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Ankylosing Spondylitis

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Ankylosing Spondylitis

para>Infants exposed to NSAIDs in 1st trimester may have a higher incidence of cardiac malformations (5)[A]. á

11 Reveille áJD, Weisman áMH. The epidemiology of back pain, axial spondyloarthritis and HLA-B27 in the United States. Am J Med Sci. 2013;345(6):431-436.22 Dougados áM, Baeten áD. Spondyloarthritis. Lancet. 2011;377(9783):2127-2137.33 Braun áJ, van den Berg áR, Baraliakos áX, et al. 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis. 2011;70(6):896-904.44 Guellec áD, Nocturne áG, Tatar áZ, et al. Should non-steroidal anti-inflammatory drugs be used continuously in ankylosing spondylitis? Joint Bone Spine. 2014;81(4):308-312.55 Adams áK, Bombardier áC, van der Heijde áDM. Safety of pain therapy during pregnancy and lactation in patients with inflammatory arthritis: a systematic literature review. J Rheumatol Suppl. 2012;90:59-61.66 Maxwell áLJ, Zochling áJ, Boonen áA, et al. TNF-alpha inhibitors for ankylosing spondylitis. Cochrane Database of Syst Rev. 2015;(4):CD005468. doi:10.1002/14651858.CD005468.pub2.77 Gensler áL, Inman áR, Deodhar áA. The "knowns"Ł and "unknowns"Ł of biologic therapy in ankylosing spondylitis. Am J Med Sci. 2012;343(5):360-363.88 Sieper áJ. Treatment challenges in axial spondyloarthritis and future directions. Curr Rheumatol Rep. 2013;15(9):356. doi:10.1007/s11926-013-0356-9.

Arthritis, Psoriatic; Arthritis, Rheumatoid (RA); Crohn Disease; Reactive Arthritis (Reiter Syndrome); Ulcerative Colitis á

  • Biologic agents: tumor necrosis factor (TNF)-╬▒ antagonistsRecommended for high disease activity or when a trial of two NSAIDs over 4 weeks have failed (3)[C]FDA-approved agents for AS include etanercept (recombinant TNF receptor fusion protein), infliximab (chimeric monoclonal IgG1 antibody to TNF-╬▒), adalimumab (fully humanized IgG1 monoclonal antibody to TNF-╬▒), and golimumab (human IgG1 kappa monoclonal antibody to TNF-╬▒).Approved agents improve pain, function, and symptoms of AS as compared to placebo (6)[A].No definitive evidence for TNF-╬▒ blockers with regards to disease remission, prevention of radiologic progression, or prevention of extra-articular manifestations (7).Monoclonal TNF-╬▒ blockers are preferred when IBD is involved (3)[C].Further investigation as to the effectiveness of TNF blocker therapy with NSAIDs is needed (8).
  • Precautions with TNF-╬▒ blockersAnti-TNFs increase the risk of serious bacterial, mycobacterial, fungal, opportunistic, and viral infections. Screen for tuberculosis and hepatitis B.Monitor for reactivation of tuberculosis and invasive fungal infections, such as histoplasmosis, in all patients, especially those who travel to (or residents in) endemic areas.Lymphomas, nonmelanoma skin cancers, and other malignancies have been reported in patients receiving anti-TNFs.Immunizations (especially live vaccines) should be updated before initiating anti-TNFs; live vaccines are contraindicated once patients receive anti-TNFs.
  • Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate and sulfasalazine, are ineffective for axial disease; sulfasalazine may be effective for peripheral arthritis (3)[C].
  • Recommended for high disease activity or when a trial of two NSAIDs over 4 weeks have failed (3)[C]
  • FDA-approved agents for AS include etanercept (recombinant TNF receptor fusion protein), infliximab (chimeric monoclonal IgG1 antibody to TNF-╬▒), adalimumab (fully humanized IgG1 monoclonal antibody to TNF-╬▒), and golimumab (human IgG1 kappa monoclonal antibody to TNF-╬▒).
  • Approved agents improve pain, function, and symptoms of AS as compared to placebo (6)[A].
  • No definitive evidence for TNF-╬▒ blockers with regards to disease remission, prevention of radiologic progression, or prevention of extra-articular manifestations (7).
  • Monoclonal TNF-╬▒ blockers are preferred when IBD is involved (3)[C].
  • Further investigation as to the effectiveness of TNF blocker therapy with NSAIDs is needed (8).
  • Anti-TNFs increase the risk of serious bacterial, mycobacterial, fungal, opportunistic, and viral infections. Screen for tuberculosis and hepatitis B.
  • Monitor for reactivation of tuberculosis and invasive fungal infections, such as histoplasmosis, in all patients, especially those who travel to (or residents in) endemic areas.
  • Lymphomas, nonmelanoma skin cancers, and other malignancies have been reported in patients receiving anti-TNFs.
  • Immunizations (especially live vaccines) should be updated before initiating anti-TNFs; live vaccines are contraindicated once patients receive anti-TNFs.

ISSUES FOR REFERRAL

  • Physical therapy can assist with treatment plan (including home regimens).
  • Coordinate care with a rheumatologist for diagnosis, monitoring, and management (anti-TNF therapy).
  • Management of aortic regurgitation, uveitis, spinal fractures, pulmonary fibrosis, hip joint involvement, renal amyloidosis, and cauda equina syndrome may require referral to appropriate specialty.

ADDITIONAL THERAPIES

  • Bisphosphonate medications if osteopenia or osteoporosis is present
  • Monitoring and management of CVD risk factors and comorbidities

SURGERY/OTHER PROCEDURES

  • Evaluate for C-spine ankylosis/instability before intubation in patients with AS undergoing surgery.
  • Total hip replacement if necessary to restore mobility and to control pain.
  • Vertebral osteotomy can improve posture for patients with severe cervical or thoracolumbar flexion.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Symptom control and maintenance of mobility and function are primary treatment goals.
  • Monitor posture and range of motion with 6- to 12-month visits; increase frequency if higher disease activity.
  • Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) or Ankylosing Spondylitis Disease Activity Score (ASDAS) can be used to measure disease activity.

PATIENT EDUCATION

  • Maintain physical activity and posture.
  • Swimming, tai chi, and walking are excellent activities.
  • Avoid trauma/contact sports.
  • Appropriate ergonomic modification of workplace
  • Counsel about risk of spinal fracture.
  • MedicAlert bracelet (helpful if intubation required)
  • Arthritis Foundation: http://www.arthritis.org
  • Spondylitis Association of America: http://www.spondylitis.org

PROGNOSIS

  • Extent and rapidity of progression of ankylosis are highly variable.
  • Progressive limitation of spinal mobility necessitates lifestyle modification.

COMPLICATIONS

  • SpineSpinal fusion causing kyphosisCervical spine fracture or subluxation carries high mortality rate; fracture can occur at any level of ankylosed spine.Cauda equina syndrome (rare)
  • Pulmonary: restrictive lung disease, upper lobe fibrosis (rare)
  • Cardiac: conduction defects at atrioventricular (AV) node, aortic insufficiency, aortitis, pericarditis (extremely rare)
  • Eye: uveitis and cataracts
  • Renal: IgA nephropathy, amyloidosis (<1%)
  • GI: microscopic, subclinical ileal, and colonic mucosal ulcerations in up to 50% of patients, mostly asymptomatic
  • Spinal fusion causing kyphosis
  • Cervical spine fracture or subluxation carries high mortality rate; fracture can occur at any level of ankylosed spine.
  • Cauda equina syndrome (rare)

REFERENCES

ADDITIONAL READING

  • Baraliakos áX, van den Berg áR, Braun áJ, et al. Update of the literature review on treatment with biologics as a basis for the first update of the ASAS/EULAR management recommendations of ankylosing spondylitis. Rheumatology (Oxford). 2012;51(8):1378-1387.
  • Garg áN, van den Bosch áF, Deodhar áA. The concept of spondyloarthritis: where are we now? Best Pract Res Clin Rheumatol. 2014;28(5):663-672.
  • Sieper áJ. Developments in therapies for spondyloarthritis. Nat Rev Rheumatol. 2012;8(5):280-287.
  • Sieper áJ, Rudwaleit áM, Baraliakos áX, et al. The Assessment of Spondyloarthritis International Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis. 2009;68(Suppl 2): ii1-ii44.
  • van den Berg áR, Baraliakos áX, Braun áJ, et al. First update of the current evidence for the management of ankylosing spondylitis with non-pharmacological treatment and non-biologic drugs: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis. Rheumatology (Oxford). 2012;51(8):1388-1396.

SEE ALSO

CODES

ICD10

  • M45.9 Ankylosing spondylitis of unspecified sites in spine
  • M08.1 Juvenile ankylosing spondylitis
  • M45.8 Ankylosing spondylitis sacral and sacrococcygeal region
  • M45.6Ankylosing spondylitis lumbar region
  • M45.0Ankylosing spondylitis of multiple sites in spine
  • M45.7Ankylosing spondylitis of lumbosacral region
  • M45.1Ankylosing spondylitis of occipito-atlanto-axial region
  • M45.4Ankylosing spondylitis of thoracic region
  • M45.3Ankylosing spondylitis of cervicothoracic region
  • M45.5Ankylosing spondylitis of thoracolumbar region
  • M45.2Ankylosing spondylitis of cervical region

ICD9

  • 720.0Ankylosing spondylitis

SNOMED

  • 9631008Ankylosing spondylitis (disorder)
  • 239805001Juvenile ankylosing spondylitis (disorder)
  • 239810002ankylosing spondylitis with organ / system involvement (disorder)

CLINICAL PEARLS

  • Diagnosis of AS is suggested by a history of inflammatory back pain, evidence of limited chest wall expansion, restricted spinal movements in all planes, radiographic evidence of sacroiliitis, and a therapeutic response to NSAIDs.
  • HLA-B27 testing supports the diagnosis if clinical features are not definitive.
  • MRI is more sensitive at detecting SI joint inflammation than plain radiography.
  • Physical therapy is important in helping to maintain posture and mobility.
  • NSAIDs and TNF-╬▒ blockers are the mainstays of pharmacologic treatment of AS.