CONCURRENT SYMPOSIUM- SPONDYLOARTHRITIS - Non radiographic SpA-Is it really AS? - Dr Anand N...

1 May 2023 Prof. Anand N. Malaviya

Non-radiographic SpA: Is it really AS?

Dr. Anand N. Malaviya, MD, Hon. FRCP (Lond.), 'Master‘-ACR &APLAR, FACP, FICP, FAMS, FNASc,

({Retired} Head of the Department of Medicine, and Chief of Clinical Immunology and Rheumatology Services,

All-India Institute of Medical Sciences, New Delhi)Consultant Rheumatologist, 'A&R Clinic'

and Visiting Sr. Consultant Rheumatologist, ISIC Superspeciality Hospital, New Delhi.

Non-radiographic term used by the 2009 ASAS classification criteria for a subset of axSpA (i.e. nr-axSpA)


Unclassifiable/Undifferentiated SpAHistorical papers

1. Prakash S, Mehra NK, Bhargava S, Malaviya AN. HLA B27 related "unclassifiable" seronegative spondyloarthropathies. Ann Rheum Dis 1983; 42:640-43.

2. Amor B, Dougados M, Mijiyawa M. [Criteria of the classification of Spondylarthropathies]. Rev Rhum Mal Osteoartic. 1990; 57:85-9.

3. Dougados M, van der Linden S, Juhlin R, et al. The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum. 1991 34:1218-27.


First clear description of non-radiographic AS-SpAJust as in Amor’s and ESSG criteria for classification –

1990, 1991 (those days we used to call it SSA-syndrome!)


Became a topic for discussion because

FDA did not approve TNFi Rx for the patients diagnosed as ‘nr-axSpA’

1. Deodhar A, Reveille JD, Van Den BF, Braun J, Burgos-Vargas R, Caplan L et al. The Concept of Axial Spondyloarthritis: Joint Statement of the SPARTN and the ASAS in Response to the US FDA's Comments and Concerns. Arthritis Rheumatol 2014; 66:2649-562. Ward MM, Deodhar A, Akl EA, Lui A, Ermann J, Gensler LS, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Care Res (Hoboken) 2016;68:151-66


I quote Michael Ward’s comments:[Michael Ward, MD, MPH, a researcher for the National Institutes of Health and the

Principle Investigator of the project that was designed to determine best practices for treating non-radiographic axial spondyloarthritis (nr-axSpA) and ankylosing spondylitis (AS)]

“(But) very little is known about this (nr-axSpA) relatively new category of rheumatic disease, and almost all questions about diagnosis and

treatment are in need of more research”


Modified NY diagnostic criteria for AS (1984)

(Possibly the ONLY Dx criteria in rheumatology)Required definite radiographic sacroiliitisHas been in use till the ASAS criteria were

enunciated(2009)

Van der Linden SM, Valkenburg HA, Cats A. Evaluation of the diagnostic criteria

for ankylosing spondylitis: a proposal for modificationof the New York criteria. Arthritis Rheum 1984;27:361–8.


Effect of disease duration on radiographic sacroiliitis

• In < 45 yrs. of age: 16% • In > 45 yrs. Of age: 38% • In those with 10-year disease duration: 40% • In those with 10-19-year disease duration: ~70% • In those with > 20-year disease duration: 86%

1. Van der Linden S, Valkenburg HA, de Jongh BM, Cats A. Arthritis Rheum 1984;27:241–9. Studied family members. 2. Mau W, Zeidler H, Mau R, Majewski A, Freyschmidt J, Stangel, W, et al. J Rheumatol 1988;15:1109–143. Said-Nahal R, Miceli-Richard C, Berthelot JM, Duche A, et al. Arthritis Rheum 2000;43:1356–65. Studied family members4. Kumar A, Bansal M, Srivastava DN, et al. Rheumatol Int 2001; 20:221-224. M:F ratio 19:15. Oostveen J, Prevo R, den Boer J, van de Laar M. J Rheumatol 1999;26:1953–8. Only 25 pts., details could not be found out

ConclusionIt MAY take years to develop DEFINITE radiographic sacroiliitis


Built-into mNY criteria is the DELAY of YEARS

in classifying patients correctly as ASThe quoted papers show

‘Disease Duration’ is pivotal for DAMAGE (i.e. radiographic sacroiliitis)

But:

Only in predisposed individualsRudwaleit M, Khan MA, Sieper J. Arthritis Rheum 2005;52:1000–8


Factors related to progression(They need early TNFi Rx)

Amor B, et al (1994):*• Hip arthritis• High ESR/CRP• Poor response to NSAIDs * J Rheumatol 1994;21:1883–7

van der Heijde et al (OASIS cohort 2004)*:• Radiological damage at baseline• Male sex• Hip arthritis• Extra-spinal manifestations (e.g.uveitis) • Peripheral arthritis correlated best with structural damage.* Ann Rheum Dis 2004;63(suppl I):98


NSAIDs/coxib-refractory TNFi treatment ~ 50% show 50% improvement (Dis.

Duration matters)*Better response in pts. with:

• Short disease duration• Osteitis (bone oedema on MRI is suppressed)• High CRP

May favourably influence long-term outcomeTherefore, an early and reliable diagnosis of AS

had become An important and highly relevant issue

*Sieper J, Rudwaleit M. ARD 2005, 64: 659-63;


Long-term longitudinal studiesBiased ?!(Be that as it may)

Several studies on family members of AS1

Our 2001 study M:F ratio: 19:1!?2

Despite some flaws, definitely a proportion of patients did progress to

develop radiographic sacroiliitis

Therefore, the following concept evolved: ‘The continuum of axial-SpA’

1. Sari I, Haroon N. Arthritis Rheumatol 2016; 68:2354-62. Kumar A, Bansal M, Srivastava DN, et al. Rheumatol Int 2001; 20:221-224


Do we need new classification criteria?

Mainly for early & reliable diagnosis of a uniform clinical condition

Why was it required?Rudwaleit M, Khan MA, Sieper J. The challenge of

diagnosis and classification in early ankylosing spondylitis: do we need new criteria? Arthritis Rheum 2005;52:1000–8

• Advent of a highly effective treatment in TNFi drugs

• Best results in early disease

Inflammatory in nature

Nr-axSpA AS AS – ‘Bamboo spine’

The continuum of

Only in predisposed individuals

Forces pushing some patients to the right


Based upon these evidences the ASAS group propounded

the new classification criteria for axial SpA

Rudwaleit M, van der Heijde D, Landewe´ R, Listing J, Akkoc N, Brandt J, et al. The development of Assessment of SpondyloArthritis international

Society classification criteria for axial spondyloarthritis (part II): validation and final

selection. Ann Rheum Dis 2009;68:777–83

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Two entry points Non-radiographic

axSpA

Radiographic

Nr-axSpA questioned by FDA making them ineligible for TNFi Rx

http://www.fda.gov/downloads/advisorycommittees/committees


Concerns regarding n-axSpA vs. ASAnalysed from 3 standpoints

1. FDA’s concerns2. Concerns of a group of experts in

the field of SpA (Robinson et al. ARD 2013; 72:162-4)

3. Studies on head-to-comparison between nr-axSpA and AS patients


1. FDA’s concerns:ASAS classified nr-axSpA

may inadvertently include patients with

‘Similar symptoms but NOT axSpA’The problem of

‘Increased sensitivity’With

‘Decreased specificity’

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Two entry points Non-radiographic

axSpA

RadiographicNr-axSpA questioned by FDA

making them ineligible for TNFi Rxhttp://www.fda.gov/downloads/advisorycommittees/committees


FDA’s concernsMisuse (wrong use) of

ASAS classification criteriaMisusing ASAS classification for diagnosis!?

‘Check-box’ approach to ‘SpA features’

All nonspecific LBPs and fibromyalgia patients will get included and may start

getting TNFi treatment


FDA’s concerns:Problems with

Imaging interpretation • Inter-observer differences in readings of S-I

radiographs, MRI• Fool-proof definition of active sacroiliitis on MRI

- Keeping in mind that a good proportion of normal/nonsp-LBP persons may show ‘active

sacroiliitis’ on MRI- Keeping in mind the other causes of ‘acute

sacroiliitis’ e.g. TB, brucellosis, many others in different geographical regions


2. Concerns of a group of experts

Robinson PC, Wordsworth BP, Reveille JD, Brown MA.

Axial spondyloarthritis: a new disease entity,not necessarily early ankylosing spondylitis.

Ann Rheum Dis 2013;72:162–4


Concerns of this group of ‘Experts’• Rudwaleit et al., provide compelling evidence for axSpA and AS

being ONLY different stages of the same disease entity based upon disease duration [Rudwaleit M, Khan MA, Sieper J. The challenge of diagnosis and classification in early ankylosing spondylitis: do we need new criteria? Arthritis Rheum 2005;52:1000–8].

But, this group of experts argues that:• Despite warnings, classification criteria will be used for diagnosis!

[Hunder GG. The use and misuse of classification and diagnostic criteria for complex diseases. Ann Intern Med 1998;129:417–18.; van den Berg R, van der Heijde DM. How should we diagnose spondyloarthritis according to the ASAS classification criteria: a guide for practicing physicians. Pol Arch Med Wewn 2010;120:452–7.]

• The two entities of axSpA and AS are different– While a currently unknown proportion of patients with axSpA do indeed

have early AS, this is far from universal– axSpA patients:

• Have greater clinical heterogeneity• Broader aetiopathogenesis


Concerns of this group of ‘Experts’Longitudinal studies - worrisome results on

• Earliest study (1988):– 54/88 suspected AS (not classifiable with mNY) available

after 10 years:• 12 (22%) had some other disease – degenerative disc disease,

fibromyalgia, psoriatic AS• 22 (41%) remained at the same stage• 20 (37%) developed AS

[Mau W, Zeidler H, Mau R, et al. Clinical features and prognosis of patients with possible ankylosing-spondylitis—results of a 10-year follow-up. J Rheumatol 1988;15:1109–14.]

• Our own study on (2001 on cases from ‘70s-’80s): – M:F ratio 19:1 – problem!; in 1970s-80s we believed it to

be ‘a male disease’! After 11 yrs 15/22 AS; male bias in the study!!

Kumar A, Bansal M, Srivastava DN, et al. Rheumatol Int 2001; 20:221-224. M:F ratio 19:1


Natural history of SpALeeds IBP study – highly informative

• 29 patients with IBP – followed for 7.7 yrs– 8 radiographic sacroiliitis (mNY)– 21 Only on MRI 7.7 yrs 3 (14%) radiographic sacroiliitis (mNY)– Over-all 11/29 AS after 7.7 yrs; Another 10 some increase in

radiographic sacroiliitis but NOT according to mNY– Psoriatic 2; Reactive arthritis 5; 11 remained ‘undifferentiated’

Conclusion: The diversity of outcomes is far greater in cohorts with axSpA

than with mNY AS• Imaging arm: 100% sensitive, 22% specific• HLA (clinical) arm: 67% sensitive; 56% specific

Aydin SZ, Maksymowych WP, Bennett AN, et al. Validation of the ASAS criteria and definition of a positive MRI of the sacroiliac joint in an inception cohort of axial spondyloarthritis followed up for 8 years. Ann Rheum Dis 2012;71:56–60.


• HLA B27 positivity: several studies that show axSpA having a significantly weaker association as compared to AS, suggesting greater heterogeneity of genetic risk underlying axSpA.

• Gender ratio: Studies showing much smaller or even negative M:F ratio in axSpA group

• Response to TNFi: Much less in axSpA (*more so in MRI neg, normal CRP gr.)

• ReA: Overlapping clinical and genetic (HLA B27) features with axSpA BUT the natural history is very different with 3/4th resolving spontaneously.

Concerns of this group of ‘Experts’Other points:

*Akkoc N, Khan MA. Arth Care Res 2016;68:886-7


CONCLUSION: Compelling evidence that axSpA and AS are

different though overlapping entities• Different:

– Prognoses– Demographics– Genetics – Responses to treatment.

• The axSpA concept captures BOTH:– Those who progress to AS– Those with other diseases of may not progress to

AS.


CONCLUSION: Compelling evidence that axSpA and AS are

different though overlapping entities• axSpA concept is a welcome initiative for early disease

recognition in order to initiate effective treatment early BUT: – The heterogeneity is high– Natural history of different diseases ‘umbrella’ of SpA (e.g. ReA,

PsA, IBD-related), poorly understood.• Long-term studies are needed to determine:

– The prognosis of this new axSpA group– The proportion that will develop into mNY AS

• The clinical, immunological and genetic subgroups that meet the current axSpA criteria must be better dissected to achieve greater homogeneity.


Major papers on the topic1. Kiltz U, Baraliakos X, Karakostas P, Igelmann M, Kalthoff L, Klink C et al. Do patients with non-

radiographic axial spondylarthritis differ from patients with ankylosing spondylitis? Arthritis Care Res (Hoboken) 2012; 64:1415-1422.

2. Wallis D, Haroon N, Ayearst R, Carty A, Inman RD. Ankylosing spondylitis and nonradiographic axial spondyloarthritis: part of a common spectrum or distinct diseases? J Rheumatol 2013; 40:2038-2041.

3. Malaviya AN, Kalyani A, Rawat R. Is Radiographic Axial SpA a Distinct Subset With More Severe Axial Involvement? Comment on the Article by Deodhar et al. Arthritis Rheumatol 2015; 67:856.

4. Malaviya AN, Kalyani A, Rawat R, Gogia SB. Comparison of patients with ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA) from a single rheumatology clinic in New Delhi. Int J Rheum Dis 2015;10-185X.

5. Jeong H, Yoon JY, Park EJ, Hwang J, Kim H, Ahn JK et al. Clinical characteristics of nonradiographic axial spondyloarthritis in Korea: a comparison with ankylosing spondylitis. Int J Rheum Dis 2015; 18:661-668.

6. Baraliakos X, Braun J. Non-radiographic axial spondyloarthritis and ankylosing spondylitis: what are the similarities and differences? RMD Open 2015;1(Suppl 1):e000053 2015; 1:e000053.

7. Gavali M, Konda K, Rajasekhar L, Devarasetti PK, Irlapati RV. A comparison of clinical and laboratory profile of non-radiographic axial spondyloarthritis and ankylosing spondylitis. Ind J Rheumatol 2015; 10: 129-32


Variables studiednr vs r-axSpA

1. Gender2. HLA-B27 status3. Age at symptom onset 4. Age at time of diagnosis 5. Age at last visit6. Delay in diagnosis (Time from symptom

onset to diagnosis), 7. Disease duration at last clinic visit 8. Disability from AS - employment 9. Current NSAID use10. Current DMARD use11. Current GC use12. Ever biologic use13. Current biologic use14. CRP, mg/l 15. ESR, mm/h 16. Total back pain, VAS, 0–10 17. Peripheral arthritis

18. Enthesitis19. BASDAI 20. BASMI 21. BASFI 22. BAS-G 23. HAQ-DI 24. SF-36 mental component 25. SF-36 physical component 26. Fatigue severity scale 0-10 27. ASQoL 28. EQ-5D 29. History of fibromyalgia30. History of uveitis31. History of psoriasis32. History of IBD33. Ever smoker34. Current smoker

Several others- Family history- Others


Explanation

• All these variables were not studied in each of the publications

• Only the variables that were statistically significantly different will be pointed out


Kiltz et al. 2012

Nr-axSpA seen predominantly in females

Female: 68%Male: 32%

No other differences


Wallis D, Haroon N et al – 2013Significant differences

• Gender: Nr-axSpA females predominate: 52% vs 23.6% in AS (r-axSpA)

• Disease duration at last clinic visit: significantly shorter in nr-axSpA (12.1 vs 17.7 yrs in r-axSpA)

• BASMI: significantly less in nr-axSpA – 1.4 vs 2.8

• CRP: significantly less in nr-axSpA – 5.2 vs. 11.4 mg/l


Malaviya AN et al 2015 - ISignificant differences

• Gender:– In nr-axSpA - females 29.7% vs males 70.3%; F:M ratio 1:2.4– In AS (r-axSpA) – females 15.5% vs males 84.5%; F:M ratio 1: 5.5

• Disease duration at presentation:– Nr-axSpA: 67 mo – AS (r-axSpA): 93 mo

• Only axial symptoms at the onset:– Nr-axSpA: 65% – AS (r-axSpA): 80%

• BASMI / Syndesmophytes: high in AS

Methotrexate use:• Nr-axSpA 38%• AS (r-axSpA)

20.8%


Malaviya AN et al 2015 - II

If nr-axSpA patients with high CRP are compared with AS (r-axSpA)

All these differences become insignificant.


Jeong H, et al. Int J Rheum Dis 2015; 18:661-668.Significant differences

• Age at disease onset: – Nr-axSpA – 29.5 yrs– AS (r-axSpA) – 25.9

yrs• Disease duration:

– Nr-axSpA – 78.3 mo– AS (r-axSpA) – 20.2

mo??

• Gender females:– Nr-axSpA – 33.5%

(F:M ratio :: 1:2)– AS (r-axSpA) – 16.6%

(F:M ratio :: 1:5.6)• Peripheral arthritis:

– Nr-axSpA – 39.4% – AS (r-axSpA) – 24.2%


Baraliakos X, Braun J. RMD Open 2015;1(Suppl 1):e000053 2015.

• Gender:– Nr-axSpA – females 68.2 % (F:M ratio :: 2.2:1)– AS (r-axSpA) – females 24 % (F:M ratio :: 1:3.1)

• CRP: – Nr-axSpA - 5.7 mg/l– AS (r-axSpA) - 11.6 mg/l


In summarynr-axSpA shows

• More females than in AS• Shorter disease duration and shorter delay in Dx

– Does it mean more severe and persistent symptoms than AS to bring them to the clinic earlier?

– Not in Korean and Hyderabad study• BUT less damage and less CRP!

– Reason??• More peripheral arthritis • Hyderabad study less family history


• No difference in – Treatment response– Drug survival– Patient Outcome– Fatigue level - ~ 80% unresponsive to TNFi in both

the groups

AS vs. nr-axSpA:

• Corli J, Flipo R-M, Philippe P, Bera-Louville A, Behal H, Wibaux C, et al. TNFi in AS and nr-axSpA: Treatment Response, Drug Survival, and Patient Outcome. J Rheumatol 2015;42:2376–82. • Bedaiwi M, Sari I, Thavaneswaran A, Ayearst R, Haroon N, Inman RD. Fatigue in Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis: Analysis from a Longitudinal Observation Cohort. J Rheumatol November 1 2015; doi:10.3899/jrheum.150463


AS vs nr-axSpA

Some similaritySome differences

Concept of a ‘spectrum’ of phenotypes in SpA

Inflammatory in nature

Nr-axSpA AS AS – ‘Bamboo spine’

The continuum of

Only in predisposed individuals

Forces pushing some patients to the right


Some genetic / environmental influences that induce

osteoproliferation Radiographic sacroiliitis

Syndesmophytes (‘bamboo spine’)?


Factors associated with progression of the disease

• Age of symptom onset younger more damage

• Gender males more damage• Number of syndesmophytes at the baseline• CRP level at baseline correlates with disease

progression; the degree and rapidity of CRP fall correlates with the efficacy of response

Braun J, Baraliakos X, Hermann K-GA, Xu S, Hsu B. Serum C-reactive protein levels demonstrate predictive value for radiographic and magnetic resonance imaging outcomes

in patients with active ankylosing spondylitis treated with golimumab. J Rheumatol 2016; 43;1704-12


Smoking and other socioeconomic / environmental factors

• Smoking and socioeconomic factors most likely confound this relationship and may have separate effects on bone formation.

• Physically demanding jobs may amplify the potentiating effects of inflammation on bone formation in AS.

• Ramiro S, Landewé R, van Tubergen A, Boonen A, Stolwijk C, Dougados M, et al. Lifestyle factors may modify the effect of disease activity on radiographic progression in patients with ankylosing spondylitis: a longitudinal analysis. RMD Open. 2015; 1(1): e000153. doi: 10.1136/rmdopen-2015-000153


Lifestyle factors may modify the effect of disease activity on

radiographic progression in patients with

ankylosing spondylitis

(A) hypothesis 1: occupational activity modifies the relationship between disease activity and radiographic progression confounded by the effect of gender, smoking status and/or low socioeconomic status . (B) Hypothesis 2: smoking status modifies the relationship between disease activity and radiographic progression confounded by the effect of gender, occupational activity and/or low socioeconomic status.


Genetic influence on phenotype?

Vendelbosch S, Heslinga SC, John M, van Leeuwen K, Geissler J, de Boer M et al. Study on the Protective Effect of the KIR3DL1 Gene in Ankylosing Spondylitis. Arthritis Rheumatol 2015 ;67 (11):2957 -65 • KIR3DL1 gene has a protective effect against the more severe

manifestations of AS.– Is this a determinant of the 2 phenotypes namely: AS and nr-axSpA?

Ustun N, Tok F, Kalyoncu U, Motor S, Yuksel R, Yagiz AE et al. Sclerostin and Dkk-1 in patients with ankylosing spondylitis. Acta Reumatol Port 2014; 39:146-151• Pathologic bone formation in AS might be due to molecular dysfunction of

sclerostin and Dkk-1 at the cellular level


Londono J, Santos AM, Peña P, Calvo E, Espinosa LR,Reveille JD, et al. Analysis of HLA-B15 and HLA-B27 in spondyloarthritis with peripheral and axial clinical

patterns BMJ Open 2015;5:e009092 doi:10.1136/bmjopen-2015-009092

• New report suggests that the presence of HLA-B15 favours the development of isolated/combined peripheral rather than isolated axSpA, while HLA-B27 promotes an isolated/combined axial disease and excludes a peripheral pattern.

• HLA-B15 should be considered in addition to HLA-B27 when diagnosing patients with SpA according to ASAS criteria.


nr-ax SpA & AS are phenotype of the same disease spectrum but, may or may not be the 2 stages of the same diseases

Forces/ factors pushing patients from ‘Aa’ to ‘Ab’ •Male gender, hip dis., extra-articular manifestations•Socioeconomic factors (including physical stress)•Environment factors (smoking, others?)•Genetic factors (HLA B27 - certain genotypes; KIR3DL1, Sclerostin and Dkk-1, others?)•Intensity of acute phase response (genetically determined, CRP, others?)•Other factors

SpA Spectrum of Diseases*

Circles represent:‘Aa’: nr-axSpA,‘Ab’: r-axSpA‘B’ : Peripheral Arthritis of SpA pattern‘C’ : Extra-articular manifestations‘D’ : IBD- related SpA‘E’ : Psoriasis related SpA‘F’ : Reactive arthritis related SpA *‘A’ often called ‘Primary’, D-E-F often called Secondary


Conclusion: • In simple terms nr-axSpA and AS are different stages on the spectrum of a

clinical entity called SpA. • There are forces/factors that push patients towards the right-end of the

spectrum that has more severe clinical, radiographic and laboratory abnormalities.

• mNY criteria are strict therefore highly specific with little chance of similar but different conditions getting included in this group.

• On the other hand, the ASAS classification criteria could have problems of specificity, as discussed by Deodhar et al.

• Due to decreased specificity, there could be an issue of inclusion of conditions that are not within the spectrum of SpA.

• Therefore, the use of ASAS classification in research studies may create problems; There is a need for its revision.

• Robinson and colleagues have discussed this issue extensively.


Take home lesson

• SpA is a spectrum of disease with varying phenotypes

• Genetic, environmental, personal and socioeconomic factors determine its natural history

Early diagnosis using the ‘nr-axSpA concept’ is a welcome change for the suffering patients

But ‘conditionally’


Take home lesson

• Unfortunately, the ASAS classification criteria for nr-axSpA is rather low in specificity.

• High potential for diseases other than axSpA to get included may get wrong treatment.

• This is because of the inclusion of non-specific factors:– Inflammatory back pain– Family history– Etc. work in progress


Question 1: Non-radiographic axial SpA (nr-axSpA); Is it really AS?

OPTIONS• A. It is within the continuum/spectrum of inflammatory

spinal disease but not exactly AS as defined by mNY criteria

• B. No. These are 2 distinct inflammatory diseases of the spine with different clinical presentation, disease course, and response to treatment.

• C. But for the presence of radiographic sacroiliitis present in those with AS, there is no difference in their clinical presentation, disease course and response to treatment.


Question 2. Do we need to modify the ASAS (2009) criteria for axial SpA?

OPTIONS:• A. No, it is serving the field of SpA research and care very

well.• B. Yes, ASAS criteria does require modification because the

so-called ‘SpA features’ include several nonspecific manifestations that are likely to make the criteria nonspecific with high chance of causes other than SpA getting included in the selected population.

• C. We require an entirely new set of criteria for the whole spectrum of diseases included under the broad category of inflammatory spinal disease called SpA


Thanks for your patience and giving me the

opportunity to present my views on this topic!!

CONCURRENT SYMPOSIUM- SPONDYLOARTHRITIS - Non radiographic SpA-Is it really AS? - Dr Anand N...

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