spondyloarthritides

Question 1

What are spondyloarthritides?

Answer 1

A group of inflammatory disorders characterised by inflammation of the axial skeleton, entheses and peripheral joints

ankylosing spondylitis (AS
psoriatic arthritis
reactive arthritis
arthritis of inflammatory bowel disease 
(Ref: GP Check)

Question 2

Why is HLA B27 not used as a screening for patients with lower back pain?

Answer 2

The association between HLA-B27 and AS occurs in 85–95% patients.

However, it also occurs in 5–15% of the general population.

Only 5% of these HLA-B27-positive people will go on to develop AS, therefore measure in inflammatory back pain but not general population with back pain

(Ref: GP Check)

Question 3

The approach to Axial AS is physio and NSAIDs.

1. What is the 1st line treatment of extra axial AS?

Answer 3

1. Sulfasalazine
   Treats the peripheral arthritis
   Does not treat the axial part of the disease, therefore effect on spinal stiffness is minimal

Question 4

1. What are the side effects of Sulfasalazine?

2. how often to do blood tests?

Answer 4

1. headache, dizzy, tinnitus 
GI upset
Rash 
Photosensitivity 
Orange discolouration of bodily secretions 

Less common: oligospermia, blood dyscrasias and hepatitis.

2. FBC.LFT’s 2-4weekly for 1st 3 months, then 3 monthly

(Ref: GP Check)

Question 5

What is the role of TNF-alpha in treating AS?

Answer 5

TNF-α is a pro-inflammatory cytokine that has a major role in the pathogenesis of SpA.

TNF-α inhibitors are biologic agents that directly target this molecule.

In Australia, these agents are listed on the Pharmaceutical Benefits Scheme (PBS), and can only be prescribed by a rheumatologist.

Criteria for this med:
inflammatory back pain for more than 3 months
reduced spinal mobility
at least bilateral grade 2 or unilateral grade 3 sacroiliitis on X-ray
active inflammatory symptoms despite 3 months of exercise and regular NSAIDs
raised ESR and/or CRP.

Question 6

% of chronic back pain attributable to AS?

Answer 6

5% (ref etg)(

Question 7

Differentiation between AS and mechanical back pain?

Answer 7

Alternating buttock pain
Pain worse in the 2nd half of the night with spinal pain or stiffness
Early A/M stiffness relieved by activity
Improvement of pain with exercise

Question 8

1/ Extra axial features of AS

2/ Less common extra axial features

Answer 8

1/ Eye - uveitis 
Peripheral arthritis (often asymmetric)
Dactilitis 
Enthesitis (e.g. Achilles Tendon, plantar fascitis, intercostal enthesitis - causing chest wall pain) 
Dactylitis
Osteoporosis 
Osteopenia

(Ref: GP Check)
2/
Increase risk of pulmonary fibrosis
Aortic valve incompetance

Question 9

Diagnosis of AS?

Answer 9

Pelvic Xray = sacroilitis

> late finding

Question 10

What % of woman have AS?

Answer 10

1/3rd

Question 11

How long before xray features maybe seen in AS?

Answer 11

5-10 years

Question 12

Measurements of spinal mobility in AS

Answer 12

Measurements of spinal mobility:
Schober’s
Occiput to Wall distance
Lateral Lumbar flexion

Question 13

1/ when would you consider the use of sulfazalaine?

2/ when would you consider TNF-alpha?

Answer 13

1/ peripheral arthritis
2/ inflammatory back pain for more than 3 months
reduced spinal mobility
at least bilateral grade 2 or unilateral grade 3 sacroiliitis on X-ray
active inflammatory symptoms despite 3 months of exercise and regular NSAIDs
raised ESR and/or CRP.