ankylosing spondylitis, how to diagnosis and managment?

1. Marwa Abou ELmaaty Besar
Lecturer of Internal Medicine
(Rheumatology Immunology unit)
(Pediatric Rheumatology)

2. A chronic systemic inflammatory rheumatic disorder
with
 Predilection for axial skeletal involvement.
 Inflammation at sites of bony insertions for tendons and ligament
(enthesitis).
 Sacroiliitis is the hallmark.
 Strong familial and genetic predisposition associated with HLA-B27.

4.  Characterized by
Absence of RF.
Inflammation of sacroiliac joints, axial spine.
Enthesitis.
Extraarticular manifestation; uveitis.
Disease include; ankylosing spondylitis,
Psoriatic arthopathy, Reactive arthritis, arthritis related to
IBD.

9. Diagnosis of Spondyloarthropathies (1)
Is there:
• Inflammatory arthritis that is asymmetric or predominantly lower extremity?
and/or
• Back pain of insidious onset of > 3 months duration associated with morning stiffness
and improvement with activity?
NO YES
Unlikely to be a
spondyloarthropathy
Is there evidence of psoriasis or
inflammatory bowel disease?

10. Diagnosis of Spondyloarthropathies (2)
NO YES
Is there evidence of psoriasis or
inflammatory bowel disease?
Consider:
• Enteropathic or
• Psoriatic Arthritis

11. Diagnosis of Spondyloarthropathies (2)
Is There One or More of the Following:
• Radiographic evidence of sacroiliitis?
• Enthesopathy?
• Dactylitis?
• Buttock pain (unilateral or alternating)?
• Family history
• Iritis?
• Acute diarrhea or non-GC urethritis or
cervicitis within 1 month of arthritis
onset?
NO YES
Is there evidence of psoriasis or
inflammatory bowel disease?

12. Diagnosis of Spondyloarthropathies (3)
Is There One or More of the Following:
• Radiographic evidence of sacroiliitis?
• Enthesopathy?
• Dactylitis?
• Buttock pain (unilateral or alternating)?
• Family history
• Iritis?
• Acute diarrhea or non-GC urethritis or
cervicitis within 1 month of arthritis
onset?
NO YES
Likely to Be a
Spondyloarthropathy
Unlikely to Be a
Spondyloarthropathy

13. Diagnosis of Spondyloarthropathies (4)
Is there evidence of spondylitis?
• Inflammatory spinal pain and
limitation of spinal movement?
NO YES
Likely to Be a
Spondyloarthropathy
Probably Reactive
Arthritis or Reiter’s Syndrome
Probably Ankylosing
Spondylitis

14.  Laura is a 41-year-old woman who has been referred to rheumatology for chronic back
pain. She presents today with a swollen R ankle. It was initially blamed on a fall when
she was carrying a laundry basket up the stairs, but that injury occurred 3 weeks ago.
She has treated the ankle with rest, ice, and elevation, but the symptoms have not
improved. She reports that this is not the first time that she has had problems with pain
and swelling in her right ankle. In fact, she says, it has been a problem on and off since
she was 18 or 19 years old. Laura also has a history of progressively worsening back
pain. She has had this back pain since the age of 23, first experiencing it after a
caesarean section.
 An x-ray of the lumbar spine was done at age 26, and was normal; however, a repeat x-
ray 1 year ago showed mild osteoarthritis in the lumbar region with degenerative disc
disease at L5-S1.
 She reports that she has been doing physical therapy exercises for her back, without
any benefit.
 What is your diagnosis?

16. The famous Egyptian
pharaoh Ramses II.

17. Inflammatory low back pain in young adult.
Radiographic evidence of sacroiliitis.
Reduction of spinal mobility, lumbar flexion.
Associated with:
Enthesitis.
Anterior uveitis.
Positive family history.
Inheritance by HLAB27.
AS occurs in 20% of HLA-B27 positive persons and have a positive family history for AS.
Male : female = 3:1
Age =15-35 years old
Caucasians worldwide

18. dull
ache
pain
deep in
buttock
Inter-mittent
or unilateral,
or alternate
then
persistent
(chronic)
and bilateral
LBP

19. Disease Progression in AS
 Obliteration of lumbar lordosis with atrophy of buttocks
 Accentuation of thoracic kyphosis
 Forward stoop of neck if the cervical spine is involved
 Hip involvement
 Flexion contractures
 Compensated for by knee flexion

20. Thoughts concerning early
diagnosis
Diagnosis is delayed by 5-6 years with early and incomplete
clinical picture
Diagnosis mainly based on radiographic changes of sacroiliac
joints. Conventional radiography is too insensitive to show
sacroiliitis
Back pain is the main symptom of AS but only a very small
proportion of the huge number of back pain have AS
In contrast to RA, AS cannot be easily recognized at physical
examination (no objective evidence of inflammation, e.g. swollen
joints)

21.  Eye: Uveitis 20%, Acute iritis.
 CVS: 2-5%, aortic incompetence, Conduction defects, cardiomyopathy.
 Lung: Restrictive lung disease, Apical fibrosis.
 GIT: mild GIT inflammation.
 Kidney: Amyloidosis, Ig A glomerulonephritis.
 Osteoporosis, Spinal fracture.
 CNS: very rare,
 Quadri- or paraplegia.
 Atlantoaxial subluxation.
 Cauda equina syndrome.

22. Inspection:
 General patient attitude and gait.
 Total spinal posture (head to toes!)
- anterior view
- posterior view
- lateral view

23. Active ROM
 Performed standing
 Assess gross movements & any limitations:
 Flexion
 Extension
 Lateral flexion: L&R
 Rotation: L&R

24.  Measures for determining spinal mobility:
 Finger to floor distance,
 Occiput to wall distance, and
 Chest expansion.
 The Schober’s test, modified.
 Gaenslen’s test.
 Patrick test (Faber test).
The ASAS recommend the Schober’s test to measure thoraco-lumbar mobility,
and the Occiput-to-wall distance to measure mobility of the cervical spine.

34. Spine Analyzer
 Helps to visualize and
measure spinal and
skeletal abnormalities.
Pivoting foot piece allows
to examine the patient
from posterior, lateral, and
medial views

35. BTE Vector

39. Radiographic picture of Sacroiliitis
1- Iliac erosions, described as serrations, in the lower third of the sacroiliac
joint & marginal sclerosis.
2- Pseudo widening of the sacroiliac joint
3- Fibrosis, interosseous bridging and ossification
4- Complete Ankylosis of the joint

41. Symmetrical Sacroiliitis
Ankylosing Spondylitis
(abnormal)
(abnormal)

47. 47
Index Metric
BASFI Disability level
BASDAI Disease activity level
ASAS - IC Composite sum of disease activity
BASFI = Bath Ankylosing Spondylitis Functional Index
BASDAI = Bath Ankylosing Spondylitis Disease Activity Index
ASAS - IC = ASsessment in Ankylosing Spondylitis Improvement Criteria

48. 48
 A self-administered instrument (using 10-cm horizontal visual
analog scales) that comprises 6 questions:
Over the last one week, how would you
describe the overall level of:
1. Fatigue/tiredness
2. AS spinal (back, neck) or hip pain
3. Pain/swelling in joints other than above
4. Level of discomfort from tender areas
5. Morning stiffness from the time you awake
6. How long does morning stiffness last?

49. 49
 Visual analog scale (VAS) – 10 cm
 Mean score of 10 questions
 Questions level of functional disability, including:
1. Ability to bend at the waist and perform tasks.
2. Looking over your shoulder without turning your body.
3. Standing unsupported for 10 minutes without discomfort.
4. Rising from a seated position without the use of an aid.
5. Exercising and performing strenuous activity.
6. Performing daily activities of living.
7. Climbing 12 to 15 steps without aid.

50. 50
ASAS 20:
An improvement of > 20% and absolute improvement of > 10 units on a 0–100
scale in > 3 of the following 4 domains:
 Patient global assessment (by VAS global assessment)
 Pain assessment (the average of VAS total and nocturnal pain scores)
 Function (represented by BASFI)
 Inflammation (the average of the BASDAI’s last two VAS concerning morning
stiffness intensity and duration)
 Absence of deterioration in the potential remaining domain
 (deterioration is defined as > 20% worsening)

51. Other Causes of Sacroiliitis
1. Hyperparathyroidism
2. Familial Mediterranean fever
3. Whipple disease
4. Paget disease
5. Paraplegia
6. Behest's disease
7. Tuberculosis
8. Brucellosis
9. Pyogenic sacroiliitis
10. Malignancy

52. 52
Axial AS:-
Alternative Options
• Pamidronate
• Thalidomide
*Only biologic approved for treatment of AS in US and Europe
†Approved in Europe only for treatment of AS
This treatment algorithm contains unlabeled use of infliximab, pamidronate and thalidomide.
Initiate physical therapy plan
with long- term exercise program to
accompany
pharmacologic intervention
• Emphasize posture, range of motion,
and strengthening
NSAIDs or Selective COX-2 inhibitors
• Efficacy and safety comparable between non-selective agents
• Selective COX-2 efficacy comparable, better safety profile, higher
cost that non-selective NSAIDs
Failure of at least two different NSAIDs/selective COX-2 inhibitors
for minimum of 3 months
Anti-TNF agents
Monoclonal ab against IL17
Monoclonal ab against IL12/23
Janus kinase
T cell co-stimulator inhibitors

53. 53
Alternative Options
• Pamidronate
• Thalidomide
* Only biologic approved for treatment of AS in US and Europe
†Approved in Europe only for treatment of AS
This treatment algorithm contains unlabeled use of infliximab, pamidronate and thalidomide.
Anti-TNF agents
Monoclonal ab against IL17
Monoclonal ab against IL12/23
Janus kinase
T cell co-stimulator inhibitors
DMARDs
• Preferably sulfasalazine
Initiate physical therapy
plan with long- term exercise program to
accompany
pharmacologic intervention
• Emphasize posture, range of motion,
and strengthening
NSAIDs or Selective COX-2 inhibitors
 Efficacy and safety comparable between non-selective agents
 Selective COX-2 efficacy comparable, better safety profile, higher
cost that non-selective NSAIDs
Failure of at least two different NSAIDs/selective COX-2 inhibitors
for minimum of 3 months