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The article discusses one of the variants of overlap syndrome – a combination of symptoms of ankylosing spondylitis (AS) and rheumatoid arthritis (RA). Three clinical cases are described, in these cases characteristic signs of both diseases were noted and the criteria of both diseases were met. The genetic factors and immunopathogenetic mechanisms underlying AS and RA are analyzed. A review of the literature on the combination of AS and RA is presented.

The paper highlights the relationship between HLA-B27-associated uveitis and spondyloarthritis (SpA). It presents the genetic aspects of inflammation of the eyes and musculoskeletal system, the role of the HLA-B27 histocompatibility antigen, and the contribution of other genes to the development of uveitis and spondylitis. The authors characterize the general pathogenetic mechanisms of the development of these diseases: the importance of factors of innate immunity, proinflammatory cytokines in the initiation of inflammation of the eyes and joints. The detection rate of SpA is analyzed in various forms of uveitis; the predictors of SpA development are identified in the patients. An algorithm is presented, which makes it possible to timely diagnose SpA in the presence of acute anterior uveitis. HLA-B27, inflammation in the ocular anterior chamber, unilateral alternating eye lesions, an acute recurrent course, and uveitis onset at the age of less than 30 years are singled out as the most significant signs associated with SpA in patients with uveitis. The features of the course and the frequency of complications in uveitis with and without SpA are compared. It is shown that exacerbations of uveitis and associated complications occur statistically significantly more frequently in SpA. There is evidence for the need for a close interaction between ophthalmologists and rheumatologists in the management of patients with uveitis.

BackgroundUveitis is a frequent extra-skeletal manifestation of ankylosing spondylitis (AS).Data on the association of uveitis with other clinical manifestations of AS are contradictory and require further study.ObjectivesTo assess the association of uveitis in AS with demographics and genetics, spine lesions, peripheral disease, coxitis, enthesitis.Methods402 AS pts (New York criteria, 1984), were observed in V.A. Nasonova Research Institute of Rheumatology. 168 pts had at least 1 episode of uveitis (group 1), 234 pts did not have uveitis (group 2). The patients underwent standard clinical, laboratory and instrumental examination, including HLA-27- testing, Х-ray examinaiton of joints and spine, ultrasonography of joints and entheses. Two groups were compared by gender, onset age and AS duration, presence of HLA-B27, damage of the spine, hip and peripheral joints and enthesitis.ResultsBoth groups were dominated by men: 117 of 168 in group 1 and 189 of 234 in group 2. However, among patients with uveitis, the proportion of women was significantly higher: 51/168 (30.3%) and 45/234 (19.2%), p=0.01. The average duration of the disease was comparable in both groups – 14.9±10.2 and 12.8±9.9 years, respectively. The number of patients with AS onset before the age of 16 also did not significantly differ: 22/168 (13.1%) in the group with uveitis, 35/234 (14.9%) in the group without uveitis, p=0.6. HLA-B27 in the group with uveitis was in 166/168 patients (98.8%) and in 221/234 (94.4%) in the group without uveitis, p=0.04. Syndesmophytes were observed in both groups with similar frequency: in the cervical spine - in 49/168 (29.1%) in group 1 and in 78/234 (33.3%) in group 2, p>0.05; in the lumbar spine – in 87 /168 (51.8%) and in 139/234 (59.4%), respectively, p>0.05. Hip joint lesion (coxitis) was present in 75/168 (44.6%) and in 112/234 (53.8%) respectively, p=0.52; enthesitis – in 114/168 (67,9%) and in 168/234(71,8%), p>0.05. Peripheral arthritis was observed significantly more often in the group with uveitis: in 113/168 (67.2%) and in 70/234 (33.2%) respectively, pConclusionAS with uveitis is characterized by a greater proportion of women and stronger association with HLA-B27, compared with patients without uveitis. Peripheral arthritis with predominant involvement of the knee and ankle joints is significantly more common in AS pts with uveitis compared with pts without uveitis.References[1]Lee JH, Choi M, Rim THT, Lee SC, Lee CS. Clinical Characteristics and Prognostic Factors in Ankylosing Spondylitis Associated Uveitis.Ocul Immunol Inflamm. 2019;27(1):64-69. doi: 10.1080/09273948.2017.1359630.Disclosure of InterestsNone declared

Extraskeletal manifestations (ESMs) are commonly observed in ankylosing spondylitis (AS). The available data on the association of ESMs with the inflammatory activity and other clinical parameters of AS are contradictory. Objective : to assess the association of ESMs with the inflammatory activity and other manifestations of AS. Patients and methods . The investigators of the V.A. Nasonova Research Institute of Rheumatology examined a total of 452 patients (363 men and 89 women) diagnosed with AS meeting the New-York criteria (1984). The patients' median age was 31.5 [24; 41] years; median disease onset age, 19.5 [15; 23] years; and disease duration, 11.5 [7; 18] years. HLA B27 was identified in 442 (97.7%) patients. In addition to standard laboratory and instrumental examinations, 172 patients underwent transthoracic echocardiography; Rehberg's test, if indicated; IgA test; histological examination of subcutaneous fat tissue or duodenal mucosa for amyloid; renal ultrasound; colonoscopy; and consultations by an ophthalmologist, a dermatologist, a nephrologist, an urologist, and a gastroenterologist. Uveitis, cardiac involvement (cardiac conduction disturbance, aortic and valvular changes), inflammatory bowel disease (IBD), glomerulonephritis, and psoriasis were considered to be ESMs. The latter were detected in 218 (48%) of the 452 patients; there was uveitis in 140 (30%), cardiac conduction disturbance in 61 (13.4%), psoriasis in 17 (3.7%), IBD in 16 (3.5%), nephritis in 16 (3.5%), and aortic and valvular changes in 71 (41.2%) of the 172 patients. The groups of patients with ESM (n = 218) and without ESM (n=234) were compared with regard to the onset age of AS, the presence of HLA- 27, peripheral arthritis, coxitis, enthesitis, syndesmophytis, fever, anemia, the need for biological agents (BAs) and/or systemic glucocorticoids (GCs), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and erythrocyte sedimentation rate (ESR). Results. The ESM and non-ESM groups were matched for gender, age, duration of AS, and the presence of HLA-В27. No significant differences were found in ESR, BASDAI, and the frequency of coxitis, enthesitis, and syndesmophytis in the spine. The ESM group versus non-ESM group was significantly more frequently observed to have peripheral arthritis in 148 (67.8%) of the 218 patients and in 70 (33.2%) of the 234 patients, respectively (p

Anterior uveitis (AU) and ankylosing spondylitis (AS) are associated with histocompatibility human leukocyte antigen (HLA)-B27. Previous genetic studies conducted in different populations have also demonstrated other genetic associations, including HLA, both general and individual ones for AU and AS. Objective: to investigate the association of HLA class I with AU depending on the presence or absence of spondyloarthritis (SpA). Patients and methods . The investigators used the data of HLA class I typing in the patients referred by ophthalmologists for examination to the V.A. Nasonova Research Institute of Rheumatology, as well as the previous databases of patients with AS. The investigation included retrospectively two groups of patients with AU: 1) 52 patients with a confirmed diagnosis of SpA (AU + SpA); 2) 96 patients who had other types of AU (idiopathic AU (n=52), viral uveitis (n=29), multiple sclerosis (n=2) toxoplasmosis (n=2), sarcoidosis (n=1), tuberculosis (n=1), chlamydiasis (n=3), Behcet's disease (n=2), juvenile chronic arthritis (n=3), and Fuchs' heterochromic cyclitis (n=1). A control group consisted of 150 healthy test donors. The distribution of HLA class I (A, B, and Cw) was analyzed when comparing the two groups of patients with AU and each control patient group. Results. HLA-B27 was detected in 96.1% of cases in the AU + SpA group, in 40.6% in the AU group, and in 7.3% in the controls. In HLA-27-positive patients, the risk (odds ratio (OR) for joint disease (AU + SpA) was 315.9 (95% confidence interval (CI), 61.9–2176.7); p

The paper gives the definition of remission in axial spondyloarthritides (axSpA), which has been developed by the Spondyloarthritis Study Group of Experts. The work used the Delphi technique. At stage 1, based on the analysis of the data available in the literature and on their own clinical experiences, the experts proposed some variants of the definition of remission and ways of its evaluation in patients with axSpA. At Stage 2, the definitions that had received at least 80% of the votes via anonymous voting were selected and adopted without further discussion. Those that had received an equal number of votes were reconsidered and additionally discussed; then there was repeat voting, by choosing the final definition. As a result of their discussion, the experts formulated the definitions of clinical laboratory and magnetic resonance imaging (MRI) remissions. They proposed the following remissions in axSpA: drug and drug-free, clinical laboratory, and MRI remissions, as well as a remission in the presence and absence of structural changes in the locomotor system, as evidenced by imaging techniques. Criteria for clinical laboratory remission and basic tools for its evaluation that can be used in real clinical practice and researches have been elaborated.

Background:Uveitis is a common extra-skeletal manifestation of various systemic diseases, in particular, spondyloarthritis (SpA). Uveal cataract is the frequent complication of endogenous uveitis. Surgical treatment of uveal cataracts is associated with certain problems, the main being a potential risk of recurrence of uveitis, especially in the case of intraocular lens (IOL) implantation.Objectives:To analyse the results of surgery of complicated uveal cataract in patients with SpA and other rheumatic disorders.Methods:30 pts (34 eyes) with uveal cataract as a result of systemic immuno-inflammatory diseases were assessed in the “Research Institute of Eye Diseases” in the period from 2006 to 2018. The postoperative follow-up period ranged from 2 to 12 years. 20 pts had different variants of SpA (Group 1):7 (7 eyes) - ankylosing spondylitis, 1 (1 eye) –reactive arthritis, 1 (1 eye) - psoriatic arthritis, 4 (6 eyes) – juvenile spondyloarthritis, 8 (8 eyes) non-radiological SpA. 10 patients (11 eyes) had other systemic diseases (Group 2): 1 (1 eye) Behcet’s disease, 1 (1 eye) - multiple sclerosis, 3 (3 eyes) - Fuchs heterochromic cyclitis, 2 (2 eyes) -cutaneous psoriasis, and 3 (4 eyes) -uveitis of unknown etiology. 4 pts (6 eyes) with juvenile arthritis and pronounced corneal ribbon degeneration were underwent standard intracapsular cryoextraction of the cataract, followed by optical correction of aphakia using spectacle lenses. In other cases, ultrasound phacoemulsification with IOL implantation was used as a surgical aid. All patients had a period of uveitis remission before opreation for at least 2 months.Аnti-inflammatory therapy using local glucocorticoid and local and systemic nonsteroidal antiinflammatory drugs was prescribed 2 weeks before and within a month after the operation. Intra and postoperative complications, fluctuations in intraocular pressure (IOP), improvement of visual acuity, and the frequency of uveitis flares after surgery were assessеd as the main criteria for analyzing the results of surgery.Results:А statistically significant decrease in the number of uveitis exacerbations was observed in all pts: in group 1 - from 2,5 ± 0,65 to 1, 2 ± 0,65 per year (pConclusion:Surgery of uveal cataracts in pts with SpA and other immuno-inflammatory diseases providing adequate pre- and postoperative аnti-inflammatory therapy improves visual acuity and reduces the frequency of uveitis relapses. Monitoring of IOP is necessary in the postoperative period.References:[1]Mora P., Gonzales S., Ghirardini S. et al. Perioperative prophylaxis to prevent recurrence following cataract surgery in uveitis patients a two-centre, prospective, randomized trial. Acta Ophthalmol. Scandinavica Fondation. 2016 Sept.; 94(6): e 390-394. http//doi. 10.1111/aos.12955. Epub 2016 Feb 5.Disclosure of Interests:None declared

The paper gives recommendations for the drug therapy of axial spondyloarthritides, which have been developed by the Spondyloarthritis Study Group of Experts. The recommendations describe the patient management tactic in the most common clinical situations, which is aimed at maximizing the efficacy and safety of treatment.

Involvement of the aorta and heart valves in ankylosing spondylitis (AS) is a manifestation of the systemic inflammatory process. Data on the frequency, clinical significance, and evolution of these manifestations are controversial. Objective : to estimate the time course of echocardiographic (EchoCG) changes in the aorta and heart valves from the results of a prospective follow-up study of patients with AS. Subjects and methods. In 2008 to 2015, the V.A. Nasonova Research Institute of Rheumatology followed up 45 patients (35 men and 10 women) with documented AS that was consistent with the modified New York criteria and the original EchoCG changes in the aorta and heart valves. All the patients underwent transthoracic echocardiography at baseline and after 1–5 years. At baseline, there was aortic root dilatation (>37 mm) in 15 patients, thickening of the aortic walls and aortic valve (AV) cusps in 21 and 32 patients, respectively, as well as thickening of the mitral valve (MV) cusps in 15, and valve prostheses in 5 patients (2 had AV and MV prostheses). Aortic regurgitation (AR) was recorded in 19 patients (grades 1–2 AR in 15 patients and grades 3–4 in 4 patients); grades 1–2 mitral regurgitation (MR) was seen in 20 patients. Ten patients had subaortic pectinate thickening (SPT) in the aortomitral junction area. Of the 45 patients, 16 took biological agents (BA); 29 received traditional therapy, including 14 patients who used nonsteroidal anti-inflammatory drugs, 11 and 4 patients had sulfasalazine and methotrexate, respectively. Results and discussion. Repeated examinations revealed negative changes in 27 (60%) of the 45 patients. Progressive aortic dilatation (1 to 6 mm) was found in 12 (80%) of the 15 patients; dilatation appeared during follow-up in 2 patients. Fourteen patients were noted to have negative valve changes: the emergence of cusp thickening in the valves (that in AV and MV in 9 and 4 patients, respectively; both in 1 patient). Four patients underwent valve replacement: 3 and 1 patients underwent AV and MV replacements, respectively. Ten of the 19 patients were observed to have AR progression by 2 grades in 2 (10.5%) patients and by one grade in 8 (42.0%) patients. MR progression by one grade was noted in 6 (30.0%) of the 20 people. A negative correlation was found between BA therapy and aortic dilation progression (r = -0.329; p = 0.03). SPT appeared in 3 patients. Of the 10 patients who had a baseline SPT, its reduction (8 to 3.5 mm) was seen in one patient; complete regression was identified in two patients; all received BAs. Thus, pathological changes in the aorta and heart valves in AS are progressive in most patients. SPT may regress, which reflects apparently a reduction in the severity of active inflammation of the aortic root. Active anti-inflammatory treatment may play a protective role in the progression of aortic dilatation.

The paper gives the recommendations for the assessment of disease activity and functional status in patients with ankylosing spondylitis in clinical practice, which have been developed by experts, by taking into account international and Russian experience in managing these patients.

Ankylosing spondylitis (AS) is a systemic inflammatory disease involving not only the skeleton, but also other organs. The data on the frequency and clinical significance of extraskeletal manifestations are contradictory. Objective: to assess the frequency and severity of extraskeletal manifestations (ESMs) of AS in the authors' own clinical practice. Subjects and methods. 452 patients (363 men and 89 women) with AS fulfilling the 1984 relevant New York criteria were examined at the V.A. Nasonova Research Institute of Rheumatology in 2005 and 2014. The patients' median age was 31.5 [24; 41] years; median disease onset age, 19 [15; 23] years; disease duration, 11 [7; 18] years; HLA B27 was identified in 442 (97.7%) patients. In addition to standard laboratory and instrumental examinations, transthoracic echocardiography was performed in 172 patients. Rehberg's test, IgA test, histological examination of subcutaneous fat tissue or duodenal mucosa for amyloid, and renal ultrasound were made if there were urinary abnormalities and elevated creatinine levels. If indicated, there were consultations by an ophthalmologist with an appropriate instrumental examination (with evidence of uveitis in the history), a dermatologist, a nephrologist, an urologist, a gastroenterologist, and a endoscopist. Uveitis, cardiac involvement (conduction disturbance, aortic and valvular changes), inflammatory bowel disease (IBD), glomerulonephritis, and psoriasis were borne in mind as ESMs. The absolute number and percentage of patients having any ESM over the follow-up period were estimated. The number of exacerbations per year and that of complications were taken into account when evaluating uveitis; the magnitude of valvular regurgitation and the presence of prosthetic valves and a pacemaker were considered when assessing cardiac damage; the total body surface area (BSA) and the psoriasis areas and severity index (PASI) were estimated in psoriasis; the presence and stage of chronic kidney disease (CKD) and/or macrohematuria were kept in mind in nephropathy; when evaluating IBD, the Harvey–Bradshaw index (HBI) was determined on the basis of a stool frequency, the presence of blood in the stool, abdominal pain, and general well-being. Results and discussion. ESMs were detected in 218 (48%) of the 452 patients. Uveitis was present in 140 (30%) patients; in one-fourth of them, it relapsed frequently: three or more exacerbations per year and more than 10 during the disease; 41 (29%) patients had uveitis complications accompanied by visual impairment. Cardiac conduction disturbance was revealed in 61 (13%) patients. Five of them underwent pacemaker implantation. 71 (41.2%) patients were found to have aortic and valvular changes, including aortic root dilatation/thickening in 60 (34.8%) patients and aortic/mitral valve leaflet thickening in 63 (36.6%). Grades 3 and 4 valvular regurgitation was noted in 10 (5.8%) patients; valve replacement was carried out in 9 (5.2%) cases. Nephritis was diagnosed in 16 (3.5%) patients, 4 of them had Stage 2 or above of CKD. Psoriasis was present in 17 (3.7%) patients; 2 of them had severe psoriasis (BSA >10%). IBD (ulcerative colitis or Crohn's disease) was diagnosed in 16 (3.5%) patients, including 4 who showed a severe course. 79 (36%) patients were observed to have a concurrence of two or more ESMs; that of uveitis and heart disease was most commonly seen. Conclusion. ESMs are observed in nearly half (48%) of the patients with AS and can be concurrent; the most common ESMs of AS are uveitis, aortic root and heart valve lesions, and cardiac conduction disturbance. ESMs worsen the course and prognosis of AS.

Relapsing uveitis is a serious problem for patients with ankylosing spondylitis (AS). Tumor necrosis factor- α inhibitors significantly reduce the frequency of uveitis attacks in AS patients, but they are not always available. In this connection, it is appropriate to evaluate the effect of traditional disease-modifying antirheumatic drugs on the course of uveitis in AS. Objective: to compare the frequency of uveitis attacks in AS during combined therapy using sulfasalazine (SULF) and nonsteroidal anti-inflammatory drugs (NSAIDs) versus monotherapy with NSAIDs. Subjects and methods. A total of 111 patients with significant AS who had at least one uveitis attack during the disease were examined. 49 subjects received combined therapy including SULF 2 grams daily and NSAIDs for at least 1 year. Six of the 49 patients were noted to have frequently relapsing uveitis (above 3 episodes yearly); 43 had no more than 3 ones per year. The remaining 62 patients took NSAIDs only throughout the follow-up period. Nine of them had an average of 3 uveitis attacks per year; 53 had no more than 3 ones per year. Out of the 49 patients receiving combined therapy with NSAIDs and SULF, 23 took NSAIDs only at least 1 year before SULF use; 10 of them were observed to have frequent relapses in that period and 13 had three or fewer episodes. Results and discussion. The entire group showed an average of 2.06±2.04 uveitis attacks per year during monotherapy with NSAIDs and 1.41±1.83 attacks yearly during combined therapy with NSAIDs and SULF (p = 0.08). Among the patients with less than 3 uveitis attacks per year, the mean number of episodes was significantly fewer during combined therapy than during NSAID monotherapy: 0.99±0.87 and 1.37±0.91, respectively (p = 0.04). Among those with frequently relapsing uveitis (more than 3 attacks per year), the mean number of episodes yearly was not significantly different during NSAID monotherapy and combined therapy: 5.7±2.5 and 5.5±2.7, respectively (p = 0.9). In a subgroup of patients receiving sequentially NSAID monotherapy and combined therapy with NSADs and SULF, 13 patients with three or fewer baseline attacks per year displayed a significant reduction in the frequency of episodes from 1.92±0.96 to 0.4±0.44 (p = 0.00003). During combined therapy versus monotherapy, 10 patients with frequently relapsing uveitis (over 3 episodes yearly) exhibited an insignificant reduction in the number of relapses from 5.9±3.02 to 5.33±1.1 (p = 0.6). Conclusion. Combined therapy with SULF and NSAIDs does not substantially affect the frequency of uveitis episodes in AS patients with frequently relapsing uveitis (above 3 attacks per year), but significantly reduces the number of episodes among patients with its mild course (less than 3 attacks yearly).

The paper gives the draft guidelines elaborated by the Expert Spondyloarthritis Diagnosis and Treatment Group by order of the Association of Rheumatologists of Russia. The guidelines include the essentials of how to use nonsteroidal anti-inflammatory drugs in axial spondyloarthrititides, including ankylosing spondylitis, contain instructions for how long they should be administered, and describe possible patient management tactics in the most common clinical situations and a preferential algorithm for evaluating the efficiency and safety of treatment.

The paper provides guidelines for the use of tumor necrosis factor- α (TNF- α ) inhibitors in the treatment of patients with axial spondyloarthritis (axSpA), including ankylosing spondylitis. It gives data on the efficacy of TNF- α inhibitors in patients with non-radiographic axSpA. By using international and Russian guidelines, the authors lay down indications for this therapy and criteria for evaluation of its efficiency and safety.

Background: Ankylosing spondylitis (AS) leads to back pain and structural damage that may result in functional impairment1. Function is usually assessed in clinical trials conducted in developed countries, with patients receiving biological therapy2,3. Objectives: To evaluate variation in the Bath Ankylosing Functional index (BASFI) over time in a AS cohort followed in a developing country. Compare the improvement in BASFI between patients achieving or not sustained (≥12 months) ASDAS-CRP remission/low disease activity (LDA). Analyze predictors for achieving a minimum clinically important improvement (MCII) in BASFI (ΔBASFI ≤ -0.6)4. Methods: This cross-sectional analysis was conducted in a retrospective cohort. Adult patients fulfilling the New York criteria for AS and followed during at least 5 years in the Spondyloarthritis clinic were included. BASFI variation (ΔBASFI) was described as median (25th/75th). Comparison of ΔBASFI between patients fulfilling or not sustained ASDAS-CRP remisson/LDA was done using the Mann-Whitney test. Hierarchical Poisson model was used to identify predictors for achieving a MCII in BASFI. Results: 69 patients were analyzed, 53.6% were men, the mean age was 48.9±11.4 years, and the mean follow-up time was 6.1±0.5 years, median (25th/75th) disease duration of 10 (5-18) years; 14.5% of the patients were on biological therapy at baseline. The median (25th/75th) ΔBASFI was low: -0.1 (-1.9 /+1.1) but 46.4% (N= 32) presented a MCII in BASFI during follow-up. Patients who achieved sustained ASDAS-CRP remission/LDA had a significant improvement in BASFI over time compared with those who did not achieve this target (p=0.026) (Figure 1). Patients with higher BASFI scores at baseline had a greater probability of achieving a MCII in BASFI (RR1.13 95%CI 1.00-1.27 p=0.047). Achieving and maintaining ASDAS-CRP remission/LDA during at least 12 months increased in 82% the probability to obtain a MCII in BASFI (RR 1.82 95% CI 1.14-2.91, p=0.012). Conclusion: Patients achieving sustained ASDAS-CRP remission/LDA had better functional outcomes over time compared to those not achieving this target. Higher BASFI scores at baseline and sustained ASDAS remission/LDA were predictors of a MCII in BASFI. References: [1] Madsen OR: Stability of fatigue, pain, patient global assessment and the Bath Ankylosing Spondylitis Functional Index (BASFI) in spondyloarthropathy patients with stable disease according to the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Rheumatol Int. 2018;38(3):425-432. [2] Baraliakos X, Kivitz AJ, et al: Long-term effects of interleukin-17A inhibition with secukinumab in active ankylosing spondylitis: 3-year efficacy and safety results from an extension of the Phase 3 MEASURE 1 trial. Clin Exp Rheumatol. 2018; 36(1):50-55 [3] Deodhar A, Reveille JD, et al: Safety and Efficacy of Golimumab Administered Intravenously in Adults with Ankylosing Spondylitis: Results through Week 28 of the GO-ALIVE Study. J Rheumatol. 2018; 45(3):341-348 [4] Kviatkovsky MJ, Ramiro S, Landewe R, et al: The Minimum Clinically Important Improvement in Patient-acceptable Symptom State in the BASDAI and BASFI for Patients with Ankylosing Spondylitis. J Rheumatol 2016; 43(9): 11680-1686. Disclosure of Interests: Juliana Maria Kerber Grant/research support from: This work was sponsored by the regional society of rheumatology (Sociedade de Reumatologia do Rio Grande do Sul)., Juliana Dias de Mello Grant/research support from: This work was sponsored by the regional society of rheumatology (Sociedade de Reumatologia do Rio Grande do Sul)., Penelope Palominos Grant/research support from: This work was sponsored by the regional society of rheumatology (Sociedade de Reumatologia do Rio Grande do Sul)., Andrese Aline Gasparin Grant/research support from: This work was sponsored by the regional society of rheumatology (Sociedade de Reumatologia do Rio Grande do Sul)., Franciele de Almeida Menegat Grant/research support from: This work was sponsored by the regional society of rheumatology (Sociedade de Reumatologia do Rio Grande do Sul)., Claiton Viegas Brenol Grant/research support from: This work was sponsored by the regional society of rheumatology (Sociedade de Reumatologia do Rio Grande do Sul)., Charles Kohem Grant/research support from: This work was sponsored by the regional society of rheumatology (Sociedade de Reumatologia do Rio Grande do Sul).

The paper briefly describes the history of spondyloarthritis studies from the works of the outstanding Russian neurologist V.M. Bekhterev up to the present time. Special emphasis is laid on the results of the representatives of the scientific school of Professor E.R. Agababova, an organizer of the first laboratory of spondyloarthritis in Russia. The major areas of the investigations that are currently under way in Russia are shown.

The rate of osteoporosis (OP) and the mechanism of its development in patients with ankylosing spondylitis (AS) and other spondyloarthrititides (SpA) have not been sufficiently investigated. Steady-state inflammatory disease activity is anticipated to be the leading factor of OP in AS. Objective: to investigate lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD) in patients with early axial SpA (axSpA) and to reveal its association with inflammatory disease activity. Subjects and methods. A total of 150 patients (59 men and 91 women) aged 18 to 45 years with inflammatory back pain for ≥3 months and ≤5 years were examined. The diagnosis of axSpA was established in accordance with the 2009 ASAS criteria. BASDAI and ASDAS-CRP were used to assess activity and functional status was evaluated with BASFI. The examination included determination of HLA-B27, X-ray of the pelvis and LS, magnetic resonance imaging (MRI) of the sacroiliac joints, LS, and hip joints (in the presence of clinical signs of their involvement), and densitometry of LS (LI–IV) and FN. By taking into account the patients’ young age, the Z score was used to estimate BMD. The Z-score -2 SD or lower in at the least one of the regions examined is considered to be diminished BMD. Results and discussion. The median Z-score was -0.7 [-1.3; -0.2] SD for FN and -0.9 [-1.6; -0.6] SD for LS. Reduced BMD in at the least one of the regions examined was diagnosed in 27 (18.0%) patients. There was lower BMD in LS in 21 (14.0%) patients and in FN in 8 (5.3%). Two (1.3%) patients were diagnosed as having osteopenia in the two examined regions. There was no association between diminished BMD and age, gender, disease activity assessed with BASDAI, ASDAS-СRP, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). An association was found between inflammatory LS changes, as evidenced by MRI (MRI spondylitis), and reduced BMD in at least one of the examined regions. MRI spondylitis was detected in 27 (18.0%) patients. Decreased BMD in any of the examined skeletal regions was seen in 9 (33.3%) of the 27 patients having MRI spondylitis; the remaining 18 (66.7%) patients had normal BMD values. In the absence of MRI spondylitis, osteopenia was identified in 18 (14.6%) patients; normal BMD values were noted in 105 (85.4%); p = 0.03). There was also a relationship between the presence of MRI spondylitis and diminished BMD in the same region. LS osteopenia was found in 7 (25.9%) patients with MRI spondylitis and LS BMD remained within the normal range in 20 (74.1%). In the absence of MRI spondylitis, LS osteopenia was observed in 14 (11.4%) patients and LS BMD was normal in 109 (88.6%) (p < 0.05). Conclusion. There was an association between inflammatory LS changes, as evidenced by MRI, and reduced BMD in the same region. Our findings confirm the hypothesis that bone mass loss in the vertebral bodies in early axSpA results from local inflammation.

Psoriatic arthritis (PsA) is a chronic inflammatory disease of the joints, vertebral column, and entesises, which is associated with psoriasis. T helper type 17 cells (Th-17) play a leading role in the development of inflammation in psoriasis and PsA so different biologicals affecting interleukins (IL) 17 and 23 are being intensively investigated. Randomized, placebo-controlled Phase III PSUMMIT 1 (NCT01009086, EudraCT 2009-012264-14) and PSUMMIT 2 (NCT01077362, EudraCT 2009-012265-60) studies were undertaken to evaluate the efficiency and tolerability of ustekinumab (UST) treatment in PsA patients. Subject s and methods. The PSUMMIT 1 study covered 152 Russian patients with active PsA (≥5 tender and ≥5 swollen joints; C-reactive protein ≥3 mg/l) who were randomly (using the dynamic centralized randomization method on the basis of an interactive vocal response algorithm) divided into three groups (at a 1:1:1 ratio): 1) subcutaneous UST 45 mg; 2) UST 90 mg; 3) placebo (PL) at baseline, 4 weeks later, and then every 12 weeks). After 16 weeks the patients showing a less than 5% reduction in the number of tender and swollen joints were given UST 45 mg (if they belonged to the PL group) or 90 mg (if they were in the UST 45-mg group). The PL-receiving patients were given UST 45 mg at weeks 24 and 28 and then every 12 weeks. The treatment duration was 2 years. A therapeutic response was estimated by theAmericanCollege of Rheumatology (ACR) response criteria. The PSUMMIT 2 study enrolled 40 Russian patients who had previously received or were currently receiving disease-modifying anti-rheumatic drugs and/or nonsteroidal anti-inflammatory drugs and tumor necrosis factor-α inhibitors. The patients were randomized to the groups of those receiving UST 45 mg or 90 mg or PL at baseline and at week 4, then once every 12 weeks. The last dose of UST was given at week 40. The follow-up lasted until week 60. Result s and discussion. In the PSUMMIT 1 study, 24-week administration of UST 45 mg and 90 mg significantly more frequently ensured a 20% improvement according to the ACR criteria than that of PL (39.2; 44.0, and 15.7%, respectively; p < 0.01); the therapeutic response persisted until week52. In the PSUMMIT 2, following 24 weeks, the UST 45-mg and 90-mg groups considerably more often showed a 20% improvement according to the ACR criteria than the PL group (64.3, 57.1, and 16.7%, respectively; p < 0.01); the therapeutic response persisted until week 52. Among 150 Russian patients taking UST, on the average, for 45.1 weeks in the PSUMMIT 1 study, 62 (41.3%) were observed to have adverse events (AE) that were serious in 6 (4.0%). Among 40 PsA patients who participated in the PSUMMIT 2 study inRussia, AEs were seen in a total of 25 (62.5%) patients, serious AEs being absent. Conclusion. The results of the PSUMMIT 1 and PSUMMIT studies in the Russian population indicated that UST treatment contributed to a significant reduction of PS symptoms and exhibited a good tolerability. DOI: http://dx.doi.org/10.14412/1995-4484-2015-125-133

By the end of the first decade of the 21st century, spondyloarthritis studies have accumulated a certain number of terms that are obsolete, but used by physicians in their everyday speech, on the one hand, and a great variety of different definitions, on the other hand. In January 2014, the first organizational meeting of the Expert Group on Spondyloarthritis, Association of Rheumatologists of Russia, decided that its primary task should be to order the terminology used in this area. The authors primarily collected the terms, which had been already used in medical vocabulary, and then divided them into two categories: obsolete definitions and terms to be finalized and unified. This publication gives guidelines for using the medical terms relevant to spondyloarthritis and separately discusses how to correctly write the term sacroiliitis.

Uveitis is a common extraskeletal manifestation of ankylosing spondylitis (AS) occurring in 20–40% of patients. Most authors underline a favorable prognosis for AS-associated uveitis. Objective: to study features of clinical picture and progression of AS-associated uveitis and to estimate the occurrence of its complications. Subjects and methods. Across-sectional study of 140 patients (98 males and 42 females) with AS, who had at least one uveitis attack over the period of disease and was followed up at V.A. Nasonova Research Institute of Rheumatology during 2008–2012. In addition to standard rheumatologic examination all patients were examined by ophthalmologist. Biomicroscopy, ophthalmoscopy, tonometry, computer-assisted perimetry, ultrasonography (B-scanning) of eyes and, if needed, fluorescein angiography and electrophysiological examination of retina were performed. Localization of uveitis, presence of complications affecting vision, total number of uveitis attacks by the moment of examination, mean number of uveitis attacks per year, correlation between the frequency of attacks and complications, presence of other extraskeletal manifestations and peripheral arthritis were assessed. The total number of uveitis attacks was defined from patients' interviews and respective medical documentation. Mean number of uveitis attacks was calculated as ratio of total number of uveitis attacks to the duration of disease for each patient. In the case of more than two attacks per year uveitis progression was considered refractory. Results. Mean duration of the disease was 17.7±11.03 years. In 19 patients (14%) AS manifested before and in 121 (86%) – after the age of 16 years. HLA-B27 was revealed in 135 (96%) patients, peripheral arthritis – in 43 (30%), whereas other extraskeletal manifestations – in 46 (32%). Early onset of uveitis in first 10 years of the disease was recorded in 81 (58%) patients, after10 years – in 21 (15%). Uveitis was the first clinical symptom of AS in 37 (26.4%) patients. 33 (24%) patients had more than 10 uveitis attacks during the disease, 17 (12%) – more than two attacks per year, whereas 18 (13%) had chronic uveitis. 118 (84%) had localized iridocyclitis, 12 (8%) – panuveitis, 2 (1%) – localized posterior uveitis. 122 (87%) patients had unilateral uveitis, 18 (13%) – bilateral, whereas 45 (36%) – alternating eye lesions (OD-OS). Uveitis complicated with vision impairment was observed in 41 (29%) patients: synechia in 26 (18%), vitreous degeneration – in 20 (14%), cataract – in 32 (23%), glaucoma – in 13 (9%), maculopathy – in 6 (4%), ribbon-like retinal degeneration – in 6 (4%), partial optic nerve atrophy – in 3 (2%). Authors revealed direct correlation between frequency of uveitis attacks and occurrence of synechia, cataract, glaucoma, vitreous degeneration. Conclusion. AS-associated uveitis is predominantly characterized by unilateral iridocyclitis (84%) and the onset in the first 10 years of disease (84.4%); 25% of cases were remarkable for frequent relapses: more than two attacks per year and more than 10 during the period of disease. One third of patients demonstrated vision impairments, and its progression correlated with the frequency of uveitis attacks.

The paper describes a wide range of diseases that can involve one joint – monoarthritis. It characterizes different types of acute and chronic monoarthritis and its causes. Criteria for the differential diagnosis of different monoarticular lesions, a clinical algorithm, and current treatment policy in such patients are presented.

The paper presents questionnaires and indices to determine the degree of activity and functional impairments in patients with ankylosing spondylitis, psoriatic arthritis, and other spondyloarthritides. It describes procedures to determine spinal mobility and to calculate the extent and severity index of psoriasis.

Objective: to estimate the value of clinical parameters of uveitis for the diagnosis of spondyloarthritis (SA). Subjects and methods. One hundred and five uveitis patients referred by ophthalmologists to the Research Institute of Rheumatology, Russian Academy of Medical Sciences, in 2007–2009 were examined. X-ray study of the pelvis and lumbar spine, HLA-B27 test, and objective examination were performed in all the patients to detect inflammatory back pain, arthritis, and enthesitis. Results. The diagnosis of SA was verified in 60 patients: 24 had ankylosing spondylitis, 2 had reactive arthritis, and 38 had undifferentiat ed SA. The diagnosis of SA was discarded in 45 patients. Subsequent examination of these patients diagnosed BehНet's disease in 2 of them, sarcoidosis in 1, toxoplasmosis in 4, virus infection-associated uveitis in 8, Fuchs' syndrome in 1, and unspecified uveitis in 29. There was unilateral uveitis in 51 (85%) of the 60 patients with SP and in 26 (58%) of the 45 patients without SP (p = 0.0033); alternat ing eye lesion in 30 (50%) of the 60 patients with SP and in 4 (8.9%) of the 45 patients without SP (p = 0.00001); anterior uveitis in 57 (95%) of the 60 patients with SP and in 32 of the 45 patients without SP (p = 0.0017); posterior uveitis in 6 (10%) of the 60 patients with SP and in 20 (44%) of the 45 patients without SP (p = 0.0001); panuveitis in 2 (3.3%) of the 60 patients with SP and in 10 (22.2%) of the 45 patients without SP (p = 0.0039), acute recurrent uveitis in 15 (33.3%) of the 45 patients without SP and in 44 (73%) of the 60 patients with SP (p = 0.0001). The age at onset was less than 30 years in 38 patients with SP and in 19 patients without SP (p = 0.04). Conclusion. The estimation of the location and course of uveitis is important in diagnosing SP that is probable in patients with acute anteri or unilateral uveitis with alternating eye lesion, which occurred before the age of 30 years.

Background Aortic and valve abnormalities are systemic inflammatory manifestations of ankylosing spondylitis (AS). Data on the prevalence, clinical significance and evolution are discrepant. Objectives To assess the dynamics of aortic and valve abnormalities detected by transthoracal echocardiography (TTE) in AS pts according to the results of prospective study. Methods 45 pts with AS (The New-York criteria) age Results Negative dynamics was detected in 27 (60%) pts in total. Progression of aortic root dilatation from 1 to 6mm was detected in 12 of 15 pts (80%), in 2 - dilatation was first identified. 14 pts had first identified valve thickening (9 – aortic, 4 – mitral, 1 – both). 5 pts were underwent valve replacement: 4 – aortic, 1 – mitral. AR progression was detected in 10 pts (in 2 – of 2 degree, in 8 – of 1 degree), MR progression – in 6 pts of 1 degree). A negative correlation was found between anti-TNF- therapy and progression of aortic root dilatation (R=-0,329, P=0,03). “Subaortic bump” was first identified in 3 pts. Among 10 pts with subaortic bump initially, decrease from 8mm to 3mm was found in 1 pts, complete regression – in 2, all used biologics. Conclusions Aortic root and valve abnormalities tend to progression in most AS pts. Subaortic bump is able to regress if it is due to inflammatory edema and not fibrosis. Active anti-inflammatory therapy can protect in cardiac disease progression. References Klingberg E, Svealv BG, Tang MS, Bech-Hanssen O, Forsblad-d9Elia H, Bergfeldt L. Aortic Regurgitation Is Common in Ankylosing Spondylitis: Time for Routine Echocardiography Evaluation Am J Med. 2015 Nov;128(11):1244–1250.e1. doi: 10.1016/j.amjmed.2015.04.032. Epub 2015 Jun 4. van der Horst-Bruinsma IE, Nurmohamed MT. Management and evaluation of extra-articular manifestations in spondyloarthritis. Ther Adv Musculoskelet Dis. 2012 Dec;4(6):413–22. doi: 10.1177/1759720X12458372. Disclosure of Interest None declared

Background Bone loss in patients (pts) with early axial spondyloarthritis is insufficiently studied. Objectives To assess 1-year bone mineral density (BMD) changes at the femoral neck (FN) and lumbar spine (LS) in pts with early axial spondyloarthritis (axSpA). Methods 47 pts (20 men and 27 women) with axSpA and Results In all 47 pts, baseline median Z-score was -0.6 (-1.3 – 0.2) SD for the FN and -0.7 (-1.8 – 0.3) SD for the LS. Z-score for the FN was significantly lower in women: -1.0 (-1.5 – -0.3) SD and 0.0 (-0.75 – 0.4) SD, respectively, p=0.0065. At baseline examination low BMD at least in one of the sites was evidenced in 8 (17%) pts (4 men and 4 women). While all 8 pts had low LS BMD, 3 of them had also low FN BMD. At baseline examination of the 47 pts association between lumbar spine MRI-spondylitis and low BMD was revealed. MRI-spondylitis was evidenced in 8 (17%) pts: 3 (62.5%) of them had low FN and/or LS BMD, while 5 (62.5%) pts of this group had normal BMD values. In contrast, within the group of pts without the LS MRI inflammation (n=39) nobody had low BMD (p=0.0006). Initially, there was found a relationship between high ASDAS activity and low BMD: 11.5% of pts with high ASDASCRP values had low BMD. In contrast, within the group of pts with low or moderate ASDASCRP values nobody had low BMD (p=0.054). Among the 8 pts with low baseline BMD, 1-year BMD normalized in 3 pts (all women and all initially had low LS BMD). In one patient (male) with normal baseline BMD values low LS BMD at the 1-year visit was observed. Therefore, at 1-year visit fewer pts had low BMD than at baseline examination (n=8, 17% vs n=6, 12.8%, respectively). In males the lowering of LS BMD at 1-year visit was evidenced with much higher confidence than in females (5 among 20 pts, 25%, vs 1 among 27 pts, 3.8%, respectively; p=0.043). Neither at baseline examination nor at 1-year visit any correlation was detected between low BMD and disease duration, high disease activity according to BASDAI, raised CRP or ESR levels, the presence of MRI-sacroiliitis or MRI-coxitis. Conclusions In the Russian cohort of axSpA pts there was found an association between active MRI-spondylitis of the LS and BMD reduction in LS and/or FN. The findings corroborate the hypothesis that low BMD in pts with early axSpA is a result of inflammation. Males more often than females had lowered LS BMD after 1 year of observation. Disclosure of Interest None declared

Objectives To analyze clinical features of patients (pts) with early axial spondyloarthritis (axSpA) and the possible interrelation of non-radiographic axSpA (nr-axSPA) and ankylosing spondylitis (AS) Methods 150 pts with axSpA and Results At the first examination, 77 (51.3%) pts had X-ray identified sacroiliitis (xSI) and their AS was determined by the mNY criteria (Group 1). 88 (58.7%) pts had sacroiliitis according to MRI (MRI-SI), while 42 of them also had xSI. 46 (30.7%) pts who had active MRI-SI and had no xSI were graded as pts with nr-aSPA (Group 2). In 27 (18.1%) pts, SI was not determined by any of the visualization methods (they were HLA-B27 positive and additionally they had ≥2 other axSPA symptoms (Group 3). Clinical features of pts from all groups are summarized in the Table. Pts of Groups 1 and 2 were comparable by demographic and clinical characteristics. Psoriasis was more common among pts of Group 2 (13.0%) vs Group 1 (1.3%; p=0.007). In Group 1, there were significantly more males than in Group 3 (49.4% and 18.5%, respectively (p=0.004). Among the SI pts (Groups 1 and 2) acute inflammation phase reactants (ESR and CRP) were significantly higher, than in pts without SI. MRI inflammation of the lumbar spine (LS) was more common among the pts with xSI (Group 1 – 25.7%, Group 3 – 7.4%, p=0.04), as well as low BMD (Z≤-2SD) in the LS (Group 1 – 22.4%., Group 3. – 3.9%, p=0.03). Dactylitis was more common among Group 3 pts as compared to the SI cohort (Groups 1 and 2) (p 1-3 =0.05, p 2-3 =0.03), as well as enthesitis (p 1-3 =0.02, p 2-3 =0.04) Conclusions Patients with nr-aSPA but active MRI-SI should be most probably considered as early AS cases, when they did not yet develop destructive changes in sacroiliac joints. Dactylitis and enthesitis are more common in axSpA patients without signs of SI (both by MRI or X-ray). Disclosure of Interest None declared

Background Relapsing uveitis is serious problem for patients with ankylosing spondylitis (AS). Anti-TNF therapy significantly reduces number of uveitis attacks in AS pts, but it is not always available. There is a need to assess influence of standard DMARDs on incidence of uveitis in AS pts. Objectives To compare rate of uveitis attacks during combined therapy using sulfaslazine and NSAIDs versus monotherapy by NSAIDs. Methods 111 pts with AS and uveitis were assessed at the Institute of Rheumathology. 49 used combined therapy by sulfaslazine 2 grams per day and NSAIDs at least 1 year, mean duration - 3,9±2,28 year. 6 of 49 pts had frequently relapsing course: more than 3 episodes of uveitis per year, 43 – not more, than 3. 62 pts used NSAIDs only during whole observation period, mean duration - 7,2±6,4 year, 9 of them had more than 3 episodes of uveitis per year, 53 – not more, than 3. 23 of 49 pts used NSAIDs only at least 1 year prior to combined therapy, 10 with more than 3 episodes of uveitis per year, 13 - not more, than 3. Results The mean rate of uveitis attacks during monotherapy by NSAIDs for whole group was 2,06±2,04 per year, during combined therapy – less, but not significantly: 1,41±1,83 per year, p=0,08. Among pts with frequency of attacks 3 and less mean rate during combined therapy was significantly lower, than during monotherapy: 0,99±0,87 and 1,37±0,91 accordingly, p=0,04. For pts with frequently relapsing course of uveitis mean rate of attacks was not significantly different: 5,5±2,7 using combined therapy and 5,7±2,5 using monotherapy, p=0,9. Among pts, used monotherapy and combined therapy sequentially, significant reducing of uveitis flares was observed in 13 pts, that had not more than 3 attack per year initially: from 1,92±0,96 to 0,4±0,44, p=0,00003. 10 pts with more than 3 attack per year initially had not significant reducing of uveitis flares: from 5,9±3,02 to 5,33±1,1, p=0,6. Conclusions Combined therapy by sulfaslazine and NSAIDs not reduces significantly number of uveitis attacks in AS pts with frequently relapsing course of uveitis, but significantly reduces among pts with mild disease. References Benitez-Del-Castillo JM, Garcia-Sanchez J, Iradier T, Banares A. Sulfasalazine in the prevention of anterior uveitis associated with ankylosing spondylitis. Eye (Lond). 2000 Jun;14 (Pt 3A):340-3. Munoz-Fernandez S, Hidalgo V, Fernandez-Melόn J. Sulfasalazine reduces the number of flares of acute anterior uveitis over a one-year period J Rheumatol. 2003 Jun;30(6):1277-957 Disclosure of Interest None declared

Objectives To study the association between MRI inflammation of the lumbar spine (LS), sacroiliac joints (SIJs) and hip joints (HJs) and bone mineral density (BMD) in LS and femoral neck (FN) in early axial spondyloarthritis (axSpA) patients. Methods 150 patients with axSpA and Results MRI inflammation of LS and/or SIJ, and/or HJs has been found in 117 (78.2%) patients. Among the 117 patients of this group 21 (17.9%) had BMD reduction in LS and/or FN. And in the group of patients without MRI inflammation (n=33; 22.0%) low BMD was found in 6 (4.0%) patients ( p =0.96). MRI-sacroiliitis was documented in 102 (68.6%) patients. Among them BMD reduction was found in 17.8%. While in the group of patients without MRI inflammation of SIJs low BMD has been found in 22.5% ( p =0.73). MRI-coxitis was observed in 24 (22.5%) patients, and was associated with low BMD in 12.5% of cases. In the group of patients without inflammatory lesion in HJs, BMD reduction was found in 22.9% patients ( p =0.27). Lumbar spine MRI-spondylitis was observed in 27 (19%) patients, and was associated with low BMD in 33.3% of cases. Meanwhile among the group of patients without MRI-spondylitis of the LS, BMD reduction was documented in 15.2% of cases ( p =0.03). MRI findings and DEXA data are shown in the Table. Conclusions Correlation has been detected between active MRI-spondylitis of the LS and BMD reduction in LS and/or FN. This demonstrates that in patients with early axSpA low BMD is a result of inflammation. Disclosure of Interest None declared

Objectives To analyze gender-specific clinical features of patients with early axSpA. Methods 150 patients with axSpA and Results The Russian cohort of 150 axSpA patients included 59 (39.3%) men and 91 (60.7%) women. The women were significantly older: the median age of men was 25 (23-27), the age of women – 30 (26-34) ( p =0.000001). Men were more often HLA B27 - positive (88% vs 75%; p =0.048). At the first examination, males more often than females had X-ray identified sacroiliitis (xSI): 65.5% vs 42.9% ( p =0.007), and their AS was determined by the mNY criteria. Acute phase inflammation reactants (ESR and CRP) were significantly higher in men. Median ESR was 13 (6-32) mm/h in men, and 8 (5-15) mm/h – in women ( p =0.02); median CRP 16. 7 (1.7-63.3) mg/L and 2.4 (0.9-7.8) mg/L, respectively ( p =0.00004). Calcaneal enthesopathy (US examination) was significantly more often present in men (55.1%), than in women (32.1%; p =0.01). There was no statistically significant difference between men and women in terms of BASDAI and ASDAS activity indexes, presence of peripheral arthritis, coxitis, dactilitis, MRI-sacroiliitis, MRI-spondylitis, low BMD, BASFI functional index, family SpA history. Conclusions In the Russian cohort of axSpA patients, males seem to have a more aggressive disease than females: they have an earlier onset of axSpA, and earlier develop destructive changes in sacroiliac joints. Men are more often HLA B27 – positive. Calcaneal enthesopathy (US-examination) is more common in men. Acute phase reactants (ESR and CRP) are higher in men than in women. Functional BASFI status was similar in both genders. Disclosure of Interest None declared

Objective : to study bone mineral density (BMD) of the lumbar spine (LS) and femoral neck (FN) in patients with early axial spondyloarthritis (SpA) and to reveal its association with inflammatory disease activity. Subjects and methods . Seventy-three patients aged 18–45 years with inflammatory back pain lasting at least 3 months and not more than 5 years were examined. Axial SpA was diagnosed according to the 2009 ASAS criteria. BASDAI and ASDAS C-reactive protein (CRP) values were used to estimate disease activity; BASFI was employed to evaluate functional status. The examination encompassed determination of HLA-B27, X-ray of the pelvis and LS, magnetic resonance imaging (MRI) of sacroiliac joints, LS, and hip joints (in the presence of clinical signs of their injuries), densitometry of LS (L I-IV ) and FN. By taking into account the young age of patients, the Z-score was applied to measure BMD. The latter is considered lower if the Z-score is 1–2 standard deviations (SD) in at least one of the segments under study. Results . The median Z-score was -0.7 (-1.3; -0.3) SD for FN and 0.9 (-1.6; -0.5) SD for LS. Reduced BMD in at least one of the segments under study was detected in 13 (17.8%) patients: that in LS and FN in 11 (15.1%) and 5 (6.8%) patients, respectively. Lower BMD was observed in two segments in 3 (4.1%) patients. No association was found between lower BMD and age, gender, disease activity (BASDAI, ASDAS), and laboratory inflammatory markers (erythrocyte sedimentation rate (ESR) and CRP). A relationship was established between inflammatory changes according to the data of MRI of LS (MRI spondylitis) and reduced BMD in the same segment. MRI spondylitis was detected in 8 patients. Five and 3 patients with spondylitis of LS were found to have lower and normal BMD in this segment, respectively. Six out of 65 patients without MRI spondylitis in LS had its reduced BMD and the remaining (n=59) patients had its normal BMD (p=0.0014). Conclusion . There was an association between the active inflammatory changes as evidenced by LS MRI and the reduced BMD in this segment of the axial skeleton. Our data validate the hypothesis that in early axial SpA, bone is lost in the vertebral bodies due to local inflammation.

Objective: to study clinical manifestations of axial spondyloarthritis (axSpA) fulfilling ASAS criteria and to evaluate Russian version of modified New York criteria for the diagnosis of AS in Russian patients. Subjects and methods . Authors examined 73 patients aged 18–45 years suffering from inflammatory back pain for a period from 3 months to 5 years. BASDAI and ASDAS-CRP were used to assess activity, whereas BASFI – to evaluate functional status. Examination included: assessment of HLA-B27 rate, X-ray of pelvis and lumbar spine, ultrasonography of hip joints and calcaneal regions, magnetic-resonance imaging (MRI) of sacroiliac joints, lumbar spine and hip joints (if clinical signs of injury are present), densitometry of lumbar spine (LII–IV) and femoral neck. Results . Mean age of patients was 28.3±6.4 years, mean duration of disease – 19.9±14.4 months. HLA-B27 was found in 94.5% of patients. Mean BASDAI value was 4.1±1.9; ASDAS – 2.7±1.3; BASFI – 2.6±2.1. Peripheral arthritis was observed in 65.8% of cases, coxitis – in 31.5%, calcaneal enthesitis – in 61.6%, dactylitis – in 19.2%, low bone mineral density – in 17.8%. MRI showed inflammatory changes of axial skeleton in 84.9% of patients, active sacroiliitis (SI) – in 72.6%. X-ray revealed definite SI in 49.3% of patients («classic» AS). According to MRI data, 30.1% of patients with active SI and without structural changes of sacroiliac joints had pre-radiological stage of AS (by Russian version of modified New York criteria). 74.0% of patients fulfilled both sets of ASAS criteria for axSpA, 5.5% – met only I criteria set, whereas 20.5% – only II criteria set. Three groups of patients were defined. The first included patients with radiologically proven SI, the second – with MRI-proven SI and the third – patients without SI. Significant difference between the groups was detected either by gender (number of males in groups I and II exceeded that in group III: p1–3=0.002, p2–=0.033) or by the rate of high activity according to ASDAS index (observed in groups I and II more frequently than in group III; p=0.02 in both cases) or by presence of inflammatory changes in spine in MRI scans (detected in 26% of patients of group III, not detected in patients of group II; p=0.05). Conclusion. Half of patients with axSpA symptoms longer than 20 months already have structural changes in sacroiliac joints, so they can be diagnosed as «classic» AS. 80% of patients who had axSpA for less than 5 years match the description of AS provided by Russian version of modified New York criteria; one third of them has pre-radiological stage of disease. Number of males with radiologically proven SI and MRI-proven SI was larger than that of patients without SI. SI is often accompanied with high activity according to ASDAS. MRI showed that, inflammatory processes in spine may precede active SI. No clinical differences were revealed between patients with radiogically proven AS and pre-radiological stage of AS described by Russian version of modified New York criteria.

Background The association between MRI inflammation and bone loss in early axial spondyloarthritis (axSpA) patients is not sufficiently studied. Objectives Establishing the association between MRI inflammation of sacroiliac joints (SIJs), lumbar spine (LS) and hip joints (HJs) and bone loss in the nearby bone-joint system in early axial axSpA patients. Methods 73 patients (33 men and 40 women) with early axSpa were examined: mean disease duration 19.9±14.4 months. Patients fulfilled ASAS criteria. Mean age 28.3±6.4 years, mean BASDAI 4.1±1.9; mean ASDAS-CRP 2.7±1.3; mean ESR 21.9±17.6; mean CRP 29.0±38.5; 66 (90.4%) patients were HLA-B27 positive. MRI of SIJs, LS and HJs (in case of hip joint involvement) was performed on Signa Ovation 0.35 T scanner (matrix 288x192). BMD was measured using dual energy x-ray absorptiometry (DXA) of the femoral neck (FN) and lumbar spine (LS) (L2–4). BMD reduction was defined as T score ≤−1. Results MRI inflammation of SIJs and/or LS and/or HJs has been found in 62 (84.9%) patients. Among the 62 patients of this group 44 (71.0%) had BMD reduction in FN and/or LS. And in the group of patients without MRI inflammation (n=11) nobody had bone loss (p=0.0001). MRI sacroiliitis (SI) was observed in 53 (72.6%) patients: 37 (69.8%) of them had BMD reduction in FN and/or LS, and 16 (30.2%) patients of this group had normal BMD values (p=0.007). MRI SI has been found in 32 out of 37 (86.5%) patients that had BMD reduction in the LS; in the group of patients without bone loss in the LS (n=36) MRI SI was observed in 21 (58.3%) patients (p=0.007). MRI SI has been found in 21 out of 27 (77.8%) patients that had BMD reduction in the FN; in the group of patients without bone loss in the FN (n=46) MRI SI was observed in 32 (69.6%) patients (p=0.45). Conclusions Correlation has been detected between inflammatory lesions in SIJs and/or LS and/or HJs and bone loss in FN and/or LS. There is an association between existence of active MRI SI and BMD reduction in the LS. This demonstrates that in patients with early axSpA bone loss is a result of inflammation. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2435

Background Uveitis is most common extraskeletal manifestation of ankylosing spondylitis (AS). In accordance with traditional views, uveitis within AS characterized by favourable course and rarely leads to impaired vision. Objectives To assess clinical course and complications of uveitis in AS pts. Methods Sectional study of 140 AS pts (98 men and 42 women) with at least one episode of uveitis during disease. In addition to standard rheumatological examination, all pts were examined by ophthalmologist using ophtalmoscopy, biomicroscopy, tonometry, computer perimetry, ultrasonic scanning, as needed - fluorescein angiography and electrophysiological studies of the retina for detection of settings and complications of uveitis. Total number of uveitis flares until study and the average number of flares per year were calculated for each pt. Results 136 (97%) pts had HLA-B27, 43 (30%) - peripheral arthritis, 46 (32%) – other extrasceletal manifestations. Onset of uveitis before manifestation of AS had 37 (26,4%) pts, during first 10 years of AS - 81 (58%), after 10 years of AS – 21 (15%). 33 (24%) had more then 10 episodes of uveitis during diseas and 34 (24,5%) had more then 2 flares per year, 18 (13%) had chronic course of uveitis with persisting of inflammation longer than 3 month. Isolated iridocyclitis was found in 118 (84%)pts, panuveitis – in 12 (8%), separate posterior uveitis – in 2 (0,01%). 122 (87%) pts had unilateral uveitis, 18 (13%) – bilateral, 45 (36%) had alternate eye attacks (D-S). Complications that led to decrease of vision was found in 41 (29%) pts: synechia – in 26 (18%), vitreous body destruction – in 20 (14%), cataract – in 32 (23%), glaucoma – in 13 (9%), maculopathy - in 6 (4%), band keratopathy - in 6 (4%), optic atrophy –in 3 (2%). Direct correlation was found between frequency of uveitis flares and development of complications (Table 1). Conclusions Uveitis within AS characterized by onset predominantly during first 10 year of disease, prevalent unilateral iridocyclitis, recurrent course. Approximately 1|3 of pts have complications with decrese of vision that correlate with frequency of uveitis flares. References Feltkamp T.E.W, Ringrose J. Acute anterior uveitis and spondyloarthropathies. Current Opinion in Rheumatology, 1998, 10: 314-318 Goueia E., Elmann D. Ankylosing spondylitis and uveitis: overview, Bras Rheumatol. 2012; 52: 5 Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.2607

Background The relationship between MRI inflammation and disease activity in early axial spondyloarthritis has not been proved sufficiently. Objectives Establishing the association between clinical activity and MRI inflammation of sacroiliac joints (SIJs), lumbar spine (LS) and hip joints (HJs) in early axial spondyloarthritis (axSpA) patients (pts). Methods 73 pts (33 men and 40 women) with early axSpa were examined: disease duration – 19.9±14.4 months. Pts fulfilled ASAS criteria. Age – 28.3±6.4 years, BASDAI – 4.1±1.9; ASDAS-CRP – 2.7±1.3; ESR – 21.9±17.6; CRP – 29.0±38.5; 66 (90.4%) pts were HLA-B27 positive. High disease activity was assumed in cases where BASDAI ≥4, ASDAS-CRP ≥2.1. MRI of SIJs, LS and hip joints (in case of hip joint involvement) was performed on Signa Ovation 0,35 T scanner (matrix 288x192). Results MRI inflammation of SIJs and/or LS and/or HJs has been found in 62 (84.9%) pts: SIJs – in 53 (72.6%) pts, HJs – in 21 (28.7%) pts and LS, – in 8 (11.0%) pts. 42 out of 62 (67.7%) pts that had MRI inflammation in at least one of the three studied sections, had high ASDAS-CRP activity; and out of the group of patients without MRI inflammation (n=11) high ASDAS-CRP has been detected in 4 (36.4%) pts (p=0.047). High ASDAS-CRP activity was observed in 38 out of 53 (71.7%) pts that had active sacroiliitis (SI); out of the group of pts without MRI SI (n=20), high ASDAS-CRP was observed in 8 (40.0%) pts (p=0.012). No association has been found between MRI data and disease activity according to BASDAI. Conclusions Correlation has been detected between inflammatory lesion in SIJs and/or LS and/or HJs and high disease activity according to ASDAS-CRP. There is an association between existence of active MRI SI and high ASDAS-CRP activity. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4134

The course of uveitis in patients with ankylosing spondylitis (AS) does not always correlate with inflammation in the axial skeleton and peripheral joints. Effect of tumor necrosis factor α (TNFα) inhibitors on uveitis has been insufficiently studied yet, unlike their effect on the peripheral joints and spine. Objective. To compare the frequency of uveitis attacks in patients with AS during treatment with TNFα inhibitors and the conventional anti-inflammatory therapy. Materials and Methods. The study included 48 patients with AS and recurrent uveitis treated with TNFα inhibitors: 25 – infliximab, 15 – adalimumab, 9 – etanercept; 7 patients received two or more drugs sequentially. Median [25th, 75th percentiles] of the treatment duration was 3 [3.5; 5] years. The duration of treatment since the first attack of uveitis until administration of TNFα inhibitors was 5 [5; 9.7] years. Eighteen patients received only nonsteroidal anti-inflammatory drugs (NSAIDs), 30 patients received NSAIDs and basic anti-inflammatory drugs (DMARDs), including sulfasalazine (n = 23), methotrexate (n = 4), and cyclosporine (n = 4). Results. The median number of uveitis exacerbations during the standard anti-inflammatory therapy was 1 [0.4; 3] per year; during treatment with TNFα inhibitors – 0 [0; 0.5] per year (p = 0.0007). In 19 of 48 patients (40%), no exacerbations of uveitis were registered during therapy with these drugs. The frequency of uveitis attacks in patients treated with infliximab decreased from 1 [0.2; 2.75] to 0.1 [0; 0.8] episodes per year (p = 0.002), adalimumab – from 1.75 [1; 4.5] to 0 [0; 0.07] (p = 0.04), etanercept – from 0.95 [0.5; 1.75] to 0 [0; 0.07] (p = 0.001). Conclusion. Administration of TNFα inhibitors significantly reduces the frequency of uveitis attacks in patients with AS.

Background Acute anterior uveitis (AAU) is most common extraskeletal manifestation of ankylosing spondylitis (AS). Course of uveitis not always correlate with spine and joint inflammation. Effect of biologics to uveitis is not studied enough. Objectives To assess significance of reducing of uveitis flares in AS pts using anti-TNF-therapy as compared with traditional anti-inflammatory therapy. Methods 48 pts with AS and recurrent uveitis, treated by anti-TNF drugs, were assessed at the Institute of Rheumathology RAMS. 25 used infliximab, 15 adalimumab, 9 etanercept. 7 pts used 2 and more drugs sequentially. Mean duration of TNF-therapy was 3,7 (3,5-5), [1;9] years. Mean duration of therapy from first attack of uveitis to start of anti-TNF therapy was 6,5 (5-9,7) [1;30] years: 18 pts used only NSAD and 30 – NSAD and DMARD, including sulfaslazine (23 pts), metotrexate(4 pts), cyclosporine (4 pts). Results The mean rate of uveitis attacks during traditional anti-inflammatory therapy was 2,2 per year, during anti-TNF therapy – 0,6 per year, p=0,0007. 19 of 42 pts (45%) had not episodes of uveitis during the course of anti-TNF therapy. For infliximab frequency of uveitis decreased from 1, 9 to 0,4 episodes per year (p=0,002), for adalimumab – from 3,25 to 0,7 (p=0,04), for etanercept – from 1,2 to 0,09 (p=0,001). Conclusions Anti-TNF therapy significantly reduces number of uveitis attacks in AS pts. References Disclosure of Interest None Declared

The paper describes the pathomorphological aspects of ankylosing spondylitis (AS) and the value of nonsteroidal anti-inflammatory drugs in its therapy. Clinical trials demonstrate the high efficacy of aceclofenac (aertal) in AS.

The paper describes current approaches to treating uveitis in rheumatic diseases and theoretical backgrounds for using tumor necrosis factor-α (TNF-α) inhibitors. The data available in the literature suggest that anti-TNF-α therapy is highly effective in relieving and preventing uveitis attacks.

Objective: to study associations between the lesion of the heart and aorta and other clinical manifestations and the characteristics of ankylosing spondylitis (AS). Subjects and methods. Three hundred and forty-four patients under 60 years of age with a valid diagnosis of AS without concomitant heart disease, followed up at the Research Institute of Rheumatology, Russian Academy of Medical Sciences, in 2005-2008, were examined. Of them, 64 (18.6%) patients had at least one attack of uveitis during the disease; 280 had never uveitis. During the disease, peripheral arthritis occurred in 160 (46.5%) patients; 184 (53.5%) had axial AS. All the patients underwent ECG; 101 had EchoCG (27 with uveitis and 74 without uveitis, 63 with arthritis and 38 without arthritis). Results. Forty-four patients were found to have cardiac conduction disturbances (atrioventricular or left bundle-branch block); of them 14 (31.8%) and 30 (68%) had uveitis and peripheral arthritis, respectively. Out of the 300 individuals without conduction disturbances, 50 (16.7%) and 130 (43%) had the above conditions (p = 0.01 and 0.003, respectively). Cardiac structural changes (aortic thickening/dilatation, subaortic bump, aortic and/or mitral leaflet thickening) were revealed in 45 patients; among them 21 (46.7%) and 34 (75%) had uveitis and arthritis, respectively; of the 56 patients without EchoCG changes, 6 (10.7%) and 29 (51%) had the above conditions (p = 0.0001 and 0.02, respectively). On the other hand, conduction disturbances were noted in 15 (23.4%) of the 64 patients with uveitis and in 29 (10.3%) of the 280 patients without this condition; p = 0.006; in 30 (19%) of the 160 patients with peripheral arthritis and in 14 (7.6%) of the 180 patients without arthritis; p = 0.003. Aortic and valvular changes were detected in 16 (59.2%) of the 27 patients with uveitis and in 28 (37.8%) of 74 without this condition; p = 0.04; in 36 (57%) patients with arthritis and in 9 (23%) of the 38 without arthritis; p = 0.018. There were no significant differences in the parameters of inflammatory activity between the groups. Conclusion. In patients with AS, cardiac lesion was significantly more frequently in the presence of uveitis and peripheral arthritis; uveitis and peripheral arthritis were significantly more common in patients with AS-induced cardiac changes.

Objective. To study heart damage in pts with ankylosing spondylitis (AS) by ECG and echocardiography (EchoCG). Material and methods. 344 pts with definite AS not older than 60 years without comorbid cardiac diseases examined in the Institute of rheumatology during 2005-2008 were included. ECG with 12 leads was performed in all pts and transthoracic EchoCG – in 101 pts. Results. Rhythm and conductivity disturbances were revealed in 67 from 344 (19,5%) pts: atrioventricular (a/v) heart block was present in 20 (5,8%) pts (16 had 1, 2 – 2 and 3 – 3 stage of a/v heart block). 27 (7,8%) pts had intraventricular heart block. EchoCG signs of aortal valve changes were revealed in 45 from 101 (44,5%) pts: thickness or dilatation of aorta – in 36 (35,6%), aortal valve cusps thickness – in 32 (31,7%), mitral – in 15 (14,8%). Local thickness in the form of a comb beneath aortal valve on the back wall of aorta basis at the site of its junction with basis of mitral anterior cusp – “subaortic bump” was found in 10 (10%) pts. Frequency of a/v heart block among pts with changes of aorta and cardiac valves was significantly higher than in pts without such changes. On the other hand frequency of aorta and cardiac valves changes in pts with a/v heart block was significantly higher than in pts without a/v heart block (p=0,0027) what shows relationship between conductivity disturbances and aorta and cardiac valves damage in AS. Conclusion. Cardiac pathology in AS is characterized by frequent (44,5%) damage of aorta basis and aorta-mitral junction zone in combination with thickness of aortal and mitral valves and conductivity disturbances.