Mohamad Bittar

Objective: To systematically review the literature to support guidance defining magnetic resonance imaging (MRI) criteria of sacroiliac joint (SIJ) involvement indicative of axial spondyloarthritis (axSpA) for classification purposes. Methods: The primary question for the systematic literature review (SLR) was the following: which MRI lesion in the SIJ, or combination of lesions, is most sensitive and specific for an MRI considered indicative of axSpA? Three additional questions addressed an endpoint of clinician diagnosis of axSpA and the extent and location of the lesion(s). The SLR included all studies from January 2017 through October 2025, and 5 databases (Scopus, Web of Science Core Collection, Ovid MEDLINE, Ovid Embase, and Cochrane Library [via Wiley]) were searched. Data extraction and risk of bias assessment were performed independently by 3 reviewers. Results: Searches returned 3908 unique results, of which 30 were selected for full review and data extraction. Only 2 reports described "MRI global indicative of axSpA" as a reference criterion and only 5 assessed MRI lesion definitions in an inception cohort study design. The quantitative component for bone marrow edema (BME) of the Assessment of SpondyloArthritis international Society (ASAS) 2009/2016 MRI definitions lacked specificity. BME in < 4 SIJ quadrants was seen in anterior SIJ slices of peripartum women and healthy individuals. Erosion and fat lesions were uncommon (< 5%) in healthy individuals and disorders that mimic axSpA. BME adjacent to erosion and/or fat lesions was highly specific for axSpA. Conclusion: The quantitative cutoffs of active and structural lesions are derived from a single inception cohort, which would require future studies for external validation. The results of this SLR reinforce the need to revise previously reported definitions of a positive MRI indicative of axSpA toward more stringent cutoffs that detail the extent and location of MRI lesions.

In keeping with other immune-mediated inflammatory rheumatic diseases, treatment choices for axial spondyloarthritis (axSpA) have expanded beyond nonsteroidal antiinflammatory drugs (NSAIDs) and physical therapy in the last 20 years. We now have 10 advanced therapies from 3 distinct modes of action (ie, tumor necrosis factor inhibitors [TNFi], interleukin 17 inhibitors [IL-17i], and Janus kinase inhibitors [JAKi]), and novel modalities are being investigated.

Objective: Psoriatic arthritis (PsA) guidelines aim to provide consistent, evidence-based recommendations. Multiple regional guidelines exist, often based on similar evidence but with different methodologies and contexts. Our aim was to compare recent PsA treatment guidelines from the American College of Rheumatology, Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, European Alliance of Associations for Rheumatology, and Pan American League of Associations for Rheumatology, identifying similarities, differences, and opportunities for global harmonization with regional adaptation. Methods: Narrative comparative review of guideline documents published between 2018 and 2024 by major rheumatology societies was performed. Data on methodology, panel composition, treatment domains, pharmacologic recommendations, and update strategies were extracted and synthesized. Results: Guidelines share core principles, including domain-based approaches, treat-to-target strategies, and the use of conventional synthetic disease-modifying antirheumatic drugs and biologics. Differences arise from methodological frameworks (eg, GRADE [Grading of Recommendations Assessment, Development, and Evaluation], domain-based, adolopment), stakeholder composition, and explicit consideration of regional drug access. Conclusion: A hybrid framework combining global core recommendations with modular regional adaptations may optimize resource use, improve guideline sustainability, and maintain local relevance. Living systematic reviews and artificial intelligence could support more timely updates.

Objective Ankylosing Spondylitis (AS) is a chronic inflammatory condition that affects the axial skeleton. Recent studies have shown that mortality risk is higher in AS patients and that it is possibly related to disease activity and duration. Our aim was to investigate the leading causes and factors associated with mortality in hospitalized AS patients in the USA. Methods This is a case–control study using the Cerner Health Facts® database between 2015 and 2017. The search was done using ICD codes and administrative claims. Cases were hospitalized AS patients who died during that hospitalization, while controls were patients who survived. In addition to demographics, we collected data on the inpatient use of medications such as NSAIDs, as well as different comorbidities and systemic disease manifestations. The discharge diagnoses for deceased patients were collected to infer causes of mortality. Analysis of association was performed using chi-square tests, t-tests, Wilcoxon rank-sum tests, and logistic regression methods. Results The leading causes of death were cardiovascular, infectious, respiratory, and traumatic. The Elixhauser comorbidity index was the factor most associated with mortality (p-value < 0.0001), with congestive heart failure and renal disease the most contributing. Drug use disorder was associated with mortality (adjusted OR = 10.9; p = 0.001). Inpatient NSAIDs use was not associated with increased odds for mortality (p-value 0.33). Conclusion Cardiovascular and renal comorbidities are associated with mortality and need to be targeted early on to lower the odds of mortality as patients age. Strategies to prevent opioid and drug abuse should be strengthened in the AS population. Key Points • Cardiovascular and renal comorbidities are associated with mortality and need to be screened for and targeted early on to lower the odds of mortality as patients age. • Drug use disorder including opioid dependence is associated with mortality, and strategies to prevent opioid and drug abuse should be strengthened in the AS population.

Purpose of Review This article aims to review the challenges in axial spondyloarthritis diagnosis and identify the possible contributing factors. Recent Findings The inability to reach an accurate diagnosis in a timely fashion can lead to treatment delays and worse disease outcomes. The lack of validated diagnostic criteria and the misuse of the currently available classification criteria could be contributing. There is also significant inter-reader variability in interpreting images, and the radiologic definitions of axial spondyloarthritis continue to be re-defined to improve their positive predictive value. The role of inflammatory back pain features, serologic biomarkers, genetics, and their diagnostic contribution to axial spondyloarthritis continues to be investigated. Summary There is still a significant amount of delay in the diagnosis of axial spondyloarthritis. Appreciating the factors that contribute to this delay is of utmost importance to close the gap. It is similarly important to recognize other conditions that may present with symptoms that mimic axial spondyloarthritis so that misdiagnosis and wrong treatment can be avoided.