spondyloarthritis for medical students

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  • 1. V Spondyloarthritis MD, PhD. Tel: 04 24729595 ext 34314; Email: wei3228@gmail.com

2. 3. Spondyloarthritis/ankylosing spondylitis Definition Pathophysiology Clinical manifestations Diagnosis Treatment Prognosis 4. Spondyloarthritis, SpA 1. 2. 3. 4. 5. (Ankylosing spondylitis, AS) (Reactive syndrome, Reiter syndrome, ReA) (Psoriatic arthritis, PsA ) (Inflammatory bowel disease-related arthritis, enteropathic arthritis) (Undifferentiated Spondyloarthritis, USpA) 5. Figure 1. Spectrum of Spondyloarthritis. 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 6. Spectrum of Spondyloarthritis By diseases Ankylosing spondylitis Psoriatic arthritis Reactive arthritis Inflammatory bowel diseases-associated arthritis Undifferentiated spondyloarthritis By clinical manifestations Axial Spondyloarthritis Non-Radiographic Axial Spondyloarthritis Established Axial Spondyloarthritis Peripheral Spondyloarthritis 7. 16 40 3 1 0.2~0.4 % 95% AS HLA-B27 HLAB27 JC WEI, PhD thesis, 2007 8. HLA-B27 HLA-B2710%AS90% Taiwan estimated prevalence: HLA-B27: 5% SpA: 1% AS: 0.4% In B27+ families, HLA-B27 is essential but not sufficient for AS 9. HLA-B27 consists of aheavy chain having three domains, which noncovalently binds short peptides and 2microglobulin ( 2 m) 10. Nat Clin Practice Rheumatol 2006; 2: 383-392 11. Immune dys-regulationHLA-B27 mis-folding causing ER stress Free form HLA-B27 homo-dimer Th17/IL17, Th1/TNFAS Environmental factorsInfection, eg. Klebsiella pneumoniae Trauma SmokingGenetic background HLA-B27, B60, B61 ERAP-1 IL23R, IL1, IL12 12. 1.2. 3. 4. (sacroiliitis) (spondylitis) (enthesitis) 13. Inflammatory back pain, IBP 1. 2. 40 3. 4. 5. For spondyloarthritis: sensitivity= 95-100%, specificity= 85-90% Calin. JAMA, 1977; Linden. Scan J Rheu, 1988. 14. (Enthesopathy) (enthesis) Sausage digit, dactylitisAchilles enthesitis 15. 40% 16. Extra-articular manifestations of AS Uveitis Psoriasis Inflammatory bowel Mucosal ulcer IgA nephropathy Heart block Apical lung fibrosisUveitisPsoriasis 17. Physical ExaminationFinger to floor test 18. Posterior SI compression testPatrick test 19. (ESR) C (CRP) IgA Urine analysis HLA-B27 typing 20. X ray finding of spondylitisAnterior Squaring of vetebral bodiesCorner enthesitis Syndesmophyte 21. Diffuse idiopathic skeletal Hyperostosis(DISH) AS with bamboo spine 22. sacroiliitis 23. Grade 2 sacroiliitisFocal erosion and sclerosis of SI joints 24. CT scan of SI jointsSacroiliitis Osteiitis condensans ilii 25. Modified New York criteria, 19841. 3 2. 3. 4.X 2 3 4 1-3 26. CASPAR Criteria for the Classification of PsA Inflammatory articular disease (joint, spine, or entheseal) With 3 points from following categories: Psoriasis: current (2), history (1), family history (1) Nail dystrophy (1) Negative rheumatoid factor (1) Dactylitis: current (1), history (1) recorded by a rheumatologist Radiographs: (hand/foot) evidence of juxta-articular new bone formation Specificity 98.7%, Sensitivity 91.4% Taylor et al. Arthritis & Rheum 2006;54: 2665-73 27. Psoriatic ArthritisACR Slide Collection on the Rheumatic Diseases; 3 rd edition. 1994. Data on file, Centocor, Inc. 28. ASAS classification criteria for peripheral spondyloarthritis2010 by BMJ Publishing Group Ltd and European League Against RheumatismRudwaleit M et al. Ann Rheum Dis 2011;70:25-31 29. (NSAID) (Disease modifying antirheumatic drugs, DMARD) anti-TNF 30. 31. National Ankylosing Spondylitis Society (NASS) AS caring society, ROC, www.ascare.org.tw www.DrWei.idv.tw 32. NSAID COX-2 inhibitors, meloxicam (Mobic), celecoxib (Celebrex), etoricoxib (Arcoxia) acetamenophen , amitriptyline 33. (DMARDs) Sulfasalazine (Salazopyrin) For peripheral PsA: Methotrexate (MTX), Leflunomide, Cyclosporine 34. Anti-TNF Etanercept (Enbrel, ), Adalimumab (Humira, ), Golimumab (Simponi, ) 80% 40 35. Ustekinumab (Stelara, ) MoAb against p40 subunit of IL-12 /IL-23 Approved for severe plaque psoriasis SC, q3m Better efficacy than TNFi: PASI90 45% vs 23% 36. 37. Take Home Message Spondyloarthritis is a gene-environment interacted chronic inflammatory disease. Early diagnosis depends on clinical manifestations, HLA-B27 and Imaging studies, esp. MRI. Optimal treatment by1.2.3. 1.Exercise and NSAID for all SpA patients. Sulfasalazine in peripheral AS and uveitis. Methotrexate, cyclosporine and leflunomide in PsA.TNF blockers are break through in the treatment of AS, PsA, psoriasis and IBD. 38. References eMedicine :Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy http://www.emedicine.com/med/topic2700.htmDr Wei Blog: http://DrWei.blogspot.com . , 2005 39. -80% -20% eMedicine :Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy http://www.emedicine.com/med/topic2700.htm