Duarte‐García, Alí

Purpose of review Antiphospholipid syndrome (APS), more common than once believed, is an autoimmune disease best known for its high risk of incident and recurrent thrombotic events. The approach to treatment potentially differs from treatment of thrombosis in the general population, and this article endeavors to review the latest updates on this topic. Recent findings The epidemiology of APS is being increasingly elucidated by large population-based studies, with APS perhaps affecting as many as 1 in 2000 individuals. Vitamin K antagonists, aspirin, and heparinoids continue to have obvious roles in the management of patients with APS. There has recently been intensive study of direct oral anticoagulants in APS, with the most recent randomized studies raising concerns about their inferiority to vitamin K antagonists, at least in some subgroups. Other approaches to treating APS beyond anticoagulants and antiaggregants are also receiving increased attention in mechanistic and preclinical studies with an eye toward future roles in patients with refractory and/or microvascular disease. Pediatric APS is identified as an area in desperate need of additional prospective research. Summary Progress continues to be made in pursuit of improving the lives of individuals afflicted with APS. The most important future directions would seem to involve leveraging modern molecular technologies in order to improve subphenotyping of antiphospholipid antibody-positive individuals. This will help personalize risk profiles and ideally define the optimal approach to therapy based on future risk, rather than past morbid events.

Objective To investigate the effect of therapies on radiographic progression in patients with axial spondyloarthritis (SpA). Methods A comprehensive database search for studies assessing radiographic progression in axial SpA (particular treatment versus no treatment of interest) was performed. Study‐specific standardized mean differences in treatment outcomes at 2 and ≥4 years were estimated and combined using random‐effects models. Results Twenty‐four studies in patients with axial SpA were identified, of which 18 involved tumor necrosis factor inhibitors ( TNF i), 8 involved nonsteroidal antiinflammatory drugs ( NSAID s), and 1 involved secukinumab. Spinal radiographic progression, as measured by the modified Stoke Ankylosing Spondylitis Spine Score ( mSASSS ), was not significantly different between TNF i‐treated and biologics‐naive patients at 2 years ( mSASSS difference −0.73 [95% confidence interval (95% CI ) −1.52, 0.12], I 2 = 28%) and ≥4 years ( mSASSS difference −2.03 [95% CI −4.63, 0.72], I 2 = 63%). Sensitivity analyses restricted to studies with a low risk of bias showed a significant difference in spinal radiographic progression between TNF i‐treated and biologics‐naive patients at ≥4 years ( mSASSS difference −2.17 [95% CI −4.19, −0.15]). No significant difference in spinal radiographic progression was observed between NSAID ‐treated and control patients ( mSASSS difference −0.30 [95% CI −2.62, 1.31], I 2 = 71%) or between secukinumab‐treated and biologics‐naive patients ( mSASSS difference −0.34 [95% CI −0.85, 0.17]). With regard to treatment differences in patients with nonradiographic axial SpA or in patients with radiographic progression measured using the sacroiliac joint score, an insufficient number of studies were available for analysis. Conclusion Although no significant protective effect of TNF i treatment on spinal radiographic progression was seen over the course of 2 years or ≥4 years in patients with axial SpA, our analysis restricted to studies with a low risk of bias showed a protective effect of TNF i after ≥4 years. Therefore, long‐term TNF i exposure might confer beneficial effects on spinal radiographic progression in axial SpA. No difference in radiographic progression at 2 years was seen in either the NSAID or secukinumab treatment groups compared to their controls. Future studies should explore the effects of biologic treatment on radiographic progression, as well as the effects of long‐term biologics exposure, in patients with early axial SpA or those with nonradiographic axial SpA.

ObjectiveBecause the American College of Rheumatology (ACR) practice guidelines affect the United States' and international treatment practice, we used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to characterize the quality of the guidelines and to identify potential areas for improvement.MethodsUsing the six quality domains in the AGREE II online tool, four reviewers assessed the practice guidelines available at the ACR website and the immediately previous version to summarize the domain scores for each guideline and examine trends over time.ResultsAs of April 2016, the ACR website listed nine guidelines, four with immediate previous versions. Based on AGREE II, the minimum and maximum for each domain (with higher being better) of the current guidelines were 78‐99 for Scope and Purpose, 57‐99 for Stakeholder Involvement, 87‐ 96 for Rigor of the Methodology, 83‐99 for Clarity of Presentation, 49‐78 for Applicability, 69‐85 for Editorial Independence, and 71‐96 overall. Over time, although the average domain quality of the guidelines improved for all, the Applicability and Editorial Independence domains had the least amount of improvement. For the four guidelines with previous versions, the mean (SD) absolute improvements for each domain were 18 (±11) for Scope and Purpose, 13 (±8) for Stakeholder Involvement, 38 (±22) for Rigor of the Methodology, 25 (±15) for Clarity of Presentation, 22 (±12) for Applicability, 24 (±17) for Editorial Independence, and 31 (±5) overall.ConclusionBased on the AGREE II instrument, the ACR guidelines have achieved high quality over the past 16 years. The Applicability and Editorial Independence domains have the greatest potential for future improvement.