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Arthritis & Rheumatology (Hoboken, N.J.) Apr 2022To provide recommendations for the management of juvenile idiopathic arthritis (JIA) with a focus on nonpharmacologic therapies, medication monitoring, immunizations,...
2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis: Recommendations for Nonpharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging.
OBJECTIVE
To provide recommendations for the management of juvenile idiopathic arthritis (JIA) with a focus on nonpharmacologic therapies, medication monitoring, immunizations, and imaging, irrespective of JIA phenotype.
METHODS
We developed clinically relevant Patient/Population, Intervention, Comparison, and Outcomes questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the quality of evidence (high, moderate, low, or very low). A Voting Panel including clinicians and patients/caregivers achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations.
RESULTS
Recommendations in this guideline include the use of physical therapy and occupational therapy interventions; a healthy, well-balanced, age-appropriate diet; specific laboratory monitoring for medications; widespread use of immunizations; and shared decision-making with patients/caregivers. Disease management for all patients with JIA is addressed with respect to nonpharmacologic therapies, medication monitoring, immunizations, and imaging. Evidence for all recommendations was graded as low or very low in quality. For that reason, more than half of the recommendations are conditional.
CONCLUSION
This clinical practice guideline complements the 2019 American College of Rheumatology JIA and uveitis guidelines, which addressed polyarthritis, sacroiliitis, enthesitis, and uveitis, and a concurrent 2021 guideline on oligoarthritis, temporomandibular arthritis, and systemic JIA. It serves as a tool to support clinicians, patients, and caregivers in decision-making. The recommendations take into consideration the severity of both articular and nonarticular manifestations as well as patient quality of life. Although evidence is generally low quality and many recommendations are conditional, the inclusion of caregivers and patients in the decision-making process strengthens the relevance and applicability of the guideline. It is important to remember that these are recommendations. Clinical decisions, as always, should be made by the treating clinician and patient/caregiver.
Topics: Antirheumatic Agents; Arthritis, Juvenile; Glucocorticoids; Humans; Immunization; Quality of Life; Rheumatology; United States; Uveitis
PubMed: 35233961
DOI: 10.1002/art.42036 -
Therapeutic Advances in Musculoskeletal... 2021Patients with inflammatory bowel disease (IBD) have an excess burden of axial spondyloarthritis (axSpA), which, if left untreated, may significantly impact on clinical... (Review)
Review
BACKGROUND
Patients with inflammatory bowel disease (IBD) have an excess burden of axial spondyloarthritis (axSpA), which, if left untreated, may significantly impact on clinical outcomes. We aimed to estimate the prevalence of axSpA, including previously undiagnosed cases, in IBD patients from studies involving cross-sectional imaging and identify the IBD features potentially associated with axSpA.
METHODS
PubMed, Embase and Cochrane databases were searched systematically between 1990 and 2018. Article reference lists and key conference abstract lists from 2012 to 2018 were also reviewed. All abstracts were reviewed by two authors to determine eligibility for inclusion. The study inclusion criteria were (a) adults aged 18 years or above, (b) a clinical diagnosis of IBD and (c) reporting identification of sacroiliitis using cross-sectional imaging.
RESULTS
A total of 20 observational studies were identified: 12 used CT, 6 used MR and 2 utilised both computed tomography (CT) and magnetic resonance (MR) imaging. Sample sizes ranged from 25 to 1247 (a total of 4096 patients); 31 studies were considered to have low selection bias, 13 included two or more radiology readers, and 3 included rheumatological assessments. The prevalence of sacroiliitis, the most commonly reported axSpA feature, ranged from 2.2% to 68.0% with a pooled prevalence of 21.0% [95% confidence interval (CI) 17-26%]. Associated IBD features include increasing IBD duration, increasing age, male sex, IBD location, inflammatory back pain and peripheral arthritis. No significant difference in the prevalence of sacroiliitis between Crohn's disease and ulcerative colitis was identified. Study limitations include variability in the individual study sample sizes and patient demographics.
CONCLUSION
This review highlights the need for larger, well-designed studies using more sensitive imaging modalities and multivariable modelling to better estimate the prevalence of axSpA in IBD. An improved knowledge of the IBD phenotype(s) associated with axSpA and use of cross-sectional imaging intended for IBD assessment to screen for axSpA may help clinicians identify those patients most at risk.
PubMed: 33786068
DOI: 10.1177/1759720X21996973 -
Skeletal Radiology Sep 2021MRI criteria are central to the diagnosis of non-radiographic axial spondyloarthropathy (nr-axSpA). The cardinal feature of nr-axSpa is inflammatory low back pain, which... (Review)
Review
INTRODUCTION
MRI criteria are central to the diagnosis of non-radiographic axial spondyloarthropathy (nr-axSpA). The cardinal feature of nr-axSpa is inflammatory low back pain, which may be difficult to distinguish from highly prevalent non-specific low back pain. This study aims to determine the frequency of relevant MRI findings in the sacroiliac joints (SIJ) of patients without Spondyloarthropathy (SpA), and therefore estimate the specificity of MRI scans for SpA.
METHODS
EMBASE and Medline were searched and limited to English. Titles were screened for relevance, with studies that included primary MRI findings in patients without SpA triggering retrieval. Retrieved papers were reviewed, data extracted by two authors and quality criteria (QUADAS 2) were applied. Findings were considered for asymptomatic and symptomatic individuals.
RESULTS
The search recovered 2172 articles. Abstracts of 117 were reviewed for full text retrieval, 11 papers met eligibility criteria. These papers described MRI findings of 1180 asymptomatic patients and 1318 with low back symptoms but without SpA. In relevant populations, bone marrow oedema was found in 22% (95% CI 19-25) of asymptomatic and 20% (95% CI 18-22) of asymptomatic individuals. In all non-Spa patients, sclerosis was found in 13.4% and erosions in 6.5%.
CONCLUSIONS
There is a significant frequency of diagnostically pertinent MRI abnormalities in the SIJ of patients without SpA. These are present in both asymptomatic and symptomatic individuals. Findings, such as oedema and sclerosis, lack specificity and should be interpreted with caution. Erosions are less frequent and are likely more specific for SpA.
Topics: Back Pain; Humans; Magnetic Resonance Imaging; Sacroiliac Joint; Sacroiliitis; Spondylarthritis; Spondylarthropathies
PubMed: 33547535
DOI: 10.1007/s00256-021-03719-6 -
Drugs Sep 2020A significant proportion of patients with spondyloarthritis (SpA) have peripheral enthesitis. Data suggest that psoriatic arthritis (PsA) patients with enthesitis have a...
A significant proportion of patients with spondyloarthritis (SpA) have peripheral enthesitis. Data suggest that psoriatic arthritis (PsA) patients with enthesitis have a higher disease burden than those without enthesitis. Over the past decade, there has been a proliferation of treatment options for spondyloarthropathy. These medications target multiple signaling pathways, including tumor necrosis factor (TNF), interleukin (IL)-17A, IL-12/23, IL-23, thymus (T)-cell co-stimulation, intracellular Janus kinases, and phosphodiesterase enzymes. As a key domain in SpA, enthesitis outcomes are included in pivotal trials of these agents and are reported as secondary outcome measures. One significant limitation is that the clinical evaluation of enthesitis relies on eliciting tenderness on palpation and is insensitive when compared with imaging. Furthermore, direct comparisons between studies are not available due to the use of different outcome measures, lack of consistent and comprehensive reporting outcomes, and subgroup analyses with a lower number of patients with enthesitis. This systematic review describes the epidemiology, pathophysiology, and available targeted therapies against enthesitis, as well as a detailed report of their efficacy. One major trend identified during this review is incomplete reporting of outcome measures, as many studies reported proportions of enthesitis prevalence. Factors that affected responsiveness in clinical trials included the entheseal instrument used, the number of subjects available for comparison, as well as the therapeutic agent. In general, anti-TNF and anti-IL-17 agents, as well as Janus kinase inhibitors, show moderate responsiveness for enthesitis. The data for IL-23 targeting is contradictory.
Topics: Antirheumatic Agents; Humans; Sacroiliitis; Spondylarthritis
PubMed: 32720292
DOI: 10.1007/s40265-020-01352-6 -
Joint Bone Spine Dec 2020Sarcoidosis and spondyloarthritis (SpA) have been regularly associated. Bone iliac granulomas have also been described. We propose herein a systematic review of...
BACKGROUND
Sarcoidosis and spondyloarthritis (SpA) have been regularly associated. Bone iliac granulomas have also been described. We propose herein a systematic review of rheumatologic axial manifestations of sarcoidosis.
METHODS
PubMed and the Cochrane Library were used to conduct this systematic literature review. Case reports and cross-sectional studies were reviewed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.
RESULTS
A total of 41 articles were eligible. Three cross-sectional studies on the association between SpA and sarcoidosis showed a prevalence of sacroiliitis and SpA ranging from 12.9 to 44.8% and 12.9 to 48.3% in inflammatory back pain (IBP) subgroups, respectively. However, the IBP definitions and sacroiliac joint (SIJ) imaging modalities (X-rays or magnetic resonance imaging) were heterogeneous, and X-ray was mainly used for sacroiliitis diagnosis (in 78% of cases). Thirty-one case-report articles of the sarcoidosis-sacroiliitis association were identified, representing 35 patients. ASAS criteria for SpA were met in half of cases (16/32) and 46% (12/26) had HLA B27 positivity. Sarcoidosis occurred after sacroiliac symptoms in 47% of cases. In the seven case-report articles with granulomatous sacroiliac bone involvement, unilateral involvement seemed higher than in the sarcoidosis-sacroiliitis group.
CONCLUSION
Literature analysis found a good evidence of the association between SpA and sarcoidosis, and special attention should be given to patients reporting IBP. Unilateral sacroiliitis may raise suspicion of granulomatous bone involvement, distinct from sacroiliitis. Imaging modalities used to study the SIJ in patients with sarcoidosis have been heterogeneous and further investigation is needed.
Topics: Back Pain; Cross-Sectional Studies; Friends; Humans; Magnetic Resonance Imaging; Sacroiliac Joint; Sacroiliitis; Sarcoidosis; Spondylarthritis
PubMed: 32622038
DOI: 10.1016/j.jbspin.2020.06.011 -
Acta Radiologica (Stockholm, Sweden :... Apr 2021Plain radiography serves a pivotal role in diagnosing axial spondyloarthritis. However, a broad range of diagnostic performance of plain radiography has been reported. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Plain radiography serves a pivotal role in diagnosing axial spondyloarthritis. However, a broad range of diagnostic performance of plain radiography has been reported.
PURPOSE
To perform a systematic review and meta-analysis to measure the diagnostic performance of plain radiography for sacroiliitis in patients suspected of having axial spondyloarthritis using magnetic resonance imaging (MRI) findings as the reference standard.
MATERIAL AND METHODS
Studies comparing radiography and MRI in the diagnosis of sacroiliitis in patients suspected of having axial spondyloarthritis were searched in PubMed and EMBASE. Additionally, studies analyzed SPondyloaArthritis Caught Early (SPACE), DEvenir des Spondylarthropathies Indifferenciées Récentes (DESIR), GErman Spondyloarthritis Inception Cohort (GESPIC), and South Swedish Arthritis Treatment Group (SSATG) cohorts were manually searched. Pooled sensitivity and specificity of radiography were calculated by using a bivariate random-effects model. Meta-regression analyses were performed to identify the sources of heterogeneity.
RESULTS
Eight eligible studies with 1579 patients were included. The pooled sensitivity and specificity of radiography were 0.55 (95% confidence interval [CI] = 0.40-0.69) and 0.87 (95% CI = 0.72-0.95). The meta-regression analyses showed prospective study design and criteria for MRI positivity considering only active bone marrow edema were associated with lower sensitivity.
CONCLUSION
The plain radiography showed low sensitivity and reasonable specificity in diagnosis of sacroiliitis in patients suspected of having axial spondyloarthritis.
Topics: Humans; Magnetic Resonance Imaging; Radiography; Sacroiliitis; Spondylarthritis
PubMed: 32536262
DOI: 10.1177/0284185120930624 -
Advances in Rheumatology (London,... Feb 2020Spondyloarthritis is a group of chronic inflammatory systemic diseases characterized by axial and/or peripheral joints inflammation, as well as extra-articular...
Spondyloarthritis is a group of chronic inflammatory systemic diseases characterized by axial and/or peripheral joints inflammation, as well as extra-articular manifestations. The classification axial spondyloarthritis is adopted when the spine and/or the sacroiliac joints are predominantly involved. This version of recommendations replaces the previous guidelines published in May 2013.A systematic literature review was performed, and two hundred thirty-seven studies were selected and used to formulate 29 recommendations answering 15 clinical questions, which were divided into four sections: diagnosis, non-pharmacological therapy, conventional drug therapy and biological therapy. For each recommendation the level of evidence supporting (highest available), the strength grade according to Oxford, and the degree of expert agreement (inter-rater reliability) is informed.These guidelines bring evidence-based information on clinical management of axial SpA patients, including, diagnosis, treatment, and prognosis.
Topics: Anti-Inflammatory Agents, Non-Steroidal; Antirheumatic Agents; Biological Therapy; Brazil; Exercise; Exercise Therapy; Glucocorticoids; HLA-B27 Antigen; Humans; Magnetic Resonance Imaging; Patient Education as Topic; Prognosis; Reproducibility of Results; Rheumatology; Sacroiliac Joint; Sacroiliitis; Societies, Medical; Spine; Spondylarthritis
PubMed: 32171329
DOI: 10.1186/s42358-020-0116-2 -
Pediatric Dermatology Jan 2020Isotretinoin is the mainstay treatment in severe acne; however, its musculoskeletal adverse effects such as lower-back pain can be disabling. Herein, we present four... (Review)
Review
Isotretinoin is the mainstay treatment in severe acne; however, its musculoskeletal adverse effects such as lower-back pain can be disabling. Herein, we present four cases of isotretinoin-induced sacroiliitis with variable severity. We also present a review of the literature of isotretinoin-induced sacroiliitis. All our cases were male and human leukocyte antigen (HLA)-B27 negative. Sacroiliitis was detected a median of 55 (10-120) days after isotretinoin initiation. Two patients were responsive to baseline sulfasalazine and indomethacin treatment, while the other two patients required more intensive treatments: adalimumab in one and methotrexate in the other. We also identified 15 articles describing 33 patients (17 of whom were female) with isotretinoin-induced sacroiliitis. Most of them were responsive to low-to-medium doses of systemic steroids or non-steroidal anti-inflammatory drugs (NSAIDs). Our patients illustrate that severity of isotretinoin-induced sacroiliitis varies from patient to patient.
Topics: Acne Vulgaris; Adolescent; Dermatologic Agents; Humans; Isotretinoin; Magnetic Resonance Imaging; Male; Sacroiliitis
PubMed: 31765029
DOI: 10.1111/pde.14035 -
Musculoskeletal Surgery Aug 2020The sacroiliac joint (SIJ) is a possible source of persistent or new onset pain after lumbar or lumbosacral fusion. The aim of this paper is to systematically review and...
The sacroiliac joint (SIJ) is a possible source of persistent or new onset pain after lumbar or lumbosacral fusion. The aim of this paper is to systematically review and analyze the available literature related to the incidence, diagnosis and management of sacroiliitis after spinal arthrodesis. The authors independently screened the titles and abstracts of all articles identified concerning sacroiliac joint pain after lumbar or lumbosacral fusion, to assess their suitability to the research focus. The average incidence of sacroiliitis after lumbar or lumbosacral arthrodesis was found to be 37 ± 28.48 (range 6-75), increasing directly to the number of fused segments involved, especially when the sacrum is included. The most accurate evaluation is the image-guided injection of anesthetic solutions in the joint. Surgery treatment may be considered when conservative therapy fails, with open surgery or with minimally invasive SIJ fusion. Although the risk of developing SIJ degeneration is unclear, the results indicate that pain and degeneration of SIJ develop more often in patients undergoing lumbosacral fusion regardless of the number of melting segments. The treatment of sacroiliitis appears to be independent of his etiology, with or without previous instrumentation on several levels.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anesthetics, Local; Arthrodesis; Child; Failed Back Surgery Syndrome; Female; Humans; Incidence; Injections, Intra-Articular; Lumbar Vertebrae; Male; Middle Aged; Postoperative Complications; Sacroiliac Joint; Sacroiliitis; Sacrum; Spinal Fusion; Young Adult
PubMed: 31065955
DOI: 10.1007/s12306-019-00607-0 -
Rheumatology (Oxford, England) Nov 2019To summarize the evidence on the performance of MRI for the diagnosis of axial SpA.
OBJECTIVES
To summarize the evidence on the performance of MRI for the diagnosis of axial SpA.
METHODS
This was a systematic literature review of all studies from January 2013 to March 2017 including adult patients with clinically suspected axial SpA undergoing MRI. Studies from a previously published systematic literature review up to January 2013 were also included.
RESULTS
Thirty-one studies were included. Six studies demonstrated good sensitivity and specificity for SI joint (SIJ) bone marrow oedema (BMO). Specificity was increased by the presence of other structural lesions alongside BMO, particularly erosions or fat infiltration. Four studies addressed the utility of SIJ fat infiltration, finding good sensitivity but poor specificity. SIJ erosions showed good specificity in five studies. Studies addressing high T1 signal in the SIJ, fluid signal in the SIJ, ankylosis, sclerosis, capsulitis, backfill and vacuum phenomenon reported limited diagnostic value. In the spine, four studies reported moderate sensitivity and specificity for corner inflammatory lesions, and four reported poor sensitivity and specificity for spinal fat infiltration. Five studies evaluated the added value of spinal MRI over SIJ MRI alone, with variable results depending on the cohort. Six studies addressed the effect of acquisition parameters on diagnostic accuracy: fat-saturated T2-weighted imaging and short tau inversion recovery (STIR) imaging showed comparable utility in identifying BMO. Three studies showed that gadolinium was of minimal added value in the detection of BMO.
CONCLUSIONS
These results confirmed the diagnostic utility of MRI in axial SpA. Performance varied according to the characteristics of the cohort and the number and combination of MRI lesions considered.
Topics: Adult; Bone Marrow; Edema; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Sacroiliac Joint; Sensitivity and Specificity; Spine; Spondylarthritis
PubMed: 31046102
DOI: 10.1093/rheumatology/kez172