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Published: 7 July 2024
Last updated: 7 July 2024

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1

Nicknam, Mohammad Hossein, ed. Ankylosing Spondylitis - Axial Spondyloarthritis. Singapore: Springer Singapore, 2022. http://dx.doi.org/10.1007/978-981-16-4733-8.

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2

Sieper, Joachim, and Jürgen Braun. Clinician’s Manual on Axial Spondyloarthritis. Tarporley: Springer Healthcare Ltd., 2014. http://dx.doi.org/10.1007/978-1-907673-85-6.

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3

Garrido-Cumbrera, Marco, Victoria Navarro-Compán, Christine Bundy, Raj Mahapatra, Souzi Makri, Carlos J. Delgado-Domínguez, Pedro Plazuelo-Ramos, and Denis Poddubnyy. Axial Spondyloarthritis: Patient-Reported Impact in Europe. Cham: Springer International Publishing, 2022. http://dx.doi.org/10.1007/978-3-030-97606-4.

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4

Sheldon, Peter John. Lymphocyte responses in rheumatoid reactive and spondyloarthritis. Birmingham: University of Birmingham, 1987.

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5

Siebert, Stefan, Raj Sengupta, and Alexander Tsoukas, eds. Axial Spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.001.0001.

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Ankylosing spondylitis (AS) is a chronic inflammatory arthritis affecting mainly the sacroiliac joints and spine, resulting in pain, stiffness, and reduced movement. Over the past decade there have been major advances in many aspects of the disease, including a broadening of the disease description to axial spondyloarthritis (axSpA). While the many advances have transformed the lives of patients with axSpA, they have also increased complexity for non-specialists in this area. This handbook contains a timely update of the key developments and current state of play in axSpA. It is intended primarily for the many healthcare professionals who encounter patients with this condition, in both primary and secondary care settings. It will also be of interest to the wider medical and research community.The handbook is written by rheumatologists with active research programmes and clinical expertise in these conditions. The topics covered include: • the clinical features • extra-articular manifestations and complications • the impact on patients’ lives • the major advances in genetics and pathogenesis • imaging advances • classification criteria and diagnosis (and the important differences between these) • treatment advances (particularly TNF inhibitors and upcoming biologics)
6

Axial Spondyloarthritis. Elsevier, 2020. http://dx.doi.org/10.1016/c2017-0-01005-4.

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7

Khan, Muhammad Asim, and Philip Mease. Axial Spondyloarthritis. Elsevier - Health Sciences Division, 2019.

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8

Siebert, Stefan, Raj Sengupta, and Alexander Tsoukas. Axial Spondyloarthritis. Oxford University Press, 2016.

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9

Brown, Matthew A., and John Reveille. Genetics of spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0005.

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In addition to sharing clinical, histopathological, and immunological features, spondyloarthritis (SpA) encompasses a group of diseases that are genetically linked through shared associations with HLA-B27, as well as other genes of the IL-23R and aminopeptidase groups. Great progress has been made since the development of the genome-wide association study approach, with better dissection of the HLA associations of this group of diseases, as well as the discovery of multiple genetic loci found outside of the major histocompatibility complex, in ankylosing spondylitis (AS) in particular. These genetic data shed light on the related pathogenesis of AS and psoriatic arthritis (PsA), inflammatory bowel disease (IBD)-related arthritis, and reactive arthritis (ReA). Genetic associations also strengthen the suggestive data that Behçet’s disease (BD) and Familial Mediterranean Fever (FMF) are related to the more classical forms of SpA.
10

Leirisalo-Repo, Marjatta, and John D. Carter. Infection and spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0009.

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Spondyloarthritis (SpA) is the designation encompassing a group of inflammatory diseases with several features in common. The patients have mono- or oligoarthritis with or without inflammatory back symptoms. Distinctive extra-articular inflammatory symptoms also characterize the diseases. The diagnostic subgroups in the SpA family include reactive arthritis (ReA), ankylosing spondylitis (AS), arthritis associated with inflammatory bowel disease (IBD), psoriasis arthritis (PsA), and some forms of juvenile-onset arthritis. These diseases share a strong association with a genetic marker, HLA-B27, absence of rheumatoid factor, tendency to family aggregation, and frequently occurring extra-articular manifestations. This chapter discusses the role of infections, either as triggering of the disease, most evident in the case of ReA, or as possibly contributing factors in the development of chronic forms of SpA and AS.
11

Burgos-Vargas, Ruben, and Shirley M. L. Tse. Juvenile-onset spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0015.

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Juvenile-onset spondyloarthritis (JoSpA) refers to the group of HLA-B27-associated paediatric rheumatic diseases that involves the synovium and entheses of peripheral joints in the initial years and, in some patients, the sacroiliac and spinal joints several years later. Patients with JoSpA may also have extra-articular manifestations, including anterior uveitis, psoriasis and inflammatory bowel disease (IBD), and this represents a disease continuum with adult-onset SpA. JoSpA might include patients with enthesitis-related arthritis (ERA) and PsA categories of juvenile idiopathic arthritis (JIA), according to the International League of Associations for Rheumatology (ILAR). The opposite does not occur, since ILAR JIA classification does not allow the possibility of clinical overlapping among the different categories, one of the most important features of SpA.
12

Khan, Muhammad Asim. Ankylosing Spondylitis-Axial Spondyloarthritis. Professional Communications, Inc., 2016.

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13

Gensler, Lianne, Michael Weisman, and Liron Caplan. Epidemiology of axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0002.

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Axial spondyloarthritis (axSpA) is an inflammatory arthritis of the sacroiliac joints and spine. The prototype is ankylosing spondylitis, the radiographic form of the disease; however, more recently, an earlier or less-differentiated presentation has been described termed non-radiographic axial spondyloarthritis (nr-axSpA). Extra-articular manifestations commonly include anterior uveitis, inflammatory bowel disease, and psoriasis. There is a strong association with the human leukocyte antigen B27 (HLA-B27) allele, and the prevalence of the disease tends to follow the frequency of the allele. Epidemiological studies in axSpA are relevant in the population studied and therefore have limited external validity. This chapter describes the epidemiology of axSpA.
14

Xu, Huji, Feng Huang, Chan-Bum Choi, and Tae-Hwan Kim. Axial spondyloarthritis in Asia. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0028.

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The prevalence of axial spondyloarthritis (axSpA) in Chinese and Korean populations is not dissimilar to that in Caucasians. However, the age of onset is younger and peripheral arthritis of the lower limb is relatively more common. Multicenter studies have revealed similarities and differences among different ethnic backgrounds. For example, the dominant HLA-B27 subtype in Chinese SpA is B2704, while it is B2705 in Koreans. Both Chinese and Korean rheumatologists have adopted ASAS/EULAR guidelines to manage axSpA. TNFi are covered by insurance in Korea but not in China. Owing to early onset and the high cost of TNFi therapy, axSpA has placed enormous burdens on both patients and society in Asia. To achieve a higher HRQoL, rheumatologists are bringing forward cost-effective and treat-to-target therapeutic strategies by integrating nonpharmacological treatment, traditional medications, and biologics in a multimodality setting. Further basic and clinical studies in Asian populations are needed to improve decision-making in clinical practice.
15

Malaviya, Anand, and Ashok Kumar. Axial spondyloarthritis in India. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0030.

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Spondyloarthritis (SpA) is among the commonest rheumatological conditions in India, second only to rheumatoid arthritis (RA). This is consistent with the fact that the prevalence of SpA is linked to the prevalence of HLA-B27 in that population. Its prevalence in different regions of the country has been reported to be approximately 6%. That would put India prominently on the SpA map of the world, reflected in the large number of publications from the late 1970s onwards, dispelling any earlier misconceptions that it is largely a ‘white man’s disease’. This chapter summarizes the various aspects of SpA as reported from India.
16

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. Complications of axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0009.

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In addition to the well-recognized extra-articular manifestations (EAMs) of ankylosing spondylitis (AS), this condition can also be associated with a number of clinically important complications. While EAMs are considered part of the spondyloarthritis (SpA), the complications are generally a consequence of having the disease. Patients with AS are at increased risk of osteoporosis and spinal fractures. The latter may occur after seemingly minor trauma and may lead to significant neurological compromise. Other potential neurological complications include atlantoaxial subluxation and compressive radiculopathy or myelopathy. Cardiac complications include cardiovascular events, valvular disease, and conduction disturbances. Pulmonary disease in AS relates to parenchymal involvement or mechanical constraint from chest wall inflammation. Renal disease is generally rare in AS.
17

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. Imaging in axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0011.

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Imaging has always been a key component in the diagnosis of ankylosing spondylitis as part of the modified New York criteria. With the increased availability of MRI and the development of the ASAS axial spondyloarthritis (axSpA) criteria, there has been a shift from x-ray imaging of structural damage to MRI imaging of inflammation. This information can help in both the diagnosis of axSpA and in guiding treatment decisions in patients with this diagnosis. However, imaging results must be evaluated in the context of the clinical picture and should not be acted on in isolation. Here we review the key imaging modalities used in axSpA, with the main focus on x-rays and MRI of the sacroiliac joints, spine, and peripheral structures. Advances in technology are also likely to lead to the development of even better imaging modalities for axSpA in future.
18

Keith, Donald. Clinician's Guide to Axial Spondyloarthritis. American Medical Publishers, 2021.

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19

O'Neill, J., and Walter Maksymowych. Imaging Atlas of Axial Spondyloarthritis. Tellwell Talent, 2020.

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20

Inman, Robert, and Joachim Sieper, eds. Oxford Textbook of Axial Spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.001.0001.

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Axial spondyloarthritis is a relatively new term, now becoming widely accepted in clinical practice, referring to inflammatory disease predominantly of the spine where the main symptom is back pain. The most common subset of AxSpA is ankylosing spondylitis. This is a rapidly evolving field with new diagnostic criteria and treatments, which are likely to evolve further. This book covers the significant recent advances in the epidemiology, genetics, pathogenesis, classification, and treatment of this disabling disease, from a truly global perspective.
21

Sampaio-Barros, Percival, and Rafael Valle-Oñate. Axial spondyloarthritis in Latin America. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0029.

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Latin American countries are often characterized by a significant miscegenation among whites, blacks, and Amerindians. These heterogeneous populations frequently represent a challenge for the design of studies analysing the genetics, incidence, and prevalence of rheumatic diseases. In this setting, axial spondyloarthritis (axSpA) frequently shows an increased associated peripheral involvement, compared with the homogeneous population. Genetic and socioeconomic factors can be associated with this clinical presentation, although further studies are necessary to confirm this hypothesis. Regarding treatment, Latin American spondyloarthritis (SpA) patients also show a higher prescription of corticosteroids, methotrexate, and sulfasalazine than European series. This chapter presents and discusses the many aspects related to the presentation of axSpA in Latin America.
22

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. The genetics of axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0004.

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Family and twin studies have long suggested a large genetic component in ankylosing spondylitis (AS). The genetic association with HLA-B27 remains one of the strongest single gene variant associations reported in any complex polygenic disease. The exact mechanism by which HLA-B27 contributes to AS remains unknown, with three main theories proposed: the arthritogenic peptide, endoplasmic reticulum stress with unfolded protein response, and homodimerization theories. Genome-wide association studies have identified a number of other important susceptibility genes for AS, several of which overlap with other spondyloarthritis conditions. Of these, ERAP1 and IL-23R, are covered in more detail, highlighting their functional importance.
23

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. Drug treatment for axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0015.

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The pharmacological therapy for patients with axial spondyloarthritis (axSpA), especially those with severe disease, has been transformed by the introduction of the biologic therapies, and anti-TNF therapy in particular. Until approximately 2005, treatment options for ankylosing spondylitis (AS) were limited to exercise therapy and non-steroidal anti-inflammatory drugs (NSAIDs). The TNF inhibitors appear to have a good safety profile in axSpA, with no new safety signals. The high cost of innovator biologics remains an issue and it will be interesting to observe the effect of the introduction of multiple biosimilar TNF inhibitors in clinical practice. New therapeutics targeting different cytokine and signalling pathways should also become available over the next few years, so it remains to be seen what their role will be in the management of axSpA. This chapter reviews some of the key drug therapies and advances in the management of axSpA.
24

Khan, Muhammad Asim. Axial Spondyloarthritis and Ankylosing Spondylitis. Oxford University Press, 2022.

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25

McGrath, Bradley. Axial Spondyloarthritis: A Clinical Approach. Foster Academics, 2021.

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26

Braun, Jürgen, and Joachim Sieper. Clinician’s Manual on Axial Spondyloarthritis. Springer Healthcare, 2014.

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27

Braun, Jürgen, and Joachim Sieper. Clinician’s Manual on Axial Spondyloarthritis. Adis, 2014.

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28

Inman, Robert, and Joachim Sieper. Oxford Textbook of Axial Spondyloarthritis. Oxford University Press, 2016.

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29

Rothschild, Bruce, and Ernst Feldtkeller. Spondyloarthritis in antiquity and in history. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0001.

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Spondyloarthropathy has a long history in the fossil record, one that even predates dinosaurs. It is prevalent in contemporary animals, especially apes, bears, rhinoceros, and Komodo dragons. Prevalence in the archaeologic record is predominantly uniform, independent of geology, except in areas where sanitation is compromised. Major advance in its diagnosis came about with the introduction of radiologic techniques, HLA-B27 tissue typing, and recognition that it was not a rheumatoid variant. In spondyloarthritis therapy, immobilization was replaced by active physiotherapy and thorough patient education.
30

van Gaalen, Floris, Désirée van der Heijde, and Maxime Dougados. Diagnosis and classification of axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0003.

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Axial spondyloarthritis (axSpA) is a potentially disabling chronic inflammatory disease affecting the spine and sacroiliac (SI) joints. Lead symptoms are chronic back pain and stiffness. The disease is called radiographic axSpA or ankylosing spondylitis (AS) when, on plain radiographs, bone changes consistent with sacroiliitis are present. When no evidence of sacroiliitis is seen on radiographs, it is called non-radiographic axSpA. In such cases, diagnosis is made based on evidence of active inflammation of SI joints on magnetic resonance imaging (MRI) and clinical and laboratory features, or a combination of clinical and laboratory features only. Apart from affecting the spine and SI joints, axSpA may involve peripheral joints (e.g. knee, ankle) and manifest in extra-articular manifestations, for example uveitis, psoriasis, and inflammatory bowel disease. In this chapter, diagnosis and classification of axSpA is discussed, including use of MRI in detecting sacroiliitis and the difference between clinical diagnosis and disease classification.
31

Passalent, Laura, and Salih Ozgocmen. Non-pharmacological management in axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0019.

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The ASAS/EULAR panel recommends a multidisciplinary and patient-centred approach that includes a combination of pharmacological and non-pharmacological treatment modalities. These updated recommendations describe a number of non-pharmacological interventions as the cornerstone of treatment in patients with ankylosing spondylitis (AS). The aims of such treatment are to: (1) reduce pain and discomfort; (2) maintain or improve muscle strength, endurance, flexibility, mobility, balance, physical fitness, and social participation; and (3) prevent spinal abnormalities, joint contractures, and deformities. This chapter presents the evidence in support of common non-pharmacological interventions for axial spondyloarthritis (axSpA) and provides recommendations regarding the implementation of such treatment strategies.
32

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. Peripheral musculoskeletal involvement in axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0007.

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In addition to the axial diseases that characterizes axial spondyloarthritis (axSpA), many patients also develop peripheral musculoskeletal involvement. This can include peripheral joint synovitis, enthesitis, and dactylitis. Peripheral musculoskeletal involvement is an important component of the disease with significant impact on function and quality of life. Many of the features may also be subtle and overlooked, unless specifically evaluated and examined. In particular, hip disease is a bad prognostic feature and, if present, may require more aggressive therapy or surgical intervention. On occasion, further imaging may be required to detect enthesitis or subtle joint inflammation in order to inform treatment decisions.
33

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. Extra-articular manifestations of axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0008.

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Axial spondyloarthritis (axSpA) is associated with a number of extra-articular manifestations (EAMs) reflecting shared clinical, genetic, and pathophysiologicalfeatures. The EAMs are considered part of the spondyloarthritis spectrum and should be differentiated from complications arising as a consequence of the disease (covered in a separate chapter). The key EAMs of axSpA are inflammatory bowel disease (IBD), uveitis, and psoriasis. EAMs carry their own morbidity and often warrant treatment in their own right. Furthermore, the presence of EAMs may influence the choice of therapy used to treat the underlying axSpA. Clinicians should ensure that the well-recognized EAMs of axSpA are actively and regularly enquired about when reviewing patients with axSpA.
34

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. Classification criteria and diagnosis in spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0012.

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The spondyloarthropathies (SpA) are heterogeneous multisystem disorders with no single ‘gold standard’ clinical, laboratory, pathological or radiological feature to confirm the diagnosis. A number of criteria have therefore been developed to support clinical practice and research. In this chapter, we highlight the important differences between classification and diagnostic criteria, which are often confused although they have very different applications. We then review some of the major SpA classification criteria including the modified New York criteria for ankylosing spondylitis (AS), the Amor and ESSG criteria for SpA, and the ASAS criteria for axial spondyloarthritis (axSpA). The evolution of these classification criteria has facilitated many significant advances in the field of axSpA and SpA in general. Specifically, the development of classification criteria for axSpA that do not rely on established radiographic damage has allowed biologic therapies to be investigated, and used, in earlier disease and for a wider population of patients.
35

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. Non-pharmacological treatment of axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0014.

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While drugs play a key role in reducing disease activity, non-pharmacological therapies are crucial in maintaining function, flexibility, and quality of life. Therefore, non-pharmacological therapy remains a key component in the optimal management of axial spondyloarthritis (axSpA), even in the era of biologics. Regular physical therapy allows patients to capitalize on the benefits of drug therapy and maintain optimal functional ability. Self-management and education strategies, supported by patient-support groups, facilitate independence and quality of life in chronic diseases. A proportion of patients with severe disease may require hip or spinal surgery. It is hoped that the availability of more effective drug therapies to control disease activity in axSpA will reduce the requirement for surgery in future. The optimal management of axSpA requires a combination of non-pharmacological and pharmacological treatments, for both initial and long-term management.
36

Cumbrera, Marco Garrido, Victoria Navarro Compán, Christine Bundy, Raj Mahapatra, and Souzi Makri. Axial Spondyloarthritis: Patient-Reported Impact in Europe. Springer International Publishing AG, 2022.

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37

Rudwaleit, Martin, and Atul Deodhar. Diagnosis, classification, and management of peripheral spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0004.

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Spondyloarthritis (SpA) can affect the axial skeleton (axSpA) but also manifest as peripheral arthritis, enthesitis, and dactylitis (peripheral SpA). Peripheral SpA can occur after bacterial infections (reactive arthritis) or be associated with psoriasis or inflammatory bowel disease. The arthritis is usually asymmetric, affects predominantly the lower extremity, and can be self-limiting but can also run a chronic course. The frequency of HLA-B27 is around 50% in purely peripheral SpA, while it is 70–90% in axSpA. For classification, the Amor, ESSG, or more recent ASAS criteria for peripheral SpA can be used. The ASAS criteria are likely to capture early peripheral SpA better than the other two. Therapy includes NSAIDs, local steroid injections, and synthetic disease-modifying antirheumatic drugs, of which sulfasalazine is best studied and the preferred drug for peripheral arthritis. A recent, placebo-controlled clinical trial with adalimumab may lead to the first approval of a biologic in peripheral SpA.
38

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. What are axial spondyloarthritis and ankylosing spondylitis? Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0001.

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Ankylosing spondylitis (AS) is a chronic inflammatory arthritis affecting mainly the sacroiliac joints and spine, resulting in pain, stiffness, and reduced movement. AS has a major negative impact on patients’ quality of life. AS is part of a larger group of related spondyloarthritis (SpA) conditions and patients with AS often have extra-articular manifestations of these conditions. Over the past decade, there have been major advances in the understanding of the genetics and pathophysiology of the disease. Advances in imaging have allowed patients to be diagnosed without having to develop the radiographic structural damage that characterize AS, resulting in the concept of axial spondyloarthritis (axSpA). Together with the development of highly effective TNF inhibitors, these advances have transformed the management and outlook of patients with this condition. It is hoped that further advances in diagnosis, assessment and treatment of axSpA will lead to further progress in future.
39

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. The pathophysiology and immunology of axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0005.

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Ankylosing spondylitis (AS) is a heterogeneous and complex disease. While the exact pathophysiology remains unclear, significant advances have recently been made in the understanding of several implicated processes. The potential role and interplay of genetic susceptibility, biomechanics, the microbiome, and key cytokines in axial spondyloarthritis (axSpA) is described in this chapter, with particular focus on the IL-23/IL-17 pathway.
40

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. The impact and cost of axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0010.

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Patients with ankylosing spondylitis (AS) and axial spondyloarthritis (axSpA) consistently report lower health-related quality of life compared to the general population. The effects of the condition include factors such as pain, reduced mobility, poor sleep, fatigue, and depression, with a similar burden of disease in patients with non-radiographic axSpA and established AS. The impact of fatigue and factors associated with fatigue in axSpA are discussed. AxSpA also significantly impacts on social and work participation. Patients with AS have lower work participation and are more likely to retire earlier than the general population. Those patients in work have reduced work productivity, due to absenteeism (ability to attend work) and presenteeism (productivity while at work) as a result of the condition. The financial cost of AS varies significantly between countries; estimates for the costs in the UK are discussed.
41

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. Assessment and monitoring outcomes in axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0013.

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Axial spondyloarthritis (axSpA) is a heterogeneous condition with multiple effects and a variable course. Monitoring outcomes is required to optimize treatment and care. There are a significant number of outcomes that could potentially be measured in patients with axSpA. Performing these in routine clinical practice has resource and logistic implications, so clinicians and teams looking after patients with axSpA need to decide which aspects they will monitor locally. Most national and international guidelines for the use of biologics require regular monitoring of disease activity. In this chapter, we outline suggested core data sets and review some of the key validated outcomes for axSpA. These include a range of patient-reported and clinician-assessed measures covering disease activity, symptoms (such as pain, stiffness, and fatigue), function, mobility, work disability, and quality of life. We also review the roles of acute phase blood tests and imaging in monitoring axSpA.
42

Cumbrera, Marco Garrido, Victoria Navarro Compán, Christine Bundy, Raj Mahapatra, and Souzi Makri. Axial Spondyloarthritis: Patient-Reported Impact in Europe. Springer International Publishing AG, 2022.

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43

Sharma, Ashish, Vivek Arya, and Abhinetri KSV. Rheumatologist's Guide to Interpreting Imaging in Spondyloarthritis. Jaypee Brothers Medical Publishers, 2020.

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44

Boonen, Annelies. Cost-of-illness and economic evaluations in axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0025.

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Consideration of costs and budgets plays an increasingly important role in decisions on access to innovative technologies. When clinicians want to influence such decisions, it is essential to understand the information on the burden of the disease and the evidence on cost-effectiveness of technologies. This chapter provides guidance to understanding the key methodological principles of economic evaluations, and describes available evidence on these issues in axial spondyloarthritis (axSpA). In the prebiologics era, the cost-of-illness for society of ankylosing spondylitis was slightly lower than for rheumatoid arthritis, and substantially lower than chronic low back pain. Cost of sick leave and work disability accounted for up to 75% of total cost-of-illness. Treatment with biologics increased cost-of-illness substantially, but the important gain in quality-adjusted life years resulted in acceptable cost-effectiveness in patients with active disease. There remains a gap in knowledge about the cost-effectiveness of diagnosing and treating axSpA earlier.
45

Nicknam, Mohammad Hossein. Ankylosing Spondylitis - Axial Spondyloarthritis: Cellular, Molecular and Environmental Factors. Springer, 2022.

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46

Nicknam, Mohammad Hossein. Ankylosing Spondylitis - Axial Spondyloarthritis: Cellular, Molecular and Environmental Factors. Springer Singapore Pte. Limited, 2021.

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47

Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. The epidemiology of ankylosing spondylitis, axial spondyloarthritis, and back pain. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0003.

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Abstract:
Low back pain is a leading cause of disability worldwide. The prevalence of inflammatory back pain (IBP) has been calculated to be in the range 8–15% in a UK primary care population and 5–7% in a US population-based cohort. IBP rates are significantly higher in patients with psoriasis, uveitis, or inflammatory bowel disease than the general population. There is a paucity of good epidemiological studies to define the true incidence and prevalence of ankylosing spondylitis (AS), axial spondyloarthritis (axSpA), and spondyloarthritis (SpA), with wide variation as a result of geographic, demographic and methodological factors. The global prevalence estimates range from 0.01–0.2% for AS, to 0.32–0.7% for axSpA and around 1% for SpA overall. The global incidence estimates range from 0.44–7.3 cases per 100,000 person-years for AS to 0.48–62.5 cases per 100,000 person-years in SpA. The demographics and natural history of disease progression are also discussed.
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Siebert, Stefan, Sengupta Raj, and Alexander Tsoukas. The current and future outlook for patients with axial spondyloarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198755296.003.0016.

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There have been major advances in axial spondyloarthritis (axSpA) over the past decade. The current and future outlook for patients with axSpA is therefore much improved and largely positive. Despite this, there is still significant unmet need in pathophysiology, prevention, diagnosis, and treatment. While several new therapeutic agents are expected to reach the clinic over the next few years, the treatment of individual patients is likely to remain largely empiric. There is a need for the development of biomarkers and rationale stratified treatment approaches in order to capitalise on previous gains for the benefit of our patients.
49

Weisman, Michael H., and Xenofon Baraliakos. Spondyloarthritis: The Changing Landscape Today, an Issue of Rheumatic Disease Clinics of North America. Elsevier, 2020.

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50

Rosenbaum, James T. Extra-articular manifestations: uveitis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198734444.003.0016.

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Acute anterior uveitis (AAU) is the most common, extra-articular, clinical manifestation of spondyloarthritis. In some patients, it is the dominant manifestation. This chapter reviews the definition of uveitis, the epidemiology of uveitis, the differential diagnosis, the relationship of HLA-B27 to uveitis, laboratory testing for suspected HLA-B27-associated uveitis, treatment considerations, and experimental models in which both uveitis and spondylitis co-exist. Although acute anterior uveitis rarely precedes spondyloarthritis, acute anterior uveitis is often the clue that chronic back pain is due to sacroiliac inflammation. Uveitis is sometimes the dominant clinical manifestation of spondyloarthritis and it can influence the choice for appropriate therapy.
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