewed during three working meetings that culminated in each recommendation receiving a grade and the level of agreement among experts being determined., Results: Five general principles and 15 recommendations were developed. They take into account pharmacological and non-pharmacological measures along with treatment methods based on the dominant phenotype present (axial, articular, enthesitis/dactylitis) and the extra-articular manifestations (psoriasis, inflammatory bowel disease, uveitis). NSAIDs are the first-line pharmacological treatment in the various presentations. Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) are not indicated in the axial and isolated entheseal forms. If the response to conventional treatment is not adequate, targeted therapies (biologics, synthetics) should be considered; the indications depend on the clinical phenotype and presence of extra-articular manifestations., Conclusion: This update incorporates recent data (published since the prior update in 2018) and the predominant clinical phenotype concept. It aims to help physicians with the everyday management of patients affected by spondyloarthritis, including psoriatic arthritis., (Copyright © 2022 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Introduction: Differentiating ankylosing spondylitis (AS) from osteitis condensans ilii (OCI) remains challenging for clinicians. The aim of this study was to determine whether Subchondral Bone Attenuation Coefficient of the SacroIliac margins (SBAC-SI) is different in AS, OCI and diffuse idiopathic skeletal hyperostosis (DISH)., Methods: A monocentric retrospective observational study was performed at the University Hospital of Besançon. Patients included were followed for AS, DISH or OCI and underwent CT scan including sacroiliac joint. Patients with tumour lesion of bone or a history of pelvic radiotherapy were excluded. AS and OCI patients were matched with a control of the same age and sex. SBAC-SI was evaluated by the sum of 24 identical circular regions of interest, 8 per slice (anterior, middle and posterior)., Results: Thirty AS and AS controls, 31 DISH, 29 OCI and OCI controls were included. SBAC-SI score was 9727 (±2430) in the OCI group (p<0.001), 3563 (±1860) in the AS group, 3899 (±1937) in the DISH group, 4224 (±1693) in the AS control group and 5445 (±1205) in the OCI control group. A threshold of 7500 HU had the best discriminative value between OCI and AS (youden index: 0.89). In AS, disease duration is negatively associated with SBAC-SI (r: -0.623; p<0.01) and HLA B27 is associated with lower SBAC-SI (6523 (5198; 7137) vs 2809 (1568; 3371); p<0.001)., Conclusion: SBAC-SI is significatively different between AS and OCI and could help to distinguish these two diseases., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The factors contributing to long-term remission in axial SpA (axSpA) are unclear. We aimed to characterize individuals with axSpA at the 5-year follow-up to identify baseline factors associated with remission., Methods: We included all patients from the DESIR cohort (with recent-onset axSpA) with an available Ankylosing Spondylitis Disease Activity Score-CRP (ASDAS-CRP) at 5-year follow-up. Patients in remission (ASDAS-CRP < 1.3) were compared with those with active disease by demographic, clinical, biological and imaging characteristics. A logistic model stratified on TNF inhibitor (TNFi) exposure was used., Results: Overall, 111/449 patients (25%) were in remission after 5 years. Among those never exposed to TNFi, 31% (77/247) were in remission compared with 17% (34/202) of those exposed to TNFi. Patients in remission after 5 years were more likely to be male, HLA-B27+, have a lower BMI, and a higher education level. Baseline factors associated with 5-year remission in patients never exposed to TNFi included lower BASDAI [adjusted odds ratio (ORa) 0.9, 95% CI: 0.8, 0.9) and history of peripheral arthritis (ORa 2.1, 95% CI: 1.2, 5.3). In those exposed to TNFi, remission was associated with higher education level (ORa 2.9, 95% CI: 1.6, 5.1), lower enthesitis index (ORa 0.8, 95% CI: 0.7, 0.9), lower BASDAI (ORa 0.9, 95% CI: 0.9, 0.9) and lower BMI (ORa 0.8, 95% CI: 0.7, 0.9)., Conclusion: This study highlights the difficulty in achieving 5-year remission in those with recent-onset axSpA, especially for the more active cases, despite the use of TNFi. Socio-economic factors and BMI are implicated in the outcome at 5 years., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Objectives: The consequences of psoriasis associated to axial spondyloarthritis (axSpA) are unclear. The objectives were to determine the prevalence and the consequences of psoriasis in recent axSpA over 6 years of follow-up., Methods: The multicentric prospective cohort DESIR (NCT01648907) of adult patients with recent inflammatory back pain suggestive of axSpA was analysed over 6 years. Psoriasis was recorded at each visit and cumulative prevalence and incidence were calculated. Patients with vs without psoriasis at any time point were compared. Outcomes included disease activity (Ankylosing Spondylitis Disease Activity Score-C reactive protein (ASDAS-CRP), joint and enthesitis count, CRP), patient-reported outcomes for function (Health Assessment Questionnaire for axSpA, HAQ-AS) and quality of life, and treatment use over 6 years. Outcomes were compared through univariable and multivariable analyses, as well as linear mixed effect models., Results: In 589 patients, mean age 40.5±8.7 years, 45.8% men and baseline mean symptom duration 1.5±0.9 years, the cumulative prevalence of psoriasis increased from 16.8% (99/589) at baseline to 26.8% (158/589) at 6 years, leading to an incidence of 2.1/100 patient-years. Over 6 years of follow-up, patients with psoriasis developed more synovitis (p=0.008), and received more methotrexate (cumulative use, 25.5% vs 11.8%, p<0.001) and biological disease-modifying drugs (55.7% vs 38.5%, p<0.001). There were no significant consequences of psoriasis on other outcomes, including disease activity (ASDAS-CRP), functional capacity (HAQ-AS) and quality of life., Conclusion: Psoriasis is frequent in early axSpA. AxSpA patients with psoriasis had more swollen joints over time and received more biologics; they did not have worse outcomes related to axSpA in terms of activity and severity., Trial Registration Number: NCT01648907., Competing Interests: Competing interests: PR: personal fees from Amgen, Galapagos, Lilly, Pfizer, Sanofi; Abbvie, BMS, Galapagos, Janssen, Novartis, UCB, outside the submitted work. DW: personal fees from AbbVie, BMS, MSD, Pfizer, Roche Chugai, Amgen, Nordic Pharma, UCB, Novartis, Janssen, Celgene, Lilly, Sandoz, Grünenthal, Galapagos, outside the submitted work. BF: grants from AbbVie, Lilly, MSD, Pfizer; personal fees from AbbVie, Amgen, Biogen, BMS, Celltrion, Fresenius Kabi, Galapagos, Gilead, Janssen, Lilly, Medac, MSD, Mylan, NORDIC Pharma, Novartis, Pfizer, Roche, Sandoz, Sanofi-Genzyme, SOBI, UCB, outside the submitted work. LG: grants from Amgen, Galapagos, Lilly, Pfizer, Sandoz, Sanofi; personal fees from AbbVie, Amgen, BMS, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis, UCB, outside the submitted work., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To describe the current methods usable to assess intestinal permeability in spondyloarthritis (SpA) and rheumatoid arthritis (RA), to analyze the available data on intestinal permeability in SpA and RA patients and the effects of drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) on intestinal permeability., Methods: A systematic review was conducted. Medline, Embase, and Cochrane Library databases were searched. Studies published in the last 40 years (January 1980-September 2020) with patients with SpA and/or RA assessing the intestinal permeability were selected., Results: A total of 2916 articles were collected, after discarding 1125 duplicate articles, we analyzed the titles and abstracts of 1791 studies. There were 459 articles that met the inclusion criteria and whose text was read. A total of 23 studies were included in the final analysis. Sample sizes ranged from 6 to 206 participants. In patients with spondyloarthritis, a large majority of studies reported an increase in intestinal permeability regardless of the method used. No increase in intestinal permeability was found in RA patients compared to healthy subject in half of the studies. NSAID treatment does not appear to influence intestinal permeability in SpA and seems to increase the intestinal permeability in RA patients as much as in healthy subjects., Conclusion: The results of our review suggest the existence of increased intestinal permeability in SpA patients even in the absence of NSAIDs use and regardless of the method assessing the intestinal permeability. Studies in RA patients are more controversial., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest in relation to this work., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Uveitis is a frequent extra rheumatological manifestation in axial Spondyloarthritis (SpA). The aim of study was to evaluate the prevalence and incidence of uveitis over the first five years of a prospective nationwide cohort of patients with high suspicion of early axial SpA, and to evaluate its associated factors., Methods: DESIR is a prospective observational cohort of patients with recent onset inflammatory back pain (more than 3 months, less than 3 years), suggestive of axial SpA, All available factors in the database were compared between patients with and without uveitis at 5 years, by uni and then multivariate analysis. Baseline factors associated with new cases of uveitis occurrence over the 5 years were also analyzed., Significance: P less than 0.05., Results: After 5 years, 91 patients (out of 480 with complete follow-up) had at least one uveitis episode, giving an estimated prevalence of 18.9% [95% CI: 15.4-22.4]. In multivariate analysis, uveitis was significantly associated with dactylitis, and elevated ESR. New incident uveitis occurred in 31 cases over 5 years, giving an estimated incidence rate of 1.29 [0.84-1.74]/100 patient-years. Incidence of new uveitis was associated in multivariate analysis with baseline factors: diagnosis of SpA, sacro iliac MRI inflammatory SPARCC score, dactylitis, syndesmophyte score. No significant association was found with HLA-B27, DMARDs, BASDAI, ASDAS, BASFI., Conclusion: Five-years data of the DESIR cohort allowed an estimation of incidence rate of uveitis of 1.3/100p-y; over five years, uveitis was associated with dactylitis, biologic and sacro iliac MRI inflammation., (Copyright © 2020 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.)

Objective: To propose a list of variables to be collected right after the diagnosis has been made and during the follow-up of patients with axial spondyloarthritis (ax-SpA) for an optimal management in daily practice., Methods: The process comprised (1) the evaluation of the interest of 51 variables proposed for the assessment of ax-SpA by means of a systematic literature research; (2) a consensus process involving 78 hospital-based or office-based rheumatologists, considering the collection of each variable in a 4 grade scale from "not very useful/useless" to "mandatory"; (3) a consensus on the minimum interval of time for periodic assessment of the selected variables on a 5 grade scale from "at each visit" to "never to be re-collected"., Results: The systematic literature research retrieved a total of 14,133 abstracts, of which 213 were included in the final qualitative synthesis. Data to be collected at the initial systematic review comprised 5 patient's self-administered questionnaires, 3 variables of the physician's interview, 2 variables of the physical examination, 2 variables of the specific ax-SpA imaging and 2 other investigations. Two variables were recommended to be systematically collected at each visit, 1 variable twice a year, 6 variables yearly and 1 variable every 2 years., Conclusions: Using an evidence-based and an expert consensus approaches, this initiative defined a core set of variables to be collected and reported right after the diagnosis and during follow-up of patients with ax-SpA in daily practice., (Copyright © 2020 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: To evaluate, factors associated with new ultrasonographic lesions of the anterior chest wall in spondyloarthritis (SpA) after a follow up of 5 years., Methods: SpA Patients included in 2013 in a first study were evaluated five years later. Ultrasound B mode and power Doppler examination of the two sternoclavicular joints and the manubrio-sternal joint were performed by the same two examinators at baseline and five years later. The presence of erosion, synovitis, ankylosis, power Doppler signal, joint effusion and joint space narrowing were assessed blind of the first evaluation., Results: Among the 131 patients at baseline, 58 patients were evaluated 5 years later. The mean age was 48.2±11.9 years old, with 86% of male and mainly an axial disease (78%). Patient characteristics are comparable to the original cohort. The most frequent lesions were ankylosis of the manubriosternal joint (38%) and erosions of the sternoclavicular joint (29%). 31 patients (53%) developed a new lesion of the ACW. There is a statistically significant association between new lesions of the ACW and higher ASDAS CRP (1,86±1,07 VS 3,0±2,17 P<0,01) and with CRP (5,34±7,85 VS 16,2±35, P=0,035) in the moment of the examination. There was no baseline factor associated with the structural progression., Conclusion: The occurrence of new lesions of the anterior chest wall is associated with a higher disease activity and a higher CRP at 5 years., (Copyright © 2020 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.)

Local sacroiliac injections represent an available treatment option in spondyloarthritis (SpA). There is no synthetic data about efficacy of this procedure in SpA. The aim of this review is to analyze the available data of the literature of local sacroiliac injections in SpA., Methods: A Pubmed search of papers published after 1990 was performed., Results: Pubmed search retained 15 publications in spondyloarthritis, 12 with corticosteroids (total of 468 injections in 268 patients), including 2 small-sized controlled studies, and 3 with TNF blockers (24 patients in open studies). With steroids, the two controlled studies (with a total number of 30 patients only) demonstrated significant results over placebo. In open studies, good response was reported in more than 80% of the cases, with a mean duration of improvement over 8 months. Reduction of sacroiliac inflammation on MRI was also found in several studies after injection. There is no consensus about the technique of injection or the type of steroid injected. No particular safety concern was reported. Many limitations have to be considered in the interpretation of these results., Conclusion: This kind of procedure should be kept in the therapeutic armament in the current setting of costly targeted systemic treatments of spondyloarthritis. However, definition of a clear position in the treatment strategy needs further well-conducted studies., (Copyright © 2019 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.)

Objective: To study changes on MRI of the spine and sacroiliac joint (SIJ) in early axial spondyloarthritis (axSpA) over time., Methods: In the Devenir des Spondyloarthropathies Indifférenciées Récentes cohort, MRI-spine and MRI-SIJ at baseline and 2 and 5 years were scored by central readers for bone marrow oedema (BME), fatty lesions, erosions, sclerosis, ankylosis and spinal bone spurs. The average mean number of lesions was reported or the agreement of ≥2 out of 3 readers for binary outcomes. Net progression was calculated by subtracting the patients that 'improved' from those that 'worsened' divided by the total number of patients., Results: Over 5 years, in 155 patients with axSpA (mean age 33.5 (SD 8.9) years, symptom duration 1.4 (0.8) years, 63% human leucocyte antigen+, 14% modified New York+), BME on MRI-SIJ decreased by a mean Spondyloarthritis Research Consortium of Canada score of 1.4 (SD 6.5) (p=0.009). The largest BME decrease was observed in patients using biological disease-modifying antirheumatic drugs at 5 years. Spinal BME increased by 0.3 (4.6) (p=0.41). Fatty lesions and/or erosions on MRI-SIJ increased by a mean of 1.0 (SD 2.6) (p<0.001). Spinal fatty lesions and/or erosions increased by 0.2 (SD 0.5) (p<0.001). Compared with baseline, at 5 years, 7.3% less patients had BME on MRI-SIJ according to the Assessment of Spondyloarthritis International Society definition, while 6.6% more patients had ≥5 fatty lesions and/or erosions. At 5 years, 0.7% less patients had ≥5 spinal BME lesions and 0.7% less patients had ≥5 spinal fatty lesions., Conclusion: Over 5 years, BME on MRI-SIJ decreased and spinal BME remained similar, but numerically, little progression of structural lesions on MRI of the SIJ and spine was seen., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The recent demonstration that DNA from several mucosal bacteria, including Prevotella spp, could be found in numerous tissues (mesenteric lymph nodes, spleen, serum, liver, lung, eye and ankle joints), either in HLA-B27 rats with or without arthritis, or control rats without HLA-B27, could be a revolution in our understanding of spondyloarthritis and close disorders, including rheumatoid arthritis. Indeed, similar translocations of dead or alive bacteria or fungi from mucosa to joints, could contribute to the onset and flares of inflammatory rheumatisms. This state of the art article addresses six questions revived by this finding: 1-How does this bacterial DNA or living bacteria traffic from mucosa to joints? 2-Can some mucosal bacteria remain alive in those tissues, including joints? 3-Could bacteria from the gut microbiota ('self-bacteria') protect the host cells from invasion by more pathogenic bacteria (like dog-shepherds protect from wolves)? 4-Does the composition of the joint or bone marrow microbiota depends on local metabolism, which might differ from gut metabolism? 5-Could bacterial antigens from mucosal microbiota be sufficient to trigger trained immunity of presenting cells in joints, or does such phenomenon (with lasting epigenetic changes of presenting cells) require intra-cellular infection of presenting cells or their ancestors? 6-In which subsets of cells could living bacteria preferentially persist for a long period in the joint area? Transient or dormant infections within bone-marrow mesenchymal stem cells leading to trained immunity of some of their daughter cells in joints or enthesis, lasting after clearance or the invader, is an attractive hypothesis to test., (Copyright © 2019 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.)

Objective: Information and education are recommended for patients with inflammatory arthritis including rheumatoid arthritis (RA) and spondyloarthritis (SpA). However, there is no consensus on which knowledge is essential to enhance patients' self-management. The aim of this study was to determine such knowledge., Methods: Based on published knowledge questionnaires (KQs) collected by a systematic literature review, a list of items was elaborated, classified in domains and sub domains. A Delphi process was performed with rheumatologists, healthcare professionals and patients in 2014-2015, selecting the items considered useful., Results: Three published KQs were analysed: 2 for RA; 1 for SpA and 5 unpublished KQs were collected. In the KQs, 90 knowledge items were mentioned for RA and 67 for SpA. The 1 st Delphi round enlarged the list to 322 items for RA and 265 items for SpA. The second round selected 69 and 59 knowledge items for RA and SpA respectively, of which 36 (52%) and 34 (57%) were not present or modified from the published KQs. Key domains included treatment strategies, managing cDMARDs and bDMARDs, managing symptomatic medications. Knowledge on non-pharmacological treatment concerned pain and fatigue, physical activity, adaptative skills to personal and professional environment, patient-HP communication and shared decision-making., Conclusion: The present study provides a corpus of knowledge considered essential for patients in the self-management of their arthritis. The selection of many items reflects recent emphasis on professional recommendations and the patients' perspective. Future work should lead to the development of new updated KQs for patients with inflammatory arthritis., (Copyright © 2019. Published by Elsevier Masson SAS.)

Objectives: We aimed to describe the prevalence and characteristics of peripheral enthesitis in recent onset axial spondyloarthritis, estimate the incidence of peripheral enthesitis over time, and determine the factors associated with the presence of peripheral enthesitis., Methods: 708 patients with recent onset axial spondyloarthritis were enrolled in the DESIR cohort ( prospective multi-centre, longitudinal). Data regarding the patients and spondyloarthritis characteristics at baseline with a specific focus on enthesitis and occurrence of peripheral enthesitis were collected during the five years of follow-up., Results: At inclusion, 395 patients (55.8%) reported peripheral enthesitis. The locations were mainly the plantar fascia (53.7%) and the Achilles tendon (38.5%). During the 5-year follow-up period, 109 additional patients developed peripheral enthesitis resulting in an estimated (Kaplan-Meier method) percentage of 71% (95% CI: 68-75). Variables associated with peripheral enthesitis in the univariate analysis were: older age, male gender, absence of HLA B27, MRI sacroiliitis and fulfilled Modified NY criteria, presence of anterior chest wall pain, peripheral arthritis, dactylitis, psoriasis, high BASDAI, BASFI, mean score ASAS-and the use of NSAIDs. Only the history of anterior chest wall pain and of peripheral arthritis were retained in the multivariate analysis (odds ratio (OR)=1.6 [95% confidence interval [1.1-2.3], and OR=2.1 [1.4-3.0], respectively)., Conclusions: This study highlights the high prevalence of peripheral enthesitis in recent onset axial spondyloarthritis, and suggests that in combination with peripheral arthritis, enthesitis might have an impact on the burden of the disease.

Aim: To evaluate the impact of an aerobic fitness program on disease activity, defined by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and on C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and the Bath Ankylosing Spondylitis Functional Index (BASFI) in case of axial spondyloarthritis., Methods: A systematic review of the literature, following the Prisma recommendations, was performed by two reviewers on the PubMed and Embase databases. Controlled trials assessing the efficacy of aerobic exercises compared to physiotherapy on axial spondyloarthritis disease activity were included. The diagnosis of axial spondyloarthritis was meeting the New York criteria and/or the Assessment in Axial Spondyloarthritis International Working Group criteria. Aerobic fitness was defined as an exercise performed at 50%-90% of the maximal heart rate or between 50% and 80% oxygen consumption (VO 2 ) peak., Results: Five hundred and twenty abstracts were identified and 93 abstracts were analyzed. Eight studies met the selection criteria and 6 were finally included in this study because of the presence of a control group. Both groups were similar in terms of age, sex ratio, disease duration. Aerobic exercise provided a positive impact on the BASDAI in the intervention group (148 patients) (weighted mean difference [WMD]: -0.52 [95% CI: -0.9 to -0.13]) (I 2 : 10.3%, P = 0.35). However, when compared to a control group (152 patients), the improvement of BASDAI didn't reach significance (WMD: -0.25 [95% CI: -0.83 to 0.32]) (I 2 : 0%, P = 0.41). Aerobic exercise did not improve BASFI, CRP or ESR., Conclusion: Aerobic exercise did not provide beneficial effects either on disease activity or on physical function and biological parameters when compared to a control group in axial spondyloarthritis., (© 2018 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

In spondyloarthritis, little is known about the relation between circulating cytokines and patient phenotype. We have quantified serum levels of T helper type 1 cell (Th1), Th2 and Th17 cytokines in patients with recent-onset axial spondyloarthritis (AxSpA) from the DESIR cohort, a prospective, multicenter French cohort consisting of 708 patients with recent-onset inflammatory back pain (duration >3 months but <3 years) suggestive of AxSpA. Serum levels of Th1, Th2, and Th17 cytokines were assessed at baseline in patients from the DESIR cohort fulfilling the ASAS criteria (ASAS+) and were compared with age- and sex-matched healthy controls. At baseline, ASAS+ patients (n = 443) and healthy controls (n = 79) did not differ in levels of most of the Th1, Th2 and Th17 cytokines except for IL-31, and sCD40L, which were significantly higher for ASAS+ patients than controls (p < 0.001 and p = 0.012, respectively). On multivariable analysis of ASAS+ patients, IL-31 level was associated with sCD40L level (p < 0.0001), modified Stoke AS Spine Score (mSASSS) < 1 (p = 0.035). The multivariable analyses showed that IL-31 was an independent factor associated with mSASSS < 1 (p = 0.001) and low bone mineral density (p = 0.01). Increased level of IL-31 might protect against structural damage but is also related to low BMD.

Objective: To update French Society for Rheumatology recommendations about the management in clinical practice of patients with spondyloarthritis (SpA). SpA is considered across the range of clinical phenotypes (axial, peripheral, and entheseal) and concomitant manifestations. Psoriatic arthritis is included among the SpA phenotypes., Methods: According to the standard procedure advocated by the EULAR for developing recommendations, we first reviewed the literature published since the previous version of the recommendations issued in June 2013. A task force used the results to develop practice guidelines, which were then revised and graded using AGREE II., Results: Four general principles and 15 recommendations were developed. The first four recommendations deal with treatment goals and general considerations (assessment tools and comorbidities). Recommendations 5 and 6 are on non-pharmacological treatments. Recommendation 7 is about nonsteroidal anti-inflammatory drugs, which are the cornerstone of the treatment, and recommendations 8 to 10 are on analgesics, glucocorticoid therapy, and conventional disease-modifying antirheumatic drugs. Biologics are the focus of recommendations 11 through 14, which deal with newly introduced drug classes, including their indications (active disease despite conventional therapy and, for nonradiographic axial SpA, objective evidence of inflammation) and monitoring, and with patient management in the event of treatment failure or disease remission. Finally, recommendation 15 is about surgical treatments., Conclusion: This update incorporates recent data into a smaller number of more simply formulated recommendations, with the goal of facilitating their use for guiding the management of patients with SpA., (Copyright © 2018 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)

Introduction: Axial spondyloarthritis is an inflammatory rheumatic disease causing back pain, functional impairment and potential ankylosis in the advanced stage. In this context, TNF blockers have been a major therapeutic advance. Etanercept is a soluble recombinant TNF receptor fusion protein in this vain. Areas covered: The aim of this review is to summarize the current published data concerning the efficacy and tolerance of etanercept in axial spondyloarthrits. The authors performed a systematic review on PubMed, using 'etanercept' and 'spondyloarthritis', 'axial spondyloarthritis' or 'ankylosing spondylitis' keywords. Expert opinion: Etanercept showed clinical efficacy on the axial (non-radiographic and radiographic) and peripheral manifestations (peripheral arthritis and enthesitis) of axial spondyloarthritis (Ax-SpA). Among the extra-articular manifestations, it works on psoriasis but not on inflammatory bowel disease, with a lack of efficacy data in anterior uveitis. Etanercept also demonstrated an interesting tolerance profile and good drug survival rates after 5 years. Etanercept was also shown to reduce MRI inflammation on the spine and the sacroiliac joints. However, like other TNF blockers, its impact on radiographic progression could not be fully demonstrated. In the context of upcoming new biologic targeted treatments, head-to-head and longer-term randomized controlled trials are now required to further define the role of etanercept in spondyloarthritis treatment strategies.

Introduction: No evaluation of factors associated with remission has been performed in early SpA. The aim of the study was to evaluate percentage of patients in remission using and comparing different definitions of remission, and to evaluate factors associated with remission at inclusion in the prospective DESIR cohort, and after 24 months., Methods: Performance of three definitions (ASAS partial remission [PR], ASDAS-CRP less than 1.3 [ASDAS-R], BASDAI less than 3.6 [BASDAI-R]) were assessed using sensibility, specificity and Youden Index. Data at M0 and M24 were analyzed in uni- and multivariate analysis., Results: Seven hundred and six patients were evaluated at M0 and 577 at M24. At M0, percentage of patients in remission was 4% (PR), 8% (ASDAS), 34% (BASDAI), and at M24: 15%, 24% and 54% respectively, in the whole population and similar in Amor, ESSG and ASAS classified patients. BASDAI less than 3.6 had the best sensitivity, and ASDAS-R the best Youden index when using each of the two other definitions of remission as a gold standard. At M24 in multivariate analysis, remission was associated with less smoking, less analgesics, ASAS clinical arm fulfilling, less NSAIDs (ASDAS-R), low CRP (ASDAS-R), low BMI (BASDAI-R). However, over the two years, this study did not allow to demonstrate a relation between remission and structural progression or morbidity., Conclusion: In this population suggestive of early SpA, smoking and CRP appear as major markers of disease activity in early SpA, and associated with absence of remission., (Copyright © 2016 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)

Objectives: Nonsteroidal anti-inflammatory drugs (NSAID) are the cornerstone of treatment in axial spondyloarthritis (axSpA). We aimed to describe the real life NSAID use in early axSpA according to the disease characteristics., Methods: The DESIR cohort is an observational study of patients presenting with inflammatory back pain suggestive of axSpA for less than 3 years. Patients who attended all 6 visits (every 6 months during the first 2 years and yearly at 3 years) were analysed. Data collected at every visit over 3 years was NSAID intake and the ASAS-NSAID score for the 6 months preceding the visit, where 100 reflects the full daily intake of an NSAID., Results: In all, 627 patients were assessed: 46.1% males, mean age: 33.7 (standard deviation: 8.7) years, mean symptom duration: 1.5 (0.9) year and mean BASDAI: 44.3 (25.3). Over the 6 months preceding inclusion, 92.8% had received NSAIDs; this proportion significantly decreased over time, to 73% patients after 3 years (P<0.001). This decrease was not different with regard to the fulfillment (or not) of the ASAS criteria at baseline, nor with regard to the "arm" of the ASAS criteria fulfilled (i.e. imaging vs. clinical). The median ASAS-NSAID score was 36 [interquartile range: 13-72] at inclusion, and substantially decreased to reach 7 [0-44] after 3 years (P<0.001), although BASDAI at 3 years was 33.8 (21.7)., Conclusion: NSAID prescription was very frequent in this early axSpA cohort, but the intake was low, and decreased significantly over time, even though symptoms remained present. Early axSpA patients may not be sufficiently treated with NSAIDs., (Copyright © 2016 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)

The links between the bowel and spondyloarthritis, although demonstrated many years ago, have been placed under the spotlight by recent findings. Thus, studies have established that bowel inflammation is associated with the joint disease activity, sacroiliac joint inflammation by magnetic resonance imaging, and elevated levels of biomarkers for bowel inflammation (S100 proteins) or antimicrobial antibodies (anti-flagellin). IL-23/Th17 pathway activation originating in the bowel has been documented in studies demonstrating that lymphoid cells expressing the IL-23 receptor can migrate to the bloodstream, bone marrow, and joints, via a mechanism involving adhesion molecules. Bacteria present in the bowel are increasingly emerging as major players. Thus, dysbiosis of the bowel microbiota can induce IL-23 production and local inflammatory responses. These new data suggest avenues of research for future treatments., (Copyright © 2016 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)