Julio Ramírez

Objective: To evaluate clinical and MRI features associated with clinical response in patients with axial spondyloarthritis (axSpA) initiating biological therapy. Methods: Forty-one biologic-naïve axSpA patients underwent baseline sacroiliac joint MRI before starting biological therapy. Clinical, inflammatory markers, disease activity scores, and MRI data (SPARCC score) were collected. Outcomes included clinical responses according to BASDAI and ASDAS. Results: Twenty-two were women (53.7%), with a median age of 40 years (IQR 34–55) and a median disease duration of 96 months (IQR 60–144). A total of 74.4% were HLA-B27 positive and all of them were clinically active, with median BASDAI and ASDAS-CRP scores prior to MRI of 6.4 (IQR 5.30–7.15) and 3.4 (IQR 2.98–4.03), respectively. At 16 weeks, 52.4% achieved BASDAI remission, which was independently associated with higher iliac erosion (OR 1.1, p 0.029). Clinically important ASDAS improvement occurred in 71.4% of patients and was significantly associated with higher baseline CRP (p 0.011). Major ASDAS improvement was linked to higher initial disease activity and iliac erosion scores, though not independently after adjustment. A combined baseline MRI score (bone edema + erosion) was significantly associated with achieving ASDAS inactive disease (AUC 0.74); No MRI or clinical variables retained independent predictive value in adjusted models. Conclusion: Higher iliac erosion scores are independently associated with BASDAI remission after biologic therapy in axSpA. A combined MRI inflammation and structural damage score may help predict ASDAS inactive disease. These findings highlight the value of MRI for identifying patients more likely to benefit from biologic therapy intervention. Key Points ∙ Baseline MRI-detected iliac erosions identify patients more likely to achieve BASDAI remission after initiation of biologic therapy in axSpA. ∙ Patients achieving rapid and deep clinical responses show higher baseline MRI scores reflecting both active inflammation (BME) and established structural damage (iliac erosions). ∙ A combined MRI score integrating bone marrow edema and erosions improves prediction of ASDAS inactive disease, supporting the value of assessment of both inflammation and structural damage.

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease associated with significant morbidity and impaired quality of life. Rapid advances in diagnosis, monitoring, and especially treatment over the past decade have increased the complexity of axSpA management and contributed to variability in clinical practice. To address this need, the Spanish Society of Rheumatology (SER) has developed an updated version of ESPOGUÍA, its clinical practice guideline for spondyloarthritis. This review summarizes the updated recommendations. A multidisciplinary panel (including rheumatologists, other medical specialists, nurses, physiotherapists, methodologists, and patients) formulated key clinical questions using the PICO framework. Systematic literature reviews covering the period 2018–2023 were conducted across major databases. Evidence quality and strength of recommendations were assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. When evidence was insufficient, recommendations were formulated through a structured deliberative consensus process using the GRADE Evidence-to-Decision framework. Patient representatives actively contributed throughout the process, and the draft guideline underwent public consultation. ESPOGUÍA provides evidence-based recommendations for the management of adult patients with axSpA, focusing on pharmacological and non-pharmacological interventions. The guideline addresses the use of biologic and targeted synthetic disease-modifying antirheumatic drugs, prognostic factors for treatment response and radiographic progression, management of treatment failure, and strategies for treatment optimization, including dose tapering. Special attention is given to extra-musculoskeletal manifestations such as uveitis, inflammatory bowel disease, and psoriasis. Non-pharmacological approaches—including physical activity, smoking cessation, weight management, and nurse-led education—are emphasized as integral components of comprehensive care. ESPOGUÍA 2024 offers a comprehensive, evidence-based framework to support harmonized and patient-centered management of axSpA in Spain. By integrating recent therapeutic advances and multidisciplinary perspectives, the guideline aims to reduce variability in clinical practice, improve outcomes, and enhance quality of life for patients with axSpA, while also identifying key areas for future research.

Psoriatic arthritis (PsA) is a heterogeneous chronic inflammatory disease affecting peripheral and axial joints, entheses, skin, and nails, requiring coordinated multidisciplinary management. Since the 2018 edition of ESPOGUÍA, significant advances—including the availability of IL-17A/F, IL-23, and JAK inhibitors, as well as emerging evidence regarding axial PsA—have prompted the need for an updated guideline. The 2024 ESPOGUÍA provides evidence-based recommendations for the diagnosis and management of PsA, integrating multidisciplinary collaboration, active nursing participation, lifestyle counseling, and specific considerations for axial disease. A panel comprising rheumatologists, dermatologists, gastroenterologists, ophthalmologists, nurses, methodologists, and patient representatives formulated clinical questions using the Population, Intervention, Comparator, and Outcomes (PICO) framework. Systematic literature reviews were performed, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was applied to critically assess the quality of evidence and guide the formulation of recommendations. The guideline emphasizes early intervention and the appropriate use of conventional synthetic DMARDs, biologic therapies, and JAK inhibitors across different disease domains, including the management of extra-musculoskeletal manifestations. Lifestyle measures, such as smoking cessation and weight management, are highlighted due to their demonstrated impact on disease activity and long-term outcomes. The essential role of specialized rheumatology nurses in patient education, treatment adherence, and counseling on modifiable risk factors is also underscored. ESPOGUÍA 2024 provides a comprehensive, multidisciplinary, and patient-centered framework for PsA management, including axial involvement, and identifies persistent gaps in early diagnosis, biomarker development, and long-term outcomes, thereby outlining priorities for future research

Objectives: The aim of this study was to identify robust predictive markers which may help personalize tapering protocols, minimizing flare risk while optimizing long-term disease management in RA patients. Methods: The OPTIBIO trial (EudraCT 2012–004482-40) was a phase IV, randomized, open-label, non-inferiority study conducted in five hospitals in Spain. RA patients in sustained remission on stable bDMARD therapy were randomized 1:1 to standard care or dose reduction. The primary outcome was to compare the proportion of joint flare between baseline and 12 months by a non-inferiority analysis analysed by the intention-to-treat principle and to identify predictors for flare and sustained remission. Results: A total of 195 patients were randomized: 99 to the control group and 96 to the optimization group. Thirty-nine flares occurred (optimization: 22.7%, control: 17.2%), with a risk difference of −5.5% (95% CI: −16.8% to 5.7%; P = 0.33). Two predictive models were developed: one for flares (AUC: 0.84) including 3v-DAS28-CRP, VAS pain, erosions, systolic blood pressure and haemoglobin, and another for sustained remission (AUC: 0.77) including 3v-DAS28-CRP, age and rheumatoid factor. Adding molecular biomarkers improved AUCs to 0.91 and 0.88, respectively. No significant differences in adverse events were observed. Conclusion: bDMARD dose optimization was not non-inferior to standard therapy on the flare rate but demonstrated similar safety. Predictive models for remission and flares were developed, which may help select patients to ensure safe implementation of this strategy, highlighting the need for personalized treatment. Trial registration: www.clinicaltrialsregister.eu; EudraCT 2012–004482-40

Objectives Optimization of biological DMARDs (bDMARDs) in patients with rheumatoid arthritis (RA) may be feasible in those who have maintained remission for at least six months. However, this approach carries the risk of disease flare, underscoring the need for reliable predictors to guide clinical decisions. Methods The OPTIBIO trial (EudraCT 2012-004482-40) was a phase IV, randomized, open-label, non-inferiority study conducted in five hospitals in Spain. RA patients in sustained remission on stable bDMARD therapy were randomized 1:1 to standard care or dose reduction. The primary outcome was to compare to proportion of joint flare at 12 months by a non-inferiority analysis analyzed by the intention-to-treat principle and identify predictors for flare and sustained remission. Results 195 patients were randomized: 99 to the control group and 96 to the optimization group. Thirty-nine flares occurred (optimization: 22.7%, control: 17.2%), with a risk difference of -5.5% (95% CI: -16.8% to 5.7%; P = 0.33). Two predictive models were developed: one for flares (AUC: 0.84) including 3v-DAS28-CRP, VAS pain, erosions, systolic blood pressure, and hemoglobin, and another for sustained remission (AUC: 0.77) including 3v-DAS28-CRP, age, and rheumatoid factor. Adding molecular biomarkers improved AUCs to 0.91 and 0.88, respectively. No significant differences in adverse events were observed. Conclusion bDMARD dose optimization was non-inferior to standard therapy on the flare rate but demonstrated similar safety. Predictive models for remission and flares were developed, which may help select patients to ensure safe implementation of this strategy, highlighting the need for personalized treatment. Key messages bDMARD dose optimization was non-inferior to standard therapy on the flare Clinical models classified patients in terms of disease severity Incorporation of molecular markers to clinical models improved their prediction power

Background: Achieving low disease activity or remission in psoriatic arthritis (PsA) remains difficult. The GRAPPA group recently defined difficult-to-treat (D2T) PsA but did not include a time-based criterion. Objectives: This study aimed to evaluate the prevalence and features of D2T PsA using several operational definitions. Methods: A cross-sectional study at a tertiary center enrolled PsA patients with active disease confirmed by clinical exam and ultrasound. D2T PsA was defined by: (1) failure of ≥1 csDMARD plus ≥2 b/tsDMARDs with different mechanisms of action (GRAPPA definition); (2) ≥2 b/tsDMARDs with different mechanisms of action within 12 months (time-based definition); or (3) failure of >3 b/tsDMARDs with different mechanisms of action (very refractory). Clinical, demographic, radiographic, and ultrasound data were analyzed, and multivariable analyses identified independent associations. Results: Seventy-two patients (54.2% female, median age 56, disease duration 84 months) all had active disease (median DAPSA 17); 68% had comorbidities. Enthesitis, dactylitis, and nail disease were seen in 20.8%, 45.8%, and 41.7%. HLA-B27 positivity was 13.9%. Radiographic erosions and ultrasound paratenonitis were present in 37.5% and 33.3%. GRAPPA D2T criteria were met by 23.6%, linked to longer disease duration, higher activity, HLA-B27, comorbidities, and combined therapy. Time-based D2T (12.5%) showed higher DAPSA and nail involvement, with ultrasound paratenonitis and combined therapy independently associated. Very refractory patients (11.1%) only correlated with combined therapy. Conclusions: Up to one-fourth of PsA patients remain active despite multiple treatments. D2T PsA is associated with disease duration, comorbidities, activity, HLA-B27, combined therapies. Remarkably, patients who fulfilled the <12-month D2T definition were more likely to present with nail involvement and ultrasound-detected paratenonitis.

Objectives: To evaluate clinical and ultrasound (US) features related to psoriatic arthritis (PsA) development in psoriasis (PsO), patients without musculoskeletal (MSK) symptoms and no systemic treatment. Methods: Prospective study including PsO patients followed by dermatologists. Clinical and US data were collected at baseline and during follow-up by rheumatologists. Results: Seventy-eight patients with PsO were included. Mean disease duration was 15.1 years (SD ± 13.4); most had mild PsO (82%), onychopathy was present in 36 (39.7%) and overweight/obesity in 38 patients (48.7%). In the US evaluation, nine patients (11.5%) had Power Doppler grade 1 at joints, 56.4% had calcifications and 30.4% bursitis at enthesis. Sixty patients completed the study. After a median of 76.60 months (IQR 39.34–85.25), 34 patients (56.6%) developed MSK symptoms. They had higher BMI (P = 0.013), abdominal circumference (P = 0.022), scored higher for pain (P = 0.047) and fatigue (P = 0.011). Their baseline US showed a higher total US score (P = 0.037). Five patients (8.3%) developed MSK inflammatory symptoms, and four met CASPAR criteria (5.5%). The mean time from baseline to PsA diagnosis was 20.20 months (SD ± 12.02). US bursitis was present in 80% of patients developing inflammatory symptoms (P = 0.049). Conclusions: In a cohort of patients with mild PsO, systemic therapy-naive and no MSK symptoms, incidence of PsA was 1% per year. US bursitis at enthesis was related to the development of symptoms suggestive of PsA. Patients who developed MSK symptoms had higher BMI, fatigue and pain VAS scores at baseline and could constitute a subgroup with higher risk for transition to PsA.

Full Papers; Authors: J. Ramírez, C.D. Adao-Abe, A. Mocritcaia, A. Garcia-Gargallo, J. Peñafiel-Sam, C. Arango, J.C. Sarmiento-Monroy, H. Flórez, J.A. Gómez-Puerta, L. Alascio, A.B. Azuaga-Piñango