Issues in AxSpA: Treatment Intensification, Pregnancy Save

The stage is set and every attendee is looking forward to another exciting annual meeting full of learning and networking opportunities for ACR Convergence 2023. This year will be my 4th time attending virtually because I recently acquired an important role, becoming a mom! It’s a good thing that despite a majority of in-person sessions and the comeback of the poster hall, provisions were still made for livestreamed sessions and access to the posters via the meeting website. 

A lot of interesting studies will be presented at the poster sessions on Sunday, November 12 and some of them address practical real-world issues such as treatment intensification and the impact of pregnancy on axSpA imaging. 

In their study (abstract #0516), Dr. Rabab Nezam El-Din and colleagues explored patient- and disease-related determinants that were associated with treatment intensification among axSpA patients with high disease activity. This was a cross-sectional study from SpA-Net, a multicentre registry for SpA in the Netherlands. Treatment intensification (TI) as the outcome was defined as 1) a higher dose or shorter interval of the same drug, 2) a switch of the current drug to another drug or 3) addition of a new drug to the current treatment regime; and only due to inefficacy of the current treatment. Primary determinants included ASDAS, ASAS HI and physician global assessment (PhGA). A total of 119 patients with HDA were included. Treatment intensification (TI) was carried out in 40 patients (33.6%). According to their study, reasons for which TI was not applied were older age, less often employed and more likely to be on biologics treatment at time of ASDAS >2.1. According to the physician-centered regression analyses, physician-based determinants were strong and independent drivers for TI (ORPhGA = 1.74 [95%CI 1.24-2.46]; while patient-based determinants were not. Based on their findings, physician-centered factors were the main drivers of treatment intensification. 

In clinical practice, treatment expectations may differ between physicians and patients. Communication lines should always be open as management decisions become individualized. 

On the other hand, a study by Dr. Elodie Portier et al (abstract #0513) aimed to evaluate the impact of pregnancy on SIJ imaging in patients with early axSpA. Three hundred eighty-one (381) patients from the DESIR cohort were included and followed-up for 5 years. Sacroiliitis on MRI and X-ray were more frequently seen in nulligravid women (16.9% vs 9.9%, p = 0.046 and 33.8% vs 19.4%, p = 0.0016, respectively). In terms of incident pregnancies, patients had more sacroiliitis on X-ray and MRI at baseline compared to nulligravid patients at the end of the follow-up period. Additionally, only the left SIJ was statistically different after delivery; mean scores of 0.67 before and 0.95 after delivery. In conclusion, pregnancy does not seem to aggravate imaging in women with axSpA. Although reassuring, further investigations may be needed to confirm these findings. Another question worth exploring is whether an association exists between clinical factors and SIJ imaging over time.