Monitoring Achilles enthesitis in ankylosing spondylitis during TNF-alpha antagonist therapy: an ultrasound study.
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.
Aydin
Sibel Zehra
SZ
Marmara University Hospital, Rheumatology Department, Tophanelioglu, Altunizade, Istanbul, Turkey. drsibelaydin@gmail.com
Karadag
Omer
O
Filippucci
Emilio
E
Atagunduz
Pamir
P
Akdogan
Ali
A
Kalyoncu
Umut
U
Grassi
Walter
W
Direskeneli
Haner
H
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
D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha; D002097:C-Reactive Protein