Reviews & Analysis

New studies demonstrate the development of anti-flagellin antibodies in patients with ankylosing spondylitis. Does their presence point to mucosal dysregulation as a pathogenic mechanism of the disease?

The 2013 update of the EULAR recommendations for the treatment of rheumatoid arthritis has evolved in several domains, and has, for the first time, elevated non-TNF-inhibitor biologic agents to the same status as TNF inhibitors. These transparently derived and scholarly recommendations will contribute to the evolving dialogue on the proper use of these agents.

Evidence of possible molecular crosstalk between inflammation and insulin resistance suggests that treatments for diabetes might be useful in patients with rheumatoid arthritis (RA), or vice versa. However, in a new trial of a PPARγ agonist in RA, the clinical effect was at most modest. So, does such an approach have a future?

The association of environmental dietary factors and polymorphisms of urate transporters with an increased risk of gout has been well established. Nevertheless, the influence of genetics and diet on serum urate concentrations, and the clinical relevance to individual patients, seems to be limited.

Musculoskeletal ultrasonography is a routine diagnostic tool in rheumatological practice. The technique has only recently been used to evaluate articular and periarticular structures. In systemic sclerosis, different aspects of hand and wrist involvement have now been described, offering hope for the transfer of ultrasonography for this condition to the clinic.

Pulmonary arterial hypertension (PAH) is a lethal complication in connective tissue diseases (CTDs) with varying frequency of occurrence; the highest incidence is in systemic sclerosis. Data for PAH screening by echocardiography in other CTDs are not strong. Should we only investigate symptomatic patients or perform regular screening for PAH in CTDs?

Takayasu arteritis is an understudied disease but a recent article emphasizes the heavy burden it imposes on patients. New assessments devised to improve disease understanding are based on physicians' concepts of disease severity. However, wide differences exist between patient and physician priorities and more work is now needed to improve patient quality-of-life.

Clinical findings and responses to biologic agents are increasing the evidence that undifferentiated spondyloarthritis (SpA) may represent the earliest stage of ankylosing spondylitis and psoriatic arthritis. New results also lend support to the hypothesis that the SpA spectrum represents one clinical condition, but hurdles in improving classification and diagnosis remain.

Recent progress in our understanding of the pathogenesis of primary Sjögren's syndrome (pSS) and the development of indices to measure disease activity in patients with this condition, offer us ample possibilities for treatment with biologic DMARDs. New biomarkers further aid selection of patients with pSS for appropriate treatment options.

Consensus guidelines for patient management can increase disease awareness and education, and facilitate evidence-based clinical decision-making. Nevertheless, new gout recommendations leave a 'déjà vu' impression. Novel evidence from clinical trials is needed to robustly advance patient care and build the next generation of guidelines.

The mind and body are thought to interact in a manner that influences health, but modelling the right aspects of each so as to best inform treatment is a tricky proposition. A new study discusses how stress can affect rheumatoid arthritis symptoms.

An incident fracture sustained during treatment for osteoporosis does not necessarily represent treatment failure, an outcome that was redefined in 2012. Predictors of the new definition have now been reported and include ≥2 falls within the past year. Preventing fractures in the most at-risk patients, however, requires improved management strategies.

Clinicians now have the therapies and outcome tools to implement treat-to-target strategies aimed at achieving and maintaining adequate function and control of symptoms in spondyloarthritis and psoriatic arthritis. However, validation of surrogate markers of structural progression is a prerequisite for treat-to-target strategies aimed at improving long-term outcomes such as joint damage.

Since the 1990s, patients with rheumatoid arthritis have been treated with at least one DMARD. Methotrexate, which is usually the first-line treatment, elicits good or even excellent clinical results in 20–30% of patients—but in most patients it does not. Thus, an important question is what to do after methotrexate failure.

Beneficial effects of bone-acting drugs in osteoarthritis (OA) are increasingly reported, but reliable conclusions regarding their efficacy are hindered by methodological drawbacks in study design. Identifying patients with osteoporotic OA, a phenotype defined by decreased density associated with high remodelling in subchondral bone, might improve the success of bone-directed agents.

Biologic medications are highly efficacious in juvenile idiopathic arthritis. However, a recent study found that a subgroup of children treated with anti-TNF agents had persistent pain despite good disease control. This finding highlights the importance of monitoring pain symptoms during treatment with modern DMARDs.

The ankylosing spondylitis disease activity score (ASDAS) is a measure of axial spondyloarthritis (SpA) disease activity endorsed by the Assessment of SpA International Society and Outcome Measures in Rheumatology. Accumulating evidence supports the utility of ASDAS in axial SpA. So, is it time to replace the Bath ankylosing spondylitis disease activity index (BASDAI)?

Periarticular bone erosions are a central feature of rheumatoid arthritis (RA) and their exact assessment is crucial for diagnosis, monitoring responses to therapy and aiding decision-making. High-resolution peripheral quantitative CT and MRI—two imaging modalities with the potential to improve the diagnosis and monitoring of RA—have now been compared.

When nonsurgical options for osteoarthritis of the glenohumeral joint are exhausted, total shoulder arthroplasty has been well studied and carries the most predictable outcome. For patients wishing to remain active, however, proven shoulder-preserving options have been less predictable. A new study now adds to preliminary evidence supporting the complete arthroscopic management procedure.

Rapid progress is being made in the field of rheumatology. Nevertheless, disappointingly, the limited resources of the paediatric rheumatology community are being expended on the publication of consensus guidelines that represent fossilization of old ideas rather than real innovation that leads to the improved care of children.