ACR 2025 SpA Topic Podcasts Compilation 1 Save

This is an ACR twenty twenty five podcast coming to you from Chicago. Hope you enjoy it.

Hi, my name is Akhil Sood reporting for RheumNow. As rheumatologists, we commonly see patients with chronic low back pain and the key question we get asked is it inflammatory or non inflammatory? Early detection of axial spondyloarthritis is critical. Delays in diagnosis can lead to irreversible structural damage and abstract 02/1935 takes an ambitious approach to capture this condition early through the SPACE cohort. This cohort includes individuals 45 with chronic low back pain defined as at least three months less than two years.

Each participant was diagnosed by rheumatologists as having ACSPA or no ACSPA. In over two years, the investigators tracked imaging changes on radiographs and MRIs. So what did they find? On conventional radiographs there were no significant changes but on MRI they observed a significant increase in fat lesions suggesting that MRI may hold early clues of axial spondyloarthritis. And this raises an important question, should we be ordering MRIs for all our patients with chronic low back pain?

While these findings are intriguing, the study doesn't tell us which patients are most likely to develop these lesions. So more research is needed before we consider changing our screening approach. Meanwhile, abstract 2,636 takes another exciting angle, a potential blood biomarker for early detection of XBA, the fourteen thirty three antibody. This serum marker shows high sensitivity and high positive predictive value, exceeding the Spartan target threshold. When combined with age, sex, and CRP, the biomarker can distinguish who has XBAW and who does not.

And this is a promising step towards a simple diagnostic tool. And of course, these findings still need validation in larger and more diverse cohorts. So what do you take from this? While we're moving closer to better diagnostics for early XBAW from MRI based detection to serology biomarkers, the next step will be identifying which patients are at higher highest risk and determining the the least invasive, most cost effective approach to early diagnosis. This is Ecclesiou to reporting for RheumNow.

Thank you.

Hello, everyone. I'm, Richard Conway reporting for RheumNow from ACR twenty twenty five in Chicago. I want to talk to you today about a poster that was presented at Sunday's poster session. This was poster five six eight by Daman at all. And this is an interesting poster to choose was about drug withdrawal when people are in remission, which is a pet hate of mine.

And we work so hard to get these difficult to treat diseases under control. And then once we achieve that, maybe spending a year or more doing it, we decide, oh, let's change things again, let's try and take away the treatments that are working and see what happens. And we've had lots of studies like that in our diseases and most of the time it just doesn't work. Things like rheumatoid arthritis, axial spondyloarthritis. Best case that we've seen, you get to about a year, might have fifty percent of people still okay off the drug, but as time goes on, pretty much all of those people fall off the wagon and everyone seems to end up needing to go back on their treatments.

And yes, most of them do fine, ninety percent recapture and they restart the treatment, but that means ten percent don't. Then what happens to those people and maybe they need to cycle through multiple other agents to regain disease control. So I've never been a fan of it. However, this study suggested that maybe that taking the drugs away is always not the wrong thing to do. So this was a ten year follow-up of a study called Crespa.

And Crespa was a study in peripheral spondyloarthritis, so early peripheral spondyloarthritis. And what they did in that study was they treated people with galimumab essentially. They had sixty people in the original study and after a year they stopped the treatment. Forty nine of the original sixty people were in remission at one year. So they then followed these forty nine patients up for the next ten years.

And at the ten year time point, eighty two percent of patients were in remission. And most impressively, thirty eight percent were in drug free remission. So that says that maybe a reasonable percentage of these people can get away with taking treatment away. I think that may be applies to these kind of slightly less common diseases we see, for want of a better word. So early peripheral spondyloarthritis is a slightly less common condition, and it seems to be that many of these people may achieve a drug free remission for a sustained period.

So I'm Richard Conway. Follow me on Twitter at Richard p a Conway. Tune in to RheumNow for all the updates from Chicago.

Hello. I'm Anthony Chan reporting for RheumNow here at ACR twenty five in Chicago. And here we are talking today about a difficult to treat and difficult to manage axial spondyloarthritis, a key area that has come out as a result of the new definition of this condition. And I'm here today joined by doctor Rodrigo Garcia Salinas from La Plata, Argentina, who has presented a poster today, poster five eight four on this very topic. So, Rodrigo, welcome to the session.

Thank you, professor.

I wonder whether you could take us through your findings from your abstract this morning.

Thank you very much. Fundamental in our poster was we had a cohort of axial SPA with more than 100 patients. Of those, only eight percent fulfilling the criteria of axial SPA difficult to manage. Do you remember maybe it's the failure two different mechanisms of action and this is activity or radiological progressions and only eight percent is a low prevalence of difficult tumor. But I believe that the most important thing of this is the baseline characteristic of the patient who fulfilling the criteria.

Yes, so could you describe to us what were the important patient characteristics in this eight percent of your patients who you classified as difficult to manage?

The characteristics always is the disease activity. The disease activity in Western, when you know you achieve the remission early, the chance to develop difficult to read is more. And in our case, for example, VASFY, VASTY and ASDAS two was the important characteristic. But when see all the another publication or another cohort of difficult to manage, the smoking smoking is one of the important factor and psoriasis too. But in our cases and in all Latin America, the peripheral manifestations, joint, inflammatory joint or or enthesitis, was in a very important characteristic to develop difficult tumor lab.

We believe that it's a phenotype in Latin America, the patient who has axial disease and peripheral disease.

Yeah, so two different subgroups there. But within that group, how many of your patients who are what we class treatment resistant, as in there were still objective signs of inflammation, but they fell within the difficult to manage group?

Yes, that is very important point, but because just four patients in our cohort were refractory treatment, two with CRP and two with active disease in MRI, in Sacroiliac MRI.

So their number was actually quite small from your cohort of patients that are difficult to manage. So what were the other factors you think that could have pushed them to having higher best die scores or other objective measures if they are not so treatment resistant? Could they be comorbidities, for example?

Yes. I believe that the pain is one of the most important factor. Maybe no capture the pain isolated, we capture the pain in bust eye, in bust eye and ASDAS too, but I believe that is one of the most important factor of the pain. For example, in our cohort, the women more frequent or difficult to manage than the men, but with no statistic difference, but numerical difference was more women had difficult to manage. I believe that, for example, another mechanism of pain like a fibromyalgia or whatever.

And then I believe the comorbidity too, we know record systematically the comorbidity, but it's one of the most important factors. So

where does this take you now in terms of your future plans about understanding this a bit more from this cohort that you have?

Yes, I believe one of the points of difficult to manage is the relation between the patient and physician and the agreement between the patient that the patient is nowadays difficult to manage. Maybe in some cases we don't have agreement between if the patient is or not difficult to manage in that case. It's one of the most important, or one factor to study in the future, one, I don't know, a patient report around, kind of whatever, to measure that relation between the physician and patient. But yes, I believe that we follow-up on our cohort, that patient who failure to different mechanisms of action than what will be something new treatment that we

Yeah, so there's this idea of patient discordance or patient physician discordance. I think that only can be met by shared decision making between the physician and the patient and identifying these many factors. So thank you very much for your presentation, and this is one of many publications that we are seeing emerging in the whole area of difficult to manage XPA. And thank you very much, Rodrigo, for sharing with us your work. Thank you very much.

Excellent.

Hello. I'm Anthony Chan reporting here from ACR twenty twenty five in Chicago. And there have been interesting posters on treatment in axial spondyloarthritis today. And we know that the advance in the treatment with biologics has really revolutionized the treatment in XBA. But there were two posters today that looked at the use of a generic tofacitinib.

And this is really important in countries where, where there might be low income or in more developing countries where the cost of biologics, may prohibit the widespread use of, treatment in XPAR. And the poster was zero five eight two, and this was a study, of XPAR patients in South India where there are two hundred and ninety patients treated with generic tofacitinib five milligram twice a day. And these patients were followed up for twenty five months. And what they showed was in this group of patients, firstly they reduced the use of anti inflammatories and also these patients had an improvement in their disease activity score using the S test. In this study, nine percent of them either achieved inactive disease or low disease activity based on the S test.

It was quite well tolerated. There were some cases of transaminitis and also cases related to fatty liver. But overall, it was well tolerated. Similarly, there was another poster zero five five four, this time in North India, where they also looked at the use of generic tofacitinib five milligram twice a day. And this was followed up for a period of, twenty four weeks.

And in this study, they had 100 patients, their long disease duration over eight years, and these patients were treated and with generic tofacitinib. And what they found that in this score of patients, seventy one percent of these patients achieved either inactive disease or low disease activity based on their S test score. So there was an improvement of improvement of 1.76 on the s test score and also a drop in the CRP. Both these studies demonstrate to us that in countries where perhaps there is a lower income and or more developing countries that such therapies such as generic tofacitinib can be very useful to treat patients of axial SpA and also to improve, the outcomes for these patients in order to prevent long term, mobilities. I'm Anthony Chan reporting here, for RheumNow in Chicago.

Hi. Welcome, everyone. It's, doctor Janet Pope. I'm tweeting for AtRoomNow at ACR twenty twenty five in Chicago. I want to talk about head to head or, for us, joint to joint or even toe to toe.

I wanted to talk about two comparative, head to head RCTs that are late breaking abstracts. The first is l b zero nine. This is the question that is always on our mind. A patient has axial SpA, so what we think of as ankylosing spondylitis, and they are TNF inadequate responders. Most in general are a secondary loss of effect.

Now what's going what are we going to use next? It's a great clinical question. So this was an RCT randomizing patients to the next TNF inhibitor or an IL seventeen inhibitor. So the bottom line is it doesn't really matter. There was no superiority.

They could both do well. So I think the take home on this head to head is if your patient isn't doing well enough on a TNF inhibitor, an Axial SpA, you can try another TNF inhibitor, a second line advanced therapy, or you could go to an I o 17. No superiority. What about the next one? I've got a patient with psoriatic arthritis, and they've been TNF, inhibitor exposed.

This was a randomized controlled trial of moving on out of class. Psoriatic arthritis, TNF exposed. Now they are randomized to secukinumab, so an IL seventeen a inhibitor, or usukinumab, an IL twelve twenty three inhibitor. So it's a big question to know because the derms in general seem to like, IL, 20 threes, but also IL twelve twenty threes on skin and IL seventeens do very well on skin as well. The winner is, drum roll, please, Cosentyx.

Why? It was both an ACR 50 and a PASI score superiority. I think the other questions would be, what if I tried a different IL seventeen? What if I tried just an IL twenty three inhibitor as opposed to a twelve twenty three? However, superiority with clinically relevant differences in tender and swollen joint counts as well as I as I mentioned, the ACR 50 and the PASI score.

So bottom line is head to head trials in real world situations really do help me to choose the next treatment for my patients with seronegative, various types of, seronegative arthritis. Thank you. Please follow me at Janet Bourdeau. Thank you.

Hi. My name is Marina Magre. I'm professor of medicine at Case Western Reserve University, University Hospitals, Cleveland. I'm here at ACR Convergence meeting twenty twenty five in Chicago and reporting for RheumNow. And, you know, last year we had, gotten approval by FDA for, bemecizumab, which is a dual inhibitor of IL-17A and IL-17F for the treatment of axial spondyloarthritis.

And in this year's meeting, lot of data has been presented about long term efficacy and safety of bimekizumab. There are two abstracts that were presented about three year efficacy and safety of bimekizumab showing that it's sustained durability and safety. In the efficacy abstract, the data was pulled from both non radiographic and radiographic patients from B Mobile one and B Mobile two studies. More than forty percent of these patients had achieved an ASAS 40 response at week sixteen and also achieved a low disease activity at week sixteen. About eighty percent of these patients continued to maintain this ASAS 40 response up till third year.

Similarly, about more than seventy five percent of these patients maintained a low disease activity up to three years, and, fifty percent of these patients actually did not lose low disease activity, which is pretty impressive. Again, reiterating that, you know, vemikizumab is both sustained efficacious and is also durable. Then similar study that looked at, long term safety of bemikizumab, it looked across, two, you know, disease groups, axial spondyloarthritis and psoriatic arthritis, included all patients from phase two, phase three trials and open label studies. What this study showed was that bimekizumab was safe over a period of three years. The most common side effects that were seen were, upper respiratory tract infections, nasopharyngitis, COVID nineteen infections.

Keep in mind, some of these studies were actually done during the COVID period, and, there was some increased, incidence of, fungal infections. Most of these infections were mild to moderate oral candidiasis, and, very infrequently did patients discontinue treatment because of these infections. There was no increased risk of other opportunistic infections or MACE events. The patients did not have an increased risk of uveitis flares in the Axial Spar group or IBD group, suggesting that the safety profile was similar to what was previously published. The drug remains safe over a period of three years.

This is very important to us as clinicians because a lot of our patients, they lose response after being on a medication for some time. These data looked very promising that some of these patients stayed on bimekizumab for three years with sustained efficacy, and it remains safe.

Hello, everyone. I'm Richard Conway from Dublin, Ireland, reporting, for RheumNow from ACR twenty twenty five in Chicago. Today, want to talk to you about Abstracts 2346. This is a poster presentation by Zavada and colleagues from Prague. And this poster looked at the effect of biologic DMARDs on sexual dysfunction in ankylosing spondylitis.

So they had fifty two men with radiographic axial spondyloarthritis. In these men, the baseline prevalence of erectile dysfunction was twenty three percent. And what they found was that six months after starting biologic agents, there was very significant improvements, both in erectile dysfunction and in other measures of sexual function. And there was a nice little companion piece to the study. There's another poster presentation by the same group, which is poster thirteen fifty.

And this is looking at female populations, as women with rheumatoid arthritis starting biologic DMARDs. And it found very similar findings with some baseline issues with sexual function and significant improvements after starting the biologic agents. So this might seem like a small thing to many of us, but I think it is something that's very, very important to patients. I think it's something that we may not be told about. These individuals may be kind of simultaneously attending their primary care and asking questions and looking for assistance with erectile dysfunction.

But I think if we have the opportunity to raise this, then we can reassure both men and women that issues with sexual function may well improve after they start their biologic agent, and particularly after this agent gets the disease under better control. So I'm Richard Connolly. Follow me on Twitter Richard Piconnolly, and do tune into RheumNow for all the updates from ACR twenty five in Chicago.

Hi. This is Bella Mehta reporting for RheumNow from ACR twenty twenty five. This is an interesting abstract talking about how we should be measuring multidimensional pain in axial SpA patients. The abstract number is 0386. And this is what they call as the West Haven Yale multidimensional pain inventory or MPI, and it is it has five domains that it covers, pain related to life interference, pain severity, effective distress, social support, and life control.

They use this MPI versus the ace ASAS OMERAC core domain set, which has things like the usual ASDAS, BASDI, CRP, patient global, total back pain, morning stiffness, and they enrolled around one thirty five patients or so. Out of them, only a 109 patients completed all the surveys, but what they found that was the construct validity supported that the pain related life interference and the pain severity did correlate with some of the core domains. But what it also shows is that things like social support, life control, or effective distress is not really captured as well in the core domains. So maybe we need to expand what we are asking of these patients. And again, I know in clinical practice sometimes it's difficult to get all these sort of domains, but as we go in the future, these patient reported outcome measures are gonna be more and more important, not only from the patient's perspective, but also insurances and drugs and whatever that we need to do for our patients.

So it's good to start getting some of these core domains in to your clinical practice, see if it's feasible. Sometimes patients who are in the in the hallways waiting for you for the next to get in to see you, this is probably a good questionnaires to have, which is disease specific and still will help overall improving the quality of life with patients. With that, thank you so much for listening. Follow us more for more RheumNow content, and follow me on Twitter at Bella underscore Mehta. Thank you.

Hello. My name is Atul Devdar. I'm a rheumatologist at Oregon Health and Science University. Perhaps the most important presentation at this year's meeting in the field of axial spondyloarthritis has been the classic study which was presented in the plenary session this morning. Classic study classic stands for classification of axial spondyloarthritis inception cohort.

And this study reported the work that was done by Spartan and ASAS, ASAS, over nine years. The study basically started in 2016 with the understanding that we need to do something about the classification criteria that existed from 2009 regarding axial spondyloarthritis. The FDA thought that the original classification criteria did not have enough specificity and probably the non radiographic axial spondyloarthritis diagnosis could be misused and fibromyalgia patients and mechanical back pain patients could be diagnosed or classified with non radiographic excess spondyloarthritis using the 2009 ASAS criteria. The classification criteria should not be used for doing diagnosis. Unfortunately, people were doing that.

And because of this concern, FDA suggested that in clinical trials, if these criteria are to be used, the 2,009 criteria, there has to be either positive CRP or positive MRI, high CRP or positive MRI. They also imposed a fifty two week placebo controlled study requirement for non radiographic axial spondyloarthritis. With all these limitations, it was decided that we should revisit the 2,009 classification criteria by ASAS, repeat the study, and see what is the sensitivity and specificity of that criteria to validate the original criteria. We decided a priori that if the sensitivity is not 75% and the specificity is not 90%, then the criteria will be revamped. Over the last six years, when I participated in this study myself, we took care of we diagnosed or we saw ten fifteen patients worldwide, five zero four in North America, which is US, Canada, and Mexico, and the remaining patients from rest of the world.

This was done during COVID. We these were patients referred to the rheumatologist with the suspicion of excess spondyloarthritis. And the rheumatologists were asked to make a diagnosis based on their just the history, the physical findings, then with their blood test and HLA B27, then the CRP and the MRI, and then the MRIs were centrally read. And the final diagnosis, when the rheumatologist made the final diagnosis, they had all the information regarding these patients. What came out was that thirty six percent of the patients in this study had Axis Spondyloarthritis.

Based on that, the old 2,009 criteria were looked at again, and we found out that they actually had seventy two percent, seventy eight percent, sensitivity, and the specificity was nowhere close to ninety percent. It was about eighty two percent. Because of that, the criteria were needed to be changed. We sat together, Lasso, analysis, which is, something similar. It's a statistical way of finding out which different criteria, which different parts of the spondyloarthritis disease are important.

And LASSO gives them a coefficient. So for example, HLA B27 and the CRP, inflammatory back pain, etc. And based on that, we came up with coefficients for the important spondyloarthritis features. Finally, these criteria were developed two different models were developed. The SPARTAN and the SS members voted.

And one of those two models, has come out as the winner of this classic, study. These criteria will soon be published. They are now in the table format. There is a stem for this criteria, which is patients with chronic back pain starting before the age of 45. But then there are numbers.

There are there are points that you give. So MRI has eight points, X-ray has got seven points, and ultimately if the patient has 11 points or higher, then they can be classified as Excess Spondyloarthritis. In my mind, this is a major advance in the field of of excess spondyloarthritis because these criteria have more than 90% specificity, more than 75% sensitivity, and they will be used going forward in clinical trials, and we can be mostly reassured that our patients who should not be included in the trial will not be included, because they will not fulfill this classification criteria.

Hi. This is Bella Mehta reporting for RheumNow from ACR twenty twenty five. This is a very interesting abstract that we came across. So what do you do after you fail the first TNF in an axSpA patient? This is late baking abstract zero nine, and what they did is was a prospective randomized multicenter open label superiority phase four trial of patients who have a pretty active axSpA with an ASAS, AS DOS greater than 3.5 or BASDIG greater than four, and randomized them to either get a second TNF or IL 17 agent.

So they call the study rock ROC SPA, ROC SPA, and this was a multicenter study, 31 sites across France and Morocco. And the primary outcome that they were looking at was forty percent oh, sorry. ASAS 40 at week twenty four, and then the secondary outcomes were the same at week twelve and fifty two just to see how these patients do. And they had pretty good sizable numbers, one fifty two patients in the TNF arm and around one forty two patients in the sorry, One forty two patients in the TNF arm and one fifty six patients in the IL 17 arm. And what they found was that the primary outcome was no different, or at least they did not prove superiority of IL seventeen as the second agent when the first TNF fails.

Now if a patient discontinued TNF because of an adverse effect, then going to the second TNFs may TNF made sense, which is what we do in clinical practice. But, you know, there was some very, very small exploratory data that they talk about where, know, going to IL-seventeen might be better in patients who who who are have HLA B27 negative or those who have CRPs less than five. I don't know if, you know, if you talk about subtyping, are a different subtype of patients that they are hinting to, but I think it's good to know that going to a second second TNF versus going to an IL 17 agent is not wrong. Like, you can choose whatever works better. And I think I think this is an important paper and that we look forward to and an abstract that would be interesting to see.

Thank you.

Hello. My name is Atul Devdar. I'm a professor of medicine at Oregon Health and Science University in Portland, Oregon. My research interest is in axial spondyloarthritis and psoriatic arthritis. And today, I'm joined here by doctor Mohammad Biktar, who is also an assistant professor at Oregon Health and Science University.

Doctor Biktar's research is very novel, And this is a big trend that actually I'm noticing in this particular conference as well, and that's why I thought I will bring him here to discuss his research. But just in short, what we are finding is that nowadays in inflammatory arthritis, axial spondyloarthritis included, the morbidity is not because of the inflammation. We are pretty good at controlling the inflammation of our patients with our biologics. Leftover pain, leftover pain, leftover fatigue is the reason why people are becoming disabled. And so Doctor.

Bittar has some very novel research ideas. He had a poster here. He also was chairing a session on this particular entity of leftover pain. So Doctor. Bittar, take it from here.

Tell us a little bit more about this leftover pain and how can we measure it and what can we do about it.

Thank you so much for having me and this is an extremely important topic that has been neglected in rheumatology. As you mentioned, we always focus on treating inflammation, inflammation, but we forget about the leftover pain, which is driving the patient's disability and the symptom and the burden of the disease, and that's why it's time for us to focus on studying pain and rheumatic diseases. So I'm very happy to share that in this conference at the ACR we've seen a lot of new work on pain in rheumatic diseases, whether in rheumatoid arthritis and psoriatic arthritis and of course in axospondyloarthritis, our research interest. I can talk to you a little bit about the project that we've done is where we are trying to look into the brain imaging and the CNS, central nervous system dysregulation in patients who have axial spondyloarthritis because this can explain why patients continue to have chronic pain without having inflammation. Particular we're interesting at looking the resting state connectivity on how different parts in the brain connect to each other and also how the brain responds to a painful stimulus.

So for example the project that we've done on ACPA patients that showed that XBA patients respond differently to a painful stimuli compared to healthy controls. For example, mainly we got two signals from the default mode network and the salience network. Default mode network, it's usually is active when we are in a relaxed state. Whenever we get an input or an insult, this should be inactivated. Our study showed that in patients who have AXPA, actually default mode network got activated, which is abnormal.

That means patients are focusing on the brain is focusing on pain and that's why they go into a chronic pain state. Also the salience network it got exaggerated responses in salience Salience Okay. And axSpA compared to healthy they control. So we got signals that different parts of the brain are working differently in axSpA patients who have chronic pain.

Yeah. So there were some abstracts yesterday, and you were chairing that one session, where some similar work has been done also in rheumatoid arthritis and psoriatic arthritis. Do you want to tell us about that?

Definitely. And there was a very interesting oral abstract that was presenting yesterday on rheumatoid arthritis where patients had, I believe it was twenty seven patients who had functional imaging of the brain and a task was an input or a painful stimulus was done on rheumatoid patients and the rest and it showed activity in the insula and the brain which is part of the salience network. Similarly, there is another session on psoriatic arthritis, but this was mainly on fatigue and that showed that insula played a role in it. So, we are seeing a different mechanism that are non inflammatory playing a role in rheumatoid and PSA and axSpA, we need to start looking at these pathways.

Yeah. This is going forward, we are going to be looking at more and more research as well as abstracts at annual meetings. And and we will hopefully one day find the differences of how the brain works with nociceptive and nocplastic and neuropathic. Those are the three different different types of pain, which parts of the brain get activated, and how we can intervene to prevent this. I think this is something that I would suggest, the viewers should keep, should be aware of and keep an eye on.

This is a very exciting new area in the field of rheumatology.