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Ankylosing spondylitis management

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Ankylosing spondylitis management

  1. 1. INVESTIGATION & TREATMENT MODALITIES
  2. 2. EVERY PATIENT SHOULD BE CAREFULLY EVALUATED AND INDIVIDUALIZED ,IN ORDER TO PROVIDE HIM THE BEST TREATMENT FOR A BETTER OUTCOME. 2
  3. 3.  THE PATIENT SHOULD BE EXPLAINED IN DETAIL ABOUT HIS CONDITION AND THE POSSIBLE OUTCOME AND COMPLICATIONS, AND THAT THE TREATMENT IS ONLY DIRECTED TOWARDS IMPROVING THE QUALITY OF LIFE. 3
  4. 4.  MANAGING A CASE OF ANKYLOSING SPONDYLITIS IS A TEAMWORK COMPRISING OF :  ORTHOPAEDISTS  RHEUMATOLOGISTS  PHYSICIANS  PHYSIOTHERAPISTS  PARENTS 4
  5. 5.  RECOGNITION OF A FULL BLOWN CASE IS NOT DIFFICULT 5
  6. 6.  THE NEED, IS OF A EARLY DIAGNOSIS OF THE DISEASE ,WHICH WOULD HELP IN A BETTER PROGNOSIS AND THIS HAS BEEN MET BY THE TWO GROUPS NAMELY:  THE ROME CRITERIA (1963)  THE NEW YORK CRITERIA (1968) 6
  7. 7.  ACCORDING TO THIS ,AS IS DIAGNOSED IF B/L SACROILIITIS IS SEEN ALONG WITH ONE OF THE FOLLOWING. a) LBA & STIFFNESS OF 3 MONTHS DURATION NOT RELIEVED BY REST b) PAIN AND STIFFNESS IN THE THORACIC SPINE c) LIMITED LUMBAR SPINAL MOVEMENT d) LIMITED CHEST EXPANSION e) HISTORY OR EVIDENCE OF IRITIS OR ITS SEQUELAE 7
  8. 8.  CLINICAL CRITERIA: a) LIMITATION OF LUMBOSACRAL MOVEMENT IN THREE PLANES b) HISTORY OF PRESENCE OF PAIN AT DL JUNCTION WITH OR WITHOUT LUMBAR SPINE PAIN c) LIMITED CHEST EXPANSION OF 2.5CM OR LESS AT 4TH INTERCOSTAL SPACE. 8
  9. 9.  RADIOLOGICAL CRITERIA BASED ON SACROILIAC JOINT RADIOGRAPHS  GR 0 : NORMAL  GR 1: POSSIBLY NORMAL(minimal sclerosis)  GR 2: DEFINITE MARGINAL SCLEROSIS  GR 3: DEFINITE EROSION AND SCLEROSIS  GR 4: COMPLETE OBLITERATION AND ANKYLOSIS 9
  10. 10. DEFINITE AS:  GR 3/4 BL SACROILIITIS WITH ATLEAST ONE CLINICAL CRITERIA OR  GR 3 / 4 UL SACROILITIS WITH CLINICAL CRITERION 1 10
  11. 11. 11 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
  12. 12. 12  Visual analog scale (VAS) – 10 cm  Mean score of 10 questions  Questions level of functional disability, including: ◦ Ability to bend at the waist and perform tasks ◦ Looking over your shoulder without turning your body ◦ Standing unsupported for 10 minutes without discomfort ◦ Rising from a seated position without the use of an aid ◦ Exercising and performing strenuous activity ◦ Performing daily activities of living ◦ Climbing 12 to 15 steps without aid
  13. 13. 13  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: ◦ Fatigue/tiredness ◦ AS spinal (back, neck) or hip pain ◦ Pain/swelling in joints other than above ◦ Level of discomfort from tender areas ◦ Morning stiffness from the time you awake ◦ How long does morning stiffness last?
  14. 14. 14  Clinical Criteria ◦ Low back pain, > 3 months, improved by exercise, not relieved by rest ◦ Limitation of lumbar spine motion, sagittal and frontal planes ◦ Limitation of chest expansion relative to normal values for age and sex • Radiologic Criteria – Sacroiliitis grade 2 bilaterally or grade 3 – 4 unilaterally • Grading – Definite AS if radiologic criterion present plus at least one clinical criteria – Probable AS if: • Three clinical criterion • Radiologic criterion present, but no signs or symptoms satisfy clinical criteria
  15. 15.  RADIOLOGICAL  LAB INVESTIGATONS  OTHER INVESTIGATIONS 15
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  22. 22.  50 % HAVE RAISED SERUM ALKALINE PHOSPHATASE LEVELS  MANY HAVE RAISED SERUM PHOSPHOKINASE  ESR IS ELEVATED  HB IS LOW. TLC RAISED.CRP RAISED  NORMOCYTIC NORMOCHROMIC ANAEMIA  HLA B27 IS POSITIVE IN AROUND 90% OF CASES AND HAS A STRONG CORROBORATIVE VALUE IN THE DIAGNOSIS 22
  23. 23.  TO RULE OUT EXTRA ARTICULAR MANIFESTATIONS SUCH AS a) UVEITIS , IRIDOCYCLITIS b) INFLAMMATORY BOWEL DISEASE c) AORTIC INCOMPETENCE AND CONDUCTION DEFECTS d) RESTRICTIVE LUNG DISEASE,PULMONARY INFECTIONS 23
  24. 24.  DRUG THERAPY  PHYSICAL THERAPY  SURGERY 24
  25. 25.  IT IS TARGETED : a) GIVING SYMPTOMATIC RELIEF TO THE PATIENT. b) TO PRODUCE IMMUNOSUPPRESION. c) SLOW DOWN THE DISEASE PROGRESS. 25
  26. 26.  TO RELIEVE PAIN AND INFLAMMATION : N S A I D s : Ibuprofen,Phenylbutazone, Indomethacin, Diclofenac,Naproxen,Celecoxib. Opiod analgesics in extended release formulations for pts having chronic pain 26
  27. 27.  DMARD S SUCH AS cyclosporin, methotrexate, sulfasalazine  CORTICOSTEROIDS ARE USED TO REDUCE THE IMMUNE RESPONSE AND PRODUCING IMMUNOSUPRESSION 27
  28. 28.  MOST PROMISING AGENTS 28
  29. 29. 29 Bone Erosions Macrophages Endothelium Synoviocytes Proinflammatory cytokines Chemokines Adhesion molecules Metalloproteinase synthesis Articular Cartilage Degradation Increased Cell Infiltration Increased Inflammation Osteoclast progenitors RANKL expression TNF
  30. 30. 30  Active disease for 4 weeks ◦ BASDAI > 4 at two times, 1 month apart  Treatment Failures ◦ All types AS – lack of response/intolerability > 2 NSAIDs for 3 months ◦ Patients with peripheral arthritis – lack of response/intolerability to > 1 DMARD, sulfasalazine preferred
  31. 31. 31  Etanercept ◦ Dose: 50 mg SC per week as two 25 mg injections administered on same day or 3 to 4 days apart  Infliximab ◦ Dose: 5 mg/kg IV at week 0, 2, and 6 and every 6 to 8 weeks thereafter
  32. 32. 32 Etanercept Infliximab Mechanism of TNF inhibition “Decoy” receptor for TNF Binds to TNF and inhibits it from binding with TNF receptor Terminal half-life 4.25 +/- 1.25 days (mean+/- SD) 8 to 9.5 days (median values) In vitro lysis of cells expressing transmembrane TNF No Yes Mode of administration Subcutaneous IV infusion (over 2 to 3 hours)
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  34. 34. 34 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 • Etanercept 50 mg SC per week as two 25 mg injections in the same day or 3-4 days apart* • Infliximab 5 mg/kg at 0, 2, and 6 weeks and every 6 to 8 weeks thereafter† • Contraindicated in patients with infections, tuberculosis, multiple sclerosis, lupus, malignancy, and pregnancy/lactation 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
  35. 35. 35  Current or recurrent infections  Tuberculosis  Multiple sclerosis  Lupus  Malignancy  Pregnant or lactating
  36. 36. 36  ASAS core set of outcome parameters to monitor patients ◦ Physical function, pain, spinal mobility, patient’s global assessment, stiffness, peripheral joints and entheses, acute phase reactant, fatigue  Assess at 6 to 8 weeks and discontinue patients who do not meet response criteria ◦ BASDAI: Reduction of 2 units and ◦ Physician Global Assessment > 1
  37. 37.  AIM: TO MAINTAIN JOINT MOVEMENT AND TO BUILD UP MUSCLES THAT OPPOSE THE DIRECTION OF DEFORMITIES I.E EXTENSORS  IT SHOULD BE STARTED ALONG WITH THE DRUG THERAPY FOR BETTER OUTCOME OR AS SOON AS THE PT HAS RELIEF FROM PAIN. 37
  38. 38.  SWIMMING  BADMINTON  JOGGING  YOGA  DEEP BREATHING EXERCISES  PRONE LYING  MODIFICATION OF WORK 38
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  40. 40. 3/13/2014 Free template from www.brainybetty.com (copyright 2007) 40
  41. 41.  IN LATE CASES,  TRACTION APPICATION IS USEFUL  FOR LOWER LIMBS : TO OVER COME FIXED FLEXION DEFORMITIES OF THE HIP AND KNEE AND TO RELIEVE SPASM.  FOR CERVICAL SPINE TO RELIEVE PAIN AND SPASM 41
  42. 42.  SEVERE DEFORMITY ( KYPHOSIS)  DEFORMITIES OF THE HIP AND KNEE  BREATHING AND VISUAL DIFFICULTIES  DANGER TO THE GREAT VESSELS AND THE SPINAL CORD ALONG WITH THE NERVE TRUNKS  COSMETIC REASONS. 42
  43. 43.  OSTEOTOMIES OF THE LUMBAR SPINE : 1. SMITH PETERSON OSTEOTOMY 43
  44. 44.  2) . PEDICLE SUBTRACTION OSTEOTOMY OF THOMASEN 44
  45. 45.  3) EGGSHELL OSTEOTOMY 45
  46. 46.  4) TRANSPEDICULAR DECANCELATION CLOSED WEDGE OSTEOTOMY 3/13/2014 Free template from www.brainybetty.com (copyright 2007) 46
  47. 47.  INDICATIONS:  TO ELEVATE THE CHIN FROM THE STERNUM. IMPROVEING THE APPEARANCE,THE GAZE,THT ABILITY TO EAT.  TO PREVENT ATLANTO AXIAL SUBLUXATION  TO RELIEVE THE OESOPHAGEAL AND TRACHIAL DISTORTION  TO RELIEVE TRACTION ON THE CERVICAL NERVE ROOTS. 47
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