No abstract

Contrast-enhanced MR imaging allows detection of sacroiliitis in early stages.

Background Therapeutic targets have been defined for diseases like diabetes, hypertension or rheumatoid arthritis and adhering to them has improved outcomes. Such recommendations are unavailable for spondyloarthritis. Objectives To define the treatment target for spondyloarthritis including ankylosing spondylitis (AS) and psoriatic arthritis (PsA) and develop recommendations for achieving the target, including a treat-to-target management strategy. Methods Based on results of a systematic literature review (performed by MS) and expert opinion, a task force of expert physicians and patients developed recommendations, which were broadly discussed and voted upon in a Delphi-like process. Level of evidence, grade of recommendation and strength of recommendation were derived by respective means. Results The literature review did not reveal trials comparing a treat-to-target approach with another or no strategy, but provided indirect evidence that facilitated the development of recommendations. The task force agreed on 5 overarching principles and 11 recommendations. Based on the current perception and classification of spondyloarthritis (including PsA, axial SpA (AS and non-radiographic axial SpA), peripheral SpA), only the last 2 recommendations are separate for axial spondyloarthritis, peripheral spondyloarthritis and PsA, while principles and 9 of the recommendations form a common trunk for all types of spondyloarthritis. The main treatment target, which should be based on a shared decision with the patient, was defined as remission, with an alternative target being low disease activity. Means to assess disease activity are discussed. Regular follow-up examinations should safeguard the evolution of disease activity toward the targeted goal. Additional items relate to extraarticular and extramusculoskeletal aspects and other factors, such as comorbidity. While the level of evidence was low for all items, the mean strength of recommendation was 9-10 (10: maximum agreement) for all recommendations. A research agenda was formulated. Conclusions The recommendations shall inform patients, rheumatologists, dermatologists and other experts as well as other stakeholders about expert opinion that allows reaching optimal outcomes of spondyloarthritis including AS and PsA. Acknowledgements This work was supported by an unrestricted educational grant from Abbott. Disclosure of Interest J. Smolen Grant/research support from: Abbott, Consultant for: Abbott, J. Braun: None Declared, M. Dougados: None Declared, P. Emery: None Declared, O. FitzGerald: None Declared, P. Helliwell: None Declared, A. Kavanaugh: None Declared, T. Kvien: None Declared, R. Landewé: None Declared, T. Luger: None Declared, P. Mease: None Declared, I. Olivieri: None Declared, J. Reveille: None Declared, C. Ritchlin: None Declared, M. Rudwaleit: None Declared, M. Schoels: None Declared, J. Sieper: None Declared, M. de Wit: None Declared, D. van der Heijde: None Declared

Seronegative and HLA B27-associated spondyloarthropathy (SpA) is a heterogeneous disease, so far without a clear origin. The term comprises five clinically defined subcategories: ankylosing spondylitis (AS), psoriatic arthritis (PsA), reactive arthritis (ReA), inflammatory bowel disease-associated arthritis and undifferentiated spondyloarthropathy (uSpA). Sacroiliitis, an inflammatory involvement of one or both sacroiliac joints, is the key symptom of all spondyloarthropathies. Sacroiliitis is often associated with inflammatory back pain, manifest as deep nocturnal back pain that is improved by exercise. The pathogenesis of SpA and the reason for the tropism for the sacroiliac joints is still obscure. A genetic background of an initially bacterial triggered infection seems to be most likely.

CT-guided intra-articular corticosteroid injection has proven an effective, symptomatic, and uncomplicated therapy of acute sacroiliitis in patients with jSpA. Dynamic MRI has a role in establishing the indication for intervention but its role for any follow-up is restricted to cases with inconclusive clinical response.