Please refer to the full Prescribing Information at CIMZIAhcp.com.
This clinical perspective is a personal reflection of Dr Leonard Calabrese.
The current monograph brings together an impressive faculty of leaders in the field of spondyloarthritis (SpA) and provides an integrated review of advances in nosology, epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of non-radiographic axial spondyloarthritis (nr-axSpA). With this background, I would like to reflect on what this may mean to both physicians and advanced practitioners, as well as patients, as we move forward.
The entity of nr-axSpA, which has been widely accepted in Europe for some time, has finally become well ensconced at all levels of practice and regulatory affairs in the United States as well.1,2 Accordingly, we as a medical community must be knowledgeable and confident in our ability to diagnose and manage the disorder. We have long recognized that plain film radiographic changes are highly insensitive for the diagnosis of axSpA, and we now appreciate that many patients have and suffer from nr-axSpA, a disorder with substantial burden.3 This recognition has come about over many years, aided by early recognition through the use of biomarkers such as HLA-B27, careful epidemiologic and natural history studies, and, more recently, the incorporation of magnetic resonance imaging (MRI) as adjunct.3 Many practitioners have seen patients with clinical syndromes compatible with axSpA whose x-rays are normal but whose MRIs indicate abnormalities. Unfortunately, it’s not so easy to obtain MRIs on questionable cases and make our diagnosis in a binary fashion. As always, advances in technology come at a price, as we now increasingly recognize that there are limitations in both the sensitivity and specificity of MRI for making the diagnosis of nr-axSpA. As discussed, many patients with nr-axSpA have normal MRIs. However, the number of patients who progress to abnormal MRIs or show changes on plain x-rays may be extensive, though this varies from study to study. There are also limitations to MRI specificity—what initially appeared to be a clear representation of diagnostic changes, especially bone edema, has now become increasingly described in populations with no hint of axSpA.3 Thus, reader skill, proficient musculoskeletal radiologists, and an interprofessional approach to patient care have become increasingly important.
From the patient perspective, the current advances are particularly exciting, as the prospects of earlier recognition and diagnosis are now becoming more feasible. Diagnostic delays of up to a decade, particularly for women, are an unfortunate reality—one we hope will be shortened dramatically with awareness and skill.4,5 Recent advancements in the management of nr-axSpA have increased the urgency of prompt and accurate diagnosis to mitigate the effects of substantial impairment of quality of life and high burden of disease.3
Finally, and a topic of great interest to me personally, is the challenge of case discovery among patients with chronic low back pain who are not under current management by rheumatologists or spine experts. As we have seen, chronic low back pain is nearly epidemic in our society. This is also true for young adults who epidemiologically are enriched for axSpA of all forms.6 Primary care physicians, particularly osteopathic practitioners, who care for a disproportionate share of patients with low back pain, chiropractors, physical therapists and other care providers must also be educated and alerted to the features of axSpA. Simply, the clinicians’ capacity and inclination, as well as education, to screen for inflammatory back pain and assess patients for allied clinical and epidemiologic features will increase the likelihood of diagnosis. At the same time, the rheumatology community must be poised to provide reasonable access for such patients, which is problematic in an era of diminished work force capacity. As always, the glass can be viewed as half empty or half full, and I clearly choose the latter.
Leonard H. Calabrese, DO
Professor of Medicine
Cleveland Clinic Lerner College of Medicine
Chief Medical Editor, Healio Rheumatology
1. CIMZIA® [prescribing information]. Smyrna, GA: UCB, Inc.; 2019.
2. Robinson PC, Sengupta R, Siebert S. Non-radiographic axial spondyloarthritis (nr-axSpA): advances in classification, imaging and therapy [published online February 20, 2019]. Rheumatol Ther. doi: 10.1007/s40744-019-0146-6.
3. Lukas C, Cyteval C, Dougados M, Weber U. MRI for diagnosis of axial spondyloarthritis: major advance with critical limitations 'Not everything that glistens is gold (standard)'. RMD Open. 2018;4(1):e000586. doi: 10.1136/rmdopen-2017-000586.
4. Feldtkeller E, Khan MA, van der Heijde D, et al. Age at disease onset and diagnosis delay in HLA-B27 negative vs. positive patients with ankylosing spondylitis. Rheumatol Int. 2003;23(2):61-66.
5. Feldtkeller E, Bruckel J, Khan MA. Scientific contributions of ankylosing spondylitis patient advocacy groups. Curr Opin Rheumatol. 2000;12(4):239-247.
6. van Hoeven L, Boonen AERCH, Hazes JMW, Weel AEAM. Work outcome in yet undiagnosed patients with non-radiographic axial spondyloarthritis and ankylosing spondylitis: results of a cross-sectional study among patients with chronic low back pain. Arthritis Res Ther. 2017;19(1):143. doi: 10.1186/s13075-017-1333-x.
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Version: August 2019
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