Ankylosing spondylitis - PowerPoint by pNhn2l4

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									    Ankylosing spondylitis
   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
   Delay in diagnosis
   Recent survey of 1614 patients with AS illustrate
    the protracted delay between onset and
   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)
            Ankylosing spondylitis
   Relative sensitivity of detecting
    active Sacroilliitis :

          Plain Radiography
          Quantitative Scintigraphy

       MRI               95%
       Plain radiography 19%
       QS                48%
J Rheumatol 1996;23-2107-15
         Ankylosing spondylitis

   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

   Symptoms early in the disease are due to
   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
   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
         Ankylosing spondylitis

   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
 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
   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
   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
All according to clinical presentations and ASAS
   core set
Frequency of monitoring should be decided on
   symptoms, severity, and drug treatment
         Ankylosing Spondylitis

    3-Optimum therapy of AS requires
     pharmacological and non-pharmacological
         Ankylosing Spondylitis

    4-Non-pharmacological treatment of AS :
    -Patient education
    -regular exercises
    -physical therapy
    -Patients associations and self help groups
     may be useful.
       Ankylosing spondylitis

 5- NSAIDs are recommended as first line
  therapy for treatment of AS with pain and
 In those with increased GI risk , selective

 COX2 inhibitors could be used.
         Ankylosing spondylitis

   6- Analgesics may be used for pain in
    whom NSAID are insufficient,
    contraindicated and or poorly controlled.
         Ankylosing spondylitis

   7- Corticosteroids injections directed to
    the local site of inflammation may be
   The use of systemic steroids for axial
    disease is not supported by evidence.
         Ankylosing spondylitis

   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.
       Ankylosing spondylitis

 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
         Ankylosing spondylitis

   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.
          Ankylosing spondylitis

   First International ASAS consensus
    statements for the use of Anti-TNF
    agents in patients with ankylosing

   Published online ARD August 2005
   Guidelines for the use on Anti-TNF in AS
        Ankylosing spondylitis

   -Anti-TNF therapy is considered as a major
    advances (breakthrough) in the treatment of AS
 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.
         Ankylosing spondylitis

   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)
          Ankylosing spondylitis
   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
         Ankylosing spondylitis

   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)
         Ankylosing spondylitis

   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
         Ankylosing spondylitis

   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
         Ankylosing spondylitis

   There is no available data that active MRI
    and high CRP are required to support
    therapy with anti-TNF in individual patient
         Ankylosing spondylitis

   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.
         Ankylosing Spondylitis

   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
         Ankylosing Spondylitis

   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

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