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Recognition and Management of Inflammatory Back Pain: Essentials for Primary Care Providers

Lianne S. Gensler, MDUniversity of California, San Francisco

Disclosures

• Advisor/consultant: Galapagos, Janssen, Lilly• Research grant/support: Amgen, Novartis, Pfizer, UCB

Case

• A 27-year-old woman with low back pain that started 2 years ago. She experienced initially alternating “hip” pain, worse in the morning, with stiffness lasting 45 minutes. The pain is made better with exercise and NSAIDs.

• Pain awakens her from sleep around 4 AM and requires getting up to take ibuprofen and stretch.

NSAIDs = nonsteroidal anti-inflammatory drugs.

Chronic Back Pain Features

NSAIDs = nonsteroidal anti-inflammatory drugs.Braun J, Inman R. Ann Rheum Dis. 2010;69:1264–1268.Braun A, et al. Ann Rheum Dis. 2011;70:1782–1787.

Feature Mechanical Inflammatory

Age of onset > 40 years < 45 years

Onset Acute Insidious

Worst time of day End of the day Morning/ 2nd part of night

Morning stiffness None or < 30 minutes > 30 minutes

Nocturnal back pain When going to bed 2nd part of night

Exercise / activity Usually worse Makes pain better

NSAIDs improve pain 15% 80%

Associated with sciatica Can be Not usually

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Inflammatory Back Pain: Hallmark Feature

Feature Odds Ratio

Insidious onset 12.7

Pain at night (with improvement upon awakening) 20.4

Age at onset <40 years 9.9

Improvement with exercise 23.1

No improvement with rest 7.7

Sensitivity 79.6%; Specificity 72.4%Positive LR = 79.6/(100-72.4) = 2.9 ~Probability = 14%

LR = likelihood ratio.

Sieper J, et al. Ann Rheum Dis. 2009;68(6)784-788; Rudwaleit M, et al. Ann Rheum Dis. 2009;68(6):777-783; Ozgocmen S, et al. J Rheumatol. 2010;37(9):1978.

Question

In the National Health and Nutrition Examination Su rvey (NHANES), chronic axial pain was found in ~20% of t he population. Of these people, what percent had inflammatory back pain?

A. 1% of the chronic back pain population

B. 5% of the chronic back pain population

C. 15% of the chronic back pain population

D. >25% of the chronic back pain population

?

20%14%

20%

46%

NHANES 2009 to 2010

• 19.2% chronic axial pain• In patients with chronic axial pain, 28% to 35.5% had inflammatory

back pain (IBP)• US prevalence of IBP: 5% to 6%

Reveille JD, et al. Arthritis Care Res (Hoboken). 2012;64(6):905-910.Weisman MH, et al. Ann Rheum Dis. 2013;72(3):369-373.

• Self-reported prevalence of ankylosing spondylitis = 0.55 *SpA = spondylarthritis; NHANES = National Health and Nutrition Examination Survey; CI = confidence interval; ESSG = European Spondylarthropathy Study Group.†Estimates were age adjusted to the midpoint of the current population survey estimate for the 2010 US civilian population. For race/ethnicity, only data for the major US subgroups are shown.

Prevalence of SpA in US adults 20 – 69 years of age: the NHANES 2009–2010*

Case typeTotal population

sampledNumber of SpA cases

Prevalence, % SE 95% CI

ESSG SpA(Overall†) 5,103 70 1.4 0.2 1.0–1.9

Rheumatoid Arthritis versus Spondyloarthritis

* In US adults aged 20 to 69 years in the NHANES 2009-2010.** Helmick CG, et al. Arthritis Rheum. 2008;58(1):15-25. Reveille JD, et al. Arthritis Care Res (Hoboken). 2012;64(6)905-910.

0.6 0.52- 0.55

1.4

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Prevalence

Rheumatoid Arthritis**

AnkylosingSpondylitis

Spondyloarthritis(Axial)*

%

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Case 2: Your Next Step Is To…

27-year-old woman with low back pain that started 4 months ago. Initially alternating “hip” pain, worse in the AM w/ stiffness lasting 45 mins. The pain is made better with exercise and NSAIDs. Pain awakens him from sleep around 4 AM and requires him to get up, take ibuprofen, and str etch.

A. Check HLA B27

B. Check ESR / CRP

C. Order imaging study

D. Obtain additional history

?

9%

23%26%

42%

Your Next Step Is To…

• Evaluate for other symptoms:– Peripheral joint pain, heel pain, chest wall pain, bloody stools/

diarrhea, rashes

• Evaluate for other diagnoses:– Acute anterior uveitis, Crohn’s disease, ulcerative colitis, psoriasis

• Assess family history:– ~20% AS patients have a first-degree relative with AS– Cross relative risk in AS and IBD = 3.0

AS = ankylosing spondylitis.

Thjodleifsson B, et al. Arthritis Rheum. 2007;56(8):2633-2639.

Case (continued)

• A 27-year-old woman with IBP:– The patient tells you that her father has psoriatic arthritis

• How does this additional data change your assessment?

AS in Chronic Low Back Pain Population 5%

Inflammatory back pain LR 3.1

3.1 multiplied by 5.1 gives a likelihood product of 15.81.Family history � LR 15.81 x 6.4 = 101.

Elevated acute phase reactants LR 2.5

Heel pain (enthesitis) LR 3.4

Peripheral arthritis LR 4.0

Dactylitis LR 4.5

Acute anterior uveitis LR 7.3

Positive family history L R 6.4

Good response to NSAIDs LR 5.1

HLA-B27 LR 9.0

MRI LR 9.0 LR 15.81 �Probability = 45%

LR 101 �Probability =

84%

Pr = 98%

Probability of Spondyloarthritis Using Multiple Cli nical and Lab Features

HLA-B27 = human leucocyte antigen-B27; LR = likelihood ratios; Pr = Probability. Rudwaleit M, et al. Arthritis Rheum. 2005;52(4):1000-1008.

BB8

Slide 12

BB8 The figure has elements from Fig 3 in the referenced article, but is not the same. No permission needed.Betti Bandura, 5/17/2017

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Axial Spondyloarthritis:

sacroiliitis and spondylitis

PsoriasisPsoriasis

Spondyloarthritis: Family of Diseases

Hochberg M, et al. In: Rheumatology. 6th ed. St. Louis, MO: Mosby; 2014:Sec 9; Ch 114, 946-950.

25% to 40%

5% to 10%

Subclinical Colitis 25% to 60%

10%Inflammatory

Bowel DiseaseInflammatory

Bowel Disease

Acute Anterior Uveitis

Acute Anterior Uveitis

Extra-articular manifestations & comorbidities

Back painSacroiliitis on MRI

Back painRadiographic

sacroiliitis

Back painSyndesmophytes

DIAGNOSIS

Axial Spondyloarthritis

Rudwaliet M, et al. Arthritis Rheum. 2005;52(4):1000-1008.

Non-radiographic stage Radiographic stage

Time (years)

Age at First Symptoms and at First Diagnosis in Ankylosing Spondylitis Patients

Feldtkeller E, et al. Curr Opin Rheumatol. 2000;12(4):239-247.

Age at first symptoms

Age at first diagnosis

920 males476 females

100

80

60

40

20

0

Cum

ulat

ed p

erce

ntag

e of

pa

tient

s

Age in years0 10 20 30 40 50 60 70

Average delay in diagnosis: 9 years

The Axial SpA Spectrum

Ankylosing Spondylitis

Non-radiographic Axial Spondyloarthritis

Radiographic sacroiliitis

Bamboo spine

DAMAGE

(Milder disease Or

Early disease)

Modified NY Criteria

ASAS = Assessment of SpondyloArthritis International Society; SpA = spondyloarthritis.Helmick CG, et al. Arthritis Rheum. 2008;58(1):15-25. Reveille JD, et al. Arthritis Rheum. 2012;64(5):1407-1411.Reveille JD, et al. Arthritis Care Res (Hoboken). 2012;64(6)905-910.

ASAS Axial SpA Criteria

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The Axial SpA Spectrum

Features Axial Spondyloarthritis

AnkylosingSpondylitis

Non-radiographic Axial Spondyloarthritis

Gender (M:F) 1:1 2-3:1 1: 1-2

HLA-B27 -- 85% 60%

Prevalence 1.4% .55% --

Damage on x-ray Variable Always

Mild possible but not required

Inflammation on MRI

VariablePossible but not

necessaryAlways for classification

Lee W, et al. Ann Rheum Dis. 2007;66(5):633-638.Reveille JD, et al. Arthritis Care Res (Hoboken). 2012;64(6):905-910.

Axial Spondyloarthritis Epidemiology

• Age of Onset: ~24 years (up to 45 years old)

• Prevalence: Follows prevalence of HLA-B27

• HLA-B27

– Ethnicity

� High: Inuit and Scandinavians

� Low: Sub-Saharan Africans, Australian Aboriginals, Japanese

axSpA = axial spondyloarthritis.

Boyer GS, et al. J Rheumatol. 1994;21(12):2292-2297; Feldtkeller E, et al. Curr Opin Rheumatol. 2000;12(4):239-247;Lee W, et al. Ann Rheum Dis. 2007;66(5):633-638; Tikly M, et al. Curr Rheumatol Rep. 2014;16(6):421.

HLA-B27 in the US Population

Reveille JD, et al. Arthritis Rheum. 2012;64(5):1407-1411.

*For race/ethnicity, only data for the major subgroups in the US are shown, which therefore do not sum to the overall sample size. All race/ethnicities are included in the overall prevalence estimates and in the prevalence estimates by sex and age. ‡P<.01 versus all other race/ethnic groups combined. §P<.05 versus non-Hispanic white persons. ¶Estimates do not meet criteria for statistical stability.

Sample Prevalence

Selected characteristicsNo. Positive for

HLA-B27Total

Population % (95% CI)

Overall US prevalence 124 2,320 6.1 (4.6, 8.2)

SexMaleFemale

5371

1,1231,197

5.8 (3.9, 8.4)6.5 (4.7, 8.9)

Race/ethnic groupNon-Hispanic whiteMexican AmericanNon-Hispanic black

79274

1,021622345

7.5 (5.3, 10.4)±4.6 (3.4, 6.1)§1.1 (0.4, 3.1)¶

Prevalence of HLA-B27 in US Adults Aged 20-69 Years, by Selected Characteristics.2009 Data.

Referral Strategy

van Hoeven L, et al. PloS One. 2015;10(7):e0131963.

Pooled dataset sensitivity and specificity of refer ral rule 75% and 58%

BB18

Slide 20

BB18 Published (Figure 2). No permission necessary under the Creative Commons License CC BY 4.0.Betti Bandura, 5/17/2017

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Rheumatology Referral Recommendations

• Inflammatory back pain• HLA-B27 • Sacroiliitis on imaging • Peripheral manifestations (synovitis, enthesitis and/or dactylitis)• Extra-articular manifestation (psoriasis, IBD and/or uveitis)• Positive family history for spondyloarthritis• Good response to NSAIDs• Elevated acute phase reactants (ESR and/or CRP)

Poddubnyy D, et al. Ann Rheumatic Dis. 2015;74(8):1483-1487.

Patients with chronic back pain (≥3 months) with onset age <45 years should be referred to rheumatology if any of the following is present:

Imaging in Axial Spondyloarthritis

Radiation Exposure

Benefit Limitation

Radiographs 0.6/1.5 mSv+ damage(erosions/new bone)

Insensitive early in disease (first 10 years)

MRI pelvis --+ inflammation best; no gad needed; structural changes helpful

$$$; correct protocol and trained MSK radiologist

CT scan 10-15 mSv Shows damage best $$; radiation

Bone Scan 6 mSv Nonspecific Not specific; $; radiation

• Start with anteroposterior pelvis

• If negative for sacroiliitis, order MRI of the pelvis without contrast – T1, STIR/T2 fat-suppressed images with coronal oblique views

Gad = gadolinium; MSK = musculoskeletal; STIR = short-tau inversion recovery.Mettler FA Jr, et al. Radiology. 2008;248(1):254-263.

Axial Spondyloarthritis Imaging

Normal sacroiliac joints

Ankylosis of the sacroiliac joints and spineMRI with inflammation

(bone marrow edema) = sacroiliitis

SI Joint Bone Marrow edema in Athletes

Weber U et al. Arth & Rheumatol Vol. 0, No. 0, Month 2018, pp 1–11 DOI 10.1002/art.40429

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Summary

• Prevalence of axial spondyloarthritis >1%• Delay to diagnosis of years – back pain common & x-rays take

time to develop damage• Hallmark feature: Inflammatory back pain• Should be considered with back pain before age of 45 years• Obtain history, consider imaging, HLA B27, and inflammatory

markers when appropriate• Imaging work up includes plain radiographs

+/- MRI sacroiliac joints, not lumbar spine

Effective Strategies for Managing AxSpA in the Primary Care Setting

Case

A 25-year-old with recent Axial Spondyloarthritis (A xSpA) diagnosis (x-rays neg, +MRI, high CRP) returns to clinicHe tells you he is having 60 mins of morning stiffn ess and wakes up at 4 am in pain. He is taking ibuprofen 600 mg TID. Be sides referral to rheumatology, your next step:

A. Start Prednisone

B. Start Methotrexate

C. Try another NSAID

D. Start a TNF inhibitor

?

34%

6%

32%28%

Ward MM, et al. Arthritis Rheumatol. 2016;68(2):282-98.

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Or consider changing to an IL-17A inhibitor*

Ward MM, et al. Arthritis Rheumatol. 2016;68(2):282-98.*van der Heijde D, et al. Annals of the Rheumatic Diseases Published Online First:13 January 2017. doi: 10.1136/annrheumdis-2016-210770

Case

A 31-year-old man with a recent axial spondyloarthr itis (axSpA) diagnosis (X-rays with sacroiliitis and normal CRP) returns to clinicHe tells you he is having morning stiffness that re solves in minutes. He has no night pain. He is exercising regularly and taking n aproxen 500 mg a couple of times per week. Besides referral to rheumatology, y our next step is to:

A. Recommend a daily dose of naproxen to prevent damage

B. Start methotrexate and folate

C. Start an TNF inhibitor

D. Refer to physical therapy

CRP = C-reactive protein; TNF = tumor necrosis factor.

?

23%

74%

4%0%

Stable Axial SpA

AS = ankylosing spondylitis; ESR = erythrocyte sedimentation rate; NSAIDs = nonsteroidal anti-inflammatory drugs; SpA = spondyloarthritis; TNFi = tumor necrosis factor inhibitors.Ward MM, et al. Arthritis Rheumatol. 2016;68(2):282-98.

Because non-radiographic axial SpA has only recently been defined, literature on treatment of this condition is limited. Recommendations were the same as for AS.

Physical Therapy and Exercise

• Physical therapy meta-analysis showing benefit

• Exercise improves function

• Tai chi improves disease activity and flexibility

• Back exercises improve disease activity

• Aerobic and pulmonary exercise

Dagfinrud H, et al. Cochrane Database Syst Rev. 2008;Jan 23(1):CD002822; Brophy S, et al. Semin Arthritis Rheum. 2013;42(6):619-26; Lee EN, et al. Evid Based Complement Alternat Med. 2008;5(4):457-62; Fernandez-de-Las-Peñas C, et al. Am J Phys Med Rehabil. 2006;85(7):559-67. Ince G, et al. Phys Ther. 2006;86(7):924-35.

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Case

A 31-year-old man with a recent axSpA diagnosis (X-r ays with sacroiliitisand normal CRP) now returns to clinicHe tells you he is having 60 minutes of morning sti ffness and wakes up at 4 am in pain. He is now taking naproxen 500 mg twic e a day. Besides referral to rheumatology which he is still waiting for, your next step is to:

A. Start prednisone

B. Start methotrexate

C. Try another NSAID

D. Start an TNF inhibitor

?

0% 0%0%0%

NSAID Algorithm for AxSpA

• NSAIDs are the first-line therapy in axSpA unless contraindicated

• It is recommended that 2 full-strength NSAIDs be tried before advancing to a biologic

• Clinical experience: Extended release formulations may work better than short acting NSAIDs, particularly at night when patients are sleeping*

Ward MM, et al. Arthritis Rheumatol. 2016;68(2):282-98.* Personal experience, Lianne Gensler, MD

Efficacy of NSAIDs in AxSpA

• AxSpA versus mechanical back pain

Amor B, et al. Rev Rhum Engl Ed. 1995;62(1):10-5.

01020304050607080

Ankylosing Spondylitis Mechanical back pain

Response to NSAIDs

N=69 N=768

Nonsteroidal Anti-inflammatory Drugs

Song IH, et al. Arthritis Rheum. 2008;58(4):929-38.

DrugHalf-life (Hours)

Typical Dosing

Maximum Dose (mg)

Naproxen 10-18 BID 1000

Ibuprofen 1.8-3.5 TID-QID 2400-3500

Meloxicam 20 QD 15

Piroxicam 30-60 QD 20

Diclofenac (XR) 2 (6.75) TID 150

Etodolac (ER) 6.4 (8.4) BID 800

Indomethacin (XR) 2 (4.5) TID (BID) 150

Celecoxib 8-12 BID 400

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NSAIDs and Cardiovascular Risk

• AS patients appear have a higher risk of MI and stroke (meta-analysis)1

• PRECISION Trial: At moderate doses, celecoxib was found to be non-inferior to ibuprofen or naproxen with regard to cardiovascular safety2

• NSAIDs may be cardio-protective in AS. Lower risk of vascular mortality in those taking NSAIDs

1 Mathieu S, et al. Semin Arthritis Rheum. 2015;44(5):551-5.2 Nissen SE, et al. N Engl J Med. 2016;375(26):2519-29. 3 Coxib and traditional NSAID Trialists' (CNT) Collaboration. Lancet. 2013; 382(9894): 769–779.

Therapies that do not Work in AxSpA

• Systemic Glucocorticoids • DMARDs – methotrexate

ASDAS = Ankylosing Spondylitis Disease Activity Score; BASDAI = Bath Ankylosing Spondylitis Disease Activity Index; BASFI = Bath Ankylosing Spondylitis Functional Index; BASMI = Bath Ankylosing Spondylitis Metrology Index; DMARDs = disease-modifying antirheumatic drugs.

Haibel H, et al. Ann Rheum Dis. 2014;73(1):243-6. Haibel H, et al. Ann Rheum Dis. 2007;66(3):419-21.

Case (continued)

The patients returns 1 month later on a full-dose o f a second NSAID and notes that the pain and stiffness have resolved , but he is now having frequent diarrhea. Your next step is to:

A. Order a stool culture

B. Evaluate for Helicobacter pylori

C. Refer for a colonoscopy

D. Order a fecal calprotectin

E. Start an TNF inhibitor

?

5% 7% 5%

21%

61%

Diarrhea in AxSpA

• NSAID-associated ileal or colonic ulcers versus IBD

• NSAIDs unmask/flare IBD• Up to 10% have definitive IBD• Up 60% with subclinical gut

inflammation

IBD = inflammatory bowel disease.

Adebayo D, et al. Postgrad Med J. 2006;82(965):186-91; De Vos M, et al. Gastroenterology. 1996;110(6):1696-703; Mielants H, et al. J Rheumatol. 1995;22(12):2266-72; Adebayo D, et al. Nat Clin Pract Gastroenterol Hepatol. 2007;4(6):347-51.

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When NSAIDs are Contraindicated or not Fully Efficacious

• A colonoscopy was performed and shows granulomatous inflammation of the colon and ileum, consistent with Crohn’s disease.

• NSAIDs are stopped. • Patient should be co-managed with Rheumatology and

Gastroenterology.• TNF inhibitor (monoclonal antibody) is started to treat both

axSpA and Crohn’s disease.

Overview of Biologic Treatment

• Biologics only FDA approved for ankylosing spondylitis (AS) at this time, but also used in patients with non-radiographic axial SpA

– All TNF-inhibitors (etanercept, adalimumab, golimumab, certolizmab [SC], and infliximab [IV])

– IL-17A inhibitor (secukinumab)

SC = subcutaneous; IV = intravenous.Ward MM, et al. Arthritis Rheumatol. 2016;68:282-298; etanercept. Prescribing information. Amgen; 2016; adalimumab. Prescribing information. AbbVie Inc. 2016; golimumab. Prescribing information. Janssen Biotech, Inc. 2016; certolizumab. Prescribing information. Janssen Biotech, Inc. 2015; infliximab. Prescribing information. UCB, Inc; 2017; secukinumab. Prescribing information. Novartis Pharmaceuticals Corporation; 2016

AxSpA: TNFi Efficacy*

4539

4744

48

14 13 1215 16

Etanercept Adalimumab Infliximab Golimumab Certolizumab

Patients achieving 40% Improvement in 5 separate tr ials

TNF inhibitor Placebo

Davis JC Jr., et al. Arthritis Rheum. 2003;48(11):3230-6; van der Heijde D, et al. Arthritis Rheum. 2006;54(7):2136-46; van der Heijde D, et al. Arthritis Rheum. 2005;52(2):582-91; Inman RD, et al. Arthritis Rheum. 2008;58(11):3402-12; Landewe R, et al. Ann Rheum Dis. 2014;73(1):39-47.

*All TNFi approved for AS, not nonradiographic axSpA.

IL-17A Inhibition (Secukinumab)

Two phase 3 trials of secukinumab in patients with active AS

Approved for AS, not nonradiographic axSpA (secukinumab. Prescribing information. Novartis Pharmaceuticals Corporation; 2016.)Baeten D, et al. N Engl J Med. 2015;373(26):2534-48.

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Case (continued)

The patient comes in for an urgent appointment with a new cough. The patient is at risk for all of the follow ing except:

A. Viral upper respiratory infection

B. Community-acquired pneumonia

C. Tuberculosis

D. Drug-induced pneumonitis

?

11%

76%

13%0%

Infection Prevention

• No live vaccines on biologics• Annual inactivated influenza vaccination• 2017 Advisory Committee on Immunization Practices (CDC)

recommendations: both pneumococcal 13-valent conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) plus booster are recommended.

13-valent pneumococcal conjugate vaccine (PCV13 [Prevnar 13]23-valent pneumococcal polysaccharide vaccine (PPSV23 [Pneumovax 23]Pneumococcal 13-valent conjugate vaccine. Product information. http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM201669.pdf. Accessed May 22, 2017; Pneumococcal vaccine polyvalent. Product information. http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM257088.pdf. Accessed May 22, 2017. Centers for Disease Control and Prevention. Adult Immunization Schedule. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. Accessed May 22, 2017.

Extra-articular Manifestations* & Comorbidities

IgA nephropathyamyloidosis

Pulmonary fibrosis (apical)Restrictive lung diseaseSleep apnea

AortitisConduction delayAortic insufficiencyIschemic heart disease

ArachnoiditisCauda equina syndrome

Osteoporosisvertebral fractures and pseudo-fractures

Depression 30%

*Anterior uveitis25% to 40%

*Psoriasis 10%

*IBD 5% to 10%

IgA = immunoglobulin A.Bremander A, et al. Arthritis Care Res. 2011;63(4):550-556;Klingberg E, et al. Arthritis Res Ther. 2012;14(3):R108;Berdal G, et al. Arthritis Res Ther. 2012;14(1):R19;Rudwaleit M, et al. Best Pract Res Clin Rheumatol. 2006;20(3):451-471.

Fracture in Ankylosing Spondylitis

1 year

2

43

65

2

3

4

2011 2012

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High Prevalence Osteoporosis in Ankylosing Spondyli tis

Men≥ 50 yrs• Osteoporosis

21%

• Osteopenia

44%

Klingberg E, et al. Arthritis Res Ther. 2012;14(3):R108. Vasdev V, et al. Int J Rheum Dis. 2011;14(1):68-73. Ghozlani I, et al. Bone. 2009;44(5):772-6.

43-year-old man with long standing AS26-year-old man with 4 years AS

Fracture & Risk Assessment in AS

•Prevalence of vertebral fractures 30%

•Population studies : OR 3.26 -7.7–Men > women with ↑after 5 yrs of diagnosis

•Fracture risk: low bone mass, ankylosis, rigidity, low BMI, disease duration, disease activity

•Cervical spine fracture associated with AS mortality

Cooper J Rheumatol 1994; Vosse Annals Rheum Dis 2009;; Haroon NN et al Seminars Arth Rheum 2014; Siu, S et al. Arth Care & Res 2015;; D. Prieto-Alhambra et al., Osteoporos Int (2015) , Ward MM et al. Arth Rheumatol 2015; Wysham Arth Care & Res 2016

Perioperative Management (Joint replacement)

• NSAIDs — To avoid the antiplatelet effect of NSAIDs, they should be stopped at least 3 half-lives prior to surgery (except celecoxib).

• DMARDsa should be continued in patients with rheumatic diseases undergoing elective hip and knee replacement.

• Biologics should be withheld prior to surgery; surgery should be planned for the end of the dosing cycle – holding 1-2 treatment cycles. Restart after clinical signs of wound healing, without evidence of infection – generally recommended around 14 days.

DMARDs = disease-modifying antirheumatic drugs.aMethotrexate, leflunomide, hydroxychloroquine, and sulfasalazine.Goodman S et al.. Arthritis Rheumatol 2017

Summary

• First-line treatment can be initiated in primary care

– NSAIDs

– Education and physical therapy referral

• Axial disease: no role for prednisone or traditional DMARDs

• Immunize patients on biologics with inactivated vaccines

• Increased risk of respiratory infections (including tuberculosis)

• Uveitis = most common extra-articular manifestation

• Common comorbidities: osteoporosis, vertebral fractures, and cardiovascular disease