Objectives Many patients with axial spondyloarthritis (axSpA) report persistent pain even when treated with anti-inflammatory agents. Our aim was to explore the presence of central sensitization (CS) and different types of illness perceptions in patients with axSpA, and to assess their associations with disease activity assessments. Methods Consecutive outpatients from the GLAS cohort were included. Besides standardized assessments, patients filled out the Central Sensitization Inventory (CSI), Illness Perception Questionnaire (IPQ-R) and Pain Catastrophizing Scale (PCS). Univariable and multivariable linear regression analyses were used to investigate the association between questionnaire scores, patient characteristics and disease activity assessments ASDASCRP, BASDAI and CRP. Results We included 182 patients with a mean symptom duration of 21.6 years. Mean ASDASCRP was 2.1, mean BASDAI 3.9, and median CRP 2.9. Mean CSI score was 37.8 (scale 0–100) and 45% of patients scored ≥40, indicating a high probability of CS. CSI score, IPQ-R domain identity (number of symptoms the patient attributes to their illness), and IPQ-R domain treatment control (perceived treatment efficacy), and obesity were significantly and independently associated with both ASDASCRP and BASDAI, explaining a substantial proportion of variation in these disease activity scores (R2=0.35 and R2=0.47, respectively). Only obesity was also independently associated with CRP. Conclusion CS may be common in patients with long-term axSpA. CS, as well as specific illness perceptions and obesity were all independently associated with the widely used (partially) patient-reported disease activity assessments ASDASCRP and BASDAI. Treating physicians should take this into account in the follow-up and treatment of their patients.

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BackgroundNon-steroidal anti-inflammatory drugs (NSAIDs) are regarded as the cornerstone of conventional treatment for AS. However little is known about concomitant NSAID use during treatment (with TNF-α inhibitors) in daily clinical practice.Methods and findingsConsecutive patients from the GLAS cohort were included. NSAID use and ASAS-NSAID index were evaluated at group level and at individual patient level during 52 weeks of follow-up. Analyses were stratified for treatment regimen. Generalized estimating equations (GEE) was used to evaluate NSAID use in relation to assessments of disease activity over time. In patients starting TNF-α inhibitors (n = 254), 79% used NSAIDs at baseline and this proportion decreased significantly to 38% at 52 weeks. ASAS-NSAID index also decreased significantly from median 65 to 0. In patients on conventional treatment (n = 139), 74% used NSAIDs at baseline with median ASAS-NSAID index of 50 and this remained stable during follow-up. At each follow-up visit, approximately half of the patients changed their type or dose of NSAIDs. GEE analysis over time showed that NSAID use was associated with AS disease activity score (p<0.05). This relation was more pronounced in patients treated with TNF-α inhibitors compared to conventional treatment (B = 0.825 vs. B = 0.250).ConclusionsIn this observational cohort of established AS patients, there was no difference in baseline NSAID use between patients with and without indication for TNF-α inhibitors. NSAID use decreased significantly after starting TNF-α inhibitors. During conventional treatment, NSAID use remained stable at group level. However, NSAID use changed frequently at individual patient level and was significantly associated with disease activity.

Background:Patients with axial spondyloarthritis (axSpA) who are more physically active experience less pain and better physical functioning.1Psychological factors such as anxiety and depression are associated with physical functioning and reduction of Quality of Life (QoL).2Furthermore, evasive coping strategies are commonly used in health-related coping.3However, as far as we know, no data is available regarding the influence of coping strategies, anxiety and depression on daily physical activity in axSpA.Objectives:To determine if coping strategies, anxiety and depression are associated with daily physical activity in patients with axSpA.Methods:Consecutive outpatients from the Groningen Leeuwarden AxSpA cohort (GLAS) participated in this study. Additionally to the standardized follow-up assessments, patients filled out the axSpA-Short Questionnaire to assess health-enhancing physical activity (axSpA-SQUASH), the Coping with Rheumatic Stressors (CORS) and the Hospital Anxiety and Depression Scale (HADS). Univariable and multivariable linear regression analyses were performed to explore associations of copings strategies, anxiety and depression, and patient- and disease related factors with daily physical activity. Additionally, patients were stratified into three tertiles of physical activity: low, intermediate and high. To identify group differences, Kruskal-Wallis test or Chi-Square test were used with post-hoc testing.Results:In total 85 patients were included; 59% were male, mean age was 49±14, median symptom duration 19.5 years (IQR 12.0-31.0), 71% were HLA-B27 positive and mean ASDAS was 2.1±1.0. Median axSpA-SQUASH total physical activity score was 9406.3 (IQR 5538.8–12081.3). Median scores of HADS-Anxiety (scale 7-28) and HADS-Depression (scale 7-28) were scores of 12 (IQR 10.0-14.0) and 10(IQR 9.0-12.5). The mostly frequently used coping strategie was comforting cognitions (for pain, range 9-36); median of 25.5 (IQR 22.0-28.0).Univariable analysis showed that lower daily physical activity was significantly associated with gender (female), higher disease activity (BASDAI), worse physical function (BASFI), worse quality of life (ASQoL), coping strategies ‘decreasing activities’ and ‘pacing’, higher depression score (HADS) and higher perceived influence of axSpA on general well-being. In multivariable analysis, only the coping strategy “decreasing activity” was independently associated with physical activity (β: -419.3, R2: 0.155, P<0.001). Additionally, patients in the highest physical activity tertile were significantly more often male, had higher working status, lower BASDAI and ASDAS, better BASFI and ASQoL and scored lower on the coping strategy “decreasing activities”.Conclusion:In this cross-sectional study in axSpA patients with established disease, multiple patient and disease related factors were associated with daily physical activity. The evasive coping strategy ‘decreasing activities’ was the only independently associated factor. These findings suggest that to improve daily physical activity in axSpA patients attention should be paid not only on targeting disease activity, but also to other patient and disease related aspects, especially coping strategies used.References:[1]Regel A et al.RMD Open. 2017;3(1):e000397.[2]Kilic G et al.Med (United States). 2014;93(29):e337.[3]Peláez-Ballestas I et al.Med (United States). 2015;94(10):e600.Acknowledgments:The authors would like to thank all patients who participated in the GLAS cohort.Disclosure of Interests:Marlies Carbo: None declared, Laura Overbeeke: None declared, Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Yvo Kamsma: None declared, Freke Wink Consultant of: Abbvie, Janssen, Davy Paap: None declared, Anneke Spoorenberg: None declared

Background:Up to 40% of ankylosing spondylitis patients report persistently high pain scores of >4 (scale of 0-10) even after responding to long-term TNF-alpha blocking therapy.[1] In other rheumatic diseases, nociplastic pain (due to altered functioning of the nervous system leading to peripheral and central sensitization) is common.[2] In axial spondyloarthritis (axSpA), patient illness and pain perceptions were shown to influence disease outcome.[3] Therefore, we hypothesized that central sensitization and patients’ illness perceptions are associated with persistently high disease activity in axSpA.Objectives:To investigate to what extent central sensitization, pain catastrophizing and patients’ perceptions play a role in axSpA and to explore associations with disease activity.Methods:Between April and September 2019, consecutive outpatients from the Groningen Leeuwarden axSpA (GLAS) cohort,[4] an ongoing large prospective cohort, were included in this study. Besides the standardized assessments, patients filled out three additional questionnaires: Central Sensitization Inventory (CSI), Pain Catastrophizing Scale (PCS) and Revised Illness Perception Questionnaire (IPQ-R). Univariable and multivariable linear regression analyses were used to investigate the association of CSI, PCS and each of the eight subscales of the IPQ-R, and disease activity assessments ASDAS-CRP, BASDAI, and CRP. We corrected for the following potential confounders: gender, symptom duration, BMI, educational level, smoking status and HLA-B27 status.Results:Of 171 included patients, 58% were male, 79% were HLA-B27 positive, median symptom duration was 21 (IQR 10-32), mean ASDAS-CRP 2.1 ± 1.0, mean BASDAI 3.9 ± 2.2 and median CRP 2.9 (IQR 1.2-6.3). Mean CSI score was 37.8 ± 14.1 (scale of 0-100), and 44% of patients scored ≥40 on the CSI.[5] Median PCS score was 15 (IQR 7-22) (scale of 0-52), median IPQ-R illness identity subscore 3 (IQR 2-4) (scale of 0-14) and mean IPQ-R treatment control subscore 18.1 ± 3.4 (scale of 5-25). In univariable regression analysis, CSI and PCS scores and IPQ-R subscores all showed significant associations with ASDAS-CRP, and all except the IPQ-R subscale personal control showed significant associations with BASDAI. Only IPQ-R treatment control was significantly associated with CRP. Central sensitization, two IPQ-R subscales (perceived treatment control and the number of symptoms patients attributed to their axSpA: illness identity) and BMI were independently associated with disease activity assessments BASDAI (R2=0.46) and ASDAS-CRP (R2=0.36) (Figure 1).Conclusion:In this axSpA population with long-term disease, 44% scored above the CSI cutoff point of 40, indicating a high probability of central sensitization. CSI score, illness identity and treatment control were independently associated with disease activity assessments.References:[1]Arends Set al.Clin Exp Rheumatol 2017;35(1):61-8.[2]Meeus Met al.Semin Arthritis Rheum 2012;41(4):556-67.[3]Van Lunteren Met al. Arthritis Care Res (Hoboken) 2018;70(12):1829-39.[4]Arends Set al.Arthritis Res Ther 2011;13(3):R94.[5]Neblett Ret al.J Pain 2013;14(5):438-45.Disclosure of Interests:Stan Kieskamp: None declared, Davy Paap: None declared, Marlies Carbo: None declared, Freke Wink Consultant of: Abbvie, Janssen, Reinhard Bos: None declared, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant of: Consultant for Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Speaker for Bristol-Myers Squibb and Novartis., Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Anneke Spoorenberg: None declared

BackgroundNon-steroidal anti-inflammatory drugs (NSAID's) are the cornerstone of conventional therapy in ankylosing spondylitis (AS). Little is known about concomitant NSAID use in AS patients treated with TNF-α blocking therapy.ObjectivesTo assess NSAID use in relation to disease activity (ASDAS) in AS patients with and without TNF-α blocking therapy during 2-years of follow-up.MethodsData were retrieved from the GLAS cohort, an ongoing longitudinal observational cohort study in daily clinical practice in the North of the Netherlands. Since November 2004, consecutive outpatients who started TNF-α blocking and since September 2009 all consecutive outpatients irrespective of treatment regime were included. Patients fulfilled the modified New York criteria for AS (>90%) or the ASAS criteria for axial spondyloarthritis. Follow-up was performed according to a fixed protocol including the assessment of disease activity (ASDAS) and NSAID use. The ASAS-NSAID index was calculated retrospectively from clinical records and stratified for none/very low use versus more regular use (NSAID index <10 and ≥10). The Paired and Independent T test were used for comparison.ResultsOf the 404 included patients, 67% was male, 79% HLA-B27 positive, mean age was 44 years (20-80), and median symptom duration 16 years (1-59). All baseline characteristics, were comparable between patients with (n=266) and without (n=135) TNF-α blocking therapy, including NSAID use. As expected, patients who started TNF-α blocking therapy had significantly higher disease activity at baseline (mean ASDAS 3.7 vs. 2.3, p<0.001). In these patients, ASDAS and concomitant NSAID use decreased significantly during follow-up. Patients treated with TNF-α blocking therapy and NSAID index <10 showed significantly lower ASDAS at all follow-up visits then patients with NSAID index ≥10. In patients without TNF-α blocking therapy, NSAID use and ASDAS remained stable over time. ASDAS was significantly lower in patients with NSAID index <10 at baseline and at 24 months of follow-up, but not at 6 and 12 months (table 1).ConclusionsIn this observational cohort study, ASDAS and NSAID use decreased rapidly over time in patients with TNF-α blocking therapy. Patients with no to very low NSAID use had lower ASDAS then patients with NSAID use on a more regular basis. In patients without TNF-α blocking therapy, ASDAS and NSAID use remained stable over time and the relationship between ASDAS and NSAID was less clear.Disclosure of InterestM. Carbo: None declared, S. Arends Grant/research support from: Abbott,Pfizer, Wyeth, E. Brouwer Grant/research support from: Abbott, Pfizer, Wyeth, F. Wink: None declared, M. Efde: None declared, H. Bootsma: None declared, E. van der Veer: None declared, F. Maas: None declared, A. Spoorenberg Grant/research support from: Abbott, Pfizer, Wyeth, Consultant for: Abbvie, Pfizer, UCB

BackgroundNon-steroidal anti-inflammatory drugs (NSAIDs) are the cornerstone of conventional treatment in ankylosing spondylitis (AS). In case of insufficient response, tumor necrosis factor-alpha (TNF-α) inhibitors are available. Still little is known about concomitant NSAID use.ObjectivesTo investigate the longitudinal association between disease activity and NSAID use in established AS patients.MethodsThe present analysis is part of the GLAS cohort, an ongoing longitudinal observational axial spondyloarthritis (SpA) cohort study in daily clinical practice. During 52 weeks of follow-up, NSAID use was recorded prospectively. The ASAS-NSAID index was calculated using the dosage and frequency assessed retrospectively from clinical records. Disease activity was assessed using ASDAS, BASDAI, and serum CRP levels.Generalized estimating equations (GEE) was used to evaluate NSAID use in relation to assessments of disease activity over time. NSAID use was analyzed using 4 parameters: NSAID use (yes/no), ASAS-NSAID index, low on demand use (index ≥10 versus <10), and high use (index ≥90 versus <90). Analyses were stratified for treatment regimen: patients starting TNF-α inhibitors and patients on conventional treatment.ResultsOf the 393 included AS patients, 67% were male, mean age was 44±13 years, median symptom duration 15 years (IQR 8–24), and 79% were HLA-B27 positive. In total, 254 (66%) patients started TNF-α inhibitors and 139 (34%) patients received conventional treatment. Patient characteristics were comparable between both groups, except higher disease activity, more often peripheral arthritis, and worse physical functioning in patients starting TNF-α inhibitors. NSAID use and disease activity reduced significantly after starting TNF-α inhibitors and remained low and stable during follow-up. In the conventional treatment group, disease activity was low and NSAID remained stable at all visits.GEE analysis over time showed that NSAID use was significantly associated with disease activity (Table 1). In the TNF-α inhibitor group, a significant association of all NSAID parameters with ASDAS was found: NSAID use yes vs. no, ASAS-NSAID index, index ≥10 vs. <10, and index ≥90 vs. <90. Comparable results were found for BASDAI and CRP. The association between NSAID use and ASDAS remained significant in the 217 patients who used TNF-α inhibitors more than 80% of the follow-up time and when analyzing only 12 to 52 weeks of follow-up to exclude the initial effect of TNF-α inhibitors, although the regression coefficients were lower in these last analyses. In the conventional treatment group, a significant but less prominent association of NSAID parameters with ASDAS was found: NSAID use yes vs. no, index ≥10 vs. <10, and index ≥90 vs. <90. BASDAI was only significantly associated with on demand NSAID use. For CRP, no significant associations with NSAID use were found.ConclusionsIn this observational cohort of established AS patients, NSAID use over time was significantly associated with ASDAS, which was most pronounced for pa...