Peripheral Manifestations of Spondyloarthritis

More than half of patients with spondyloarthritis (SpA) have peripheral manifestations. Clementina Lopez-Medina, MD, PhD, a postdoctoral student at Cochin Hospital, France, and colleagues recently investigated the factors associated with the presence of peripheral manifestations in these patients. The researchers evaluated data from patients in the Assessment of Spondyloarthritis International Society-Comorbidities in Spondyloarthritis (ASAS-COMOSPA) study to assess the effect these symptoms had on treatment and patient-reported outcomes. They found psoriasis and the absence of HLA-B27 were associated with the development of peripheral symptoms.

The results, published April 15 in The Journal of Rheumatology, indicate that any peripheral symptom at the time of a visit to a rheumatologist is associated with higher scores in all patient-reported outcomes.¹ The study included a worldwide population, with 3,984 patients who represented not just patients with axial SpA, but the entire SpA spectrum. The cross-sectional study identified correlations, but was not designed to determine causation.

“To our knowledge, this is one of the first studies to attempt to evaluate peripheral manifestations, not only in axSpA, but also in the whole group of SpA,” write the authors in their discussion. “Our study shows that more than 64.3% of patients with SpA, regardless of the initial presentation, report at least one peripheral manifestation at some point during the course of the disease. This study confirms the high prevalence of peripheral rheumatological manifestations in the past history of patients presenting axial symptoms, emphasizing the importance to check for those clinical features to facilitate the diagnosis of SpA.”

The investigators note the most frequently reported peripheral manifestation was peripheral arthritis (51.5%). The prevalence of peripheral enthesitis was 37.8%, and the prevalence of dactylitis was 15.6%.

“In our study, considering patients who only fulfill the axial ASAS criteria, the percentage of peripheral arthritis decreased to 37.2%, slightly higher than reported in axial SpA (20–30%). This [finding] can be explained by the great heterogeneity of COMOSPA participants, which include South American patients, who are more likely to develop peripheral manifestations,” write the authors.

Peripheral manifestations were also more frequent among older patients (i.e., defined by the researchers as those older than 43 years). These manifestations were less common among HLA-B27 positive patients, patients with chronic inflammatory bowel disease and smokers. Additionally, the investigators found a higher prevalence of peripheral manifestations in patients with South American history, a history of uveitis and current or history of psoriasis.

The investigators studied patients who had peripheral manifestations at the time of the study and compared them with patients who had a history of, but were no longer experiencing, peripheral manifestations, as well as with patients who had never experienced such symptoms. They found the patients who had peripheral manifestations at the time of the study were more likely to report negative outcomes than the two other patient groups. Thus, not only do most SpA patients have at least one peripheral manifestation, but there is also a high probability these symptoms will occur after the onset of axial symptoms. Moreover, the presence of any of the three peripheral manifestations was associated with a greater use of any drug.