para>Infants exposed to NSAIDs in 1st trimester may have a higher incidence of cardiac malformations (5)[A]. á
Second Line
- Biologic agents: tumor necrosis factor (TNF)-╬▒ antagonists
- 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).
- Precautions with TNF-╬▒ blockers
- 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.
- Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate and sulfasalazine, are ineffective for axial disease; sulfasalazine may be effective for peripheral arthritis (3)[C].
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
Patient Monitoring
- 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
- Spine
- 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)
- 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
REFERENCES
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.
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
Arthritis, Psoriatic; Arthritis, Rheumatoid (RA); Crohn Disease; Reactive Arthritis (Reiter Syndrome); Ulcerative Colitis á
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.