Transcript Ankylosing Spondylitis

Ankylosing spondylitis
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Ankylosing spondylitis
can impose significant
physical limitations on
the patient
It affect their ability
to work and reducing
quality of life
The onset being early
(third decade) which
increases the lifetime
impact of the disease
Ankylosing spondylitis
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Delay in diagnosis
Recent survey of 1614 patients with AS illustrate
the protracted delay between onset and
Diagnosis
Average of 8.9 years mean delay of making Dx.
In women the mean delay 9.8 vs 8.4 in Males
(probably due to misconception that only men
are affected)
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Relative sensitivity of detecting
active Sacroilliitis :
MRI
Plain Radiography
Quantitative Scintigraphy
MRI
95%
Plain radiography 19%
QS
48%
J Rheumatol 1996;23-2107-15
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Only 50-70% of AS patients with active
disease exhibit biological markers of
inflammation with elevated ESR and CRP
Relative late appearance of radiographic
sacroiliitis , by up to several years after
first symptoms
Ankylosing spondylitis
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Symptoms early in the disease are due to
inflammation
Symptoms later in the disease are caused
by a mixture of inflammation , structural
spinal damage and secondary damage to
soft tissue such as muscles and ligaments.
Ankylosing Spondylitis
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Predictive factors for long term outcome:
-Hip arthritis is the strongest predictive factor
being associated with 23-fold increase in the risk
of severe arthritis
Other factors:
- Age-onset before 16
- High ESR
- Unresponsive to NSAID
- Limitation of lumbar spinal movement
Ankylosing spondylitis
About 60-75% of patients with AS show good to
very good response to full dose NSAIDs in 48
hours , in contrast with only 15% of patients
with mechanical back pain.
 Recent study has shown that patients with AS
treated continuously over two years with a daily
dose of NSAIds has less radiological progression
compare to those who took NSAIDs on demand
Arth Rheum 2005;52-1756-65
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20-50% of AS patients still have active
disease despite treatment with NSAID.
For those patients , Anti-TNF have meant
a breakthrough in treatment
Ankylosing spondylitis
-MRI follow up studies during treatment
with etanrcept and infliximab have shown
that acute inflammatory lesions in the
spine and sacroiliac joints can be
effectively suppressed , bony destruction
and proliferation can be prevented
Etanercept in AS
Sustained durability and tolerability for 96 weeks.
A&R 2005-64:1557-62
-277 AS patients who were enrolled in RCT
(257 continued open labeled Etanrcept.
AS patients continuing Etanrcept Rx had sustained
response for almost 2 years
 Improvement is symptoms , signs and spinal
mobility
 None of the most serious safety concerns :TB,
drug induced lupus, MS or lymphoma were
reported .
Outcome in Active AS, Clinical and
MRI data , 2-years
A&R December 2005
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26 patients with active AS treated with
etanercept 25mg twice weekly
Conclusion : The clinical efficacy and safety of
etanercept in patients with active AS without
simultanous administration of DMARDs or
steroids over 2 years of continuous treatment is
confirmed
Spinal inflammation as depicted by MRI
decreased significantly.
Ankylosing Spondylitis
ASAS/EULAR recommendations for
Management of AS
22 expert participants:
Ten Key recommendations for the treatment
of AS were developed and assessed using
a combination of research based evidence
and expert consensus.
Ankylosing Spondylitis
 1- Treatment of AS should be tailored
according to:
- Current Manifestations of the disease
-Level of current symptoms, clinical
findings and prognostic indicators
-General clinical status
-Wishes and expectation of the patient
Ankylosing Spondylitis
2-Disease Monitoring:
-patient history
-clinical parameters
-laboratory tests
-Imaging
All according to clinical presentations and ASAS
core set
Frequency of monitoring should be decided on
symptoms, severity, and drug treatment
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3-Optimum therapy of AS requires
pharmacological and non-pharmacological
treatment
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4-Non-pharmacological treatment of AS :
-Patient education
-regular exercises
-physical therapy
-Patients associations and self help groups
may be useful.
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5- NSAIDs are recommended as first line
therapy for treatment of AS with pain and
stiffness.
 In those with increased GI risk , selective
COX2 inhibitors could be used.
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6- Analgesics may be used for pain in
whom NSAID are insufficient,
contraindicated and or poorly controlled.
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7- Corticosteroids injections directed to
the local site of inflammation may be
considered.
The use of systemic steroids for axial
disease is not supported by evidence.
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8-There is no evidence for the efficacy of
DMARDs including SSZ and MTTX for the
axial manifestations .
SSZ may be considered in patients with AS
and peripheral arthritis.
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 9-Anti-TNF Rx should be given to patients
with persistently high disease activity
despite conventional treatment
 There is no evidence to support the
obligatory use of DMARDs before or
concomitant with anti-TNF treatment in
patients with axial disease
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10-Total hip arthroplasty should be
considered in patients with refractory pain
and disability and radiographic evidence
of structural damage.
Spinal surgery-for example corrective
osteotomy and stabilization procedure
may be value in selected cases.
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First International ASAS consensus
statements for the use of Anti-TNF
agents in patients with ankylosing
spondylitis
Published online ARD August 2005
Guidelines for the use on Anti-TNF in AS
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-Anti-TNF therapy is considered as a major
advances (breakthrough) in the treatment of AS
patients
 There is a need to identify
i-patients with active disease
ii-Patients with threatening functional disability
iii-patients who may have most benefits from Rx.
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Etanrcept 25mg biweekly and infliximab
5mg/kg every 6-8weeks are approved in
US and Europe for the treatment of signs
and symptoms of patients with active AS
Adalimumab is not yet approved for AS
( US and EUROPE)
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Only patients with active disease should be
considered for treatment with antiTNF agents
Active disease as indicated by both
 1- BASDAI score of =or>4 and
 2- physician global assessment of =or>2
on a Likert Scale (1=mild,2=moderate,
3=severe , 4=very severe)
should be present to warrant anti-TNF therapy
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Failure to respond to at least 2 NSAIDs ,
each NSAID should have been used for at
least 3 months at maximum dose
Failure treatment of at least one DMARD
for peripheral arthritis (SSZ or MTX)
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Assessment of response to Rx is
recommended after 6-8 weeks.
Improvement Criteria :
Improvement in BASDAI of=or > 2 in
BASDIA score and physician global
assessment of =or>1
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Discontinuation of Anti-TNF :
If the response criteria are not met within
6-8 weeks , it is recommended to D/c
the anti-TNF agents
The use of other anti-TNF may be
considered.
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There is no available data that active MRI
and high CRP are required to support
therapy with anti-TNF in individual patient
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Conclusion:
AS can and has to be diagnosed earlier
than is being done at present even before
radiological changes are evident
Therapies with NSAIDs and TNF blockers
are most effective for the signs ,symptoms
that are caused by inflammation.
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The disappearance of inflammation in the
spine and sacroiliac joints during
treatment, as detected by MRI is a
demonstration of great efficacy of TNF
blockers and also suggests that structural
damage may also be prevented
Ann Rheum Dis 2005-0nline
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Whether and how these new treatments
also have the potential to induce long
term remission if given early enough has
to be shown in the future.
Ann Rheum Dis 2005-0nline