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IdentificationofPsoriaticArthritisandAnkylosingSpondylitis—EarlyDetectiontoFacilitateAppropriateCare

Joy Schechtman D.O.Professor

Midwestern University

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Disclosures

•None

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LearningObjectives

• Understandtheevolvingconceptofspondyloarthritis (SpA)• Recognizethesignsandsymptomsofpsoriaticarthritis(PsA)• Recognizethesignsandsymptomsofankylosingspondylitis(AS)• Understandhowtoscreenandwhentorefer toarheumatologistforfurtherevaluation

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PsAandAS:PartoftheSpondyloarthritides (SpA)

KhanMA.AnkylosingSpondylitis.2009;1-147.Rudwaleit M. In:Rheumatology.5thed.2011:1123-1127.

AnkylosingSpondylitis

PsoriaticArthritis

ReactiveArthritis

UndifferentiatedSpA

EnteropathicArthritis

Spondylo-arthritis

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PredominantlyAxialDisease

Ankylosingspondylitis(radiographicSpA)

NonradiographicaxialSpA

TwoSubtypes ofSpA

PredominantlyPeripheralDisease

Psoriaticarthritis

Reactivearthritis

Inflammatoryboweldisease-associated arthritis

Undifferentiated SpA

Rudwaleit M.AnnRheumDis.2009;68(6):777-783.Rudwaleit M.AnnRheumDis.2011;70(1):25-31.Zochling Jetal.Rheumatology (Oxford).2005;44(12):1483-1491.

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Co-management oftheAS/PsAPatient

Primarycaregivers• Performbaselinescreeningwith

history,examination+/- testing• Recognizethesignsandsymptoms

ofAS/PsA• Refertospecialisttoensure

appropriatediagnosisandmanagement

Rheumatologist• Confirmdiagnosis• Educatepatient• Prescribeandmonitortherapy• CoordinateSpAcarewithother

providerswhenappropriate(PCP,ophthalmologist,physicaltherapy,etcetera)

• Monitorpatient’sprogressandadjusttherapywhenappropriate

ACRSubcommittee onRAGuidelines. Arthritis Rheum.2002;46(2):328-346.GraydonSLetal. JRheumatol. 2008;35(7):1378-1383.KountzDSetal. JFamPract.2007;56(suppl10A):59A-74A.Weinblatt MEetal. JFamPract.2007;56(suppl4):S1-S8.

Continuedcoordinationandcommunication

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PsoriaticArthritis(PsA)

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WhatIsPsA?

• Aninflammatoryspondyloarthropathyassociatedwithpsoriasis• Characterizedbyinflammationinjointsandsurroundingbone,ligaments,andtendons

Plaquepsoriasis

©2013 ACR; usedwithpermission.©2012 ASSH;usedwithpermission.

Fitzgerald O. In:Kelley’sTextbook ofRheumatology.8thed. 2008:1201-1218.Gladman DD.In:Primer ontheRheumatic Diseases.13thed.2008:170-177.Gottlieb Aetal. JAmAcadDermatol. 2008;58(5):851-864.HaroonMetal.AnnRheumDis. 2013;72(5):736-740.

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WhoDoesPsAAffect?

• PsAaffectsfemalesandmalesinequalratio• Themosttypicalageofonset isfrom30yearsold,butitmayoccuratanyage• Theprevalence isestimatedtorangefrom0.1%to1.0%ofthegeneralpopulation,withanincidenceofabout3to23newcasesper100,000people–Upto42%ofpatientswithpsoriasiswilldevelopPsA

–Inabout84%ofpatients,skindiseaseprecedesjointdisease

Fitzgerald O. In:Kelley’sTextbook ofRheumatology.8thed. 2008:1201-1218.Gladman DD.In:Primer ontheRheumatic Diseases.13thed.2008:170-177.Gottlieb Aetal. JAmAcadDermatol. 2008;58(5):851-864.

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Importance ofEarlyDiagnosisandAppropriateManagement

• EarlyrecognitionandappropriatemanagementofPsAareimportantto:–Reducesymptomssuchaspain,stiffness,andskinlesions–Preventfurther jointdamageandimprovephysicalfunction

• Inonestudy,upto47%ofPsApatientswithdiseasedurationof2yearshadevidenceofradiographicdamage

AhlehoffOetal. JIntern Med.2011;270(2):147-157.KaneDetal.Rheumatology. 2003;42(12):1460-1468.Mease PJetal. Int JAdvRheumatol. 2006;4(2):38-48.

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WhatAretheMostCommonManifestationsofPsA?

• Recognizingsomeofthemostcommonsigns,symptoms,andmanifestationsofPsAcanimproveearlyrecognition–Psoriaticskinlesions–Peripheralarthritis–Axialdisease–Dactylitis–Enthesitis–Naildisease–Elevatedacutephasereactants

Gladman DD.In:Primer ontheRheumatic Diseases.13thed.2008:170-177.Gottlieb Aetal. JAmAcadDermatol. 2008;58(5):851-864.

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Psoriasis

• Chronicinflammatorydiseaseoftheskin• Occursinapproximately2%ofthepopulation• Plaquepsoriasischaracterizedbyraisedplaqueswithscale• Commonlocationsinclude:–Scalp–Knees/elbows–Hands/feet–Lowerback/buttocks

©2012 American Academy of Dermatology.

Gottlieb Aetal. JAmAcadDermatol. 2008;58(5):851-864.Menter Aetal. JAmAcadDermatol. 2008;58(5):826-850.AAD.http://www.aad .org/skin-conditions/dermatology-a-to-z /psoriasis.

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• Painandswellinginanyjointoutsideofthespineandpelvis• Occursin95%ofpatientswithPsA• Fluctuatingcourseofflaresandimprovement• Maycausejointdamageanddeformities• Distalinterphalangeal(DIP)involvementcanhelpdistinguishPsAfromothertypesofinflammatoryarthritis,butmaynotalwaysbepresent• About5%maydeveloparthritismutilanswithsubstantialbonelossanddeformities ©2013 ACR; usedwithpermission.

Bruce IN. In:Rheumatology. 5thed.2011:1183-1194.Gottlieb Aetal. JAmAcadDermatol. 2008;58(5):851-864.KaneDetal.Rheumatology. 2003;42(12):1469-1476.

PeripheralArthritis

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©2013 ACR; usedwithpermission.Subchondral bone resorption ofthe distalinterphalangeal jointof thethumb andmiddle fingers has resulted inthe “pencil-in-cup” appearance.Bruce IN. In:Rheumatology. 5thed.2011:1183-1193.

HusniME. In:Rheumatology. 5thed.2011:1179-1181.

PeripheralArthritis(cont’d)

• X-raysmaybenormal• Erosivebonelossmaycauseirreversible jointdamage• Fusionwithbonegrowthacrossjoints(ankylosis)canoccur

©2013 ACR; usedwithpermission.Note theankylosis of allinterphalangeal joints, except for thethumb

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AxialInvolvement inPsA

• Inflammationinsacroiliacjointsand/orspine–20%to50%havebothperipheralandaxialdisease–5%haveaxialdiseasewithoutperipheraldisease

• Inflammatorybackpain(moretocomeinASreview)

Gottlieb Aetal. JAmAcadDermatol. 2008;58(5):851-864.

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Dactylitis

• Inflammationoftendonsinfingersandtoes• Occursinapproximately30%to40%ofPsApatients• Differsfromarthritisonexaminthatthereistendernessandswellingbetweenthejointsaswellasaroundthejoints• Causesthedigittohave“sausage”appearance• Mostcommonly involves1or2digitsatatime

©2013 ACR; usedwithpermission.Brockbank JEetal.AnnRheumDis.2005;64(2):188-190.Bruce IN. In:Rheumatology. 5thed.2011;1138-1194.

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Enthesitis

• Inflammationwheretendonsandligamentsinsertintobone• Symptomaticenthesitisoccursin20%to40%ofpatientswithPsA• MostcommonsitesareAchilles andplantarfasciainsertions• Usuallypresentssimilarly tomechanicalenthesopathy,butmorerefractoryandoftenatmorethanonesite• Characterizedbytendernessonexamination,swellingmaynotbeapparentonexamination

Bruce IN. In:Rheumatology. 5thed.2011:1183-1194.Gladman DD.In:Primer ontheRheumatic Diseases.13thed.2008:170-177.

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NailDisease inPsA

• 60%to80%ofpatientswithPsAhavepsoriaticnaildiseases• Characterizedby:–Pitting–Thickeningofnails(hyperkeratosis)–Separationofnailsfromnailbed(onycholysis)

• ThenailthickeningandseparationinPsAcanbeindistinguishable fromfungalinfectionsonexamination

©2013 ACR; usedwithpermission.

©2013 ACR; usedwithpermission.

Fingernailpitting

Fingernailpittingandonycholysis

Bruce IN. In:Rheumatology. 5thed.2011:1183-1194.KacarNetal. ClinExpDermatol. 2007;32(1):1-5.

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PsA:LaboratoryMeasures

• Acutephasereactantshavevalueinassessingactiveinflammationinperipheral joints• IncreasedCRP*levels arelesscommonlyobserved inPsAvsRA,butareassociatedwithpooreroutcomesinPsA• 5%to9%ofpatientswithPsAcanberheumatoidfactor(RF)positive

*CRP=C-reactive protein.

Kavanaugh Aetal.ClinExpRheum. 2005;23(suppl39):s142-s147.

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FlagsforReferral

YoushouldreferallpatientswithanyofthefollowingtoarheumatologistforsuspectedPsA:• Psoriasisorafamilyhistoryofpsoriasiswithasuspicionforinflammatory arthritis• Psoriasisorafamilyhistoryofpsoriasiswithasuspicionforenthesitis• Psoriasisorafamilyhistoryofpsoriasisandeitherswollenorpainfuljoints• Suspicionfordactylitis• Suspicionforinflammatory spinedisease

Salisbury NHSFoundation Trust.Referral pathway forpsoriaticarthritis. www.icid.salisbury.nhs.uk/CLIN ICALMANAGEMENT/RHEUMATOLOGY/P ages/PsA.aspx

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SampleScreeningQuestions

Thefollowingscreeningquestionscanbeusedtoidentifyappropriatecandidatesforreferral:• Haveyouhadswellinginyourjointsfornoapparentreason?• Doyouhaveahistoryofpsoriasis?• Doyouexperiencemorningstiffnessforlongerthan30minutes?• Doyouhavechronicpaininyourbackthatimproveswithexercise,notwithrest?• Haveyouhadtendernessorswellinginyourheel(s)fornoapparentreason?• Haveyouhadafingerortoethatbecamecompletelyswollenfromtiptobasefornoapparentreason?• Doyouhavepitsinyournails?

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PsACaseStudy

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CaseStudy:Presentation

• FK,a32-year-oldfemale, isadedicatedlong-distancerunner• Shepresentsintheofficewitha1-yearhistoryofleftanklepainanda2-monthhistoryofrightkneepain• Nohistoryofpsoriasis,buthashad“dandruff” for3months

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CaseStudy:ClinicalAssessment

• Cutaneousexam–Naildystrophyoftheright2ndand3rddigits– Scalingplaque,rightocciput

• Peripheralarticularexam–Rightkneeswelling–DIPswellingoftheright2ndand3rddigits

• Labs

Test Result

CBC Normal

ESR Normal

CRP Mildlyelevated

RF Negative

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CaseStudy:Conclusion

• Provisionaldiagnosis:psoriaticarthritis• Prescribenaproxen500mgBID• Refertorheumatologistforanearlyappointmentandconsiderdermatologyreferralforskinmanagement

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TherapeuticManagementofPsA

Goalsoftherapy:• Toimprovesignsandsymptoms• Preventprogressionofjointdamage• Improvephysicalfunction

Kavanaugh Aetal. JRheumatol. 2006;33(7):1417-1421.

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AnkylosingSpondylitis(AS)

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WhatIsAS?

• ASisachronicinflammatorydisease• Mostcommonly affectedsites:–Axialskeleton(sacroiliac jointsandthespinalcolumn)

–Entheses (siteswherethetendonsandligamentsattachtobones)

–Peripheraljoints

• Overtime,inseverecases,maycauseprogressive,vertebralfusion(ankylosis)

vanderHeijde D.In:Primer ontheRheumaticDiseases.13thed.2008:193-199.vanderLindenSetal. In:Kelley’s TextbookofRheumatology. 8thed.2008:1169-1189.

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WhoDoesASAffect?

• Symptomsusuallystartbetween20and30yearsofage(rarelyafterage40)• Unfortunately,mostpatientswithASareeitherdiagnosedlateoralreadycompromisedupondiagnosis• Traditionally,AShasbeenadiseasethoughttobemoreprevalentinmalesthaninfemales,witharatioofabout2to3:1.However,datasuggestthatthepercentageofwomenwithASisdependentontheyearofdiagnosis,andinrecentyearsthegenderratiohasapproached1:1

Ageofonset,ASvsRA

German rheumatological database: disease duration≤5years; 1993to1998data.Usedwithpermission.

Feldtkeller Eetal.CurrOpinRheumatol. 2000;12(4):239-247.KhanMA.AnnInternMed.2002;136(12):896-907.vanderLindenSMetal. In:Kelley’s TextbookofRheumatology. 8thed.2008:1169-1189.ZinkAetal.AnnRheumDis.2001;60(3):199-206.

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Note:Prevalencefigureswerederivedfromdifferingpopulationsandstudies

a Theage-adjusted prevalence ofaxial SpAvaries from0.9%to1.4%

Helmick CGetal. ArthritisRheum. 2008;58(1):15-25.Reveille JDetal.ArthritisCareRes.2012.doi:10.1002/acr.21621.

PrevalenceofAxialSpA, IncludingAS,vsRA

• Theage-adjustedprevalenceofaxialSpAvariesfrom0.9%to1.4%– Approximately1.7millionto2.7millionpatientswithaxialSpA

– Estimatebasedonadultsaged20to69yearsexaminedinthe2009-2010USNHANESwhofulfilledtheAmororESSGcriteria

• Theestimated reportedprevalenceofASis0.52%– Estimatesbasedonmoderateorsevereradiographicsacroiliitisonpelvicradiographsinmen,aged25to74years,andwomen,aged50to74years

– Questionsregardinginflammatorybackpainwerenotasked;therefore,theexactprevalenceofAScannotbeascertained

• Theestimated prevalenceofrheumatoidarthritis(RA)is0.6%

a

Estimated Prevalence in US

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Averagedelayindiagnosis:9years

Therewasasignificantlylongerdelayindiagnosisinwomencomparedtomen(9.8vs8.4years;P<0.01)

AgeatFirstSymptomsandatFirstDiagnosisinASPatients

Feldtkeller Eetal.CurrOpinRheumatol. 2000;12(4):239-247.(withpermission).

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BarrierstoEarlyDiagnosis:ASurveyof127ASPatients

• Patientsslowtoseekcare:–35%delayedconsultingahealthcareprofessionalfor>12monthsaftersymptomonset

–71%assumedthattheirsymptomswouldresolve

• ASisdifficultforproviderstorecognize:–Priortodiagnosis:• 68%consultedaphysicaltherapist(3ormore:16%)• 44%,achiropractor(3ormore:9%)

–DiagnosisofSpA was suspected in<2%

Grigg SEetal.Arthritis Rheum.2011;63(suppl10):1308.

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Importance ofEarlyDiagnosisandAppropriateManagement inAS

Earlydiagnosisandappropriatemanagementareimportantforseveralreasons:• Appropriatetreatmentcanhelpimprovesymptoms• Patientsintheearlycourseofdiseasehaveasimilarburdenofdiseasetothoseinlaterstages• Anearlydiagnosisavoidsunnecessarydiagnosticproceduresandinappropriatetreatment

BrandtHCetal. AnnRheumDis. 2007;66(11):1479-1484.Braun Jetal.AnnRheumDis. 2011;70(6):896-904.Rudwaleit Metal.Arthritis Rheum.2005;52(4):1000-1008.Sieper Jetal.AnnRheumDis.2005;64(5):659-663.

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EvolutionofAS

• ItisnotyetknownifeverypatientinthenonradiographicstageofaxialSpAwillprogress

BackpainBackpain

Radiographicsacroiliitis

BackpainSyndesmophytes

Time(years)

Radiographicstage(AS)

NonradiographicstageofAxialSpA ModifiedNewYorkCriteria1984

Rudwaleit Metal.Arthritis Rheum.2005;52(4):1000-1008.Rudwaleit Metal.Arthritis Rheum.2009;60(3):717-727.

NonradiographicstageofAxialSpA

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ClassificationCriteriaforAnkylosingSpondylitis (AS):1984ModifiedNewYorkCriteria

A:Diagnosis• Clinicalcriteria:– Lowbackpainandstiffnessfor>3months,whichimprovewithexercisebutarenotrelievedbyrest

– Limitationofmotionofthelumbarspineinboththesagittalandfrontalplanes– Limitationofchestexpansionrelativetonormalvaluescorrelatedforageandsex

• Radiologic criterion:– Sacroiliitis (grade≥2bilaterallyorgrade3–4unilaterally)

B:Grading

DefiniteAS=radiologicalcriterionpresent+≥1clinicalcriterionProbableAS=3clinicalcriteriapresentorradiologiccriterionpresentwithoutanysignsorsymptomssatisfyingtheclinicalcriteria

vanderLindenetal.Arthritis Rheum. 1984;27(4):361-368.

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WhatDoesASLookLike?

RecognizingthecommonmanifestationsofAScanimproveearlyrecognition:• Axialdisease– Inflammatorybackpain–Sacroiliitis–Rangeofmotion limitationsandposturalchanges

• Peripheralarthritis• Enthesitis• Uveitis

vanderHeijde D.In:Primer ontheRheumaticDiseases.13thed.2008:193-199.

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InflammatoryBackPain(IBP)

• Notallbackpainisthesame:• ThecharacterofSpAbackpainisdifferentthanmechanicalbackpaininthatitisofinflammatoryorigin• 1outofevery3chronicbackpainpatientshasIBP• WhatdoesIBPlooklike?–Onsetbeforetheageof40–Worseatnightorearlymorningafterprolongedimmobility– Improveswithexerciseoractivity,notrelievedbyrest–Morningstiffnessfor>30minutes–Alternatingbuttockpain

Weisman MHetal.AnnRheumDis.2013;72(3):369-373.

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Jointspacewidening

Jointspacenarrowing

Erosion

Sclerosis

Normalsacroiliacjoint

Rudwaleit Metal.NatRevRheumatol.2012;8(5):262-268.vanderHeijde D.In:Primer ontheRheumaticDiseases.13thed.2008:193-199.

Sacroiliitis

• SacroiliitisonimagingisconsideredthehallmarkofAS• Imagingisnotgenerallysuggestedforscreeninginprimarycaresettingsduetocosts,radiationexposure,anddifficultiesininterpretation.However, ifavailable,animagingresultshowingclearsacroiliitiswarrantsimmediatereferral toarheumatologist

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RangeofMotionLimitationsandPosturalChanges

• Fusionofvertebraerestrictsspinalmotion–Thisfeatureismoreevident inlaterstagesofdisease,thusislessuseful inidentifyingearlyAS

–Patientsoftencomplainaboutdifficultylookingupwardandovertheirshoulder

–Overtimepatientsmay“stoopforward”

• InonestudyofpatientswithAS,radiographswerescoredaccordingtodiseaseduration.Complete spinalfusionoccurredin28%ofpatientswithdiseaseduration>30yearsand43%withdiseaseduration>40years

Ankylosisofall cervical jointsfromthesecondcervical vertebrae downward

OVERTIME

Jang JHetal.Radiology.2011;258(1):192-198.vanderLindenSMetal. In:Kelley’s TextbookofRheumatology. 8thed.2008:1169-1189.

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PeripheralArthritis

• Classicallyoligoarticular, largejointsoflowerextremities,butmayaffectanyjoint• Inflammatoryhipdiseaseoccursin30%to50%ofASpatientsandisassociatedwithmoreseveredisease• Cancauseerosivebonelossorbonyfusionacrossjoints,similartoPsA

©2013 ACR; usedwithpermission.Advanced narrowing ofthe entire hipjoint spacecharacteristicofinflammatory arthritis.

HamdiWetal. JointBoneSpine.2012;79(1):94-96.

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Enthesitis

• Mayoccuranywheretendonsandligamentsattachtobone,butoccursmostofteninAchillesandplantarfascia• Diagnosedbyapplyingenoughpressuretoblanchyourfingernail• DiagnosiscanbeconfirmedwithultrasoundorMRI

CommonsitesforpainassociatedwithenthesitisOliveri Ietal.Rheumatology (Oxford).2006;45(10)1315-1317.

vanderHeijde D.In:Primer ontheRheumaticDiseases.13thed.2008:193-199.

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AcuteAnteriorUveitis

• Uveitisoccursinaboutone-thirdofASpatients• Suddenonsetpain,redness,andblurredvision• AlthoughuveitisrarelyprecedestheclinicalonsetofAS,itisoftenthefirstcluetotherecognitionthatlowbackpainisinflammatory• 80%ofHLA-B27+peoplewithrecurrentuveitishaveSpA• Diagnosisrequiresslitlampexam• Patientssuspectedofhavinguveitisshouldbereferredtoanophthalmologistforfurtherevaluation

MonnetDetal.Ophthalmology. 2004;111(4):802-809.vanderHeijde D.In:Primer ontheRheumaticDiseases.13thed.2008:193-199.

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HLA-B27

• Estimates from2009NationalHealthandNutritionExaminationSurvey(NHANES)demonstrateda6.1%prevalencerateofHLA-B27inadultsaged20to69years

• Thestrength ofdisease associationvariesamongthedifferentformsofSpAandthemanyethnicandracialgroupsworldwide– Amongwhites,4%to13%ofthegeneralpopulationpossessHLA-B27,butmorethan90%ofthepatientswithASpossessthisgene

– AmongAfricanAmericans,2%to4%ofthegeneralpopulationpossessHLA-B27,whereas50%to60%ofpatientswithASpossessthisgene

• HLA-B27testing isdiagnosticallyusefulonlyincombinationwithotherfeaturesofSpA– Forexample,axialSpAdiagnosisoccursin58%ofpatientswithbothHLA-B27and inflammatorybackpain

BrandtHCetal. AnnRheumDis. 2007;66:1479-1484.Braun J. In:PrimerontheRheumaticDiseases.13thed.2008;200-208.KhanMA.AtlasofRheumatology. 2005;154-180.Reveille JDetal.ArthritisRheum. 2012;64(5):1407-1411.

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ImprovingEarlyRecognitionofAS

• ChronicinflammatorybackpainistheleadingsymptominpatientswithaxialSpA,includingAS,andshouldserveasakeyscreeningparameter–Noincrementalcostforassessment–SensitivityofinflammatorybackpainforASis75%

Sieper Jetal.AnnRheumDis. 2005;64(5):659-663.

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Recognizing InflammatoryBackPain

Assessment inSpondyloArthritisInternationalSociety(ASAS),criteriaforIBPpresentastandardframeworkforscreeningpatients

Inpatientswithchronicbackpain(>3mo),IBPcriteriaarefulfilledifatleast4outof5parametersarepresent*

Ozgocmen Set al. JRheumatol.2010;37(9):1978-1979.Sieper Jetal.AnnRheumDis.2009;68(supplII):ii1-ii44.

*Sensitivity of79.6%andspecificityof72.4%basedonexpert clinical judgment fromASAS Validation Study; n=648.Mnemonic iPAIN© andiPAIN© arecopyrighted (Ozgocmen Setal. JRheumatol. 2010;37(9):1978-1979).

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IBPAscertainmentTool

Thefollowingscreeningquestionscanbeusedtohelpidentifypatientswithinflammatorybackpain:

AdaptedfromDevelopmentandValidationofaCaseAscertainmentToolforASQuestionitem RationaleWhat isyourgender? Historically there hasbeen a2:1male tofemale ratio in thediagnosisofAS,however,

recent datasuggest the ratio isapproaching 1:1

Have youexperienced painorstiffnessthat lasted forat least3months? If so,please indicate the location(s).

ASAS IBPcriteria are tobeapplied topatients withchronicbackpain lasting forat least3months.Presence ofneckand/or hippainhasasignificant positiveassociationwith AS

Approximately howoldwere youwhen youfirsthadpainor stiffnessinyourback that lasted foratleast 3months?

BasedonIBPcriteria, age ofonsetis<40yearsoldwithadurationofbackpain>3months

Approximately how longhaveyouhadbackpainor stiffness?

Have youfeltnumbnessor tingling that spread intoordownyour leg(s)thatyouthinkorhavebeen toldmighthave been causedbyyourbackpainorstiffness?

Ifanswer is “Yes,”backpain islikely mechanical vsinflammatory

Isthepainor stiffnessdue tofall, sprain,orother incidents, suchastwistingorlifting?

Howdoesexercise affect thepainor stiffnessinyour lower backorbuttocks? Exercise typically alleviates IBP/stiffness

Howdoesdaily physicalactivity affect thepainor stiffnessinyour lower backorbuttocks?

IBP/stiffness tends todecrease withdaily physicalactivity

Doyoutake anyNSAID medication(s)? Ifso,dotheyhelp reduce yourbackpainorstiffnesswithin 48hours?

Patients with IBP/stiffnessgenerally haveagood response toNSAIDswithin 48hours

Have youbeen diagnosed with iritis? Uveitis isacommon extra-articular manifestation, occurring in25%-40%ofASpatients

Weisman MHetal.Arthritis CareRes (Hoboken). 2010;62(1):19-27.

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AGuidetoReferringforASEvaluation

• Patientswithchroniclowbackpainwiththeonsetofsymptoms<45yearsoldshouldbereferredtoarheumatologist inthepresenceof:– IBP–HLA-B27–Sacroiliitis

• Chronicdiarrhea,enthesitis,uveitisandpsoriasisarealsoconsideredvaluablecluesforidentifyingpatientsthatshouldbereferredtoarheumatologistforfurtherassessment

IBP• Sensitivity75%;specificity76%• Ifpositive,about1/5patientshasaxialSpA

OR OR

Refertorheumatologistforfurtherevaluation

• Chroniclowbackpain>3months• Firstsymptoms<45yearsold

HLA-B27• Sensitivity80-90%;specificity90%• Ifpositive,about1/3patientshasaxialSpA

Sacroiliitis• Onlyifavailable(Notrecommendedforscreening)• ByX-rayorMRI

Sieper Jetal.AnnRheumDis. 2005;64(5):659-663.

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ASCaseStudy

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CaseStudy:Presentation

• JD,a28-year-oldmale, isamechanic• Hecomesintoyourofficecomplainingofworseningbackpainandstiffnessfor>2years• Historyofneckspasmssinceage18• Regularlyseesachiropractorforhislowerbackpain

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CaseStudy:ClinicalAssessment

Signsandsymptoms• Backpainthatisworseatnightandoftenawakenshimfromsleep• Markedearlymorningstiffnessthatimprovesafterwalkingaroundforabout45minutes• Hisheelhasbeensoreformonths

Physicalexam• Reducedforwardflexionatthewaist• Tenderness attheAchillesinsertionofRheel

©2012 ACR; usedwithpermission.

LabTest Result

CBC Normal

ESR Mildlyelevated

CRP Normal

RF Negative

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CaseStudy:Conclusion

• Provisionaldiagnosis: inflammatorybackpainandenthesitis• Prescribeindomethacin50mgBIDandphysicaltherapy• Refertoarheumatologist,suggestearlyappointment

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2010ASAS/EULARRecommendationsfortheManagementofAS

• TheoptimalmanagementofpatientswithASrequiresacombinationofnonpharmacological andpharmacologicaltreatments.Somenonpharmacological optionsincludephysicaltherapy/rehabilitation,exercise,andpatienthelpgroups• NSAIDsrecommended asfirstlineoftherapyforASpatientswithpainandstiffness• Extra-articularmanifestations,suchaspsoriasis,uveitisandIBD,shouldbemanagedincollaborationwithappropriatespecialists• BiologictherapyshouldbegiventoappropriatepatientswithpersistentlyhighdiseaseactivitydespiteconventionaltherapiesaccordingtotheupdatedASASrecommendations

Braun Jetal.AnnRheumDis. 2011;70(6):896-904.

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Conclusions

Spondyloarthritis includesheterogeneousdiseasesthatarechallengingtodiagnose.

Earlydiagnosisandtreatmentareimportant.

PsoriasispatientsshouldbescreenedforPsAriskandeducatedaboutPsAsymptoms.

Chronicbackpainpatientsshouldbescreenedforandeducatedaboutinflammatorybackpain(considerreferringtobackpainprojectwebsite).

RefertoarheumatologistearlyifyoususpectanytypeofSpA.

©2016AbbVie Inc. NorthChicago, IL60064 November 2016 Printed inU.S.A.