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Arthritis Care & Research Jun 2019To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non-systemic polyarthritis, sacroiliitis, or enthesitis.
2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis.
OBJECTIVE
To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non-systemic polyarthritis, sacroiliitis, or enthesitis.
METHODS
The Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions were developed and refined by members of the guideline development teams. A systematic review was conducted to compile evidence for the benefits and harms associated with treatments for these conditions. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of evidence. A group consensus process was conducted among the Voting Panel to generate the final recommendations and grade their strength. A Parent and Patient Panel used a similar consensus approach to provide patient/caregiver preferences for key questions.
RESULTS
Thirty-nine recommendations were developed (8 strong and 31 conditional). The quality of supporting evidence was very low or low for 90% of the recommendations. Recommendations are provided for the use of nonsteroidal antiinflammatory drugs, disease-modifying antirheumatic drugs, biologics, and intraarticular and oral glucocorticoids. Recommendations for the use of physical and occupational therapy are also provided. Specific recommendations for polyarthritis address general medication use, initial and subsequent treatment, and adjunctive therapies. Good disease control, with therapeutic escalation to achieve low disease activity, was recommended. The sacroiliitis and enthesitis recommendations primarily address initial therapy and adjunctive therapies.
CONCLUSION
This guideline provides direction for clinicians, caregivers, and patients making treatment decisions. Clinicians, caregivers, and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
Topics: Anti-Inflammatory Agents, Non-Steroidal; Antirheumatic Agents; Arthritis, Juvenile; Biological Products; Consensus; Enthesopathy; Glucocorticoids; Humans; Occupational Therapy; Physical Therapy Modalities; Rheumatology; Risk Factors; Sacroiliitis; Treatment Outcome
PubMed: 31021516
DOI: 10.1002/acr.23870 -
AJR. American Journal of Roentgenology May 2019Accurate and reproducible MRI assessment of the sacroiliac joint (SIJ) is challenging. Numerous scoring systems have been proposed to facilitate consistent SIJ... (Review)
Review
Accurate and reproducible MRI assessment of the sacroiliac joint (SIJ) is challenging. Numerous scoring systems have been proposed to facilitate consistent SIJ assessment. The purpose of this article is to evaluate the diagnostic accuracy and reliability of existing MRI-based SIJ scoring systems for the evaluation of spondyloarthropathy. Among existing methods, there is fair (grade B) evidence to recommend the Spondyloarthropathy Research Consortium of Canada scoring systems as tools for MRI evaluation of the SIJ. However, limited data on criterion validity limit assessment of scoring system accuracy.
PubMed: 30860884
DOI: 10.2214/AJR.17.19429 -
Rheumatology International Oct 2018Ultrasound (US) is an accessible imaging technique with a possible role to diagnose active sacroiliitis, so this technique is projected as a promising diagnostic tool...
Ultrasound (US) is an accessible imaging technique with a possible role to diagnose active sacroiliitis, so this technique is projected as a promising diagnostic tool for the diagnosis of SpA. We analyse the available evidence about the use of US as a diagnostic tool in sacroiliitis in patients with SpA, by a systemic review of the literature fulfilling OMERACT criteria. A systematic literature search for original articles was carried out using four databases (Medline, Embase, Scopus and Web of Science). Data from studies were included only if participants had SpA and a US examination of sacroiliac joint (SIJ) was performed. The methodological quality of the studies was assessed using QUADAS-2 tool. Thirteen studies were included. All studies were observational, prospective and cross-sectional. In most articles (76.9%), the main US finding compatible with sacroiliitis evaluated was the presence of vascularisation (Doppler signals) with measurements of the resistive index (RI). The sensitivity and specificity analysis were performed in seven studies (58.8%) and were good, with a median of 90 and 89.2%, respectively. The studies showed a positive to moderate a strong correlation between the US and the gold standard but this was optimal only in four studies. In general, the agreement was good in all studies (≥ 0.80). The methods of evaluation of sacroiliitis vary between the studies included. To date, there is not enough evidence to support the use of ultrasound as a diagnostic method for sacroiliitis but it has potential to identify structural lesions at SIJ's level.
Topics: Cross-Sectional Studies; Humans; Prospective Studies; Sacroiliac Joint; Sacroiliitis; Spondylarthritis; Ultrasonography, Doppler
PubMed: 30099591
DOI: 10.1007/s00296-018-4126-x -
Gastroenterologia Y Hepatologia Jan 2018To define clinical screening criteria for spondyloarthritis (SpA) in patients with inflammatory bowel disease (IBD) and vice versa, which can be used as a reference for... (Review)
Review
OBJECTIVE
To define clinical screening criteria for spondyloarthritis (SpA) in patients with inflammatory bowel disease (IBD) and vice versa, which can be used as a reference for referring them to the rheumatology or gastroenterology service.
METHOD
Systematic literature review and a two-round Delphi method. The scientific committee and the expert panel were comprised of 2 rheumatologists and 2 gastroenterologists, and 7 rheumatologists and 7 gastroenterologists, respectively. The scientific committee defined the initial version of the criteria, taking into account sensitivity, specificity, standardization and ease of application. Afterwards, members of the expert panel assessed each item in a two-round Delphi survey. Items that met agreement in the first or second round were included in the final version of the criteria.
RESULTS
Positive screening for SpA if at least one of the following is present: onset of chronic low back pain before 45 years of age; inflammatory low back pain or alternating buttock pain; HLA-B27 positivity; sacroiliitis on imaging; arthritis; heel enthesitis; dactylitis. Positive screening for IBD in the presence of one of the major criteria or at least two minor criteria. Major: rectal bleeding; chronic diarrhea with organic characteristics; perianal disease. Minor: chronic abdominal pain; iron deficiency anemia or iron deficiency; extraintestinal manifestations; fever or low grade fever, of unknown origin and duration >1week; unexplained weight loss; family history of IBD.
CONCLUSION
Screening criteria for IBD in patients with SpA, and vice versa, have been developed. These criteria will be useful for early detection of both diseases.
Topics: Delphi Technique; Diarrhea; Early Diagnosis; Gastroenterology; Gastrointestinal Hemorrhage; HLA-B27 Antigen; Humans; Inflammatory Bowel Diseases; Low Back Pain; Rectum; Referral and Consultation; Rheumatology; Sacroiliitis; Sensitivity and Specificity; Spondylarthritis; Symptom Assessment
PubMed: 28882616
DOI: 10.1016/j.gastrohep.2017.03.012 -
BMC Musculoskeletal Disorders Jun 2017Axial spondyloarthritis (AxSpA) is a relatively frequent and debilitating disease, with a prevalence ranging from 0.1 to 2% in the Caucasian population. Current... (Review)
Review
BACKGROUND
Axial spondyloarthritis (AxSpA) is a relatively frequent and debilitating disease, with a prevalence ranging from 0.1 to 2% in the Caucasian population. Current Assessment of Spondyloarthritis International Society (ASAS) classification criteria of AxSpA rely either on sacroiliitis on imaging plus one SpA feature or positive HLAB27 antigen plus two SpA features, in a patient with chronic low back pain and age at onset of less than 45 years. Therefore, HLA-B27 is a central feature in SpA classification and plays a pivotal role in referral strategies and early diagnosis. The primary objective of the study is to review the prevalence of HLA-B27 in normal and AxSpA populations in Middle Eastern and Arab Countries and to assess the strength of association between HLA-B27 antigen and AxSpA. The secondary objective is to identify the gaps in the methodology of the studies and suggest a framework for future research.
METHODS
Studies were included in the analysis if they reported prevalence of HLA-B27 in AxSpA and/or general population and if they covered geographical location in the Middle East or Arab countries in the Mediterranean basin. Odds ratios (OR) were calculated for each country, as a measure of the strength of association between HLA-B27 and AxSpA, compared to the normal population, using the two-by-two frequency table. Available data from the literature were analyzed according to the following quality indicators: sample size, method of HLA-B27 testing, presence of control group and external validity.
RESULTS
Twenty-seven studies were analyzed. HLAB27 prevalence in the normal population ranged from 0.3% (Oman) to 6.8% (Turkey). HLA-B27 prevalence in AxSpA ranged from 26.2% (Lebanon) to 91% (Turkey). HLA-B27 prevalence in all SpA ranged from 13.87% (Lebanon) to 69.43% (Kuwait). Peripheral SpA was less associated with HLA-B27 than AxSpA, indicating the need of differentiating between the two entities when calculating prevalence. When available (8 studies), the OR ranged from 21.63 (Morocco) to 105.6 (Syria). The high heterogeneity between the results can be due to differences in methodology: study sample size, different classification criteria, absence of control groups, HLA-B27 testing method.
CONCLUSIONS
The prevalence of HLA-B27 in the normal population is significantly lower in the Middle Eastern and Arab countries than in Western Countries. However, HLA-B27 testing can be useful for AxSpA positive diagnosis, given the high OR. Heterogeneity between countries may be due to methodological differences.
Topics: HLA-B27 Antigen; Humans; Middle East; Spondylarthritis
PubMed: 28662723
DOI: 10.1186/s12891-017-1639-5 -
Journal of Crohn's & Colitis May 2017Inflammatory bowel disease [IBD] is a chronic disease which affects up to 0.5% of the population. Various extraintestinal manifestations occur, among which are rheumatic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND AIMS
Inflammatory bowel disease [IBD] is a chronic disease which affects up to 0.5% of the population. Various extraintestinal manifestations occur, among which are rheumatic manifestations, grouped together under the name spondyloarthritis. The objective of this systematic review and meta-analysis was to give a systematic overview of the prevalence and incidence of spondyloarthritis in patients with inflammatory bowel disease.
METHODS
We systematically searched Embase, Pubmed, OvidSP, Scopus, and Web-of-Science databases from inception to August 2016. All articles that addressed the prevalence or incidence of the different features of spondyloarthritis in adult inflammatory bowel disease patients were included. Methodological quality was assessed using a modified quality assessment tool developed for prevalence studies.
RESULTS
A total of 71 studies were included, reporting on the prevalence of sacroiliitis, ankylosing spondylitis, arthritis, enthesitis, and dactylitis. Pooled prevalences were calculated for sacroiliitis (10%; 95% confidence interval [CI] 8-12%), ankylosing spondylitis [3%; 95% CI 2-4%], and arthritis [13%; 95% CI 12-15%]. Geographical area, setting and use of different criteria contribute to the large heterogeneity. Few estimates were available for enthesitis [prevalence range from 1% to 54%] and dactylitis [prevalence range from 0% to 6%]. Only three incidence studies were identified, which report cumulative incidences from 5 to 30 years.
CONCLUSIONS
Spondyloarthritis occurs in up to 13% of patients with IBD. Ankylosing spondylitis is the least common [3%] followed by sacroiliitis [10%] and peripheral arthritis [13%].
Topics: Arthritis; Humans; Incidence; Inflammatory Bowel Diseases; Prevalence; Sacroiliitis; Spondylarthritis; Spondylitis, Ankylosing
PubMed: 28453761
DOI: 10.1093/ecco-jcc/jjw199 -
International Journal of Spine Surgery 2015A number of studies have been published regarding minimally invasive surgical (MIS) fusion of the sacroiliac (SI) joint using a lateral transarticular approach. Herein...
BACKGROUND
A number of studies have been published regarding minimally invasive surgical (MIS) fusion of the sacroiliac (SI) joint using a lateral transarticular approach. Herein we report a systematic review and meta-analysis to summarize operative measures and clinical outcomes reported in published studies of MIS SI joint fusion.
METHODS
The systematic review was done according to PRISMA standards. PubMed and EMBASE were searched using the terms sacroiliac joint AND fusion. Original peer-reviewed articles in the English language that reported clinical outcomes on at least 5 cases of MIS SI joint fusion using a lateral transarticular approach were included. Random effects meta-analysis (RMA) was performed on selected variables using the DerSimonian and Laird method, including operative measures, VAS SI joint pain ratings (0-10 scale) and Oswestry Disability Index (ODI). Mean and 95% confidence intervals (CI) were calculated and heterogeneity was assessed. Other findings were summarized qualitatively.
RESULTS
A total of 18 articles met the inclusion criteria. After accounting for overlapping cohorts, 12 unique cohorts from 4 countries were extracted for a total of 432 subjects. The RMA mean (range) was 59 minutes (27-78) for procedure time, 36.9cc (10-70) for estimated blood loss and 1.7 days (range 0-7) for length of stay (LOS). The RMA mean [95% CI] pain score dropped by 5.2 points at 6 months and 5.3 points at 12 months (baseline score of 8.1 [7.8-8.4], 12-month score of 2.7 [2.1-3.3]), and a 24-month score of 2.0(1.4-2.5). ODI decreased by 31 points at 12 months (baseline score of 56.2 [51.0-61.5], 6-month score of 30.7 [21.8-39.6], and 12-month score of 25.1 [12.3-37.9]). Some estimates showed significant variation across studies and between the types of implants used. Other reported outcomes were supportive of the positive effects of SI joint fusion.
CONCLUSION
Published studies of MIS SI joint fusion using a lateral transarticular approach confirm its minimally invasive characteristics with minimal blood loss and short operating room times, and show consistent, rapid, sustained and clinically important improvements in patient reported SI joint pain, disability and quality of life scores.
PubMed: 26273558
DOI: 10.14444/2040 -
Annals of the Rheumatic Diseases Aug 2015The aim of this work was to develop a consensual recommendation under the auspices of the Assessment of SpondyloArthritis international Society (ASAS) for early referral... (Review)
Review
The aim of this work was to develop a consensual recommendation under the auspices of the Assessment of SpondyloArthritis international Society (ASAS) for early referral of patients with a suspicion of axial spondyloarthritis by non-rheumatologists. The development of a referral recommendation consisted of four phases: (1) systematic literature review, (2) the first Delphi round aiming at identification of unmet needs and development of a candidate list of referral parameters, (3) the second Delphi round aiming at identification of the most useful combination of referral parameters and (4) final discussion and formal endorsement by ASAS membership. The following consensus on a referral recommendation was achieved as a result of the Delphi processes and final voting: "Patients with chronic back pain (duration ≥3 months) and back pain onset before 45 years of age should be referred to a rheumatologist if at least one of the following parameters is present: Inflammatory back pain; human leucocyte antigen-B27; Sacroiliitis on imaging if available (X-rays or magnetic resonance imaging); Peripheral manifestations (arthritis, enthesitis, dactylitis); Extra-articular manifestations (psoriasis, inflammatory bowel disease, uveitis); Positive family history for spondyloarthritis; Good response to non-steroidal anti-inflammatory drugs; Elevated acute phase reactant." A consensual ASAS-endorsed referral recommendation for patients suspected of having axial spondyloarthritis was developed as a flexible and universal strategy to be used in clinical practice by primary care physicians or non-rheumatology specialists. The practical value of this strategy applied in different settings should be determined in future studies.
Topics: Back Pain; Chronic Disease; Delphi Technique; Humans; Program Development; Referral and Consultation; Rheumatology; Spondylarthropathies
PubMed: 25990288
DOI: 10.1136/annrheumdis-2014-207151