Rheumatology News

NEWS 3

Vol. 4 • No. 1 • 2016 • R heumatology N ews

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

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”. 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.

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

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

Second dose of herpes zoster vaccine beneficial to seniors

BY DEEPAK CHITNIS Frontline Medical News

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.

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

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.”

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 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.