title: Monitoring Achilles enthesitis in ankylosing spondylitis during TNF-alpha antagonist therapy: an ultrasound study.
abstract: OBJECTIVE
  Enthesitis is considered as the primary anatomical lesion in ankylosing spondylitis (AS). Therapeutic effects of TNF-alpha antagonist treatments for enthesitis on imaging changes are still limited to case reports or small sample-sized trials. We aimed to investigate the potential of ultrasonography (US) to detect early changes after TNF-alpha antagonist therapy of Achilles enthesis of AS patients.
  
  
  METHODS
  Forty-three AS patients with active disease, requiring TNF-alpha antagonist therapy, were included. Physical examination was performed to detect Achilles enthesitis and/or retrocalcaneal bursitis. US of the Achilles tendon was performed bilaterally. Grey-scale (GS) and power Doppler (PD) scores on a 0-2 semi-quantitative scale and total additive scores (TS) were calculated. Follow-up US examinations were performed 2 months after the initiation of therapy.
  
  
  RESULTS
  At baseline, 11 patients (26.2%) were symptomatic in physical examination for either Achilles enthesitis or retrocalcaneal bursitis, whereas 36 (83%) had GS US pathological findings and 10 (23.3%) had PD signal. GS score and TS decreased significantly [3.6 (3.0) vs 2.3 (2.2), P < 0.001 and 4.7 (4.9) vs 2.7 (3.3), P < 0.001, respectively], whereas the decrease in PD score was not significant after 2 months of follow-up. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), ESR and CRP levels also showed significant improvements.
  
  
  CONCLUSIONS
  Subclinical Achilles enthesitis, detected only with GS US, is present in a subset of AS patients and a significant improvement can be demonstrated after 2 months of TNF-alpha antagonist therapy. In addition to standard outcome measures, US might be an additional useful tool to monitor therapy in SpA patients with Achilles enthesitis.
authors.affiliation: Marmara University Hospital, Rheumatology Department, Tophanelioglu, Altunizade, Istanbul, Turkey. drsibelaydin@gmail.com
authors.forename: Sibel Zehra
authors.initials: SZ
authors.lastname: Aydin
authors.forename: Omer
authors.initials: O
authors.lastname: Karadag
authors.forename: Emilio
authors.initials: E
authors.lastname: Filippucci
authors.forename: Pamir
authors.initials: P
authors.lastname: Atagunduz
authors.forename: Ali
authors.initials: A
authors.lastname: Akdogan
authors.forename: Umut
authors.initials: U
authors.lastname: Kalyoncu
authors.forename: Walter
authors.initials: W
authors.lastname: Grassi
authors.forename: Haner
authors.initials: H
authors.lastname: Direskeneli
mesh_terms: D000125:Achilles Tendon / Q000000981:diagnostic imaging*; D000328:Adult; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001799:Blood Sedimentation; D002097:C-Reactive Protein / Q000378:metabolism; D016903:Drug Monitoring / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012720:Severity of Illness Index; D013167:Spondylitis, Ankylosing / Q000150:complications* / Q000000981:diagnostic imaging / Q000188:drug therapy; D052256:Tendinopathy / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology*; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*; D014463:Ultrasonography; D055815:Young Adult
chemical_list: D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha; D002097:C-Reactive Protein