Zeitschrift fur Rheumatologie最新文献

Patients with immune-mediated inflammatory diseases (IMID) are characterized by increased vulnerability to spinal trauma and distinct fracture patterns. Inflammatory alterations of periosseous soft tissues, along with impaired bone metabolism, lead to reduced mechanical resilience with unfavorable spinal alignment and biomechanics. A common denominator across IMID is secondary osteoporosis, which predisposes patients to pathological or fragility fractures, often triggered by low-impact trauma. Due to the heterogeneity of postinflammatory changes, ranging from focal structural destruction to long-segment ankylosis, the fracture morphology within this patient group varies considerably. From both a pathomechanical and therapeutic perspective, osteoporotic fractures must be clearly distinguished from fractures occurring in ankylosing diseases. Although reduced bone density and insufficient residual stability may endanger the spinal cord in the long run, fractures of a fused spine carry an acute risk of displacement and spinal cord injury, potentially resulting in paraplegia. Despite these differences, the therapeutic goal remains the same: to achieve a mechanically stable osseous bridging of the fractured segment. This article highlights the distinct challenges of fracture management in various IMID types compared to structurally healthy spines. This is illustrated based on two representative clinical cases.

Since the 1980s, various terms have been used to describe diseases with the primary finding of sterile bone inflammation (osteitis), which is attributed to the rheumatological spectrum. Various terms, such as SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, SCCH (sternocostoclavicular hyperostosis), and ACW (anterior chest wall syndrome), are in use to describe overlapping clinical phenomena with the leading finding of sterile, nonbacterial osteitis that have not yet been classified as a uniform entity. Against this background, an international panel of experts developed statements and recommendations in 2023 and 2024 as part of a consensus process using a standardized procedure. These establish adult chronic nonbacterial osteitis (CNO) as the uniform name for the disease. In addition, 16 recommendations for diagnosis and therapy were formulated and discussed. On this basis, the clinical implementation of the consensus recommendations has the potential to significantly improve the quality of treatment for adult CNO. This is described in detail below. It is important to emphasize the independence of adult CNO as an entity, which is not a subgroup of axial spondyloarthritis (axSpA) or psoriasis arthritis (PsA), but nevertheless occurs as an overlapping disease in 20-30% of cases. Diagnosis focuses on clinical activity parameters for quantifying symptoms and targeted radiological imaging of osteitis in the affected region (preferably with magnetic resonance imaging). The consensus recommendations provide relatively specific treatment recommendations, starting with NSAIDs (for 4-12 weeks, depending on therapy response), alternatively or subsequently coxibs, then intravenous bisphosphonates (for 3-12 months, depending on therapy response), alternatively or subsequently TNFi (also for 3-12 months), whereas no specific recommendations are formulated for long-term therapies. There are specific features for the use of these therapeutic modalities in Germany that must be taken into account, particularly with regard to off-label use. Conventional DMARDs are not used for adult CNO, unless there is an indication for this in patients with overlapping PsA or axSpA.

Background: Insufficient access to specialist rheumatology services in Germany results in prolonged waiting times and delayed diagnostic confirmation, which impedes timely and effective initiation of therapy.

Objectives: This study examines the impact of early versus delayed access to specialist care on medication prescribing patterns and associated costs.

Materials and methods: A cost analysis was conducted within the Deliver-Care study using health insurance claims data from 2015-2020. Patients with a confirmed rheumatoid arthritis diagnosis (ICD-10 M05/M06) were stratified by the timing of their initial specialist consultation: early access (within the diagnosis quarter, Q1) versus late access (Q2-Q4). Medication costs were compared across these groups.

Results: More than half (57.4%) of M05 patients and about one quarter (24.4%) of M06 patients had no access to a specialist during the first year after the initial suspected diagnosis. Among patients who did have specialist contact (n = 3781), 82.7% obtained early specialist access. Patients with delayed specialist access incurred higher medication costs (€ 4343 in Q4 vs. € 1763 in Q1; p < 0.0001). A sensitivity analysis showed that patients with delayed specialist access were switched to high-cost medications earlier than those with early access.

Conclusion: Early specialist access is associated with reduced biologic prescribing and lower medication costs. These findings highlight that timely diagnosis and treatment not only lessen patient disease burden but also generate substantial cost savings in the management of rheumatoid arthritis.

Centromere-antibody-positive limited cutaneous systemic sclerosis (LCSSc) is a common disease. It generally takes a benign course, but can still considerably reduce quality of life. Our patient-a woman born in 1987 who was first diagnosis 2017-suffered from pain and declining hand function due to sclerodactyly and calcinosis. Methotrexate (MTX) and analgesics were not effective. After commencing off-label treatment with filgotinib, the patient reported rapid improvement. An X-ray after 8 months showed a reduction in calcinosis load. Filgotinib is well tolerated. Sclerodactyly has resolved, and hand function continues to improve. The clinical and radiological response merit further enquiry of Janus kinase (JAK) inhibitors in centromere-antibody-positive LCSSc.

Over the past 25 years, the results of treatment in pediatric rheumatology have greatly improved due to enormous developments in medical therapies. Today, reaching inactive disease or remission has become a realistic aim. Controlling inflammation and avoiding damage still remain the most important issues. Scores and tools for the measurement of disease activity have mostly been designed to be applicable in studies. Priorities may be different in a patient's perspective. This paper illustrates the different perspectives from a patient's and physician's view, thus, trying to describe the requirement, potentials, and limitations of shared decision-making in children, adolescents and young adults suffering from rheumatic diseases.