Ankylosing spondylitis.ppt

Assessing disease activity in
Ankylosing Spondylitis

07/12/06 BSR/BHPR Innovations in service delivery
Assessing disease activity in AS
• Understanding the impact of the disease
• Measuring the disease
• Anti-TNF therapy for AS
• Smoking and AS - audit
• Collaborative HCP working
• Case studies

Social and psychological
impact of AS
• Pt population relatively young – mainly men
• Change to body image
• Loss of self esteem
• Reduction in functional ability and independence
• Fatigue
• Pain
• Employment
Calin (1995) The individual with ankylosing spondylitis: defining disease status and the impact of the
illness Journal of Rheumatology 34: 663-72.
Chorus AMJ et al (2002) Employment prospects of patients with AS. Ann Rheum Dis 61 693-99
Chorus AMJ et al (2003) Quality of life and work in patients with RA and AS of working age. Ann
Rheum Dis 62(12) 1178-84

Measuring the impact of AS
• Bath Ankylosing Spondylitis Disease Activity Index
(BASDAI) Garret S et al 1994
• Bath Ankylosing Spondylitis Functional Index (BASFI)
Calin et al 1994
• Bath Ankylosing Spondylitis Patient Global Score
(BAS-G) Jones et al 1996
• Bath Ankylosing Spondylitis Metrology Index (BASMI)
Jenkinson et al 1994
• Ankylosing Spondylitis Quality of Life (ASQoL)
Doward et al 2003

BASMI
2 versions – both devised in Bath
Second version more sensitive
Decide which version you will be using and stick
with it.

BSR guidelines for prescribing TNFα
blockers in adults with AS – eligibility
for treatment
• Diagnosis of AS according to New York criteria
• Active AS –
BASDAI =>4
Spinal pain (VAS) =>4cms
Both on 2 occasions at least 4 weeks apart without any change in
treatment
• Failure of conventional treatment with 2 or more NSAIDs each
taken sequentially at max tolerated/recommended dosage for 4
weeks
BSR (July 2004) BSR Guideline for Prescribing TNFα Blockers in Adults with Ankylosing
Spondylitis www.rheumatology.org.uk

blockers in adults with AS – response
to treatment
• Reduction of BASDAI by 50% of pre-treatment value or a fall
=/>2 units
• Plus reduction of spinal pain VAS by =/>2 cm
• Assessments of response should be carried out between 6-12
weeks after initiation of treatment – if response criteria are not met
at 6/52 – second assessment at 12/52
• Response criteria should be reviewed 3/12
• Failure to maintain response lead to repeat assessment after 6/52,
failure to maintain response on both occasions leads to cessation
of treatment
BSR (July 2004) BSR Guideline for Prescribing TNFα Blockers in Adults with Ankylosing
Spondylitis www.rheumatology.org.uk

blockers in adults with AS- treatment
regimes and central registry of data
• As per manufacturers recommendations for treatment of AS
• Treatment should be reviewed periodically once consistent
response achieved – titrate drug dose and intervals between
dosing.
• Central registry – biologics register doesn’t currently exist –
however, BSR is currently pursuing this.
BSR (July 2004) BSR Guideline for Prescribing TNFα Blockers in Adults with
Ankylosing Spondylitis www.rheumatology.org.uk

Why and how the clinic was
developed - background
• Mid 1990’s – annual review by Cons rheumatologist
• Referred to physio dept for week long intensive
programme
• RP service progressed instigated a practitioner – led
service for AS – limited in scope
• In 2003 financial and manpower incentive to change our
practice

AS you like it – the potential size of the
UK AS population meriting Anti-TNFα
treatment.
Patricia Cornell BSc(hons)
Jane Haynes
Dr Selwyn Richards
Rheumatology Dept, Poole Hospital NHS Trust, Poole, Dorset,
UK
Tel: 01202 442849
Email: trish.cornell@poole.nhs.uk
Cornell P, Haynes J, Richards S (2004a) AS you like it – the potential size of the UK AS population meriting Anti-TNF treatment Br J Rheum 43 Abstract supp
p 124

AS you like it – the potential size of the
UK AS population meriting Anti-TNFα
treatment
Background
Limited treatment for AS
until recently
RCT’s show benefit
from Anti TNF therapy
Practitioner – led clinic
in Poole Hosp
ASAS guidelines
Method
Pt’s complete BASDAI,
BAS-G, BASFI
Evaluated with pt
demographics,
NSAID/DMARD and
CRP/ESR.
If BASDAI>4 repeated
after 4/52

Results
n(%) 81(100%) Spinal AS Peripheral AS
Numbers 57(70%) 24(30%)
BASDAI>4 19(23%) 17(21%)
CRP/ESR -15 7(9%) 11(14%)
Meet ASAS criteria
for Anti-TNF
therapy
5(6%) 6(7%)
Need to try SZP to
meet ASAS criteria
5(6%)

Conclusions
• Population base of 250,000 in Poole.
• 105 pt’s attend the AS clinic 11(14%) had a
combination of all 3 indices with a failure of >NSAIDs
and with expert opinion would be eligible for anti-
TNFα therapy.
• 5(6%) pt’s would need to fail SZP prior to being eligible
• Extrapolation using a UK population of 59 million
would qualify 2596 pt’s for ant-TNFα therapy.

Smoking and Ankylosing Spondylitis –
can health professionals make a
difference?
Smoking and AS
• Poor clinical outcome
• Poor functional outcome
• Poor radiological outcome

Aim of survey
To assess the magnitude of the smoking
population within our AS patients and establish
whether hey wanted to give up smoking

Methods
• A questionnaire was devised and approved by
the Trust questionnaire committee
• Mailed to all AS patients who attend our clinic
with sae
• Anonymous but pt’s could add names if they
wanted to receive help.
• Cigarette smoking defined as currently smoking
more than 1 cigarette/cigar per day or ½oz
tobacco per week.

Results
• 110 questionnaires mailed out – 86 returned
(78%)
• M:F 1.9:1
• Age range 21-77
• Mean age 50.8yrs
• 18(21%) admitted to smoking
• 16 wished to give up but only 2 had been
offered help from a health professional

Conclusion
• Most patients who smoke wish to give up but
few had been offered help.
• Targeted advice including benefits may lead to
improved concordance with the implementation
of health promotion programmes – eg
SmokeStop
• Specific leaflet devised and given to patients
who smoke.

The Combined Rheumatology
Practitioner and Physiotherapy
Clinic for Ankylosing
Spondylitis Patients

Why and how the clinic was
developed - background
• Decided on a one stop clinic for AS pt’s
utilising skills of both RP and physio
• Improve access for pt’s
• Decrease costs for pt’s to physio dept
• Provide timely service for existing pt’s
• Provide a service that utilises evidence based
measurements for disease activity
• Underpins criteria for new treatments

Objective of the clinic
• To provide a comprehensive and individual care
for people with AS – recognising the importance
of responding to the individuals needs,
respecting their privacy, dignity, beliefs and
values. We aim to maintain or improve the
quality of life for our patients and their carers.
Our clinical expertise and practice is based on a
core of professional knowledge and skills,
supported by current research and founded on
professional values.

How does the clinic function?
• Poole Hospital is a district general hospital serving a
population of approx 250,000 people
• 110 Ankylosing Spondylitis (AS) patients attend the
combined rheumatology practitioner and physiotherapy
clinic
• Initial diagnosis of AS is made by the rheumatology
consultants and registrars
• The patients are then referred into the combined
rheumatology practitioner and physiotherapy clinic
• Combined clinics are held fortnightly

Attendance
• Appointments can last up to 1 hour. The time is
distributed as required between the rheumatology
practitioner and the physiotherapist.
• At the initial attendance the patient receives information
about the clinic including the telephone advice line and
may be referred to other support services as necessary
• Patients on NSAIDs attend between 6-12 months
depending on disease activity
• Patients on DMARDs attend every 3-6 months depending
on disease activity
• Patients on Anti-TNF therapy attend every 3/12
• Anti-TNF infusions and IV steroids are not administered
at this clinic

The Rheumatology Practitioner
Assessment
• A proforma is used to gather information from the patient regarding:
– Current problems
– Current medications
– Pain Visual Analogue Scale (VAS) level
• AS disease activity VAS level
– BASDAI and BASFI
– Duration of morning stiffness
– Level of exercise
– Potential problem areas including eyes, skin, joints, feet, gut, cardiac
and functional activities – cardiac ascultation and blood pressure
– Smoking status
Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) Garret S et al 1994. Bath Ankylosing Spondylitis Functional Index (BASFI) Calin et al 1994

The Rheumatology Practitioner
Assessment continued
• Recent blood test results are monitored for ESR, CRP, LFTs,
U&E’s and FBC
• A problem and action list are generated from the discussion and
results. Actions may include:
– Adjustment of current medications
– Monitoring of heart sounds
– IM steroid injection in clinic
– IA injection in clinic
– Referral for IV steroid pulses
– Referral for hip/SIJ or epidural injections
– XRay and referral on to orthopaedic surgeons

Physiotherapy Assessment
A proforma is used to gather information from the patient regarding:
 Subjective report of pain and stiffness
 Objective assessment of physical difficulties
 Measurements using BASMI (Bath Ankylosing Spondylitis Metrology
Index)
 Personalised exercise plans are created with relation to current problems
 Education and advice about AS is given
 Accelerated onwards referral to physiotherapy for hydrotherapy,
acupuncture or further physiotherapy can be made
 Patients are encouraged to exercise via local leisure schemes or exercise
referral
 Patients can be referred directly into the evening AS group run by the
physiotherapy department
 Patients are discussed with RP for decisions regarding injection and
onward referral
Bath Ankylosing Spondylitis Metrology Index (BASMI) Jenkinson et al 1994

Patient response - patient
satisfaction survey
The Modified Leeds Patient Satisfaction Questionnaire was used
to survey the AS population attending this clinic
• Categories of satisfaction were:
• General satisfaction
• Giving of information
• Empathy with patients
• Technical quality and competency
• Attitude towards patients
• Access and continuity
• RP/ Physiotherapist bespoke section
Hill J (1997) Patient satisfaction in a nurse-led rheumatology clinic. Journal of Advanced Nursing (25) pp347-354.
Cornell P, Haynes J, Richards S, Thompson P (2005) Patient satisfaction with a combined rheumatology practitioner and physiotherapist Ankylosing Spondylttis clinic. Rheumatology vol 44
suppl 1 pi153

Patient Satisfaction Survey -
Results
• 62/110 questionnaires were returned
• Percentages given are for satisfied and highly satisfied responders:
• General satisfaction 82.26% (51/62)
• Giving of Information 95.16% (59/62)
• Empathy with patient 80.65% (50/62)
• Technical Quality and Competency 98.39% (61/62)
• Attitude towards the patient 95.16% (59/62)
• Access and Continuity 80.65% (50/62)
• RP and Physio bespoke section 90.32% (56/62)
suppl 1 pi153

Patient satisfaction survey -
conclusion
• The Combined AS clinic offers a comprehensive medical and
physiotherapy service for all our AS patients at one appointment
• All aspects of patient satisfaction covered by the survey
demonstrated a very positive patient response to the service
• Data from the clinic could be used for future audit and research to
compare this clinic model to standard medical care
• Interdisciplinary working has created strong links between the
physiotherapy and rheumatology departments
suppl 1 pi153

RP/Physio clinic - advantages
• One stop clinic for pt’s with AS – uses skills of
both RP and physio
• Improved access for pt’s to physiotherapy
• Reduced cost for both physiotherapy and pt’s
• Provides a timely service for new and exisiting
pt’s
• Provides a service that utilises evidence based
medicine
• Underpins criteria for new treatments

RP/Physio clinic - disadvantages
• Unable to compare with medical –led care
• If medical problem have to wait for Consultant
to see pt
• RP needs to know limitations of own scope of
practice
• Limited to fortnightly combined clinics but need
more combined sessions - financial

AS Case study - Craig age 37
Male - diagnosis at age 22
Grade IV sacroilitis and peripheral arthropathy
PMH: Trigeminal neuralgia, Hypertension
Aortic valve replacement Aug 2001
Cerebral haemorrhage Aug 2001
Previous DMARD history: Previous NSAID history
Sps 3gm day – ineffective Indocid 75mg BD
Mtx 25mg wk – ineffective Vioxx 25mg od
Leflunomide 20mg od – ineffective
Inflixamab 5mg/kg 6/52
Pred 7.5mg

AS Case study - Craig
current medication
• Humira 40mg 2/52 s/c
• Mtx 20mg wk
• Folic acid 5mg wk
• Arcoxia 90mg od
• Solpadol prn
• Lansoprazole
• Bendrofluazide
• Istin
• Warfarin
• Labetalol 300mg
• Candesarten
• Ramipril
Medication stopped since
commencing anti-TNF
• Pred 7.5mg
• Oromorph 10mls prn
• Codiene 30mg qds

AS Case study - Craig
measurements
Prior to
therapy
3/12 6/12 1yr 18mths
BASDAI 8.64 3.06 2.9 2.38 2.4
BASFI 7.9 3.95 3.6 4.3 3.91
BASMI 6 2.6 2.4 2.5 2.6
DAS 5.23 2.69 2.15 1.95 2.15
ESR 97 21 13 12 16

AS Case Study Michael age 34
Male diagnosed age 31
Referred to Ortho 2002 with pain in Right Foot ? Reflex
sympathetic dystrophy
Referred onto Pain Clinic 2002 – Guanethidine blocks x2
Referred to Rheumatology 2004
HLAB27 +ve
Raised inflammatory markers – CRP 50+
Enthesis ankles
Monthly ankle injections Autumn 2004
Pulsed x3 methylpred 500mg – lasted 4/7
Previous DMARD history: Previous NSAID history
Sps 3gm day – ineffective Indocid 75mg BD
Mtx 25mg wk – ineffective Mobic 15mg od

AS case study Michael – treatment
plan
Commenced Inflixamab 5mg/kg 6/52 Feb 05
Continued:
Mtx 25mg wk
Folic acid 5mg 6/7
Mobic 15mg od
Changed to Adalimumab April 2006 – didn’t like coming
in for infusions
Reduced Mtx June 2006 – nausea
Stopped Mtx Aug 2006
Stopped Adalimumab Dec 2006

AS case study - Michael
Prior to
therapy
3/12 6/12 1yr 18mths
BASDAI 6.3 1.9 1.42 2.07 1.76
BASFI 2.37 0.5 0.7 0.43 0.6
ESR 68 7 13 8 12

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