Following his introductory talk from 2018, Dr Webb CEO of NASS, explained how he strived to execute his plans to ensure a widespread and effective implementation of NICE clinical guidelines and quality standards with the launch of the NASS Every Patient Every Time campaign. Also, an all-party parliamentary group (APPG) for axial spondyloarthritis has been established to provide national oversight. The Aspiring to Excellence award programme was also launched at the recent BSR conference to encourage service improvement in axial SpA care. He introduced NASS ‘Voices’ which will launch the APPG enquiry report and be the awards ceremony for the first cohort of Aspiring to Excellence. NASS Allies was also mentioned which showcased working with osteopaths and chiropractors to improve AS knowledge. NASS has been renamed National Axial Spondyloarthritis Society to keep up to date with terminology changes in the condition. There are also new resources on the new NASS main website and ASone. In summary, it has been a very busy but exciting year for NASS and the axSpA community.
Sarah Rudkin, head of clinical studies and experimental medicine, explained the transition of Versus Arthritis from Arthritis Research UK and Arthritis Care. Using their website, she explained their broad research remit and how the charity uses their research funds. The charity will fund across the spectrum of healthcare from disease [?]to treatment and health services; in both pre-clinical and clinical studies; in fundamental and health service research. Research advisory groups have replaced clinical study groups which function to connect the patient, research and practitioner communities in activities around research prioritisation. Dr Rudkin was keen to highlight that the charity works closely with patients from participation to engagement to involvement in all stages of the research cycle.
Dr Derakhshan gave a whistle-stop tour updating his activities over the last year. Firstly, he talked about the dactylitis vs enthesitis phenotypes of SpA in relation to cardiovascular comorbidities from an analysis of the COMOSPA cohort. In patients with SpA, both dactylitis and enthesitis are associated with higher risk of hypertension and dyslipidaemia. The loss of these associations with dactylitis with adjustment for BMI could suggest a potential shared underlying metabolic mechanism. Secondly, he talked about the factors associated with extra-articular manifestations in patients with axial spondyloarthritis (axSpA) from an analysis of the BSRBR-AS Register Database. The key findings here are that HLA-B27 is associated with higher incidence of AAU but lower incidence of psoriasis and IBD; Smoking (ever) is associated with lower incidence of AAU but not associated with psoriasis or IBD. Lastly, he talked about the impact of extra-articular manifestations on the choice of TNF Inhibitor in patients with axSpA in the BSRBR-AS Register. He concluded that the decision to prescribe a first TNFi (vs non-biologics) is not influenced by the presence of extra-articular manifestations. Further information can be found from abstracts which have been presented in EULAR in June 2019 in Madrid.
Dr Galloway provided a brief glimpse of the first year’s results of the audit. Some headline results include the following: approximately one third of patients enrolled ultimately diagnosed as early inflammatory arthritis; approaching 40% are seen within 3 weeks; just over half of cohort start DMARDs <6 weeks; education provision is high. From an axSpA view, axSpA only makes up <5% of cases, but he reported that very few of these referrals came from other specialities (ophthalmology, gastroenterology, dermatology); symptom duration prior to referral is substantially longer. He admits that the audit probably raises more questions than answers, given the small sample and limited data available for analysis in axSpA compared to other inflammatory arthritis
Dr Siebert updated the group on the progress of the BAxSIC (British Axial Spondyloarthritis Inception Cohort) Study on behalf of BRITSpA and NASS. This is a prospective longitudinal inception observational cohort that will include adults older than fifteen with a physician diagnosis of axSpA in the National Early Inflammatory Arthritis Audit (NEIAA) who have given consent. The primary objective is to provide real-world data to evaluate the impact of delay on work participation and functional outcomes, the natural history and impact of newly diagnosed axSpA. He talked about the troubleshooting needed in order to get the study started and encouraged the audience to become involved simply by recruiting axSpA patients to the NEIAA (by asking for consent to be contacted and their email address).
Sizheng Steven Zhao – Incorporating natural language processing to improve classification of axSpA using electronic health records
Steven gave an intriguing prize-winning abstract presentation (Service delivery and improvement) on how the incorporation of free-text data using Neuro-Linguistic Programming can improve the accuracy of algorithms identifying diseases in electronic health records, and how automation can efficiently identify large cohorts, even with evolving disease definitions.
Dr Emma Garcia-Melchor – Assessing the role of tendon-T cell interactions in the development of chronicity in spondyloarthritis
In the basic science winning abstract, Dr Garcia-Melchor gave a convincing presentation on how tendon damage can activate tendon stromal cells to induce expression of inflammatory mediators which could lead to the activation of T cells and their migration into the tendon of healthy cells. Her group will be proceeding to experiment on pathological cells and feel that the research could uncover dysregulated pathways in psoriatic arthritis.
Dr Jones presented his award-winning clinical science abstract using analysis from the BSRBR-AS registry. His results showed that the three independent predictors of improved treatment response to biologics (TNFi) were full-time employment, longer education and better mental health. He also reported that increasing co-morbidities was independently associated with a poorer response to biologic treatment. These results showed that factors associated with treatment response were wide-ranging, and can include clinical, socioeconomical and patient-reported factors.
Dr Goodson started the review by talking about articles related to the diagnosis of axSpA. Inflammatory back pain (IBP) using currently available criteria (Carlin, Berlin, ASAS) had a higher likelihood ratio when used in primary care than in rheumatology, due to the increased prevalence of IBP, thus rheumatologists need to know the pre-test probability in their own local population before using these defined IBP criteria as a diagnostic feature in their practice. There was still a significant mean delay to diagnosis of 5.7 years in a German study, with HLA-B27 positive and male gender still associated with earlier diagnosis. Thus there was still a need for education and referral guidelines/strategies. The prevalence of extra-articular and peripheral disease manifestations was equal between males and females, while radiographic sacroiliitis (via mNYC) had higher prevalence in males, and females reported higher disease activity (including higher ESR) in a recent real-life cross-sectional cohort with clinical diagnosis of axSpA. We were also informed that in axSpA-suspected patients, a positive family history of AS or uveitis was not associated independently of HLA-B27 with a diagnosis of axSpA, indicating that in most patients presenting with back pain, a positive family history does not contribute to the likelihood of an axSpA diagnosis if HLA-B27 status was known. Moving on to imaging, we were advised to be cautious when interpreting imaging results as there is emerging recognition that bone marrow oedema may be sensitive but less specific for axSpA and structural SIJ abnormality may be more specific. An interesting pilot study “Fitbit and flares study” gives a possible future use of activity trackers to detect flares with great accuracy and minimal patient burden, compared to online questionnaires or in-person visits.
Dr Siebert then continued to tell the audience about new approaches and new therapies in axSpA. Despite an explosion of treatment options for psoriatic arthritis with IL-12/IL-23 inhibitors, IL-17RA inhibitors, kinase inhibitors, T-cell co-stimulation modulator and the current arsenals (TNFi, IL-17A inhibitors, PDE4 inhibitors), there is currently only TNF inhibitor and IL-17A inhibitors for the treatment of axSpA. Nonetheless there is good response to first TNFi treatment (depending on the definition of response) and good 12-month retention rates from a large European database of axSpA patients. He mentioned briefly that drug levels may be useful to optimising treatment in axSpA. Results of a phase 3 study in Ixekizumab for AS naïve and TNF-IR are promising, and for Filgotinib (JAK1inhbitor) in phase 2 (AS naïve patients). From an imaging perspective, we were told that diffusion weighted imaging (DWI) was being investigated as an alternative to STIR and T2-fat saturated sequences for SIJ; and a positive PET was not correlated with positive MRI or structural sacroiliitis on CT scans. In summary, there was still a need for more treatment options in axSpA and the recent failure of trials in 12/IL-23 inhibition has thrown up more questions in the pathogenic mechanism of axSpA; also more understanding is needed between the correlation of symptoms and imaging findings.
Dr Dunkley showcased her Sheffield experience in transitional and age-appropriate care in spondyloarthritis by explaining the Sheffield rheumatology/uveitis transition pathways and the Rheumatology 16-25 service. Through the presentation, audience had a better appreciation of the importance of transitional care from paediatric services, and understood the differences in approach between management of JIA (ERA) and adult SpA, and value of age-appropriate care.
Dr Shouvik Dass – Drugs in pregnancy
Dr Dass shared key learning points in the management of pregnancy in rheumatological patients including maximising disease control (with greater scope now especially with biologics) at/before conception; medication changes should be personalised, with tailored treatment of emergent flare/disease manifestation in a pragmatic fashion; and for practitioners to be prepared for uncertainties.
Dr Maria Mouyis – Pregnancy outcomes
Dr Mouyis who has a specialist interest in reproductive rheumatology shared her expertise in pregnancy outcomes in the spondyloarthropathies. Her take-home messages were that AS disease activity increased in pregnancy, except for peripheral arthritis and active disease is associated with adverse pregnancy outcomes. On the other hand, psoriatic arthritis disease activity improved by up to 50% in pregnancy with no evidence of adverse pregnancy outcomes, but disease activity then increased in the post-partum period in 40-80%.
Team Bump (Claire Jeffries AStretch) – Physio in pregnancy
Claire Jeffries and colleagues enthusiastically presented the advantages of physiotherapy in pregnancy for symptoms control, including the importance of the multidisciplinary team input, through a series of case studies and interactive audience participation. They were keen to promote the importantance for patients to keep exercising for as long as possible during pregnancy as this will help, both with their general health and their axial SpA (AS). As their pregnancy advances, patients may find it easier to exercise in the swimming pool where the water helps to support their weight, and this was where the physiotherapist can provide further advice (aquanatal exercise) toward their care.
Professor van der Horst enlightened the audience on the importance of sex and gender differences in diagnosis and treatment. AxSpA is under-diagnosed in women and the use of uveitis screening may help to improve identification of cases. Women have a lower level of response to TNF inhibitors and shorter drug retention. Lastly, we must not forget to consider the management of osteoporosis in young males with axSpA. She finished her talk with the remark “Adam is not Eve”.
Professor Barnes gave an eloquent account, starting with the history of cannabis and the endocannabinoid system. There are many components in the nature plant which may have medicinal properties. The main two components are THC and CBD but terpenes and flavonoids may also have effects. Delivery methods, evidence for use in conditions/symptoms, regulations around use and prescription, and current guidance by RCP/BPNA were presented to the audience
Chris presented passionately and encouraged everyone to prescribe exercise because there was consensus in the literature supporting the need to the make exercise therapy an ‘integral part of standard care’ in Spondyloarthritis, and that promoting physical activity and exercise was everyone’s business. He argued that exercise in SpA was safe and should consist of a mixture of aerobic, neuromotor, resistance and flexibility components. He suggested that high intensity training, specifically resistance training, may be an under-utilised area of exercise therapy in SpA and more research is needed to help establish optimum dosage to aid prescription of exercise.
Professor Bundy provided a roadmap for motivational interviewing to enhance the SpA consultation, using the framework of planning, evoking, focusing and engaging. She enthusiastically encouraged the audience to use the consultation as an opportunity to introduce behaviour change and that the 10-minute framework of motivational interviewing should be a routine tool. She described how motivational interviewing was patient-centred and had good evidence base for increasing capability and motivation. She demonstrated that the techniques were easy to use and effective when practiced consistently.
Dr Zhao gave a clear and concise talk regarding multi-morbidity in AxSpA. He showed evidence that comorbidity is common, with clustering around mental health and cardiovascular diseases. As such there was a need to approach care in rheumatology in a holistic way as it can impact on treatment response/patient reported outcomes, and there was ongoing further research in this area.