Axial spondyloarthritis (axSpA) is an inflammatory rheumatic disease resulting in heterogeneous symptoms. Medical and nonmedical management relies on a treat-to-target (T2T) principle, as well as light monitoring and regular assessments.

These quality standards are not always met, in part due to time limitations on the part of the provider, according to the authors of an article in Journal of Rheumatology.

Kempin R, Richter JG, Schlegel A, et al. Monitoring of Disease Activity With a Smartphone App in Routine Clinical Care in Patients With Axial Spondyloarthritis. J Rheumatol. 2022 Aug;49(8):878-884. doi: 10.3899/jrheum.211116.

 

 

 

Treatment targets

 

As outlined in a 2023 review published by Best Practice & Research: Clinical Rheumatology, the 2017 T2T recommendations and the 2023 EULAR management recommendations relating to axSpA and psoriatic arthritis endorse a treatment target approach to monitor disease activity and provide treatment options to a patient if their target isn’t met.

Bosch P, Zhao SS, Nikiphorou E. The association between comorbidities and disease activity in spondyloarthritis - A narrative review. Best Pract Res Clin Rheumatol. 2023 Aug 2:101857. doi: 10.1016/j.berh.2023.101857.

This target can be either low disease activity or remission, and treatment targets are measured by a composite score.

 

 

It consists of the following three parts:

• Patient-reported outcomes (PROs), such as complaints about back pain, peripheral joint pain/swelling, and the duration of morning stiffness per responses on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI);

• The patient's global assessment of the disease; and

• Concentrations of C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR).

The ASDAS was introduced in 2011 as a novel composite index assessing disease activity in axSpA.

“It [fulfills] important aspects of truth, feasibility and discrimination. Criteria for disease activity states and improvement scores are important for use in clinical practice, observational studies and clinical trials and so far have not been developed for the ASDAS,” according to the authors of an extended report published in the Annals of the Rheumatic Diseases.

Machado P, Landewé R, Lie E, et al. Assessment of SpondyloArthritis international Society. Ankylosing Spondylitis Disease Activity Score (ASDAS): defining cut-off values for disease activity states and improvement scores. Ann Rheum Dis. 2011 Jan;70(1):47-53. doi: 10.1136/ard.2010.138594.

 

There are four disease activity states with the ASDAS: inactive disease, moderate, high, and very high disease activity.

 

 

Radiographic progression

 

Imaging tests are key to detecting and monitoring inflammation and structural damage secondary to axSpA. The authors of an editorial in Frontiers in Medicine link progressive structural damage—or radiographic progression—to disability, worse quality of life, and increased healthcare costs.

Pimentel-Santos FM, Atas N. Editorial: Radiographic progression in axial spondyloarthritis. Front Med (Lausanne). 2023 Jun 16;10:1216466. doi: 10.3389/fmed.2023.1216466.

 

X-rays, MRI scans, computed tomography, and ultrasound are used to evaluate the structural damage. Although each modality has its benefits and drawbacks, experts recommend that a combination of imaging tests and clinical assessments is required for accurate and timely diagnosis and monitoring of the disease, the Frontiers in Medicine authors note. Examples of such scoring methods include the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) and the Berlin MRI score.

In one study, researchers used group-based trajectory modeling and decision trees to isolate patterns/predictors of radiographic progression in patients with axSpA. Patients were classified into four groups based on mSASSS scores: no progression, slow progression, moderate progression, and rapid progression.

The investigators also designed decision trees that highlighted the principal predictor of each group.

Other research has shown that pregnancy doesn’t substantially impact radiographic progression, and may mitigate disease activity by lowering inflammation. On the other hand, smoking predicts radiographic progression.

 

Health apps

 

Digital tools such as electronic PRO (ePRO) can facilitate patient-centered communication and adaptive T2T strategies. 

“Health apps provide opportunities to improve communication between patients and physicians and empower patients to manage their disease independently,” said the investigators writing in Journal of Rheumatology. “There is evidence that closer monitoring of patients with rheumatoid arthritis (RA) has a positive effect on clinical outcomes. Since the majority of assessments used in axSpA are patient-reported, health apps may help to save resources and facilitate data acquisition to improve efficiency in clinical routine.”

 

In the proof-of-concept study, the investigators asked axSpA patients to record PROs with the AxSpA Live App every 2 weeks for 2 months. They also compared scores on the app with paper-based PROs filled out at each visit. The authors found that although adherence was low, which may be due to the overly ambitious target of bimonthly engagement with the app, certain groups were more likely to use it, including the elderly and those with severe disease. 

“As it stands now, it seems reasonable to concentrate on compliant patients with higher disease activity. The consequences for the time management of rheumatologists, the possibility of nurses educated to handle a health app, and economic consequences also deserve more study,” the authors wrote.