Volume 8 Issue 5, May 2012

Although systemic lupus erythematosus is the prototype multisystem disease, many other inflammatory diseases are also promiscuous, with symptoms manifesting in many organs. Now, new data emphasize the extra-articular involvement in spondyloarthritis, predominantly affecting the eye; however, the factors that account for the observed organ involvement remain unknown.

Although methotrexate is the most widely used medication for psoriatic arthritis (PsA), evidence for its effectiveness is scant. The recent MIPA trial failed to show disease-modifying effects. Was this outcome due to true inefficacy, or to trial issues? Data on symptom-modulating and disease-modifying effects of methotrexate in PsA are explored.

The heterogeneity and interrelatedness of the conditions comprising spondyloarthritis (SpA) complicate diagnosis and patient classification; however, a number of criteria sets have been developed to aid these processes. Here, the authors critically review the currently available SpA classification criteria and highlight the important part that MRI will play in facilitating early diagnosis of this disease.

Owing to the long diagnostic delay in spondyloarthritis (SpA), the effective identification of those individuals who are likely to have axial SpA among patients with chronic back pain in primary care and their subsequent referral to a rheumatologist for establishing a correct diagnosis is worth pursuing. In this article, the authors discuss potential referral criteria and present clinical studies in which their effectiveness in identifying patients with SpA has been examined.

Spondyloarthritis in childhood (juvenile SpA) is distinct from the disease in adults, typically affecting the lower extremities (peripheral arthritis and enthesitis) with spinal or sacroiliac joint involvement rare at disease onset. This Review provides an update on the advances in diagnosis and management of juvenile SpA, summarizing classification and diagnostic criteria, clinical features, outcomes and guidelines for treatment.

Although NSAIDs and physical therapy remain the first-line treatment recommendations for SpA, therapy options are evolving rapidly with advances in understanding, classifying and diagnosing the disease. TNF blockers are effective in NSAID-resistant disease but other biologic agents have thus far failed to deliver results. New capacities to enroll patients at an earlier stage in the disease, and to stratify studies by SpA subtype, will facilitate further therapeutic developments.

Why does chronic inflammation manifest not only in the joints but also in the gut in a substantial proportion of patients with SpA? Insights into the genetic and environmental factors that link inflammatory bowel disease and SpA are provided in this Review. Furthermore, the authors present a transition model, describing a phase in the disease process during which acute inflammation is transformed into chronic pathology, and suggest that it might present the opportunity for effective therapeutic intervention.

Overlapping heredity in ankylosing spondylitis, psoriasis and inflammatory bowel disease indicates common pathological pathways between these diseases. Modern genetic techniques are unraveling the similarities—and differences—in the genetic backgrounds of these complex inflammatory disorders, and promising new approaches to tackle them. How the association ofHLA-B27with SpA might contribute to the disease process is among the factors discussed in this Review.

The six specially commissioned Reviews and two News & Views articles in this Focus issue on spondyloarthritis (SpA) outline the latest research developments in both adult and juvenile SpA, and how these translate into clinical practice. New approaches and referral strategies for early diagnosis are discussed, alongside accurate disease classification, therapeutic developments, insights into extra-articular manifestations of SpA, and advances in our understanding of the genetics and pathophysiology of SpA.