Transcript Ankylosing Spondylitis Late Complications

Ankylosing Spondylitis
Late Complications
Atul Deodhar MD
Associate Professor of Medicine
Medical Director, Rheumatology Clinics
Oregon Health & Science University
Portland, OR
Spondylitis Association of America Webinar
March 21st, 2009
General Comments on AS
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Major part of the disease progression occurs in the
first 10 years of the disease1
‘Bamboo spine’ occurs in 20% after 20 years3
Women have more involvement of cervical spine &
peripheral joints than men2
AS has no adverse effect on fertility, pregnancy or
fetus
Unlike in RA, pregnancy has no consistent effect on
AS disease activity
Men have worse radiographic progression than
women, but ‘self-reported’ functional limitations are
worse in women4
1Carette
S. et al. Arthritis Rheum 1983;26:186-90 2Lee W et al. Arthritis Rheum 2008;59:449-54
3Sampaio-Barros PD J Rheumatol 2001;28:560-65 4Lee w et al. Ann Rheum Dis 2007;66:633-8
Self-Reported AS Symptoms and
Quality-of-Life Concerns*
*7 greatest QOL
concerns reported
Ward M. Arthritis Care Res. 1999
Prognosis of AS
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Following factors at presentation indicate increased
disease severity
 Hip arthritis — odds ratio (OR) 23
 Sausage-like finger or toe — OR 8
 Poor response to NSAID — OR 8
 High ESR (>30 mm/h) — OR 7
 Limitation in range of motion @ lumbar spine — OR 7
 Oligoarthritis — OR 4
 Onset less than 16 years of age — OR 3
If no factor is present: mild outcome is likely (sensitivity
93%, specificity 78%)
If hip is involved or 3 other factors are present, severe
disease is predicted: sensitivity 50%, specificity 98%
AS Burden of Disease: % of Male
Patients with Disability (Steinbrocker > II)
RA (n=11,643)
Proportion of Patients (%)
60
AS (n=5,581)
* P<0.0025
*44
* 39
40
25
29
31
41-50
51-60
53
*48
35
38
22
20
0
<41
Years
61-70
>70
Zink A, et al. J Rheumatol. 2000;27:613-22.
AS Burden of Disease: % of Female
Patients with Disability (Steinbrocker >II)
RA (n=38,180)
Proportion of Patients (%)
80
AS (n=2,487)
* P<0.0025
60
60
42 44
40
* 20
28 26
46
33 34
16
20
0
<41
41-50
51-60
Years
61-70
>70
Zink A, et al. J Rheumatol. 2000;27:613-22.
Early Retirement in AS
• AS patients 3 times more likely to become disabled1
— 31% after 20 years in Dutch study
— 36% after 20 years in French study
• Survey of 100 Norwegian AS patients2 (mean age: 42
years, disease duration: 16.5 years)
• 26% of patients were retired2
60
Years
Men
Women
42.9
40
20
36.1
P<0.02
15.6
6.4
0
Disease duration at retirement
96.2% retired due to AS
1Boonen
2Gran
A Clin Exp Rheumatol 2002;20(suppl 28):S23-S26.
JT et al. Br J Rheumatol 1997;36:766-71
Retirement age
Other Disease Manifestations in AS
Eyes
(Acute Anterior Uveitis)
Up to 40%
Heart
(Aortic Insufficiency, Heart Block)
3% to 10%
Gut
(Inflammatory bowel disease,
Microscopic inflammatory lesion)
Microscopic involvement 20-70%
6.5% have Crohn’s Disease
Dactylitis
Lungs
(Restrictive Lung Disease,
Apical Fibrocystic Disease)
Kidneys
(Amyloidosis)
Skin
(Psoriasis & Nail Changes)
Up to 10%
Cauda Equina Syndrome
Osteopenia, Osteoporosis
Spinal Fracture
Spectrum of AS
Early
Moderate
Severe
Courtesy of J. Cush, MD
Late Complications of AS
Skeletal Complications
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Bamboo spine
Osteoporosis
Spinal fractures
Fused hips and shoulders
Fused ribs: reduced chest
wall expansion
Non-skeletal Complications
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Heart: valvular (aortic and
mitral) regurgitation,
conduction abnormalities,
diastolic dysfunction
Lung: apical fibrosis,
restrictive lung disease
Kidney: amyloidosis
Neurological: cauda equina
syndrome, spinal cord
compression
Aortic Dilatation in AS
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Aortic regurgitation seen in 3.5% of patients after 15yrs; 10%
at 30 yrs, and is associated with peripheral arthritis
Warning signs: None! Be aware of the complication
Treatment: medical management. In severe cases: valve
replacement
Bergfeldt Am J Med 1988;85:12-18, Bulkley & Roberts Circulation 1973;48:1014-27
Heart & Lung Disease in AS
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Conduction abnormalities (heart block) & diastolic
dysfunction seen in a minority of patients with long-standing
AS
Whether these changes are more common in AS compared
to general population, is controversial. One Swiss study
found no increased prevalence1
Pulmonary manifestations of long-term AS: Interstitial lung
disease, upper lobe fibrosis, reduced chest expansion (due
to fused ribs and restricted chest cage movement)
Warning signs: New onset of shortness of breath, cough,
palpitations, missed heart beats, swelling on legs
Treatment: pacemaker, diuretics, vasodilators,
bronchodilators etc
1Lang
U et al. Eur J Med Res 2007;12(12):573-81
Spinal cord injury in AS
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Osteoporosis is common in AS
Spinal BMD can be falsely increased due of new bone
formation – femoral BMD measurement recommended
Patients with AS suffer spinal fractures at an increased
rate with minimal trauma (lifetime incidence 4%-18%)
Incidence of spinal cord injury increased > 10-fold when
compared to the general population of Finland
Compression of the spinal cord at atlanto-axial level can
occur with paraparesis or tetraparesis
Warning signs for fracture: sudden onset of new
severe back pain after stable disease
Warning signs for spinal cord injury: new onset
sensory or motor symptoms (tingling, numbness,
weakness, bladder/bowel involvement)
Cauda Equina Syndrome in AS
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Neurological complications are rare (2%) in AS
Cauda equina syndrome is very rare complication, seen
in long standing AS
Affects nerve roots from lumbar & sacral spine
May be secondary to inflammation of the covering of the
spinal cord (called arachnoiditis)
Warning signs: Slowly progressive pain, numbness in
the saddle distribution, bowel/bladder incontinence
Rarely, muscle weakness symptoms seen
Diagnosed by imaging (CT, MRI)
Treatment: recently, surgery (laminectomy, lumboperitoneal shunt) has been shown to be effective
Mortality in Ankylosing Spondylitis
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Mortality in AS is slightly increased (1.5 times the
normal population) Major causes are:
 Cardiovascular disease
 Pulmonary diseases
 Spinal fractures
 Violence, alcohol
 Gastrointestinal bleeding
 Amyloidosis, nephritis
 Colon cancer
Myllykangas-Luosujarvi R et al. Br J Rheumatol 1998; 37:688 (N = 71)
Lehtinen K. Ann Rheum Dis 1993; 52:174 (N = 398)
Khan MA et al. J Rheumatol 1981; 8:86 (N = 56)
Radford EP et al. NEJM 1977; 15:297 (N = 836)
In Conclusion:
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Late stage complications of Ankylosing Spondylitis can
involve skeleton as well as internal organs
Skeleton: Bamboo spine, osteoporosis
Heart: valve disease, conduction abnormality, heart
contractility reduced
Lungs: Apical fibrosis, restrictive lung & chest-wall disease
Kidneys: amyloidosis
Neurological system: spinal cord injury and cauda equina
syndrome
Early detection by recognizing warning signs is the key
All complications are treatable with symptomatic treatment
Whether anti-TNF agents can prevent/treat these
complications remains to be seen
With determination, you can achieve
anything!
Mr. KM on Mount Hood, OR, at 11,000 feet, May 2003