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MRI findings beyond sacroiliitis not necessary for
classifying nonradiographic axial SpA
BY JEFF EVANS
Frontline Medical News
From Annals of the Rheumatic Diseases
C
urrent recommendations for identifying
sacroiliitis on MRI to classify patients
with nonradiographic axial spondyloar-
thritis should still depend on the presence of
subchondral bone marrow oedema, but ad-
ditional evidence of structural lesions can be
taken into account to define the presence of
inflammatory lesions, according to a consen-
sus review by experts from the Assessment in
SpondyloArthritis International Society MRI
working group.
The additional information provided by
structural lesions, such as erosions, detected
via MRI of the sacroiliac (SI) joint or spine
is not necessary for the definition, but “may
enhance confidence in the classification of axial
SpA [spondyloarthritis],” said the panel of 16
rheumatologists, 4 radiologists, and 1 research
fellow, who presented their summary and draft
proposal at the January 2014 annual assembly
of theAssessment in SpondyloArthritis Interna-
tional Society (ASAS) (
Ann RheumDis
2016 Jan
14. doi: 10.1136/annrheumdis-2015-208642),
where members unanimously approved it.
The group’s goal was to examine whether new
data published on axial SpA in the 5 years fol-
lowing the 2009 publication of theASAS recom-
mendations were “sufficient tomerit a change in
the MRI definition of a positive MRI and clarify
any misunderstanding of the existing definition.”
Overall, the working group determined that
the addition of “structural damage changes of
the SI joints and the addition of features on
MRI of the spine for classification purposes
is not yet clear and this continues to be an
important research agenda.”
Adding any single lesion or combination of
lesions to the current classification criteria
for nonradiographic axial spondyloarthritis
(nr-axSpA) did not increase the sensitivity of
the MRI definition without losing specificity
in one cohort, whereas there was an unclear
benefit to adding SI erosion to the definition
in another cohort. The evaluation of these
lesions on MRI depended on the use of T1
weighting and fat-suppression techniques, as
well as the contextual interpretation of MRI,
which currently add too much complexity to
the definition of a positive SI joint MRI to be
useful in achieving a “consensus for defini-
tions for each MRI structural damage lesion
and the setting of thresholds for any defined
lesion or combination of lesions,” the working
group wrote.
The panelists found that there was no con-
sistent beneficial effect of adding features of
SpA on spine MRI to the definition. Spine
MRI added incremental sensitivity in other
analyses, but also increased false-positive SpA
diagnoses.
In a commentary reviewing the controversy
and evidence for classifying diseases within
the spectrum of axial SpA, Dr Atul Deodhar of
Oregon Health and Science University, Port-
land, and his colleagues noted that “there is
no need to differentiate between a diagnosis of
nr-axSpA and that of [ankylosing spondylitis]
in clinical practice, since the only purpose for
having these two labels is classification.” They
said the need for formal distinction between
nr-axSpA and ankylosing spondylitis may
require some exceptions, such as when it is
necessary “to specify an approved indication
for TNFi [tumour necrosis factor inhibitor]
therapy, when off-label use of biologics must
be avoided ... and to clarify the presence of
structural changes that are required for pa-
tients to receive coverage from their insurance
carrier to use a TNFi”.
Second dose of herpes zoster vaccine beneficial to seniors
BY DEEPAK CHITNIS
Frontline Medical News
From the Journal of Infectious Diseases
T
he herpes zoster vaccine should
be administered earlier rather
than later in order to achieve
optimal immune response, but an
additional booster shot for individu-
als 70 years or older is also advisable.
This is according to a recent
study published in the
Journal of
Infectious Diseases
, which looked
at four distinct cohorts – 200 sub-
jects at least 70 years old who had
already received the herpes zoster
vaccine (ZV) 10 years or more prior
(Group 1), 200 subjects at least 70
years old who had never received ZV
(Group 2), 100 subjects ages 60–69
years old who had never received ZV
(Group 3), and 100 subjects 50–59
years old who had never received
ZV (Group 4) – to determine the
efficacy of relatively late ZV admin-
istration on inducing an adequate
immune response.
“During ageing there is a progres-
sive decline in immune responsive-
ness to vaccination and a shortening
of the duration of vaccine-induced
immunity,” wrote Dr Myron J. Levin
of the University of Colorado, Den-
ver, and his associates, who added
that “as an initial step in investigating
the potential for reversing this de-
cline in efficacy, we determined that
a booster dose of ZV administered
to adults [at least] 70 years of age
elicits a varicella-zoster virus (VZV)
antibody response that is noninferior
to that of ZV administered as a first
dose.”
Dr Levin and his coinvestiga-
tors separated subjects into one of
the four aforementioned cohorts,
enrolling individuals who had a
history of varicella and had been
US residents for at least 30 years,
but had no history of herpes zoster
prior to enrollment. All individuals
received a single, subcutaneous,
deltoid region ZV injection of 0.65
mL on the first day of the study,
with subsequent blood samples
collected and analysed at 1, 6, and
52 weeks after receiving ZV. Sub-
jects in Group 2 were matched with
subjects in Group 1 based on age to
compare results.
Baseline levels of both interferon
gamma (IFN-gamma) and inter-
leukin 2 (IL-2) were significantly
higher in Group 1 than in Group 2.
The geometric mean count of
VZV-specific effector memory
cells per million peripheral blood
mononuclear cells in Group 1 was
47 at baseline, 88 at week 1, 90 at
week 6, and 65 at week 52, vs 36 at
baseline, 65 at week 1, 73 at week
6, and 37 at week 52 in Group 2
(P < 0.05). Similar disparities were
seen between Groups 3 and 4, too,
with Group 4 having consistently
and significantly higher geometric
mean counts at each collection of
blood samples throughout the study.
“All age groups developed an
increase in GMT [geometric mean
titer] at week 1 after ZV receipt
that peaked at week 6,” the authors
explained. However, “the booster
dose of ZV administered to adults [at
least] 70 years old after [at least] 10
years elicited a GMT and geometric
mean fold-rise in VZV antibody titer
that was noninferior to that of ZV
administered as a first dose to sub-
jects [at least] 70 years old.”
The indication of that, the authors
conclude, is that cell-mediated
immunity is affected by ZV and
enhanced by a stronger, or more re-
cent, dose. This lends credence to
the theory that although it is better
to get a ZV shot earlier in life, those
who are approaching age 70 years
can – and, in many cases, should –
get a booster shot to strengthen and
maintain that immunity.
“Although the practical implica-
tions of the current findings are not
fully understood, the similarity of
[enzyme-linked immunosorbent
spot] responses to those observed in
the successful efficacy trial of ZV in
vaccinees [at least] 60 years of age
supports further investigation of ad-
ministration of ZV at an early age vs at
a later age and further investigation of
a booster dose for elderly individuals
at an appropriate interval after initial
immunisation against HZ,” Dr Levin
and his coauthors concluded.
The study was funded by Merck,
Sharp & Dohme. Dr Levin reported
having received grants, personal fees,
and royalty payments from Merck.
Several other coauthors disclosed
individual potential.
There is no need to differentiate
between a diagnosis of nr-axSpA
and that of [ankylosing spondylitis]
in clinical practice, since the only
purpose for having these two labels is
classification.
Although the practical implications of the current findings
are not fully understood, the similarity of [enzyme-linked
immunosorbent spot] responses to those observed in the
successful efficacy trial of ZV in vaccinees [at least] 60 years of
age supports further investigation of administration of ZV at an
early age vs at a later age and further investigation of a booster
dose for elderly individuals at an appropriate interval after initial
immunisation against HZ.
Vol. 4 • No. 1 • 2016 •
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