Spondyloarthritis


Axial SpA


Peripheral SpA


Back pain ≥3 months


Age of onset <45 years


Peripheral arthritis and/or enthesitis and/or dactylitis and either column below


Sacroiliitis on imaging (Acute inflammation on MRI OR definite radiographic sacroiliitis)


AND


≥1 SpA feature (next column)


HLA-B27 positive


AND


≥2 other SpA features:


 Inflammatory back pain


 Arthritis


 Enthesitis


 Uveitis


 Dactylitis


 Psoriasis


 IBD


 NSAID response


 Family history of SpA


 HLA-B27


 Elevated CRP


≥1 SpA feature:


 Uveitis


 Psoriasis


 IBD


 Preceding infection


 HLA-B27


 Sacroiliitis on imaging


≥2 other SpA features:


 Arthritis


 Enthesitis


 Dactylitis


 Inflammatory back pain


 Family history of SpA




Patient History


The patient history is an important feature in the diagnosis of SpA. Classic historical features involve inflammatory back pain, enthesitis, peripheral arthritis, and dactylitis. The cornerstone for diagnosis of axial SpA is dependent on the patient reporting the presence of inflammatory back pain lasting longer than 3 months, which began in an individual before the age of 45 years old. Inflammatory back pain is defined as having an insidious onset, improving with exercise and not with rest, and oftentimes pain at night that improves upon getting up and moving. Peripheral SpA is based upon a history of oligoarticular arthritis, enthesitis, or dactylitis. There are other historical non-musculoskeletal features that are important to elucidate and include inflammatory eye symptoms (photophobia, blurred vision), inflammatory bowel symptoms (diarrhea, hematochezia), recent GI or GU infection, and psoriasis. As one hallmark of SpA is a favorable response to NSAIDs, it is useful to assess if the patient has tried these drugs and their effect on the presenting symptoms. Finally, family history of SpA, psoriasis, uveitis/iritis, or IBD should be assessed.


Physical Exam


On physical exam, it is important to evaluate for axial, peripheral, and non-musculoskeletal findings. Axial symptoms can be investigated by looking for low back pain associated with sacroiliac joint tenderness and decreased range of motion. There are multiple objective measurements that can be performed to monitor disease progression over time. These include the Schober’s test (measuring lumbar flexion distance at the level of L5), occiput-to-wall (measuring cervical neck extension), lateral spine side flexion, thoracic chest expansion, and hip internal rotation. Enthesitis is a hallmark of SpA, and there are multiple sites of ligament and tendon insertions that can be evaluated, but most commonly the Achilles tendon insertion of at the heel is assessed. There are multiple validated enthesitis indices from the Berlin Enthesitis Index (BEI), Masstricht AS Enthesitis Score (MASES), and Spondyloarthritis Research Consortium of Canada (SPARCC) that can be performed [12]. A full peripheral joint exam should be performed to assess for tenderness, effusions, warmth, and limitation of range of motion as well as evidence of dactylitis in the fingers or toes.


A full physical exam should additionally be conducted to evaluate for extra-articular manifestations. This should include a thorough skin evaluation to look for signs of psoriasis along extensor surfaces, behind ears, in the umbilicus, and within the crease of the buttocks; evaluation for signs of gastrointestinal or sexually transmitted diseases; and evaluation for SpA comorbidities such as cardiovascular and respiratory disease.


Lab Testing


There are no diagnostic labs for SpA. Common lab tests include HLA-B27 and acute phase reactants such as ESR or CRP, which may serve to support clinical suspicion. It is important to note that the absence of these does not rule out SpA. Additional tests may be ordered related to details of the history and physical exam, such as fecal calprotectin or sexually transmitted infection testing if considering IBD-associated SpA or reactive arthritis, respectively. All patients need to be assessed for blood cell counts, liver and kidney function, hepatitis and HIV screening, and TB screening depending upon their treatment plan.


Imaging


X-rays are the first-line imaging modality, which can demonstrate SI joint abnormalities ranging from blurring of the joint margins to evidence of sclerosis and erosions and ultimately with complete joint fusion. These images can also be obtained using the Ferguson view, entailing a 20-degree caudocephalic AP X-ray. The findings are usually bilateral in SpA, and unilateral findings should prompt one to consider alternative diagnoses. Spinal X-rays in AS can demonstrate vertebral body squaring, shiny corner sign (small erosions at the corners of the vertebral bodies), ossification of spinal ligaments/discs, enthesophytes, and progressive bamboo spine. Peripheral joint X-rays are more variable and may not always demonstrate abnormality. However, in PsA, X-rays in established disease often demonstrate erosive disease, particularly in the hands and feet in which the classic pencil-in-cup appearance of IP joints can be observed.


MRI can also be performed in the appropriate clinical setting, such as a high suspicion for axial SpA in the setting of normal X-rays but a suspicious clinical history. The most appropriate MRI sequences to identify SI joint inflammation are T1 and STIR. MRI findings will demonstrate synovial enhancement and increased STIR signal representing edema during acute inflammation and increased T1 signal representing bone marrow metaplasia suggesting past inflammation.


Imaging can also be useful for monitoring progression over time or to determine changes in therapy. For example, a patient with AS may complain of continued back pain while on therapy, and X-rays have not changed in the past several years. In this case an MRI can help determine if features of joint inflammation are present to warrant therapy changes.


Differential Diagnosis


Based upon the appropriate workup, an appropriate differential diagnosis must be considered that includes both inflammatory and noninflammatory disorders. Other disease processes to consider include the following: mechanical back pain, osteoarthritis, fibromyalgia, diffuse idiopathic skeletal hyperostosis (DISH), iliac condensans ilii, Paget’s disease, Brucellosis, Whipple’s disease, SI joint infection, gout, and osteochondrosis.


Treatment


The 2016 SPARTAN/GRAPPA recommendations for the management of axial SpA support use of physical therapy for all patients. NSAIDs are recommended as first-line therapy, followed by TNF-inhibitors and then alternate biologic agents [13]. Specific agents and uses are discussed below.


NSAIDs


The first line of therapy for all SpAs is scheduled high-dose NSAIDs. After the initial diagnosis of axial SpA, the treatment requires a minimum of two separate NSAIDs at maximum dosage for a total of 2–4 weeks each before escalation of therapy. Consideration must be taken with other comorbidities such as coronary artery disease and chronic kidney disease and the risk of long-term NSAID usage. NSAIDs have demonstrated an ASAS20 (20% partial response) rate of >70% and ASAS40 (40% partial response) rate of >50% in patients that start with an NSAID [14].


Conventional Synthetic DMARDs


Conventional synthetic DMARDs are generally ineffective in the setting of axial disease, but can be beneficial in peripheral joint symptoms. Sulfasalazine has demonstrated some efficacy in the setting of peripheral arthritis and decreased inflammatory markers, with no evidence for benefit in spinal mobility, patient/physician assessment, or enthesitis [15]. Methotrexate has been found to have similar lack of efficacy with regard to axial symptoms but also found to have lack of efficacy for peripheral joint symptoms in AS [16]. For PsA, though, the csDMARDs methotrexate, sulfasalazine, leflunomide, and cyclosporin all have demonstrated efficacy for arthritis and varying results for skin [17].


Biologic DMARDs


There are a number of biologic medications that have been FDA approved for SpA or are under investigation. Table 8.2 summarizes currently approved medications, targets, and indications. TNF-alpha inhibitors such as infliximab, etanercept, adalimumab, golimumab, and certolizumab are first-line biologic therapies and highly effective. The number needed to treat to achieve partial remission is between 2.3 and 6.5 [18]. Whether TNF-inhibitors halt radiographic progression remains a question; overall, they may not have a significant impact, but early (within 5 years of disease onset) and sustained use may reduce progression [19]. Etanercept has less clinical efficacy in the setting of GI symptoms and uveitis [20]. The most significant contraindications to TNF-inhibitor therapy include active infection (including latent or active tuberculosis), advanced heart failure, systemic lupus erythematosus, and multiple sclerosis.


Table 8.2

Currently approved biologic medications with target and indication

























































Drug


Target


Indication


Infliximab


TNF-alpha


PsA, AS, IBD associated SpA


Etanercept


TNF-alpha


PsA, AS


Adalimumab


TNF-alpha


PsA, AS, IBD-associated SpA, uveitis


Golimumab


TNF-alpha


PsA, AS


Certolizumab


TNF-alpha


PsA, AS, nr-SpA


Secukinumab


IL-17A


PsA, AS


Ixekizumab


IL-17A


PsA


Ustekinumab


IL-12 and IL-23 common subunit (p40)


PsA


Abatacept


T-cell co-stimulation


PsA


Apremilast


Phosphodiesterase-4


PsA


Tofacitinib


JAK kinase


PsA


Newer FDA-approved biologics target the Th17 pathway. The side effect profile of these agents is similar to TNF-inhibitors. There is some caution advised for use of IL-17 inhibitors in individuals with IBD as there is rare occurrence of developing IBD while on the drug and the phase II trial of secukinumab in Crohn’s disease demonstrated worsening of bowel inflammation [21].


Abatacept acts on T-cell costimulation and is currently approved for PsA. Abatacept prevents CD28 from binding to CD80/CD86. The side effect profile of abatacept is similar to TNF-alpha inhibitors.


Target-Specific DMARDs


Apremilast is a newly approved medication that is indicated for PsA. The mechanism of action involves inhibition of phosphodiesterase-4. Clinical efficacy has been shown in multiple clinical trials, and it is recommended not to be used in combination with other biologic medications.


Janus kinase (JAK) inhibitors are currently also being investigated for use in the treatment of SpA. Thus far tofacitinib has been approved for PsA with numerous others currently in the clinical trial phase. Clinical trials have shown tofacitinib to be comparable in efficacy to TNF-alpha inhibitors.


Other Treatments


Other important treatment modalities for patients with SpA include physical therapy (PT), intra-articular steroid injections, and possible surgical interventions to help with pain and quality of life. Physical therapy has a large role in the management of pain and physical function. Cochrane review data shows that an individual home based or supervised exercise program is better than no intervention, supervised PT is better than home exercise, and spa-exercise therapy with PT is better than PT alone [22]. Intra-articular injections can be beneficial in the management of isolated inflamed joints, including SI joints, and systemic steroids can have a role in peripheral disease (ineffective in axial disease). It is generally advised to avoid any type of surgery in axial SpA except for emergent situations due to risk of severe fracture.


Disease Monitoring


Regular follow-up is recommended to assess disease activity and determine whether a change in therapy is indicated. Clinically, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) can be utilized (Table 8.3) [23]. A thorough history and exam should be performed at each visit and imaging considered. The clinical measurements that are listed above in the examination section such as Schober’s test and occiput-to-wall measurements can be performed and help guide therapy. The combination of patient reported symptoms, physical exam findings (including measurements), lab data, and imaging can all help to guide therapy and decide whether or not an escalation or change in therapy is warranted.


Table 8.3

BASDAI score for AS disease severity [23]
































Answer the following questions on a scale from 1 (minimal) to 10 (severe) for activities during the past week


 1. How would you describe the overall level of fatigue/tiredness you have experienced?


 2. How would you describe the overall level of ankylosing spondylitis neck, back, or hip pain you have had?


 3. How would you describe the overall level of pain/swelling in joints other than neck, back, or hips you have had?


 4. How would you describe the overall level of discomfort you have had from any areas tender to touch or pressure?


 5. How would you describe the overall level of discomfort you have had from the time you wake up?


 6. How long does your morning stiffness last from the time you wake up? Scale from 0 to 2 hours


Scoring:


 1. Add up the scores from questions 1 to 4


 2. Add up the scores from questions 5 and 6, then divide by 2


 3. Add the results of parts 1 and 2 for a total BASDAI score


Interpretation:


Scores ≥4 indicate high disease activity and need for aggressive treatment


Comorbidities


There are a number of relevant comorbidities in patients that have SpA, including cardiovascular disease (CVD), obesity, diabetes, inflammatory bowel disease, ophthalmic disease, malignancy (lymphoma), restrictive lung disease, liver/kidney disease, and depression/anxiety. Cardiovascular disease has an incidence between 3.3% and 9.6% in patients with PsA [24], and a hazard ratio of 1.41 relative to matched controls in AS [25]. The rheumatologist should help manage cardiovascular risk in conjunction with the Primary Care Physician. EULAR recommendations for CVD management include optimally controlling rheumatologic risk and using NSAIDs with caution. Basic screening should be performed with regard to monitoring blood pressure, monitoring lipids, and counseling on smoking cessation. Other relevant screening should be performed such as monitoring for obesity with appropriate counseling, monitoring fasting blood glucose or hemoglobin A1C, monitoring liver and kidney labs, and monitoring for symptoms regarding eye or GI involvement of disease.


Prognosis


Overall outcomes are generally good for SpA if diagnosed and treated in an appropriate amount of time; however, up to 30% of patients with SpA will be on disability 20 years after diagnosis [26]. Earlier diagnoses usually manifest as undifferentiated SpA, which carries a 40% progression rate to diagnosed AS [27]. Patients with SpA are at high risk of bone fracture, and require close monitoring for bone health, as well as an ongoing need for physical and occupational therapy. Trauma is also a concern in these patients, as the higher rate of spinal fracture can lead to neurologic emergencies such as spinal cord impingement or cauda equina syndrome.


Questions





  1. 1.

    A 45-year-old man with known psoriasis and psoriatic arthritis presents to clinic with worsening skin plaques. Symptoms were previously well controlled on Etanercept. The patient reports abrupt worsening of plaques diffusely across his trunk, elbows, and knees.


    On examination, the patient has a temperature of 100.8 degrees Fahrenheit and is hemodynamically stable. Synovitis is noted diffusely throughout the bilateral PIPs, DIPs, wrists, knees, and ankles. Skin plaques are noted diffusely throughout the aforementioned areas.


Oct 24, 2020 | Posted by in RHEUMATOLOGY | Comments Off on Spondyloarthritis
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