AS Diagnosis, Remission, Flare

New name and classification criteria for ankylosing spondylitis may help with earlier diagnosis and treatment.

Having spent over a week contemplating various aspects of AS, from diagnosis to treatment options, from prognostication to tapering; it may come as somewhat of a surprise to you that the criteria for Diagnosis, Remission and Flare in AS are still works in progress.
The latest diagnostic (classification, to be precise) criteria proposed in 2012 are still awaiting validation and widespread adoption (usually under the joint auspices of the ACR and EULAR).

ASAS Classification Criteria for Spondyloarthritis

The new classification criteria for spondyloarthritis may lead to earlier and more effective diagnosis and treatment.

Treating to target in axial spondyloarthritis: defining the target and the arrow

(2015). Treating to target in axial spondyloarthritis: defining the target and the arrow. Expert Review of…
The new term axial spondyloarthritis (SpA) covers both patients with ankylosing spondylitis (AS) according to the modified New York criteria, for which the presence of radiographic sacroiliitis is mandatory, and patients with non-radiographic axial disease. The latter group can be defined either by…

We are all agreed that the TARGET of therapy in AS is REMISSION, as in other rheumatic diseases for which we actually have effective therapies.

But what does remission in AS look like? Is it just pain relief and functional restoration, or is the prevention of structural progression of ultimate importance? Surely without defining it, we may be wasting lots of costly arrows (eg the biologics) without quite achieving our target.

We need to do better than answer, as Judge Stewart did for hardcore pornography, “I know it when I see it”.

Remission is the current target of management of chronic rheumatic diseases1,2. Whereas in rheumatoid arthritis remission criteria have been proposed3, in spondyloarthritis (SpA), no activity score allows a specific definition for remission. SpA activity is evaluated with the BASDAI score (Bath Anky…

Like the natural history of AS, definitions, criteria and guidelines move much slower compared to RA. One major difficulty in defining remission criteria in AS is that disease activity may be different in the various domains of the disease (eg axial inflammation, enthesitis, uveitis).

Spondyloarthritis (SpA) is a chronic inflammatory rheumatic disease with many phenotypes,1 but the frame of the disease is still a matter of debate, particularly regarding the non-radiographic forms of axial SpA.2 ,3 The disease evolution may have several profiles, mainly related to the treatment st…

Even if the diagnosis is not in doubt, and treatment has delivered deep clinical and radiological remission in all domains of AS, the task at hand is to detect disease flare early enough to allow for a brief therapeutic intensification to restore remission.

Flare criteria/definition is not simply the loss of remission criteria (which is still a work in earnest progress). If the experience with RA is anything to go by, a recent study suggests that the RA patient is better able to discern a flare than all the metrology and the physician’s assessment. I call this the “How-ya-doin’ ” score. It actually involves talking to the patient; not just filling charts, checking bloods and scanning joints.