Axial SpondyloarthritisEpidemiology in South East Asia

and Patient JourneyJames Cheng-Chung WEI, MD, PhD

Chief, Division of Allergy, Immunology and RheumatologyDirector, Chinese Medicine Clinical Trial Center

Associate Professor, Chung Shan Medical University

Outline

Concept of SpA• and non-radiographic axial

spondyloarthritis (nr-axSpA) Epidemiology of SpA in South East

Asia Patient journey Take home message

AS, ankylosing spondylitis; PsA, psoriatic arthritis; ReA, reactive arthritis; IBD, inflammatory bowel diseases-associated arthritis; USpA, undifferentiated spondyloarthritis.JC Wei. Chronic Inflammation: Causes, Treatment Options and Role in Disease.  Nova Science Publishers, Inc. 2013

Spectrum of Spondyloarthritis.(seronenative spondyloarthropathies)

ASAS, 2009 ASAS, 2011

MNY, 1984

Non-radiographic axial spondyloarthritis

(nr-axSpA) Fit axial SpA (ASAS classification criteria for

axSpA, Rudwaleit et al 2009)), but not radiographic criteria of AS (Modified New York criteria, Calin et al 1984).

Usually early or mild or atypical cases Some of them might develop AS and have

similar health burden. New disease entity

• Adalimumab in nx-axSpA: approved by EMEA, but not FDA• Certolizumab Pegol in axSpA approved by EMEA & FDA

Outline

Concept of SpA• and non-radiographic axial

spondyloarthritis (nr-axSpA) Epidemiology of SpA in South East

Asia Patient journey Take home message

Epidemiological survey in China

N=10 921 , aged >16 years; of these, 7.21% had LBP 0.78% axial SpA(12% in subjects with LBP) 0.25% ankylosing spondylitis (AS) 0.50% undifferentiated axial SpA (USpA) 0.02% psoriatic arthritis (PsA) Of the axial SpA patients, 82.67% were HLA-B27

positive, clearly a greater percentage than those (11.65%) in other LBP groups.

Liao, Gu. Scand J Rheumatol. 2009 Nov-Dec;38(6):455-9.

AS in Taiwan

Population: 23 million 5% were HLA-B27 positive 92% HLA-B27 positive AS prevalence: 0.2-0.4 % Sex ratio (M:F) was 2.8 : 1 Delay diagnosis 5.9 years 42.6 ％ have family history of

SpA

JC Wei, PhD thesis, 2007, Clinical Rheumatology (2007) 26:1685–1691

Variables Patient (%)

History of uveitis, no. (%) 24.1

History of psoriasis, no. (%) 13.9

History of hematuria no. (%) 6.8

History of oral ulcer, no. (%) 11.6

Onset symptom, no. (peripheral arthritis / IBD / uveitis) (%)

21.5/2.9/2.5

Extra-articular manifestations of AS in Taiwan, n=805

JC Wei. Clinical Rheumatology (2007) 26:1685–1691

Outline

Concept of SpA• and non-radiographic axial

spondyloarthritis (nr-axSpA) Epidemiology of SpA in South East

Asia Patient journey Take home message

12% in 2 years

Non-radiographic axial SpA Ankylosing spondylitis

no definite radiographic sacroiliitis (grade 0 at the right side, grade 1 – possible subchondral sclerosis – at the left side)

definite radiographic sacroiliitis (grade 2 bilaterally) fulfilling the radiographic criterion of the modified New York criteria

Progression of Non-radiographic Axial SpA to AS: Data from GESPIC*

Main predictor:elevated CRP**

*GESPIC = GErman Spondyloarthritis Inception Cohort

**Odds ratio for progression in patients with elevated serum C-reactive protein level (>6 mg/l) was: 4.11 (95% CI 1.13-14.95).

Poddubnyy D et al. Ann Rheum Dis 2011;70:1369-74

How to identify SpA pts?

LBPLow back pain

IBPInflammatory back pain

SpASpondyloarthritis

IBP Dx by general physicians

SpA Dx by rheumatologists

Referral

Unmet Needs of SpA in Asia

Unmet needs Actions to doDelayed diagnosis 1. Educate GP and rheumatologist

about new concepts of SpA2. When to see a rheumatologist,

ie. Refer strategy for GP and Pt3. When and how to test X-ray,

HLA-B27, MRI

Inadequate treatment 1. Educate Pt and GP2. Accessibility and cost of TNFi 3. Safety, esp TB and HepB

Take Home Message

1. SpA affect 1% of population with variable features.

2. SpA cause severe health burden due to delay diagnosis and inadequate treatment in Asia.

3. Need practical referral strategy to identify patients.

4. ASAS criteria for IBP and axSpA is useful for clinical studies and daily practice

5. Diagnose nr-axSpA by HLA-B27 and/or MRI.

6. Accessibility of TNFi and safety, esp TB and HepB are major concerns in SEA.