ankylosing spondylitis and undifferentiated spondyloarthropathy

7/25/2019 Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy

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Ankylosing Spondylitis and UndifferentiatedSpondyloarthropathy

Author: Lawrence H Brent, MD; Chief Editor: Herbert S Diamond, MD more...

Overview

re!entation

DD"

#or$u%

&reatment

Medication'%dated: (an )*, )*+

ractice E!!entia-!

Bac$round

atho%h/!io-o/

Etio-o/

E%idemio-o/ rono!i!

atient Education

Show A--

Mu-timedia Librar/&ab-e!0eference!

ractice E!!entia-!

An$/-o!in !%ond/-iti! 1AS2, a !%ond/-oarthro%ath/, i! a chronic, mu-ti!/!tem inf-ammator/ di!orderinvo-vin %rimari-/ the !acroi-iac 1S32 4oint! and the a"ia- !$e-eton. &he outcome in %atient! with a

!%ond/-oarthro%ath/, inc-udin AS, i! enera--/ ood com%ared with that in %atient! with a di!ea!e!uch a! rheumatoid arthriti!. See the imae be-ow.

Antero%o!terior radiora%h of!acroi-iac 4oint of %atient with an$/-o!in !%ond/-iti!. Bi-atera- !acroi-iiti! with !c-ero!i! can be ob!erved.

'ndifferentiated !%ond/-oarthro%ath/ 1'S%A2 ma/ re%re!ent an ear-/ %ha!e or incom%-ete form of ASor another !%ond/-oarthro%ath/.

Signs and symptoms

Ankylosing spondylitis

5e/ com%onent! of the %atient hi!tor/ that !ue!t AS inc-ude the fo--owin:

3n!idiou! on!et of -ow bac$ %ain 6 &he mo!t common !/m%tom
http://emedicine.medscape.com/article/332945-overviewhttp://emedicine.medscape.com/article/332945-clinicalhttp://emedicine.medscape.com/article/332945-differentialhttp://emedicine.medscape.com/article/332945-workuphttp://emedicine.medscape.com/article/332945-treatmenthttp://emedicine.medscape.com/article/332945-medicationhttp://emedicine.medscape.com/article/332945-overview#a1http://emedicine.medscape.com/article/332945-overview#a2http://emedicine.medscape.com/article/332945-overview#a3http://emedicine.medscape.com/article/332945-overview#a4http://emedicine.medscape.com/article/332945-overview#a5http://emedicine.medscape.com/article/332945-overview#a6http://emedicine.medscape.com/article/332945-overview#a7http://emedicine.medscape.com/article/332945-overview#showallhttp://reftablelistshow%28%29/http://refimgshow%288%29/http://emedicine.medscape.com/article/332945-overviewhttp://emedicine.medscape.com/article/332945-clinicalhttp://emedicine.medscape.com/article/332945-differentialhttp://emedicine.medscape.com/article/332945-workuphttp://emedicine.medscape.com/article/332945-treatmenthttp://emedicine.medscape.com/article/332945-medicationhttp://emedicine.medscape.com/article/332945-overview#a1http://emedicine.medscape.com/article/332945-overview#a2http://emedicine.medscape.com/article/332945-overview#a3http://emedicine.medscape.com/article/332945-overview#a4http://emedicine.medscape.com/article/332945-overview#a5http://emedicine.medscape.com/article/332945-overview#a6http://emedicine.medscape.com/article/332945-overview#a7http://emedicine.medscape.com/article/332945-overview#showallhttp://reftablelistshow%28%29/


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Management

Pharmacologic therapy

Aent! u!ed in the treatment of AS inc-ude the fo--owin:

?on!teroida- anti6inf-ammator/ dru! 1?SA3D!2

Su-fa!a-aine &umor necro!i! factor6F 1&?


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&he diano!i! of AS i! enera--/ made b/ combinin c-inica- criteria of inf-ammator/ bac$ %ain andenthe!iti! or arthriti! with radio-oica- findin!. Ear-/ diano!i! i! im%ortant becau!e ear-/ medica-and %h/!ica- thera%/ ma/ im%rove functiona- outcome. A! with an/ chronic di!ea!e, %atienteducation i! vita- to fami-iarie the %atient with the !/m%tom!, cour!e, and treatment of the di!ea!e.&reatment mea!ure! inc-ude %harmaco-oic, %h/!ica- thera%/, and !urica-.

atho%h/!io-o/&he !%ond/-oarthro%athie! are chronic inf-ammator/ di!ea!e! that mo!t common-/ invo-ve the S34oint! and the a"ia- !$e-eton, with hi% and !hou-der 4oint! -e!! freuent-/ affected. eri%hera- 4oint!and enthe!e! and certain e"tra6articu-ar oran!, inc-udin the e/e!, !$in, and cardiova!cu-ar !/!tem,ma/ be invo-ved to a -e!!er deree.

&he %rimar/ %atho-o/ of the !%ond/-oarthro%athie! i! enthe!iti! with chronic inf-ammation, inc-udinCD7Jand CDJ& -/m%hoc/te! and macro%hae!. C/to$ine!, %articu-ar-/ tumor necro!i! factor6F1&?or -e!!. !A"#$%re!tricted CDJ1c/toto"ic2 & ce--! ma/ %-a/ an im%ortant ro-e in bacteria-6re-ated!%ond/-oarthro%athie! !uch a! reactive arthriti!. 987An e%i!tatic interaction between!A"#&'and !A"#$%increa!e! the ri!$ of deve-o%in AS.98=

&ab-e +. A!!ociation of S%ond/-oarthro%athie! #ith !A"#$%1O%en &ab-e in a new window2

Population or Disease Entity HLA-B27Positive

Healthy whites 8%

Healthy African Americans 4%

Ankylosing spondylitis (whites) 92%
http://www.emedicinehealth.com/pain_medications/article_em.htmhttp://emedicine.medscape.com/article/1264191-overviewhttp://emedicine.medscape.com/article/1264191-overviewhttp://emedicine.medscape.com/article/1264191-overviewhttp://emedicine.medscape.com/article/1263571-overviewhttp://emedicine.medscape.com/article/1263571-overviewhttp://emedicine.medscape.com/article/1264527-overviewhttp://reftableshow%28%27layertableta4b1d9195%27%29/http://www.emedicinehealth.com/pain_medications/article_em.htmhttp://emedicine.medscape.com/article/1264191-overviewhttp://emedicine.medscape.com/article/1264191-overviewhttp://emedicine.medscape.com/article/1263571-overviewhttp://emedicine.medscape.com/article/1264527-overviewhttp://reftableshow%28%27layertableta4b1d9195%27%29/


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Ankylosing spondylitis (African Americans) 50%

eacti!e arthritis "0#80%

$soriasis associated with spondylitis "0%

&' associated with spondylitis "0%

solated acte anterior !eitis 50%

ndifferentiated spondyloarthropathy 20#25%

&he !hared amino acid !euence between the antien6bindin reion of !evera-!A"#$%enot/%ic!ubt/%e!, e!%ecia--/ HLA6B)*=, and nitroena!e from(le)siella pneumoniae!u%%ort! mo-ecu-armimicr/ a! a %o!!ib-e mechani!m for the induction of !%ond/-oarthro%athie! in enetica--/!u!ce%tib-e ho!t! via an environmenta- !timu-u!, inc-udin bacteria in the 3 tract. 98 &he !%ecific! ofthi! re-ation!hi% remain unc-ear.

Severa- other ene! have been !tudied with re!%ect to their %otentia- invo-vement in the deve-o%mentof AS 1!ee &ab-e ) be-ow2.

&ab-e ). enetic! of An$/-o!in S%ond/-iti!1O%en &ab-e in a new window2

Genes Chromosome Location Gene Product/Function

Definitely associated

HLA-B27

IL-1gene clster

CYP 2D6

ARTS1(ERAP1)

IL23R

"p2*+,

2-*2+*

22-*,+2

5-*5

*p,*+*

Antigen presentation

.odlator of inflammation

.eta/olism of eno/iotics

1 aminopeptidase *

#2, receptor

Possibly associated

ANKH

HLA-DRB1

5p*5

"p2*+,

1ctopic minerali3ation

Antigen presentation

Not associated

TGF-, MMP3, IL-10, IL-6, Igallotypes TCR, TLR4, NOD2CARD1!, CD14, NFBIL1,PTPN22,etc .ltiple .ltiple

&he inter-eu$in 13L26+ ene c-u!ter i! an im%ortant -ocu! a!!ociated with !u!ce%tibi-it/ to AS. 98, 8 C*P

$+&i! wea$-/ a!!ociated with AS.

9)@

ARTS,i! a-!o a!!ociated with AS. &hi! ene encode! theendo%-a!mic reticu-um amino%e%tida!e, which c-eave! c/to$ine rece%tor! for 3L6, &?


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from the ce-- !urface and i! im%ortant in antien %re!entation b/ c-a!! + ma4or hi!tocom%atibi-it/com%-e" 1MHC2 mo-ecu-e!.98@, 8*, 8+

I!$-R, which encode! the rece%tor for 3L6)8, i! a-!o a!!ociated with AS.98@, 7*, 7+, 7), 8*, 8+ 3L6)8 %romote!!urviva- of &H+ CD7J& ce--!. &H+ ce--! %-a/ an im%ortant ro-e in inf-ammator/ re!%on!e! b/%roducin variou! %roinf-ammator/ c/to$ine! 1e, 3L6+, 3L6, and &? of the enera- %o%u-ation.
http://emedicine.medscape.com/article/211316-overviewhttp://emedicine.medscape.com/article/211316-overview


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Age-related demographics

&he ae of on!et of AS i! u!ua--/ from the -ate teen! to ae 7* /ear!. A%%ro"imate-/ +*>6)*> of a--%atient! e"%erience !/m%tom on!et before ae + /ear!; in !uch %atient!, the di!ea!e i! referred toa! 4uveni-e6on!et AS. On!et of AS in %er!on! o-der than =* /ear! i! unu!ua-, a-thouh diano!i! ofmi-d or a!/m%tomatic di!ea!e ma/ be made at a -ater ae. 9=+

&here i! often a !inificant de-a/ in diano!i!, u!ua--/ occurrin !evera- /ear! after the on!et ofinf-ammator/ rheumatic !/m%tom!. 3n a !tud/ of erman and Au!trian %atient! with AS, the ae ofon!et of di!ea!e !/m%tom! wa! )= /ear! in !A"#$%%o!itive and ) /ear! in !A"#$%neative%atient!, with a de-a/ in diano!i! of .= /ear! in !A"#$%%o!itive and ++.7 /ear! in !A"#$%neative %atient!.9=)

3n a !tud/ of &ur$i!h %atient! with AS, the ae of on!et of di!ea!e !/m%tom! wa! )8 /ear!, with ade-a/ in diano!i! of =.8 /ear! in !A"#$%%o!itive %atient! and @.) /ear! in !A"#$%neative%atient!.9=8 atient! with inf-ammator/ bac$ %ain or a %o!itive fami-/ hi!tor/ of AS had a !horterdiano!tic de-a/.

'S%A i! enera--/ found in /oun to midd-e6aed adu-t! but can deve-o% from -ate chi-dhood into thefifth decade of -ife.9=7

Sex-related demographicsAS, in enera-, i! diano!ed more freuent-/ in ma-e!; the ma-e6to6fema-e ratio i! 8:+.97, =+ However,fema-e! ma/ have mi-der or !ubc-inica- di!ea!e. &he ma-e6to6fema-e ratio for 'S%A i! +:8. 9=7

ace-related demographics

&he %reva-ence of AS %ara--e-! the %reva-ence of !A"#$%in the enera- %o%u-ation. &he %reva-enceof !A"#$%and AS i! hiher in white! and certain ?ative American! than in African American!,A!ian!, and other nonwhite ethnic rou%!.98), )@AS i! -ea!t %reva-ent in !ub6Saharan Africa. &he -e!!common 4uveni-e6on!et ver!ion of AS i! more common amon ?ative American!, Me"ican!, and%er!on! in deve-o%in countrie!.

'S%A i! not a!!ociated a! !tron-/ with !A"#$%2a-thouh it i! more %reva-ent in white! than innonwhite ethnic rou%!.9=7

rono!i!

&he outcome in %atient! with !%ond/-oarthro%athie!, inc-udin AS, i! enera--/ ood com%ared withthat in %atient! with a di!ea!e !uch a! rheumatoid arthriti!. atient! often reuire -on6term anti6inf-ammator/ thera%/. Morbidit/ can occur from !%ina- and %eri%hera- 4oint invo-vement or, rare-/,e"tra6articu-ar manife!tation!. oor %rono!tic indicator! inc-ude %eri%hera- 4oint invo-vement, /ounae of on!et, e-evated er/throc/te !edimentation rate 1ES02, and %oor re!%on!e to non!teroida- anti6inf-ammator/ dru! 1?SA3D!2.

At the on!et of the di!ea!e, !/m%tom! are enera--/ uni-atera- and intermittent. A! the di!ea!e%rore!!e!, %ain and !tiffne!! enera--/ become more !evere and more con!tant. Adeuate e"erci!ecan im%rove !/m%tom! and 0OM.

Some %atient! have few, if an/, !/m%tom!. A !inificant %ortion of AS %atient! deve-o% chronic%rore!!ive di!ea!e and deve-o% di!abi-it/ due to !%ina- inf-ammation -eadin to fu!ion, often withthoracic $/%ho!i! or ero!ive di!ea!e invo-vin %eri%hera- 4oint!, e!%ecia--/ the hi%! and !hou-der!.atient! with !%ina- fu!ion are %rone to !%ina- fracture! that ma/ re!u-t in neuro-oic deficit!. Mo!tfunctiona- -o!! in AS occur! durin the fir!t +* /ear! of i--ne!!. 9==

Severe %h/!ica- di!abi-it/ i! not common amon %atient! with AS. rob-em! with mobi-it/ occur ina%%ro"imate-/ 7> of %atient!. Di!abi-it/ i! re-ated to the duration of the di!ea!e, %eri%hera- arthriti!,cervica- !%ine invo-vement, /ouner ae at on!et of !/m%tom!, and coe"i!tin i--ne!!e!. Di!abi-it/ha! been demon!trated to im%rove with %ro-oned %eriod! of e"erci!e or !urica- correction of%eri%hera- 4oint and cervica- !%ine invo-vement.

Mo!t %atient! remain fu--/ functiona- and continue wor$in after the on!et of !/m%tom!. 9=, =, =, =@, *,+ Gocationa- coun!e-in ha! been demon!trated to decrea!e the ri!$ of em%-o/ment di!abi-it/ b/

more than *>.9)

A-thouh mo!t %atient! are ab-e to continue to wor$, a! man/ a! 8> chaneoccu%ation! to -e!! %h/!ica--/ demandin 4ob! a! !/m%tom! %rore!!.
http://emedicine.medscape.com/article/331715-overviewhttp://emedicine.medscape.com/article/331715-overview


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Chronic invo-vement of the !%ine eventua--/ can -ead to decrea!e! in 0OM and fu!ion of thevertebra- bodie!. 3nvo-vement of the cervica- and u%%er thoracic !%ine can -ead to fu!ion of the nec$in a !too%ed forward6f-e"ed %o!ition 1!ee the imae! be-ow2. &hi! %o!ition can !inificant-/ -imit the%atient! abi-it/ to ambu-ate and -oo$ !traiht ahead.

atient with an$/-o!in !%ond/-iti! affectin cervica- and u%%er thoracic!%ine. atientN! !%ine ha! been fu!ed in f-e"ed %o!ition.

o!terior view of %atient with an$/-o!in !%ond/-iti! affectincervica- and u%%er thoracic !%ine. atientN! !%ine ha! been fu!ed in f-e"ed %o!ition.

Articular manifestations


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Spine

Stiffne!! of the !%ine and $/%ho!i! re!u-tin in a !too%ed %o!ture are characteri!tic of advanced6!tae AS. Ear-ier in the cour!e of the di!ea!e, indirect evidence of !acroi-iiti! and !%ond/-iti! ma/ beob!erved, inc-udin tenderne!! of the S3 1e-icited b/ either direct %re!!ure or indirect com%re!!ion2 ora -imited !%ina- 0OM. Some %atient! ma/ have a deformit/ of the !%ine, mo!t common-/ with a -o!!of -umbar -ordo!i! and accentuated thoracic $/%ho!i!.

&he 0OM of the -umbar !%ine can be a!!e!!ed u!in variou! method!, of which the Schober te!t i!the mo!t %o%u-ar. 1&hi! te!t i! not !%ecific for AS.2

erform the Schober te!t b/ mar$in a +*6cm -enth of the -umbar !%ine 1with the %atient in the erect%o!ition2, !tartin at the fifth -umbar !%inou! %roce!!. 3n!truct the %atient to f-e" hi! or her !%inema"ima--/. 0emea!ure the di!tance between the mar$!. ?orma- f-e"ion increa!e! the di!tance b/ at-ea!t = cm. Lo!! of che!t e"%an!ion 1 86cm difference between minimum and ma"imum che!tdiameter2 i! u!ua--/ found on-/ in %atient! with -ate6!tae di!ea!e and i! enera--/ not he-%fu- indiano!i!.

Peripheral entheses and 7oints

eri%hera- enthe!iti! occur! in a%%ro"imate-/ 88> of %atient!. &he!e -e!ion! are %ainfu- and tender

u%on e"amination and ma/ be a!!ociated with !we--in of the tendon or -iament in!ertion.

&he mo!t common and characteri!tic %eri%hera- !ite! of enthe!iti! are the in!ertion of the Achi--e!tendon on the ca-caneu! and the in!ertion of the %-antar fa!cia on the ca-caneu!. Certain anatomicarea! ma/ be more %rone to enthe!iti! becau!e of biomechanica- !tre!!. Carefu--/ e"amine %atient!for tenderne!! u%on %a-%ation.

Enthe!iti! and !/noviti! account for !ome of the %eri%hera- 4oint invo-vement. eri%hera- 4oint di!ea!eoccur! in 88> of %atient!, mo!t common-/ in the hi%!. Hi% invo-vement u!ua--/ occur! in the fir!t +*/ear! of the di!ea!e cour!e and i! t/%ica--/ bi-atera-.

Other 4oint! ma/ be invo-ved, inc-udin the !hou-der ird-e 1-enohumera-, acromioc-avicu-ar, and!ternoc-avicu-ar 4oint!2, co!tovertebra- 4oint!, co!to!terna- 4unction!, manubrio!terna- 4oint!,!/m%h/!i! %ubi!, and tem%ora- mandibu-ar 4oint!. Additiona--/ %eri%hera- 4oint! are uncommon-/

invo-ved; when the/ are invo-ved it i! in an a!/mmetric o-ioarticu-ar %attern.

Dact/-iti! 1!au!ae diit2 i! ver/ uncommon in %atient! with AS. 3!o-ated !ma--64oint invo-vement ofthe hand!, feet, or dact/-iti! !tron-/ !ue!t! reactive arthriti! 10eA2, %!oriatic arthriti! 1!A2, orundifferentiated !%ond/-oarthro%ath/ 1'S%A2.

De!tructive arthriti! ma/ affect the hi%! or !hou-der ird-e, which ma/ re!u-t in -imited rane of motionand f-e"ion deformitie!.

Extra-articular manifestations

Screen for e"tra6articu-ar manife!tation! of AS b/ %erformin !%ecific e"amination! 1e,o%htha-mo-oic, cardiac, and a!trointe!tina-132 e"amination!2. Such manife!tation! ma/ inc-udethe fo--owin:

'veiti!

Cardiova!cu-ar di!ea!e

u-monar/ di!ea!e

0ena- di!ea!e

?euro-oic di!ea!e

3 di!ea!e

U8eitis

'veiti! 1a-!o ca--ed iriti! or iridoc/c-iti!2 i! the mo!t common e"tra6articu-ar manife!tation of AS,occurrin in )*68*> of %atient!.9*, + Of a-- %atient! with acute anterior uveiti!, 8*6=*> have or wi--deve-o% AS. &he incidence i! much hiher in individua-! who are !A"#$%%o!itive 176@*>2.atient! with uveiti! ma/ a-!o have or ma/ deve-o% other !%ond/-oarthro%athie!, inc-udin 0eA 1=6

+*>2, 'S%A 1)6=>2, and !A 1 +>2, a-thouh thi! i! -e!! common. 3!o-ated inf-ammator/ bowe-di!ea!e 13BD2 i! a-!o a!!ociated with uveiti!.


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&he uveiti! a!!ociated with AS i! u!ua--/ acute in %re!entation and uni-atera-, and !/m%tom! inc-udea %ainfu- red e/e with %hoto%hobia, increa!ed -acrimation, and b-urred vi!ion. &he invo-vement i!u!ua--/ anterior, rare-/ inc-udin %o!terior e-ement!. Attac$! u!ua--/ re!o-ve over )68 month! withtreatment, and re!idua- vi!ua- im%airment i! un-i$e-/ un-e!! treatment i! inadeuate or de-a/ed.0ecurrence! are common.

&he uveiti! that deve-o%! in 0eA i! !imi-ar to the uveiti! that deve-o%! in AS, wherea! the uveiti! that

deve-o%! in !A and in !%ond/-oarthro%ath/ a!!ociated with 3BD tend! to be more chronic andbi-atera- and often invo-ve! %o!terior e-ement!.

Cardio8ascular in8ol8ement

C-inica--/ !inificant cardiova!cu-ar invo-vement occur! in fewer than +*> of AS %atient!, t/%ica--/tho!e with !evere -on6!tandin di!ea!e. However, !ubc-inica- di!ea!e can be detected in man/%atient! and ma/ occur a! an i!o-ated c-inica- entit/ in a!!ociation with !A"#$%.

Aortiti! of the a!cendin aorta ma/ -ead to di!tortion of the aortic rin, re!u-tin in aortic va-vein!ufficienc/. Mitra- va-ve in!ufficienc/ rare-/ occur!. of %atient! with AS and 'S%A. atient! with e!tab-i!hed AS on-/ rare-/ deve-o% Crohndi!ea!eoru-cerative co-iti!.

Meta)olic )one disease

A-thouh AS i! a!!ociated with new bone formation at !ite! of !%ina- and %eri%hera- enthe!iti!,o!teo%enia and o!teo%oro!i!have been documented in %atient! with -on6!tandin !%ond/-iti!,re!u-tin in an increa!ed ri!$ of fracture. 0eeva-uate %atient! with AS who have !evere !%ond/-iti!and who %re!ent with acute e"acerbation! of bac$ or nec$ %ain for %o!!ib-e fracture, e!%ecia--/ in the!ettin of trauma. Standard radiora%h/ ma/ not be revea-in; com%uted tomora%h/ 1C&2 or M03ma/ be reuired to aid in diano!i!.

Heteroto%ic bone formation ma/ occur after tota- hi% re%-acement.

Ankylosing spondylitis in 9omen

Accordin to radiora%hic !urve/ !tudie!, %reva-ence rate! of AS are a%%ro"imate-/ eua- in menand women. C-inica- AS i! more common in men than in women, with a ma-e6to6fema-e ratio ofa%%ro"imate-/ 8:+. Studie! indicate that ma-e and fema-e AS %atient! !how !imi-ar c-inica-

manife!tation!, a-thouh men have more !evere radiora%hic chane! in the !%ine and hi%! thanwomen.9)
http://emedicine.medscape.com/article/239927-overviewhttp://emedicine.medscape.com/article/239927-overviewhttp://emedicine.medscape.com/article/172940-overviewhttp://emedicine.medscape.com/article/172940-overviewhttp://emedicine.medscape.com/article/183084-overviewhttp://emedicine.medscape.com/article/183084-overviewhttp://emedicine.medscape.com/article/330598-overviewhttp://emedicine.medscape.com/article/239927-overviewhttp://emedicine.medscape.com/article/239927-overviewhttp://emedicine.medscape.com/article/172940-overviewhttp://emedicine.medscape.com/article/172940-overviewhttp://emedicine.medscape.com/article/183084-overviewhttp://emedicine.medscape.com/article/330598-overview


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:u8enile ankylosing spondylitis

(uveni-e AS i! c-inica--/ !imi-ar to adu-t AS.98, 7 3n a%%ro"imate-/ +*6)*> of a-- ca!e!, !/m%tom on!etoccur! before ae + /ear!. &he ma-e6to6fema-e ratio of 8:+ i! !imi-ar to that of adu-t!.

Enthe!iti! i! %rominent ear-/ in the cour!e of the di!ea!e, whi-e !%ina- !/m%tom! and -imitation ofmotion ma/ not be %re!ent unti- !evera- /ear! -ater. eri%hera- arthriti!, e!%ecia--/ in the -ower

e"tremitie!, and dact/-iti! are more common in chi-dren than in adu-t!. S/!temic manife!tation! 1e,fever, weiht -o!!, anemia, -eu$oc/to!i!2 occur at di!ea!e on!et in chi-dren more freuent-/ than inadu-t!.

3nitia- radiora%h/ findin! of the !acroi-iac reion! and !%ine are often norma- or difficu-t to inter%retin chi-dren. &he!e factor! ma$e a definitive diano!i! of AS difficu-t in chi-dren. 3n !uch ca!e!, the%re!ence of !A"#$%wou-d be !u%%ortive of the diano!i! of a !%ond/-oarthro%ath/.

Some chi-dren e"hibit a !/ndrome of !eroneativit/, enthe!o%ath/, and arthro%ath/ 1SEA2 that i!c-inica--/ !imi-ar to 'S%A. &he!e chi-dren often deve-o% AS over time, with t/%ica- radiora%hicchane!, u!ua--/ b/ ear-/ adu-thood. A variant, an$/-o!in tar!iti!, i! de!cribed in chi-dren who%re!ent with enthe!iti! in the tar!a- reion. &hi! can -ead to o!!ification, which re!u-t! in acharacteri!tic radiora%hic a%%earance. #hen tar!a- inf-ammation i! %art of the c-inica- %icture in achi-d or adu-t, !tron-/ con!ider one of the !%ond/-oarthro%athie!.

Undifferentiated spondyloarthropathy

'S%A ha! feature! con!i!tent with the !%ond/-oarthro%athie!, but affected %atient! do not fu-fi--criteria for an/ !%ecific !%ond/-oarthro%ath/.9=, =

'S%A ma/ re%re!ent an ear-/ %ha!e or incom%-ete form of AS or another !%ond/-oarthro%ath/. 3nfact, !evera- !tudie! of 'S%A inc-uded man/ %atient! who %robab-/ !hou-d have been diano!ed withAS, 0eA, or 3BD6a!!ociated !%ond/-oarthro%ath/, which made the c-inica- de!cri%tion ver/ambiuou!. However, !ub!euent data !ue!t that the!e %atient! ma/ re%re!ent a di!tinct di!ea!eentit/ on the ba!i! of demora%hic and c-inica- criteria.

A-thouh no !%ecific criteria are identified, u!in modified Amor criteria can be he-%fu- in confirmin ac-inica- diano!i! of 'S%A 1!ee &ab-e 8 be-ow2.9=7, , =

&ab-e 8. Diano!tic Criteria for 'ndifferentiated S%ond/-oarthro%ath/ '!in Modified AmorCriteria1O%en &ab-e in a new window2

Inclusion Criteria Eclusion Criteria

nflammatory /ack pain * point 'iagnosis of specific spondyloarthropathy

nilateral /ttock pain * point acroiliitis on radiograph 6 grade 2

Alternating /ttock pain 2 points $recipitating genitorinary7gastrointestinal infection

1nthesitis 2 points $soriasis

$eripheral arthritis 2 points eratoderma /lennorrhagicm

'actylitis (sasage digit) 2 points nflammatory /owel disease (rohn disease or lcerati!e colitis)

Acte anterior !eitis 2 points $ositi!e rhematoid factor

HLA-B27:positi!e or family history of spondyloarthropathy 2 points $ositi!e antinclear anti/ody titer ; * of %atient!, and inc-ude acute anterior uveiti! 1+6)>2, ora- u-cer!, ra!h, non!%ecific 3BD,

%-euriti!, and %ericarditi!.
http://reftableshow%28%27layertabletbf149ad99%27%29/http://reftableshow%28%27layertabletbf149ad99%27%29/


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&ab-e 7. C-inica- and Laborator/


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&he mo!t !eriou! com%-ication re-ated to AS i! a vertebra- fracture. Gertebra- fracture! a!!ociatedwith AS are mo!t common in the cervica- !%ine and are u!ua--/ the re!u-t of a minor fa--. in %atient! with AS. 9, &he %reva-ence in a!/m%tomatic%atient! i! un$nown.

&he etio-o/ of !%ond/-odi!citi! i! debatab-e. Some author! arue that the!e -e!ion! are the re!u-t ofmechanica- factor!, wherea! other! be-ieve that the inf-ammation cau!ed b/ AS i! the !ource. Eachof the!e %o!!ib-e etio-oie! i! -i$e-/ ca%ab-e of %roducin !imi-ar -e!ion!.

S%ond/-odi!citi! can occur at an/ time, reard-e!! of the !everit/ of AS. atient! enera--/ %re!entwith acute6on!et -oca-ied %ain. ain i! e"acerbated with movement and i! a--eviated with re!t. &he!e!/m%tom! can be ea!i-/ differentiated from the norma- %ain %attern of AS, which i! in!idiou! in on!et

and re-ieved with motion.

0adio-oic evidence of !%ond/-odi!citi! varie! with the di!ea!e %rore!!ion but can inc-udede!tructive foci throuhout the di!$overtebra- 4unction, bon/ !c-ero!i! on both !ide! of the affecteddi!c -eve-, widenin or narrowin of the di!c !%ace, and o!teo-/!i! of the vertebra- bodie!. 9, @ -ainradiora%h! are not a-wa/! !ufficient to identif/ !%ond/-odi!citi!. C& !can!, M03, and bone !can! areoften he-%fu- in confirmin the diano!i!.

&he %rono!i! i! enera--/ ood with con!ervative thera%/, inc-udin re!t, admini!tration of ?SA3D!,and %h/!ica- thera%/. Surica- treatment i! indicated on-/ in ca!e! where there i! evidence of !%ina-in!tabi-it/ or neuro-oic in4ur/.

Diano!tic Con!ideration!

&he diano!i! of an$/-o!in !%ond/-iti! 1AS2 i! enera--/ made b/ combinin c-inica- criteria ofinf-ammator/ bac$ %ain and enthe!iti! or arthriti! with radio-oic findin!. 97, =, &wo !et! of !en!itiveand !%ecific criteria are avai-ab-e for diano!i! of !%ond/-oarthro%ath/ in enera-: 1+2 the Euro%eanS%ond/-oarthro%ath/ Stud/ rou% 1ESS2 criteria and 1)2 the Amor criteria 1!ee &ab-e = be-ow2. &woother !et! are u!ed wide-/ for diano!i! of AS: the ?ew or$ criteria and the 0ome criteria 1!ee &ab-e be-ow2.

&ab-e =. ESS and Amor Criteria for Diano!i! of S%ond/-oarthro%ath/1O%en &ab-e in a newwindow2

E%%G Criteria &mor Criteria'

nflammatory spinal pain or syno!itis and one of the following< nflammatory /ack pain * point

Alternating /ttock pain nilateral /ttock pain * point

1nthesitis Alternating /ttock pain 2 points

acroiliitis 1nthesitis 2 points
http://reftableshow%28%27layertablet79ad3e001%27%29/http://reftableshow%28%27layertablet79ad3e001%27%29/http://reftableshow%28%27layertablet79ad3e001%27%29/http://reftableshow%28%27layertablet79ad3e001%27%29/


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&' $eripheral arthritis 2 points

$ositi!e family history of spondyloarthropathy 'actylitis (sasage digit) 2 points

Acte anterior !eitis 2 points

HLA-B27:positi!e or family history of spondyloarthropathy 2 points

=ood response to @A's 2 points

'iagnosis of spondyloarthropathy with " or more points+

1ropean pondyloarthropathy tdy =rop (1=)B &' 6 inflammatory /owel diseaseB @A' 6 nonsteroidal anti#inflammatory drg+

&ab-e . ?ew or$ and 0ome Criteria for Diano!i! of An$/-o!in S%ond/-iti!1O%en &ab-e in a newwindow2

Ne" (or) Criteria *ome Criteria

ow /ack pain with inflammatory characteristics

imitation of lm/ar spine motion in sagittal and frontal

planes

'ecreased chest epansion

&ilateral sacroiliitis grade 2 or higher

nilateral sacroiliitis grade , or higher

ow /ack pain and stiffness for ;, months that is not relie!ed

/y rest

$ain and stiffness in the thoracic region

imited motion in the lm/ar spine

imited chest epansion

History of !eitis

'efinite ankylosing spondylitis when the forth or fifth criterion

mentioned presents with any clinical criteria

'iagnosis of ankylosing spondylitis when any clinical criteria present with

/ilateral sacroiliitis grade 2 or higher

&he ?ew or$ criteria for the diano!i! of AS, which are ba!ed on c-inica- and radiora%hic findin!,inc-ude the fo--owin:

Limitation of motion of the -umbar !%ine in a-- 8 %-ane!

Hi!tor/ of %ain or %re!ence of %ain at the thoraco-umbar 4unction or in the -umbar !%ine

Limitation of che!t e"%an!ion to + inch or -e!!, a! mea!ured at the fourth interco!ta- !%ace

0adiora%hic !acroi-iac 1S32 chane! are raded a! fo--ow!:

rade * ?orma-

rade + Su!%iciou!

rade ) Minima- !acroi-iiti!

rade 8 Moderate !acroi-iiti!

rade 7 An$/-o!i!

&he di!ea!e %rore!!ion i! a radua- %roce!!, and the radin i! !omewhat !ub4ective.

A definite diano!i! of AS i! met if there i! 1+2 rade 867 bi-atera- !acroi-iiti! with at -ea!t + c-inica-criterion or 1)2 rade 867 uni-atera- !acroi-iiti! or rade ) bi-atera- !acroi-iiti! with c-inica- criterion + orwith both c-inica- criteria ) and 8. A %robab-e diano!i! of AS i! made if rade 867 bi-atera- !acroi-iiti!e"i!t! without an/ !in! or !/m%tom! that !ati!f/ the c-inica- criteria.

3n addition to the condition! -i!ted in the differentia- diano!i!, the fo--owin %rob-em! !hou-d becon!idered:

3nf-ammator/ bowe- di!ea!e 13BD2a!!ociated !%ond/-oarthro%ath/ 1S%A2

(uveni-e idio%athic arthriti!

Diffu!e idio%athic !$e-eta- h/%ero!to!i!

C-a!!ification of a"ia- and %eri%hera- !%ond/-oarthro%ath/

&he A!!e!!ment of S%ond/-oArthriti! 3nternationa- Societ/ 1ASAS2 ha! deve-o%ed criteria for thec-a!!ification of a"ia- and %eri%hera- S%A. &he!e criteria incor%orate the emerin conce%t ofnonradiora%hic a"ia- S%A, which refer! to %atient! who have !in! and !/m%tom! of a"ia- di!ea!ebut -ac$ the radiora%hic damae to the !acroi-iac 4oint! needed to meet the modified ?ew or$criteria.9* Some, but not a--, of the!e ca!e! wi-- %rore!! to AS over time.

A;ial spondyloarthropathy
http://reftableshow%28%27layertableted6bda390%27%29/http://reftableshow%28%27layertableted6bda390%27%29/http://reftableshow%28%27layertableted6bda390%27%29/http://reftableshow%28%27layertableted6bda390%27%29/


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ASAS c-a!!ification criteria for a"ia- S%A are a! fo--ow!9* :

Bac$ %ain for 8 month! or -oner

Ae at on!et 7= /ear!

Sacroi-iiti! on imain 1radiora%h! or M032 %-u! one or more S%A feature! or

!A"#$%%-u! two or more other S%A feature!

S%A feature! are a! fo--ow!:

3nf-ammator/ bac$ %ain

Arthriti!

Enthe!iti! 1head2

'veiti!

Dact/-iti!

!oria!i!

Crohn di!ea!e

ood re!%on!e to ?SA3D!


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3main in Diffu!e 3dio%athic S$e-eta- H/%ero!to!i! 1D3SH2

5/%ho!i!

Lower Cervica- S%ine


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A-$a-ine %ho!%hata!e 1AL2 i! e-evated in =*> of %atient!; thi! indicate! active o!!ification

but doe! not corre-ate with di!ea!e activit/. Creatine $ina!e 1C52 i! occa!iona--/ e-evatedbut i! not a!!ociated with mu!c-e wea$ne!!. &he !erum immuno-obu-in A 13A2 -eve- ma/be e-evated, corre-atin with e-evated acute6%ha!e reactant!.

?inet/6two %ercent of white %atient! with AS are !A"#$%%o!itive; the %ercentae i! -ower

in %atient! of other ethnic bac$round!. Determinin !A"#$%!tatu! i! not a nece!!ar/ %art

of the c-inica- eva-uation and i! not reuired to e!tab-i!h the diano!i!. However, in %atient!!u!%ected of havin a !%ond/-oarthro%ath/, determinin !A"#$%!tatu! ma/ he-% !u%%ortthe diano!i!, e!%ecia--/ in %o%u-ation! with a -ow %reva-ence of !A"#$%.

0adiora%h/ 0adiora%hic evidence of inf-ammator/ chane! both in the !acroi-iac 1S32 4oint! and in the

!%ine are u!efu- in the diano!i! and onoin eva-uation of the di!ea!e %roce!!. 9 &hi!di!ea!e enera--/ bein! in the di!ta- %ortion! of the !%ine and %rore!!e! more %ro"ima--/with time in a continuou! fa!hion.

3nvo-vement of the S3 4oint i! a reuirement for the diano!i! of AS. Sacroi-iiti! i! a bi-atera-

inf-ammator/ condition -eadin to bon/ ero!ion! and !c-ero!i! of the 4oint! 1!ee the imaebe-ow2.

Antero%o!terior radiora%h

of !acroi-iac 4oint of %atient with an$/-o!in !%ond/-iti!. Bi-atera- !acroi-iiti! with !c-ero!i! can beob!erved.

&he !acroi-iiti! !een in AS i! u!ua--/ bi-atera-, !/mmetric, and radua--/ %rore!!ive over

/ear!. &he -e!ion! %rore!! from b-urrin of the !ubchondra- bone %-ate to irreu-ar ero!ion!of the marin! of the S3 4oint! 1%!eudowidenin2 to !c-ero!i!, narrowin, and fina--/ fu!ion.Ero!ion! of the !ubchondra- bone of the S3 4oint are enera--/ !een ear-ier in the -ower%ortion of the 4oint 1becau!e thi! %ortion i! -ined b/ !/novium2 and on the i-iac !ide 1becau!eof the thinner carti-ae coverin thi! !ide of the 4oint2.

&he radiora%hic !in! of AS are due to enthe!iti!, %articu-ar-/ of the anu-u! fibro!u!. Ear-/

radiora%hic !in! inc-ude !uarin of the vertebra- bodie! cau!ed b/ ero!ion! of the!u%erior and inferior marin! of the!e bodie!, re!u-tin in -o!! of the norma- concavecontour of the anterior !urface of the vertebra- bodie! 1!ee the imae! be-ow2. &heinf-ammator/ -e!ion! at vertebra- enthe!e! ma/ re!u-t in !c-ero!i! of the !u%erior and inferior

marin! of the vertebra- bodie!, ca--ed !hin/ corner! 10omanu! -e!ion2.
http://refimgshow%288%29/


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Antero%o!terior radiora%h of !%ine of %atient with an$/-o!in !%ond/-iti!.

O!!ification of anu-u! fibro!u! at mu-ti%-e -eve-! and !uarin of vertebra- bodie! can be ob!erved.

Antero%o!terior radiora%h of !%ine of %atient with

an$/-o!in !%ond/-iti!.
http://refimgshow%2811%29/http://refimgshow%2810%29/


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&hi! radiora%h of the -umbar !%ine of a %atient with

end6!tae an$/-o!in !%ond/-iti! !how! bridin !/nde!mo%h/te!, re!u-tin in bamboo !%ine.

&hi! radiora%h of the cervica- !%ine of a %atient with

an$/-o!in !%ond/-iti! !how! fu!ion of vertebra- bodie! due to bridin !/nde!mo%h/te!. S%ina- di!ea!e a!!ociated with inf-ammator/ bowe- di!ea!e 13BD2 i! !imi-ar to AS with

bi-atera- !/mmetric !acroi-iiti! and radua--/ a!cendin !%ond/-iti! and marina-!/nde!mo%h/te!. On the other hand, reactive arthriti! 10eA2 and %!oriatic arthriti! 1!A2t/%ica--/ e"hibit a!/mmetric !acroi-iiti! and di!continuou! !%ond/-iti! with nonmarina-!/nde!mo%h/te!.

0adiora%h! of other area! ma/ !how evidence of enthe!iti! with o!teiti! or arthro%ath/.

0adiora%h! of the %e-vi! ma/ !how o!!if ication of variou! enthe!e!, !uch a! the i-iac cre!t,i!chia- tubero!it/, and femora- trochanter, which i! termed whi!$erin. Occa!iona--/, the!/m%h/!i! %ubi! deve-o%! ero!ive chane! 1o!teiti! %ubi!2.


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eri%hera- enthe!e! ma/ deve-o% radiora%hic chane!, inc-udin ero!ion, %erio!tea- new

bone formation, and fina--/, o!!ification, e!%ecia--/ in the feet at the in!ertion of the Achi--e!tendon and the %-antar fa!cia on the ca-caneu!.

eri%hera- 4oint invo-vement i! mo!t common in the hi%! and !hou-der! and ma/ re!u-t in

uniform 4oint !%ace narrowin, c/!tic or ero!ive chane!, deformation, and !ubchondra-!c-ero!i! without o!teo%enia 1!ee the imae be-ow2. Heteroto%ic bone formation ma/ occur

after tota- 4oint re%-acement, e!%ecia--/ in the hi%. '-timate-/, %eri%hera- 4oint! ma/ underoan$/-o!i!. See the radiora%h! be-ow for an e"am%-e.

0adiora%h! of hand 1to%2 and arm 1bottom2 of %atientwith %eri%hera- invo-vement of an$/-o!in !%ond/-iti!. 2, a fracture wa! not identified on %-ain radiora%h!. 9 On-/ = %atient!1+=.>2 %re!ented immediate-/ after the in4ur/. Of the += %atient! 17.@>2 who were initia--/neuro-oica--/ intact, 8 %atient! had neuro-oic deterioration before admi!!ion. Ear-/diano!i! with a%%ro%riate radio-oic inve!tiation! ma/ %revent %o!!ib-e -on6termneuro-oic cord damae.

atient! with a hi!tor/ of AS who re%ort an/ recent trauma or an increa!ed -eve- of bac$ or

nec$ %ain !hou-d be fu--/ eva-uated for the %o!!ibi-it/ of a vertebra- fractureand !ub!euent!%ina- in!tabi-it/ 1!ee the imae be-ow2.
http://www.medscape.com/resource/fracturehttp://refimgshow%2813%29/http://www.medscape.com/resource/fracture


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0adiora%h !how! vertebra- fracture in %atient with

an$/-o!in !%ond/-iti!. M03 and C& M03 or C& !cannin of the S3 4oint!, !%ine, and %eri%hera- 4oint! ma/ revea- evidence of

ear-/ !acroi-iiti!, ero!ion!, and enthe!iti! that are not a%%arent on !tandard radiora%h!. 9@,+* M03 u!in fat6!aturatin techniue! !uch a! !hort tau inver!ion recover/ 1S&302 or M03with ado-inium i! !en!itive for inf-ammator/ -e!ion! of enthe!iti!.9, &he !o6ca--ed M0corner !in, characteried b/ inf-ammator/ -e!ion! at the corner! of vertebra- bodie!, wa!

common in the thoraco-umbar reion of the !%ine in %atient! with AS.9@ 3nve!tiation! of %atient! with AS u!in !eria- M03 over time ha! !hown a -in$ between

inf-ammator/ -e!ion! and the -ater deve-o%ment of !/nde!mo%h/te!. 9@*M03 can be u!ed a!an ad4unct to eva-uate the inf-ammator/ chane! and to a!!e!! neura- com%romi!e 1!ee theimae be-ow2. However, M03 and C& are not %art of the routine eva-uation of AS %atient!,becau!e of their re-ative-/ hih co!t.
http://refimgshow%2815%29/


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Saitta- M03 of thoraco-umbar !%ine of a %atient with an$/-o!in

!%ond/-iti!. Deenerative di!c di!ea!e and bridin o!teo%h/te! can be ob!erved at mu-ti%-e -eve-!. atient! with a fu!ed !%ine are %rone to fracture!, which ma/ be hard to diano!e with

!tandard radiora%h/. C& !cannin or M03 ma/ be reuired to document the %re!ence of afracture in %atient! with -ate6!tae !%ina- di!ea!e 1!ee the imae! be-ow2.

&hi! +=6/ear6o-d fema-e

%atient %re!ented with recent on!et of riht6!ided -ow bac$ %ain. -ain radiora%h/ findin! werenorma-.


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M03 of the !ame %atient

who!e radiora%h/ findin! were norma- 1%reviou! imae2. She underwent further eva-uation, inc-udinM03. &he M03 1!hort tau inver!ion recover/ 9S&302 !howed increa!ed !ina- inten!it/ in the riht!acroi-iac 4oint, revea-in !acroi-iiti!. Other -aborator/ !tud/ findin! were e!!entia--/ norma-. &he%atient wa! !tarted on indomethacin and ra%id-/ im%roved.

atient! who deve-o% bowe- or b-adder d/!function !hou-d be eva-uated immediate-/ with

M03 to a!!e!! for %o!!ib-e cauda euina !/ndrome !econdar/ to !%ina- !teno!i!. &he%re!ence of cauda euina !/ndrome i! a !urica- emerenc/ nece!!itatin decom%re!!ionwithin 7 hour! to %revent %ermanent -o!! of function.

Hi!to-oic


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Out%atient care !hou-d be aimed toward %rovidin adeuate %ain contro- and ma"imiin motion andfunctiona- abi-it/. Such care inc-ude! %ain medication, e"erci!e %roram!, recreationa- thera%/, andvocationa- thera%/. 0eu-ar e"erci!e he-%! reduce the !/m%tom! and ma/ !-ow the %rore!! of thedi!ea!e. enera--/, no dietar/ re!triction! are im%-emented for %atient! with AS; however, %atient!with coe"i!tin di!ea!e!, !uch a!inf-ammator/ bowe- di!ea!e13BD2, have dietar/ re!triction!.

harmaco-oic &hera%/%onsteroidal anti-inflammatory drugs

?on!teroida- anti6inf-ammator/ dru! 1?SA3D!2 im%rove the !/m%tom! of the di!ea!e b/ reducin%ain and decrea!in inf-ammation. ?umerou! choice! are avai-ab-e, and the/ are !e%arated intodifferent fami-ie! of aent!.9@7 3f one ?SA3D i! ineffective, another from a different fami-/ can often%rovide re-ief.

Efficac/ and adver!e effect %rofi-e! differ amon aent! and fami-ie!. 3ndomethacin ma/ be moreeffective than other ?SA3D!, a-thouh thi! %otentia- advantae ha! not been %roved. Sa-ic/-ate!!e-dom ive adeuate re-ief. C/c-oo"/ena!e6) 1COT6)2 inhibitor! a%%ear to be a! effective a!non!e-ective ?SA3D!.9@=

Sie%er et a-, in a randomied, doub-e6b-ind, contro--ed !tud/ com%arin two do!ae! of ce-eco"ib

1)** m once dai-/ and )** m twice dai-/2 to dic-ofenac 1= m twice dai-/2, noted that bothdo!ae! of ce-eco"ib were com%arab-e to the dic-ofenac do!ae with re!%ect to -oba- %ain inten!it/.9@ However, with re!%ect to chane! in di!ea!e activit/, functiona- and mobi-it/ ca%acitie!, andadver!e event!, once6dai-/ ce-eco"ib wa! not a! effective in reducin certain inf-ammation6a!!ociated %arameter! a! twice6dai-/ ce-eco"ib and dic-ofenac were.

ive ?SA3D! in fu-- anti6inf-ammator/ do!e!. Continuou! treatment with ?SA3D! a%%ear! to reduceradiora%hic %rore!!ion in AS. 9@= Common to"icitie! invo-ve the a!trointe!tina- 132 tract 1nau!ea,d/!%e%!ia, u-ceration, b-eedin2, the $idne/!, and the centra- nervou! !/!tem 1C?S2.

Sulfasala&ine

Su-fa!a-aine i! u!efu- in AS %atient! who do not re!%ond to or who have contraindication! to?SA3D!, a! we-- a! in tho!e with coe"i!tin 3BD. 3n %articu-ar, it i! often iven to treat %eri%hera- 4ointinvo-vement, for which it ha! demon!trated efficac/. Su-fa!a-aine reduce! !%ina- !tiffne!!, %eri%hera-arthriti!, and the er/throc/te !edimentation rate 1ES02, but there i! no evidence that it im%rove!!%ina- mobi-it/, enthe!iti!, or %h/!ica- function. 9@, @, @@ 3n a randomied, doub-e6b-ind !tud/, treatmentwith !u-fa!a-aine re!u-ted in !inificant-/ -e!!er im%rovement when com%ared to treatment with the&?< inhibitor etanerce%t.9+**Su-fa!a-aine to"icitie! inc-ude ra!h, nau!ea, diarrhea, andaranu-oc/to!i! 1rare-/2.

'%$-( antagonists

&?< i! a c/to$ine with two identified form!, which have !imi-ar bio-oic %ro%ertie!. &?


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&o"icitie! a!!ociated with &?


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Lef-unomide wa! eva-uated in a randomied, doub-e6b-ind, %-acebo6contro--ed !tud/ in active AS butwa! not found to be effective.9++ Bi!%ho!%honate! ma/ mode!t-/ affect c-inica- di!ea!e activit/ in AS.Ana$inra, a recombinant human 3L6+ rece%tor antaoni!t, ma/ be effective in treatment6re!i!tant AS.

uide-ine6directed &hera%/

uide-ine! on treatment for an$/-o!in !%ond/-iti! and nonradiora%hic a"ia- !%ond/-oarthriti! have

been i!!ued b/ the American Co--ee of 0heumato-o/.9+)7

In adults 9ith acti8e ankylosing spondylitis

Stron-/ recommend treatment with non!teroida- anti6inf-ammator/ dru! 1?SA3D!2 over no

treatment with ?SA3D!.

Conditiona--/ recommend continuou! treatment with ?SA3D! over on6demand treatment with

?SA3D!.

?o recommendation for an/ %articu-ar ?SA3D a! the %referred choice.

Stron-/ recommend aain!t treatment with !/!temic -ucocorticoid!.

In adults 9ith acti8e AS despite treatment 9ith .SAI+s>

Conditiona--/ recommend aain!t treatment with !-ow6actin antirheumatic dru! 1SAA0D!2.

Stron-/ recommend treatment with a tumor necro!i! factor inhibitor 1&?


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Laborator/ va-ue!, inc-udin the ES0 and the C6reactive %rotein 1C02 -eve-, are common-/em%-o/ed to monitor the %rore!!ion of the di!ea!e and the effectivene!! of treatment. uide-ine!from the Euro%ean Leaue Aain!t 0heumati!m 1E'LA02 recommend that conventiona- radiora%h/of the !acroi-iac 1S32 4oint!, !%ine, or both ma/ be u!ed for -on6term monitorin of !tructura- damae,%articu-ar-/ new bone formation. 3f %erformed, it !hou-d not be re%eated more freuent-/ than ever/!econd /ear.98

M03 ma/ %rovide additiona- information. M03 of the S3 4oint! andVor the !%ine ma/ be u!ed to a!!e!!and monitor di!ea!e activit/ in a"ia- !%ond/-oarthro%ath/. 3n enera-, !hort tau inver!ion recover/1S&302 !euence! are !ufficient to detect inf-ammation, and the u!e of contra!t medium i! notneeded.98

3n addition, numerou! too-! have been deve-o%ed to mea!ure AS di!ea!e activit/, e!%ecia--/ in the!ettin of c-inica- tria-!.9++@, +)*, +)+ &he!e too-! inc-ude the fo--owin:

Bath An$/-o!in S%ond/-iti! Di!ea!e Activit/ 3nde" 1BASDA32 6 &hi! i! a ue!tionnaire that

a!!e!!e! fatiue, %ain 1in the nec$, bac$, and hi%2, %eri%hera- 4oint %ain and !we--in, di!comfort,and !everit/ and duration of mornin !tiffne!!

Bath An$/-o!in S%ond/-iti!


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atient! with !inificant invo-vement of the hi%! ma/ benefit from tota- hi% arthro%-a!t/ 9+) ;occa!iona--/, tota- !hou-der re%-acement ma/ be indicated. &he!e %rocedure! ma/ be ver/ u!efu- forreducin %ain and im%rovin function when the hi% and !hou-der 4oint! become !evere-/ damaed.

Heteroto%ic bone formation ma/ occur after tota- 4oint re%-acement, e!%ecia--/ around the hi%.Heteroto%ic bone formation can be reduced b/ ivin ?SA3D! 1e, indomethacin2 or em%-o/inradiation thera%/ %o!to%erative-/. 3n enera-, outcome! of tota- 4oint re%-acement in %atient! have

been !ati!factor/.

h/!ica- &hera%/ and E"erci!e

h/!ica- thera%/ i! im%ortant for maintainin function. 9+)), +)8A %ro%er e"erci!e %roram i! a crucia-com%onent of !uch thera%/. atient! obtain a !inificant reduction in !/m%tom! after e"erci!in.0eferra- to %h/!ica- thera%/ or to a rehabi-itation !%ecia-i!t i! u!efu- in a!!i!tin %atient! to deve-o%an a%%ro%riate e"erci!e %roram. #ater thera%/ and !wimmin are e"ce--ent activitie! formaintainin mobi-it/ and fitne!!.

o!tura- trainin i! a-!o u!efu-. S%ina- e"ten!ion and dee%6breathin e"erci!e! he-% maintain !%ina-mobi-it/, encourae erect %o!ture, and %romote che!t e"%an!ion. Maintainin an erect %o!ture durindai-/ activitie! and !-ee%in on a firm mattre!! with a thin %i--ow a-!o tend to reduce the tendenc/toward thoracic $/%ho!i!.

Con!u-tation!

Con!u-tation! with the fo--owin !%ecia-i!t! ma/ be a%%ro%riate:

0heumato-oi!t 6 &hi! con!u-tation i! indicated for eva-uation and manaement of onoin

medica- treatment of %atient! with AS; additiona- coe"i!tin !%ond/-oarthro%athie! can be a!!e!!ed

O%htha-mo-oi!t 6 &hi! con!u-tation i! indicated for %atient! with !/m%tom! of acute anterior

uveiti!

a!troentero-oi!t 6 &hi! con!u-tation i! indicated for %atient! with !/m%tom! !ue!tin

coe"i!tin 3BD

Cardio-oi!t 6 &hi! con!u-tation i! indicated for %atient! with cardiac invo-vement, inc-udin

aortiti! or heart b-oc$

h/!ica- thera%i!t or %h/!ica- medicine and rehabi-itation !%ecia-i!t 6 &hi! con!u-tation i!indicated for a-- %atient!

Sureon 1ortho%edic, neuro-oic, or both2

enetici!t 6 atient! ma/ be referred for enetic coun!e-in to a!!e!! ue!tion! reardin

the %robabi-itie! of re-ative! deve-o%in the di!ea!e

Su%%ort rou%! 6 Man/ %atient! benefit from variou! !u%%ort rou%!, which can %rovide

further education on the di!ea!e %roce!! and avai-ab-e treatment o%tion!

Medication Summar/ &he oa- of %harmacothera%/ i! to reduce morbidit/ and to %revent com%-ication!W

!%ecifica--/, b/ reducin the %ain and inf-ammation a!!ociated with an$/-o!in !%ond/-iti!1AS2.

?on!teroida- Anti6inf-ammator/ Dru!

#lass Summary ?on!teroida- anti6inf-ammator/ dru! 1?SA3D!2 are u!efu- for reducin %ain !econdar/ to

inf-ammation and !/!temic !/m%tom! in AS %atient!. &he!e aent! reduce inf-ammator/!/m%tom! of !%ina- and %eri%hera- 4oint %ain and mornin !tiffne!! and a%%ear to have amode!t di!ea!e6modif/in effect on !%ina- di!ea!e. C/c-oo"/ena!e6) 1COT6)2 inhibitor!a%%ear to be a! effective a! traditiona- ?SA3D!.

?SA3D! and COT6) inhibitor! ma/ increa!e the ri!$ of !eriou! cardiova!cu-ar thrombotic

event!, m/ocardia- infarction 1M32, and !tro$e, which can be fata-. &he/ a-!o increa!e the ri!$of !eriou! adver!e a!trointe!tina- 132 effect!, inc-udin !tomach or inte!tina- b-eedin,u-ceration, and %erforation, which can a-!o be fata-. E-der-/ %atient! are at reater ri!$ for!eriou! 3 event!.

Su-fa!a-aine i! a-!o u!efu- in im%rovin !/m%tom!, mo!t notab-/ %eri%hera- arthriti!.

Giew fu-- dru information

Indomethacin ,Indocin
http://reference.medscape.com/drug/indocin-tivorbex-indomethacin-343290http://reference.medscape.com/drug/indocin-tivorbex-indomethacin-343290http://reference.medscape.com/drug/indocin-tivorbex-indomethacin-343290http://reference.medscape.com/drug/indocin-tivorbex-indomethacin-343290


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3ndomethacin i! thouht to be the mo!t effective ?SA3D for the treatment of AS, a-thouh no

!cientific evidence !u%%ort! thi! c-aim. 3t i! u!ed for re-ief of mi-d to moderate %ain; it inhibit!inf-ammator/ reaction! and %ain b/ decrea!in the activit/ of COT, which re!u-t! in adecrea!e of %ro!ta-andin !/nthe!i!.


I!uprofen ,I!u-.//0 Motrin0 Advil0 %eo"rofen

3bu%rofen i! u!ed for re-ief of mi-d to moderate %ain; it inhibit! inf-ammator/ reaction! and

%ain b/ decrea!in the activit/ of COT, which re!u-t! in a decrea!e of %ro!ta-andin!/nthe!i!.


%aproxen ,%aprosyn0 %aprelan0 Aleve0 Anaprox

?a%ro"en i! u!ed for re-ief of mi-d to moderate %ain; it inhibit! inf-ammator/ reaction! and

%ain b/ decrea!in the activit/ of COT, which re!u-t! in a decrea!e of %ro!ta-andin!/nthe!i!.


Diclofenac ,*oltaren0 #ataflam 10 2ipsor0 #am!ia

Dic-ofenac inhibit! %ro!ta-andin !/nthe!i! b/ decrea!in COT activit/, which, in turn,

decrea!e! formation of %ro!ta-andin %recur!or!. =6Amino!a-ic/-ic Acid Derivative! #lass Summary

=6Amino!a-ic/-ic acid derivative! inhibit %ro!ta-andin !/nthe!i! and reduce the inf-ammator/

re!%on!e to ti!!ue in4ur/.


Sulfasala&ine ,A&ulfidine0 A&ulfidine E%-ta!s

Su-fa!a-aine ha! been !hown to reduce the inf-ammator/ !/m%tom! of AS in contro--ed

!tudie!; it! mo!t common to"icitie! inc-ude nau!ea, diarrhea, and h/%er!en!itivit/ reaction!1ra!h2.

DMA0D!, &?< 3nhibitor! #lass Summary

&umor necro!i! factor a-%ha 1&?


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Golimuma! ,Simponi

o-imumab i! a human 3+X mAb directed aain!t &?

ankylosing spondylitis and undifferentiated spondyloarthropathy

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