The document discusses new developments in the classification and treatment of spondyloarthropathies. It covers:
1) New classification criteria have been developed to classify axial spondyloarthritis, with "ankylosing spondylitis" being replaced by the broader term "axial spondyloarthritis".
2) New NICE guidance on the management of spondyloarthropathies provides recommendations on pharmacological treatments, non-pharmacological treatments like exercise and physical aids, and ensuring access to specialist care.
3) New therapies continue to be developed and approved for the treatment of psoriatic arthritis and ankylosing spondylitis, including drugs targeting tumor necrosis factor (TNF),
Diagnosis of inflammatory arthritis - Dr Louise Warburtonpcsciences
Co-host of the 2017 Musculoskeletal Education Day, Dr Louise Warburton helps healthcare professionals understand the difficulties in diagnosing inflammatory arthritis
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
Gout - what should I be doing in Primary Care?pcsciences
Dr Ed Roddy, Reader in Rheumatology (Keele University) and Consultant Rheumatologist (Haywood Hospital) presented at this year's 'Musculoskeletal Education Day'. Here Ed advises what health care professionals should be be doing when dealing with patients suffering with gout based on recent research findings.
A brief introduction to what Keele's Stratified care for low back pain: Subgrouping and targeting treatment for low back pain in primary care (STarT Back).
The STarT Back approach uses a simple tool to match patients suggesting with back pain to treatment packages appropriate for them. This has been shown to decrease disability from back pain, reduce time off work, and save money by making better use of health resources.
Evidence based management of osteoarthritis in primary care - Dr Jonathan Quickepcsciences
Dr Jonathan Quicke is an NIHR Academic Clinical Lecturer in Physiotherapy (Keele University). Dr Quicke presented at the 2017 Musculoskeletal Education Day, where he discussed how we can ensure that best practice can be implemented within general practice for patients suffering with osteoarthritis
This document summarizes a presentation on physiotherapy for non-cancer chronic pain. It discusses that physiotherapy aims to restore and promote optimal physical function and quality of life for those with persistent pain. It provides an overview of evaluation processes in physiotherapy and various treatment modalities. It also summarizes evidence on approaches for common persistent pain conditions like low back pain, whiplash associated disorder, and osteoarthritis. Screening tools for risk of long-term disability are also briefly covered.
Clinical prediction rules use combinations of clinical findings to predict the probability of a specific condition or outcome. This document summarizes several clinical prediction rules for orthopedic conditions seen in outpatient settings, including rules for ankle injuries, knee injuries, patellofemoral pain, hip osteoarthritis, and low back pain. It provides details on the clinical findings and validation levels for each rule. The document concludes by describing where to find more information on clinical prediction rules and validation studies.
1. The document provides guidelines and information on treating back pain, including non-invasive and interventional options.
2. Non-pharmacological treatments like heat, massage, acupuncture, and spinal manipulation can provide small to moderate relief for acute/subacute back pain. Exercise and mindfulness therapies provide small to moderate relief for chronic back pain.
3. Pharmacological options for chronic back pain include NSAIDs as first line, and tramadol or duloxetine as second line. Opioids should only be considered as a last resort option for chronic back pain.
Diagnosis of inflammatory arthritis - Dr Louise Warburtonpcsciences
Co-host of the 2017 Musculoskeletal Education Day, Dr Louise Warburton helps healthcare professionals understand the difficulties in diagnosing inflammatory arthritis
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
Gout - what should I be doing in Primary Care?pcsciences
Dr Ed Roddy, Reader in Rheumatology (Keele University) and Consultant Rheumatologist (Haywood Hospital) presented at this year's 'Musculoskeletal Education Day'. Here Ed advises what health care professionals should be be doing when dealing with patients suffering with gout based on recent research findings.
A brief introduction to what Keele's Stratified care for low back pain: Subgrouping and targeting treatment for low back pain in primary care (STarT Back).
The STarT Back approach uses a simple tool to match patients suggesting with back pain to treatment packages appropriate for them. This has been shown to decrease disability from back pain, reduce time off work, and save money by making better use of health resources.
Evidence based management of osteoarthritis in primary care - Dr Jonathan Quickepcsciences
Dr Jonathan Quicke is an NIHR Academic Clinical Lecturer in Physiotherapy (Keele University). Dr Quicke presented at the 2017 Musculoskeletal Education Day, where he discussed how we can ensure that best practice can be implemented within general practice for patients suffering with osteoarthritis
This document summarizes a presentation on physiotherapy for non-cancer chronic pain. It discusses that physiotherapy aims to restore and promote optimal physical function and quality of life for those with persistent pain. It provides an overview of evaluation processes in physiotherapy and various treatment modalities. It also summarizes evidence on approaches for common persistent pain conditions like low back pain, whiplash associated disorder, and osteoarthritis. Screening tools for risk of long-term disability are also briefly covered.
Clinical prediction rules use combinations of clinical findings to predict the probability of a specific condition or outcome. This document summarizes several clinical prediction rules for orthopedic conditions seen in outpatient settings, including rules for ankle injuries, knee injuries, patellofemoral pain, hip osteoarthritis, and low back pain. It provides details on the clinical findings and validation levels for each rule. The document concludes by describing where to find more information on clinical prediction rules and validation studies.
1. The document provides guidelines and information on treating back pain, including non-invasive and interventional options.
2. Non-pharmacological treatments like heat, massage, acupuncture, and spinal manipulation can provide small to moderate relief for acute/subacute back pain. Exercise and mindfulness therapies provide small to moderate relief for chronic back pain.
3. Pharmacological options for chronic back pain include NSAIDs as first line, and tramadol or duloxetine as second line. Opioids should only be considered as a last resort option for chronic back pain.
This randomized controlled trial evaluated the effectiveness of acetyl-L-carnitine (ALC) for treating diabetic neuropathy. Over 1,200 patients with type 1 or 2 diabetes and mild neuropathy were randomized to receive 500 mg or 1,000 mg ALC 3 times daily or placebo for 52 weeks. ALC treatment significantly improved vibration perception threshold and nerve fiber regeneration compared to placebo. Adverse effects were mild and similar between groups. While limited by a short trial period and some baseline differences, ALC appears to be a relatively safe and potentially effective treatment option for mild diabetic neuropathy.
There research on the effectiveness of Physical Therapy for back pain is not compelling. This presentation overviews the current evidence base and discusses the potential for classification of back pain to demonstrate stronger support for Physical Therapy.
The Specific Treatment of Problems of the Spine (STOPS) trial protocol is then presented. This study was recently completed showing moderate to strong effect sizes favouring Physical Therapy over evidence-based advice.
Note that the clinical protocol details in the presentation are examples only. For the full clinical protocol visit Physical Therapy Reviews
The document discusses the role of a physiotherapist working in a multidisciplinary spine clinic. The physiotherapist has over 30 years of experience working with spinal and orthopaedic patients. In the clinic, they assess, educate, treat, and manage patients. Sessions involve assessment, education, manual therapy and exercise. The physiotherapist works as part of a team, following patients before and after surgery, conducting joint sessions with surgeons and an exercise physiologist, and liaising with other specialists. The goal is to provide continuum of care for patients.
This document discusses interventional pain procedures for chronic pain, including epidural injections, facet joint injections, medial branch blocks, and radiofrequency nerve ablation. It provides details on how each procedure is performed, when they are appropriate, and their potential benefits which include temporary pain relief and allowing patients to progress in rehabilitation. It also covers guidelines for opioid prescribing for chronic pain, including maximum recommended doses, conversion between opioid medications, requirements for authorities to prescribe, and factors to consider in opioid trials and maintenance therapy.
This document discusses mood and sleep disorders that can occur after concussions. It notes that common sleep issues include insomnia, hypersomnia, and poor sleep quality. Poor sleep after concussions is associated with prolonged recovery times and worse outcomes. It also discusses the high rates of mood issues like anxiety and depression after concussions. Treatment options discussed include sleep hygiene, melatonin, CBT-I, and medications. The relationship between sleep, mood, and concussion recovery is bi-directional, so screening and treating both is important for optimal recovery.
Critical care rehabilitation is an important part of the recovery process for ICU patients. It begins with early mobilization like passive range of motion exercises and progresses to active transfers, sitting at the edge of the bed, and eventually ambulation. A multidisciplinary team approach that includes nurses, physiotherapists, and other allied health professionals comprehensively assesses patients and develops individualized rehabilitation plans and goals. Regular evaluation during the ICU stay, before discharge, and after discharge is important to optimize recovery outcomes and quality of life.
Dave is a 38-year old factory worker who presents with worsening back pain that has failed to improve with rest, over-the-counter medications, and a prescription for Endone. He wants advice on his diagnosis, pain management options, submitting a workers' compensation claim, and the possibility of surgery. A comprehensive assessment and multidisciplinary approach is needed to properly manage Dave's chronic back pain.
The document discusses shoulder pain, specifically subacromial pain/non-specific shoulder pain. It notes that shoulder pain is prevalent, can impact daily activities, and for 40% of patients the pain is ongoing or recurrent after 12 months. Imaging and physical exams are not always reliable in diagnosing the source of pain. Exercise appears to be the most promising intervention for shoulder pain, though what type or amount of exercise is unclear. A proposed intervention focuses on teaching patients self-management skills and a home exercise program with 1-5 sessions from a physiotherapist and proactive follow-up.
This document provides the schedule and objectives for a concussion symposium on September 12, 2020. The full-day virtual event will feature several speakers presenting on topics such as best practices in concussion care, return to learn and play protocols, post-concussion headaches and migraines, cervicogenic deficits, mood and sleep disorders, COVID-19 guidelines, and a multidisciplinary rehabilitation panel. The symposium aims to educate health care professionals, athletic trainers, and physical therapists on defining and managing different aspects of concussion care. It will offer up to 4 continuing education credits for physicians and athletic trainers.
This document discusses various interventional pain procedures for chronic pain management, including their indications and how they are performed. It describes epidural injections, facet joint injections, sacroiliac joint injections, medial branch blocks, and radiofrequency nerve ablation. Epidural injections are most effective for nerve root compression and spinal stenosis. Facet joint injections target back pain from facet joints, while sacroiliac joint injections are for referred pain in the low back or lower extremities. Medial branch blocks and radiofrequency ablation can provide diagnostic information and long-term pain relief by denervating facet joints. Proper patient selection, aseptic technique, imaging guidance, and monitored sedation are important for safety. The document also reviews
The document summarizes a randomized controlled trial that assessed the effectiveness of arm ergometer training for improving spasticity, range of motion, and motor control in patients with sub-acute and chronic stroke. 40 patients were divided into two groups - one that received conventional therapy alone and one that received conventional therapy plus arm ergometer training. The results showed that the group receiving arm ergometer training in addition to conventional therapy had significantly greater reductions in spasticity, as well as greater improvements in range of motion and gross motor function compared to the conventional therapy alone group. The study concluded that conventional therapy combined with arm ergometer treatment was effective for reducing spasticity and improving motor outcomes in sub-acute and chronic stroke
Professor Andrew Davies is an Intensivist working at Peninsula Health in Melbourne. He has performed clinical research in the field of critical care for 20 years, as a participating investigator in over 50 studies (mostly clinical trials), predominantly in the areas of critical care nutrition, mechanical ventilation and acute lung injury and severe sepsis. He is a past Vice Chair of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS-CTG) with a special interest in nutrition in the ICU, and is a past Chair of the Australian and New Zealand Society of Parenteral and Enteral Nutrition (AuSPEN).
In this talk, Professor Davies tackles the often overlooked aspect of nutrition in the ICU and it’s potential benefits for our patients.
This comprehensive exam discusses the management of Alzheimer's disease. It provides epidemiological data on AD, describes the pathophysiology involving beta-amyloid plaques and neurofibrillary tangles. It summarizes treatment guidelines from various organizations recommending acetylcholinesterase inhibitors for mild to moderate AD and memantine for moderate to severe AD. It also reviews several randomized controlled trials investigating the use of statins in AD treatment that did not show clear benefits in slowing progression. The health promotion model of Katharine Kolcaba's Comfort Theory is also critiqued, which focuses on strengthening patients by achieving relief, ease and transcendence in physical, psychospiritual, sociocultural and environmental contexts.
This case describes a 60-year-old woman presenting with choreiform movements, weight loss, and dysarthria over the past 6 months. Imaging showed T1 hyperintensity in the basal ganglia. She tested positive for anti-CRMP-5 antibodies, which are associated with malignancy in over 90% of cases. Further workup revealed a small cell lung cancer. Her symptoms improved with cancer treatment and decreasing antibody levels, indicating this was a paraneoplastic neurological syndrome.
Kimberley Haines is a senior ICU physiotherapist and the Allied Health Research Lead at Western Health. Her academic research focusses on the long term progress of ICU survivors. Here she discusses the developing puzzle of ICU outcomes.
Non-operative treatment for common back conditions SpinePlus
Lumbar disc herniation and stenosis are common causes of low back pain that often improve without surgery. Post-surgery rehabilitation focuses on education, low-impact exercises, and a gradual return to normal activities. Key goals include reducing pain and improving function to allow patients to return to work and daily life. Appropriate exercises target areas like the lumbar spine, hips, and core to improve mobility and reduce recurrence, while avoiding movements that increase pain. Outcomes are best with a multidisciplinary approach including exercise prescription tailored to individual needs and abilities.
The document discusses the investigation and treatment modalities for ankylosing spondylitis. It states that each patient should receive an individualized evaluation and treatment plan to provide the best outcome. Treatment involves a team approach including orthopedists, rheumatologists, physiotherapists and others. Drug therapy aims to relieve symptoms, slow disease progression, and produce immunosuppression. Physical therapy focuses on maintaining joint movement and strengthening muscles. Surgery may be considered for severe deformities or other complications.
Abhijeet Danve, MD, FACP, FACR, prepared useful Practice Aids pertaining to axial spondyloarthritis for this CME activity titled “Overcoming Challenges in the Diagnosis and Management of Axial Spondyloarthritis: New Insights and Implications for Clinical Practice.” For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/2A6Xi8d. CME credit will be available until August 27, 2021.
This randomized controlled trial evaluated the effectiveness of acetyl-L-carnitine (ALC) for treating diabetic neuropathy. Over 1,200 patients with type 1 or 2 diabetes and mild neuropathy were randomized to receive 500 mg or 1,000 mg ALC 3 times daily or placebo for 52 weeks. ALC treatment significantly improved vibration perception threshold and nerve fiber regeneration compared to placebo. Adverse effects were mild and similar between groups. While limited by a short trial period and some baseline differences, ALC appears to be a relatively safe and potentially effective treatment option for mild diabetic neuropathy.
There research on the effectiveness of Physical Therapy for back pain is not compelling. This presentation overviews the current evidence base and discusses the potential for classification of back pain to demonstrate stronger support for Physical Therapy.
The Specific Treatment of Problems of the Spine (STOPS) trial protocol is then presented. This study was recently completed showing moderate to strong effect sizes favouring Physical Therapy over evidence-based advice.
Note that the clinical protocol details in the presentation are examples only. For the full clinical protocol visit Physical Therapy Reviews
The document discusses the role of a physiotherapist working in a multidisciplinary spine clinic. The physiotherapist has over 30 years of experience working with spinal and orthopaedic patients. In the clinic, they assess, educate, treat, and manage patients. Sessions involve assessment, education, manual therapy and exercise. The physiotherapist works as part of a team, following patients before and after surgery, conducting joint sessions with surgeons and an exercise physiologist, and liaising with other specialists. The goal is to provide continuum of care for patients.
This document discusses interventional pain procedures for chronic pain, including epidural injections, facet joint injections, medial branch blocks, and radiofrequency nerve ablation. It provides details on how each procedure is performed, when they are appropriate, and their potential benefits which include temporary pain relief and allowing patients to progress in rehabilitation. It also covers guidelines for opioid prescribing for chronic pain, including maximum recommended doses, conversion between opioid medications, requirements for authorities to prescribe, and factors to consider in opioid trials and maintenance therapy.
This document discusses mood and sleep disorders that can occur after concussions. It notes that common sleep issues include insomnia, hypersomnia, and poor sleep quality. Poor sleep after concussions is associated with prolonged recovery times and worse outcomes. It also discusses the high rates of mood issues like anxiety and depression after concussions. Treatment options discussed include sleep hygiene, melatonin, CBT-I, and medications. The relationship between sleep, mood, and concussion recovery is bi-directional, so screening and treating both is important for optimal recovery.
Critical care rehabilitation is an important part of the recovery process for ICU patients. It begins with early mobilization like passive range of motion exercises and progresses to active transfers, sitting at the edge of the bed, and eventually ambulation. A multidisciplinary team approach that includes nurses, physiotherapists, and other allied health professionals comprehensively assesses patients and develops individualized rehabilitation plans and goals. Regular evaluation during the ICU stay, before discharge, and after discharge is important to optimize recovery outcomes and quality of life.
Dave is a 38-year old factory worker who presents with worsening back pain that has failed to improve with rest, over-the-counter medications, and a prescription for Endone. He wants advice on his diagnosis, pain management options, submitting a workers' compensation claim, and the possibility of surgery. A comprehensive assessment and multidisciplinary approach is needed to properly manage Dave's chronic back pain.
The document discusses shoulder pain, specifically subacromial pain/non-specific shoulder pain. It notes that shoulder pain is prevalent, can impact daily activities, and for 40% of patients the pain is ongoing or recurrent after 12 months. Imaging and physical exams are not always reliable in diagnosing the source of pain. Exercise appears to be the most promising intervention for shoulder pain, though what type or amount of exercise is unclear. A proposed intervention focuses on teaching patients self-management skills and a home exercise program with 1-5 sessions from a physiotherapist and proactive follow-up.
This document provides the schedule and objectives for a concussion symposium on September 12, 2020. The full-day virtual event will feature several speakers presenting on topics such as best practices in concussion care, return to learn and play protocols, post-concussion headaches and migraines, cervicogenic deficits, mood and sleep disorders, COVID-19 guidelines, and a multidisciplinary rehabilitation panel. The symposium aims to educate health care professionals, athletic trainers, and physical therapists on defining and managing different aspects of concussion care. It will offer up to 4 continuing education credits for physicians and athletic trainers.
This document discusses various interventional pain procedures for chronic pain management, including their indications and how they are performed. It describes epidural injections, facet joint injections, sacroiliac joint injections, medial branch blocks, and radiofrequency nerve ablation. Epidural injections are most effective for nerve root compression and spinal stenosis. Facet joint injections target back pain from facet joints, while sacroiliac joint injections are for referred pain in the low back or lower extremities. Medial branch blocks and radiofrequency ablation can provide diagnostic information and long-term pain relief by denervating facet joints. Proper patient selection, aseptic technique, imaging guidance, and monitored sedation are important for safety. The document also reviews
The document summarizes a randomized controlled trial that assessed the effectiveness of arm ergometer training for improving spasticity, range of motion, and motor control in patients with sub-acute and chronic stroke. 40 patients were divided into two groups - one that received conventional therapy alone and one that received conventional therapy plus arm ergometer training. The results showed that the group receiving arm ergometer training in addition to conventional therapy had significantly greater reductions in spasticity, as well as greater improvements in range of motion and gross motor function compared to the conventional therapy alone group. The study concluded that conventional therapy combined with arm ergometer treatment was effective for reducing spasticity and improving motor outcomes in sub-acute and chronic stroke
Professor Andrew Davies is an Intensivist working at Peninsula Health in Melbourne. He has performed clinical research in the field of critical care for 20 years, as a participating investigator in over 50 studies (mostly clinical trials), predominantly in the areas of critical care nutrition, mechanical ventilation and acute lung injury and severe sepsis. He is a past Vice Chair of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS-CTG) with a special interest in nutrition in the ICU, and is a past Chair of the Australian and New Zealand Society of Parenteral and Enteral Nutrition (AuSPEN).
In this talk, Professor Davies tackles the often overlooked aspect of nutrition in the ICU and it’s potential benefits for our patients.
This comprehensive exam discusses the management of Alzheimer's disease. It provides epidemiological data on AD, describes the pathophysiology involving beta-amyloid plaques and neurofibrillary tangles. It summarizes treatment guidelines from various organizations recommending acetylcholinesterase inhibitors for mild to moderate AD and memantine for moderate to severe AD. It also reviews several randomized controlled trials investigating the use of statins in AD treatment that did not show clear benefits in slowing progression. The health promotion model of Katharine Kolcaba's Comfort Theory is also critiqued, which focuses on strengthening patients by achieving relief, ease and transcendence in physical, psychospiritual, sociocultural and environmental contexts.
This case describes a 60-year-old woman presenting with choreiform movements, weight loss, and dysarthria over the past 6 months. Imaging showed T1 hyperintensity in the basal ganglia. She tested positive for anti-CRMP-5 antibodies, which are associated with malignancy in over 90% of cases. Further workup revealed a small cell lung cancer. Her symptoms improved with cancer treatment and decreasing antibody levels, indicating this was a paraneoplastic neurological syndrome.
Kimberley Haines is a senior ICU physiotherapist and the Allied Health Research Lead at Western Health. Her academic research focusses on the long term progress of ICU survivors. Here she discusses the developing puzzle of ICU outcomes.
Non-operative treatment for common back conditions SpinePlus
Lumbar disc herniation and stenosis are common causes of low back pain that often improve without surgery. Post-surgery rehabilitation focuses on education, low-impact exercises, and a gradual return to normal activities. Key goals include reducing pain and improving function to allow patients to return to work and daily life. Appropriate exercises target areas like the lumbar spine, hips, and core to improve mobility and reduce recurrence, while avoiding movements that increase pain. Outcomes are best with a multidisciplinary approach including exercise prescription tailored to individual needs and abilities.
The document discusses the investigation and treatment modalities for ankylosing spondylitis. It states that each patient should receive an individualized evaluation and treatment plan to provide the best outcome. Treatment involves a team approach including orthopedists, rheumatologists, physiotherapists and others. Drug therapy aims to relieve symptoms, slow disease progression, and produce immunosuppression. Physical therapy focuses on maintaining joint movement and strengthening muscles. Surgery may be considered for severe deformities or other complications.
Abhijeet Danve, MD, FACP, FACR, prepared useful Practice Aids pertaining to axial spondyloarthritis for this CME activity titled “Overcoming Challenges in the Diagnosis and Management of Axial Spondyloarthritis: New Insights and Implications for Clinical Practice.” For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/2A6Xi8d. CME credit will be available until August 27, 2021.
Chair, Leonard H. Calabrese, DO, prepared useful Practice Aids pertaining to axial spondyloarthritis for this CME activity titled “Recognition and Management of Axial Spondyloarthritis: Best Practices for Family Medicine Physicians.” For the full presentation, downloadable Practice Aids, and complete CME information, and to apply for credit, please visit us at https://bit.ly/36ZTplc. CME credit will be available until June 22, 2023.
Spondyloarthritis (SpA) refers to a group of inflammatory diseases involving the spine and joints. It includes ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and undifferentiated spondyloarthritis. Key features are inflammation of the spine and sacroiliac joints, peripheral arthritis, enthesitis, and extra-articular manifestations affecting the eyes, bowels, and lungs. Diagnosis involves assessing clinical features, laboratory tests like HLA-B27, and imaging of the sacroiliac joints and spine. Treatment focuses on reducing pain and inflammation with NSAIDs, TNF inhibitors, exercise and maintaining function.
Clinical prediction rules (CPRs) are tools that use clinical findings to predict outcomes. This document summarizes several CPRs for orthopedic conditions seen in outpatient settings. It describes the Ottawa Ankle Rules and Ottawa Knee Rules, which use symptoms and physical exam findings to determine if imaging is needed for ankle or knee injuries. It also summarizes CPRs related to patellofemoral pain, hip osteoarthritis, benefit from manual therapy or exercise, and carpal tunnel syndrome. The document provides details on the clinical findings and validation levels for each CPR.
Hypertension in pediatric has been increased around the world. there is a lot of factors plays a role in this increased. Here, we described the AAP 2017 protocol for pediatric
Coversyl Plus and Coversyl Plus HD is Potent ACE Inhibitor of class drugs with Cardiovascular and stroke Protection with significant Mortality & Morbidity reduction in wide class of Patients with Newly Diagnosed Hypertension Patients,CAD Patients,Patients with H/O stroke/TIA ,hypertensive Diabetic Patients and CKD Patients
The document summarizes research on the effectiveness of optic nerve sheath fenestration (ONSF) for treating idiopathic intracranial hypertension. Case series show that ONSF is effective in the short term for resolving papilloedema and preventing visual deterioration in 85-94% of patients, though not as effective for headaches. While unilateral ONSF may be sufficient, long-term recurrence is common. ONSF appears similarly effective as lumbar punctures or ventriculoperitoneal shunts, though randomized controlled trials are still needed to determine best treatment.
The document discusses several cases of patients presenting with low back pain and how to approach them. It provides guidance on red flags to watch out for that could indicate a serious underlying cause. Conservative treatment is generally recommended as the first approach unless red flags are present. This includes medications, physical therapy, exercise and counseling. Further investigation may be needed if red flags are present or the patient does not improve with initial treatment.
This document summarizes two phase 3 clinical trials that evaluated the efficacy and safety of secukinumab, an interleukin-17A inhibitor, for the treatment of ankylosing spondylitis. In both trials, patients were randomly assigned to receive subcutaneous secukinumab at doses of 150 mg or 75 mg, or placebo, and assessed at 16 weeks. The primary outcome was the proportion of patients achieving at least a 20% improvement in Assessment of Spondyloarthritis International Society criteria. At 16 weeks, secukinumab 150 mg resulted in significantly higher response rates compared to placebo in both trials, while secukinumab 75 mg was significantly better than placebo in one trial. Through 52 weeks, significant improvements were sustained. In
This document discusses the pharmacology of postoperative pain management. It outlines various tools for pain assessment and factors to consider when evaluating a patient in pain. It then covers the principles of multimodal analgesia, including both pharmacological and non-pharmacological modalities. The major drug classes discussed are NSAIDs, opioids, and various adjuvants. Risks and guidelines for use are provided for different analgesic classes.
Back pain is a common problem that affects up to 90% of the population. It can be classified as acute (less than 6 weeks), subacute (6-12 weeks), or chronic (more than 12 weeks). Red flags on history and exam can indicate more serious underlying causes like cancer, infection, or fracture that require further evaluation. For nonspecific back pain without red flags, treatment focuses on analgesics, activity modification, and physical modalities. Referral is considered if red flags are present, pain persists after 4-6 weeks, or neurological deficits develop.
Pharmaceutical Care of People with Chronic PainNES
This document provides an overview of chronic pain management from a pharmaceutical care perspective. It discusses the causes and types of chronic pain, assessments, pharmacological and non-pharmacological treatment options, and key issues for patients including effectiveness, safety, adherence, and self-management. It also describes a chronic pain management project where the pharmacist identified opportunities to optimize patients' medication regimens and refer those with risks like gastrointestinal issues or neuropathic pain elements.
A 60-year-old female with diabetes and hypertension presented with altered mental status and fever for 3 days. On examination, she had a high heart rate, low blood pressure, high respiratory rate, and high blood glucose. Initial lab work showed high lactate, low platelets, and signs of infection on urine and blood tests. This patient is showing signs of sepsis such as altered mental status, hypotension, and elevated lactate. The initial response should be rapid fluid resuscitation with crystalloids, broad-spectrum antibiotics, and vasopressors if needed to maintain blood pressure. Close monitoring and treatment based on sepsis guidelines is needed in the first critical hours to prevent further organ dysfunction.
1) A 41-year-old man reports sudden onset of low back and left leg pain after yard work, which has worsened over 2 days. Physical exam finds severe left leg pain with straight-leg raise to 40 degrees.
2) Herniated lumbar disks are a common cause of sciatica. The natural history is generally favorable, with most patients finding relief within 3 months with conservative treatment like analgesics.
3) For patients with persistent sciatica over 4-6 weeks, MRI can confirm disk herniation and help determine if more aggressive treatment is needed. Conservative care is generally recommended for 6 weeks before considering injections or surgery.
Chair, Loren D.M. Pena, MD, PhD, prepared useful Practice Aids pertaining to Pompe disease for this CME activity titled “Advancing the Treatment of Pompe Disease: Clinical Updates in Newborn Screening and Enzyme Replacement.” For the full presentation, downloadable Practice Aids, and complete CME information, and to apply for credit, please visit us at http://bit.ly/3pxDr5K. CME credit will be available until June 9, 2022.
Similar to Spondyloarthropathies - Dr Jon Packham (20)
Satisfying Spa Massage Experience at Just 99 AED - Malayali Kerala Spa AjmanMalayali Kerala Spa Ajman
Our Spa Massage Center Ajman prioritizes efficiency to ensure a satisfying massage experience for our clients at Malayali Kerala Spa Ajman. We offer a hassle-free appointment system, effective health issue identification, and precise massage techniques.
Our Spa in Ajman stands out for its effectiveness in enhancing wellness. Our therapists focus on treating the root cause of issues, providing tailored treatments for each client. We take pride in offering the most satisfying Pakistani Spa service, adjusting treatment plans based on client feedback.
For the most result-oriented Russian Spa treatment in Ajman, visit our Massage Center. Our Russian therapists are skilled in various techniques to address health concerns. Our body-to-body massage is efficient due to individualized care and high-grade massage oils.
Exploring Stem Cell Solutions for Parkinson's Disease with Dr. David Greene A...Dr. David Greene Arizona
Dr. David Greene of Arizona is at the forefront of stem cell therapy for Parkinson's Disease, focusing on innovative treatments to restore dopamine-producing neurons. His research explores the use of embryonic stem cells, induced pluripotent stem cells, and adult stem cells to replace lost neurons and potentially reverse disease progression. By transplanting differentiated cells into affected brain areas, Dr. Greene aims to address the root cause of Parkinson's. His work also investigates the neuroprotective benefits of stem cells, offering hope for effective, long-term treatments. Discover how Dr. Greene's pioneering efforts could transform Parkinson's Disease therapy.
Solution manual for managerial accounting 18th edition by ray garrison eric n...rightmanforbloodline
Solution manual for managerial accounting 18th edition by ray garrison eric noreen and peter brewer_compressed
Solution manual for managerial accounting 18th edition by ray garrison eric noreen and peter brewer_compressed
About CentiUP - Product Information Slide.pdfCentiUP
A heightened child formula, with the trio of Nano Calcium, HMO, and DHA mixed in the golden ratio, combined with NANO technology to help nourish the body deeply and comprehensively, helps children increase height, boost brain power, and improve the immune system and overall well-being.
Cancer treatment has advanced significantly over the years, offering patients various options tailored to their specific type of cancer and stage of disease. Understanding the different types of cancer treatments can help patients make informed decisions about their care. In this ppt, we have listed most common forms of cancer treatment available today.
Test bank clinical nursing skills a concept based approach 4e pearson educati...rightmanforbloodline
Test bank clinical nursing skills a concept based approach 4e pearson education
Test bank clinical nursing skills a concept based approach 4e pearson education
Test bank clinical nursing skills a concept based approach 4e pearson education
VEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdfVedanta A
Air Ambulance Services In Rewa works in close coordination with ground-based emergency services, including local Emergency Medical Services, fire departments, and law enforcement agencies.
More@: https://tinyurl.com/2shrryhx
More@: https://tinyurl.com/5n8h3wp8
1. It’s the Keele difference.
Research Institute for Primary
Care & Health Sciences
Keele University
Delivering high quality multidisciplinary research in primary care.
2. It’s the Keele difference.
What’s new in
spondyloarthropathy?
Dr Jon Packham
Honorary Senior Lecturer – Keele University
Consultant rheumatologist – Haywood Hospital
Delivering high quality multidisciplinary research in primary care.
3. New classification criteria
New management guidance
• New NICE guidance on spondyloarthropathies
Latest therapies
• New guidance
• Forthcoming therapies for PsA and AS
Biosimilars
• New guidance
• Safety and efficacy data
• Switching
Overview
29. .
Efficacy and safety of adalimumab in patients with non-radiographic axial spondyloarthritis: results
of a randomised placebo-controlled trial (ABILITY-1)
J Sieper et al Ann Rheum Dis. 2013 Jun; 72(6): 815–822
• Adalumimab ASAS 40 response at week 12
– (A) Full analysis set
– (B) Symptom duration <5 years or ≥5 years.
– (C) Age <40 years or ≥40 years.
– (D) CRP normal/elevated at baseline.
– (E) HLA-B27 +ve / -ve.
Predictors of biologic response
(indicator of ‘true’ axial inflammation?)
30. ABILITY-1 ASAS 40 response %
0
10
20
30
40
50
60
All Sx < 5
years
Sx > 5
years
Age
<40
Age
>40
Placebo
Adalumimab
31. ABILITY-1 ASAS 40 response %
0
10
20
30
40
50
60
All Sx < 5
years
Sx > 5
years
Age
<40
Age
>40
Placebo
Adalumimab
32. ABILITY-1 ASAS 40 response %
0
10
20
30
40
50
60
All Sx < 5
years
Sx > 5
years
Age
<40
Age
>40
Placebo
Adalumimab
33. ABILITY-1 ASAS 40 response %
0
10
20
30
40
50
60
All CRP
normal
CRP
raised
B27 -ve B27
+ve
Placebo
Adalumimab
34. ABILITY-1 ASAS 40 response %
0
10
20
30
40
50
60
All CRP
normal
CRP
raised
B27 -ve B27
+ve
Placebo
Adalumimab
35. ABILITY-1 ASAS 40 response %
0
10
20
30
40
50
60
All CRP
normal
CRP
raised
B27 -ve B27
+ve
Placebo
Adalumimab
36. ABILITY-1 ASAS 40 response %
0
10
20
30
40
50
60
All SPARCC <2SPARCC >2
Placebo
Adalumimab
37. ABILITY-1 ASAS 40 response %
0
10
20
30
40
50
60
All SPARCC <2SPARCC >2
Placebo
Adalumimab
38. Ability-1 conclusions
• Good predictors of treatment response to
adalimumab
– Objective evidence of active inflammation at baseline
• positive MRI
• elevated CRP level
• Little evidence to support treatment of
‘clinical arm’ axial SpA with normal CRP
39. Diagnosis of non-radiographic axial spondyloarthritis divided people into 3
groups:
1/ people with MRI changes
2/those with no MRI changes but elevated C-reactive protein levels
3/ those without MRI changes and without elevated C-reactive protein
For people with symptoms of non-radiographic axial spondyloarthritis,
but without objective signs of inflammation
No recommendations for treatment with TNF-alpha inhibitors X
NICE Axial SpA TA (25/9/15)
42. Ankylosing spondylitis
MRI +ve SIJs +
1 SpA feature
‘Real’ diagnostic groups
under ASAS criteria
MRI +ve spine +
1 SpA feature
43. Ankylosing spondylitis
Back pain + HLA B27 +
↑CRP + 1 SpA feature
MRI +ve SIJs +
1 SpA feature
‘Real’ diagnostic groups
under ASAS criteria
MRI +ve spine +
1 SpA feature
44. Back pain with
no inflammation
?No disease stage
Ankylosing spondylitis
Back pain + HLA B27 +
↑CRP + 1 SpA feature
MRI +ve SIJs +
1 SpA feature
Back pain + HLA B27
+ 2 SpA features
‘Real’ diagnostic groups
under ASAS criteria
MRI +ve spine +
1 SpA feature
45.
46. B27 +ve clinical arm SpA
– what is it?
HLA-B27 +ve in 9.7% of population
Axial inflammation in <1% of population
>90% of B27 +ve patients do not have axial SpA
True axial
inflammation
Fibromyalgia Mechanical
back pain
47. Mechanical low back pain
• Third of all adults
• Commonly progresses to ‘chronic pain’
• In relatives of HLA-B27 +ve SpA patients
– ASAS clinical criteria
relatively easy to meet
48. Clinical axial SpA
• 20 year old son of AS patient with 3/12 LBP
• HLA-B27 +ve (50% likelihood)
• Family history (100%)
• + 1 from:
– Arthritis / dactylitis / enthesitis
– Inflammatory back pain
– Uveitis / psoriasis / colitis
– Raised CRP
– NSAID response
49.
50. New NICE referral and management
spondyloarthropathy guidelines 2017
51. New NICE guidance on SpA covers
the whole patient journey
NICE, National Institute for Health and Care Excellence
NICE Guideline NG65: Spondyloarthritis in over 16s: diagnosis + management: https://www.nice.org.uk/guidance/ng65. Feb
2017.
Recognition,
referral and
diagnosis
Pharmacological
management
Non -
pharmacological
management
Surgical
interventions
Organisation of
long term care and
monitoring
Information for people with
SpA
This guideline covers diagnosis and management of suspected or confirmed spondyloarthritis in adults
aged 16 years or older
These guidelines are available at:
www.nice.org.uk/guidance/ng65
If a diagnosis of
peripheral
spondyloarthritis
is confirmed,
offer plain film
X-ray of the
sacroiliac joints
52. New guidance increasingly covers EAMs in SpA
NICE: Spondyloarthritis in over 16s: diagnosis and management. Guideline Feb 2017 over 16s: diagnosis + management:
https://www.nice.org.uk/guidance/ng65. Feb 2017, p6, 12, 14, 17, 23.
Information
Organisation
of long term
care and
monitoring
Surgical
interventions
Non-
pharmacology
management
Pharmacology
management
Recognition,
referral and
diagnosis
Raise HCP
awareness of
SpA
NSAIDs Only if spinal
deformity
severe +
affecting QoL
Ensure cross-
disciplinary
communication
is supported
Ensure
tailored +
appropriateConsider
EAMs
Exercise
program
Consider
hydrotherapy
Consider
physical aids
Access to
specialist care
Consider
EAMs
Advise on
flares +
management
Advise on
EAMs
Recognise
risk
factors/early
signs +
symptoms
Consider
EAMs
CONSIDER
SKIN, GUT, EYES
See sections 1.1.2, 1.3.3, 1.4.5, 1.4.18, 1.9.3
53. Referral for suspected axial spondyloarthritis
NICE SpA guidleines 2017 (Braun 2013 >=4)
If a person has low back pain that started before age 45 years > 3 months:
Refer the person to a rheumatologist for a spondyloarthritis assessment if
4 or more of the following additional criteria are also present:
– low back pain that started before the age of 35 years
(increased likelihood that back pain is due to spondyloarthritis compared with
low back pain that started between 35 and 44 years)
– waking during the second half of the night because of symptoms
– buttock pain
– improvement with movement
– improvement within 48 hours of taking non-steroidal anti-inflammatory drugs
(NSAIDs)
– a first-degree relative with spondyloarthritis
– current or past arthritis
– current or past enthesitis
– current or past psoriasis.
• If exactly 3 of the additional criteria are present,
perform an HLA-B27 test.
If HLA-B27 positive,
refer to a rheumatologist for a spondyloarthritis assessment
54. Referral for suspected axial spondyloarthritis
NICE SpA guidleines 2017 (Braun 2013 >=4)
If a person has low back pain that started before age 45 years > 3 months:
Refer the person to a rheumatologist for a spondyloarthritis assessment if
4 or more of the following additional criteria are also present:
– low back pain that started before the age of 35 years
(increased likelihood that back pain is due to spondyloarthritis compared with
low back pain that started between 35 and 44 years)
– waking during the second half of the night because of symptoms
– buttock pain
– improvement with movement
– improvement within 48 hours of taking non-steroidal anti-inflammatory drugs
(NSAIDs)
– a first-degree relative with spondyloarthritis
– current or past arthritis
– current or past enthesitis
– current or past psoriasis.
• If exactly 3 of the additional criteria are present,
perform an HLA-B27 test.
If HLA-B27 positive,
refer to a rheumatologist for a spondyloarthritis assessment
55. New therapies for PsA and AS
http://pathways.nice.org.uk/pathways/spondyloarthritis
58. Other (NICE) treatment options in PsA
DMARDs (at least x2)
Etanercept
Adalumimab
Infliximab
Golumimab
If >3 active joints
59. Other (NICE) treatment options in PsA
DMARDs (at least x2)
Etanercept
Adalumimab
Infliximab
Golumimab
Aprelimast Ustekinumab
If >3 active joints
60. Expected NICE guidance on treatments in PsA
Secukinumab (after DMARDs)
Certolizumab pegol [ID579]2
Under final consultation summer 2017
61. Other (NICE) treatment options in PsA
DMARDs (at least x2)
Etanercept
Adalumimab
Infliximab
Golumimab
Aprelimast Ustekinumab
If >3 active joints
62. Other (NICE) treatment options in PsA
DMARDs (at least x2)
Etanercept
Adalumimab
Infliximab
Golumimab
Certolizumab
Aprelimast Ustekinumab
If >3 active joints
63. Other (NICE) treatment options in PsA
DMARDs (at least x2)
Etanercept
Adalumimab
Infliximab
Golumimab
Certolizumab
Aprelimast Ustekinumab Secukinumab
If >3 active joints
64. IL-17 inhibitors: considerations relating
to EAMs in patients with PsA
IBD, inflammatory bowel disease
1. Eli Lilly and Company. Taltz (ixekizumab). Summary of Product Characteristics. April 2016. Available at: https://www.medicines.org.uk/emc/medicine/32054.
Accessed: Jan 2017; 2. FDA Briefing Document BLA761032. July 2016. Available at: http://bit.ly/2lS0lV2. Accessed: Jan 2017; 3. Baeten D, et al. N Engl J Med.
2015;373:2534–48; 4. Hueber W, et al. Gut. 2012; 61: 1693–700; 5. Targan S, et al Am J Gastroenterol. 2016;111:1599–607; 6. Novartis Pharma. Cosentyx
(secukinumab). Summary of Product Characteristics. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-
_Product_Information/human/003729/WC500183129.pdf. Accessed: March 2017; 7. Dick AD, et al. Ophthalmology. 2013;120:777-87; 8. Hueber W, et al. Sci
Transl Med. 2010;2:52–72; 9. Letko E, et al. Ophthalmology. 2015;122:939–948.
IL-17 inhibitors have been associated with new and worsening IBD
in clinical studies1–5
Use with caution is suggested in patients with IBD1,6
Studies of IL-17 inhibitors have shown variable results in uveitis7–9
65. Forthcoming agents for PsA
Mechanism of action Drug name Development stage
TNF inhibitor Amgevita, Solymbic
(adalimumab)
EMA CHMP positive opinion, Jan 20171,2
JAK inhibitor Tofacitinib Phase III3
Upadacitinib (ABT-494) TBC
Fusion protein Abatacept Phase III4
IL-17 inhibitor Ixekizumab Phase III5–7
Brodalumab Phase III8
IL-23 inhibitor Guselkumab Phase II9
Risankizumab Phase II10
IL-6 inhibitor Clazakizumab Phase II11
Anti-PSGL-1 mAb Neihulizumab (AbGn-168H) Phase II12,13
1. EMA CHMP Summary of Opinion: Amgevita. Jan 2017; 2. EMA CHMP Summary of Opinion: Solymbic. Jan 2017; 3. Clinical Trials.gov: NCT01976364; 5. Clinical Trials.gov:
NCT01860976; 6. Clinical Trials.gov: NCT01695239; 7. Clinical Trials.gov: NCT02349295; 8. Clinical Trials. gov: NCT02584855; 10. Clinical Trials.gov: NCT02024646; 9. Clinical
Trials.gov: NCT02319759; 10. Clinical Trials.gov: NCT02986373; 11. Mease PJ, et al. Arthritis Rheumatol. 2016;68(9):2163-73; 12. Clinical Trials.gov: NCT02267642; 13. AbGenomics
Press Release: http://www.abgenomics.com/news_detail.php?NNo=24, 26.04.16.
66. Non pharmacological care of AS/AxSpA
Refer to a specialist physiotherapist for a structured
exercise programme:
stretching, strengthening and postural exercises
deep breathing
spinal extension
range of motion exercises for the spine
aerobic exercise
Consider hydrotherapy to manage pain and improve
function
Develop an individualised flare plan
67. NSAIDs in AS/AxSpA
Offer non-steroidal anti-inflammatory drugs
(NSAIDs) at the lowest effective dose
Monitoring of risk factors
Use gastroprotective treatment
If an NSAID taken at the maximum tolerated
dose for 2–4 weeks does not provide adequate
pain relief, consider switching to another NSAID
Etoricoxib – trial reduction of 90mg to 60mg
NSAID study metanalyses x2
Naproxen does NOT appear to carry additional
cardiovascular risk
Ibuprofen ??
68. Other (NICE) treatment options in AS/AxSpA
NSAIDs (no longer at least x2!)
Etanercept Etanercept
Adalumimab Adalumimab
Infliximab
Golumimab
Certolizumab Certolizumab
AS AxSpA
If BASDAI and pain VAS >4/10
69. Other (NICE) treatment options in AS/AxSpA
NSAIDs (no longer at least x2!)
Etanercept Etanercept
Adalumimab Adalumimab
Infliximab
Golumimab Secukinumab
Certolizumab Certolizumab
AS AxSpAAS
If BASDAI and pain VAS >4/10
70. Forthcoming agents for AS
Mechanism of action Drug name Development stage
JAK inhibitor Tofacitinib Phase III
IL-17 inhibitor Ixekizumab Phase III
Brodalumab Phase III
IL-23 inhibitor Guselkumab Phase II
Risankizumab Phase II
Anti TNF Golumimab Phase III
IL12/23 inhibitor Ustekinumab Phase III
IL-17 inhibitor Secukinumab Phase III
Phosphodiesterase 4
(PDE4) inhibitor
Aprelimast Phase III
Forthcoming agents for AxSpA
72. Large molecule biosimilars authorised
by the EMA and launched in the UK
Reference1
A considerable number of anti-TNF biosimilars are due to enter
the UK market in coming years6,7
MSD
Remicade
(infliximab)
Hospira
Inflectra
(infliximab)
Napp
Remsima
(infliximab)
INFLIXIMAB
Reference4 Biosimilars5
Pfizer
Enbrel
(etanercept)
Biogen Idec
Benepali
(etanercept)
ETANERCEPT
Biogen Idec
Flixabi
(infliximab)
Biosimilars2,3
73.
74.
75. EMEA (and MHRA) statement on
biosimilars
“If biosimilarity has been demonstrated in one indication,
the EMA considers that extrapolation of efficacy and safety
data to all other indications of the reference product may be
acceptable with appropriate scientific justifications”
If a biosimilar study shows it works in one disease
(i.e. rheumatoid arthritis)
Then it is presumed that it will work similarly for all other
indications of the originator molecule
76. • Benepali (SB4; etanercept)
• Received marketing approval in Jan 20161
• Phase III RCT, moderate to severe RA,
Benepali (n=299) vs originator etanercept (Enbrel; n=297)
50 mg weekly in combination with methotrexate;
no prior treatment with biologic agents2
• ACR20 at Week 24 demonstrated equivalent efficacy; overall safety comparable
Benepali (etanercept) biosimilar licensed
for PsA in biologic-naïve patients
78.1 80.3
0
20
40
60
80
100
ACR20 at Week 24
n=247 n=234
Benepali Enbrel
Patients(%)
77. BSR provides five recommendations
around the use of biosimilars
BSR Position statement on biosimilar medicines.
http://www.rheumatology.org.uk/includes/documents/cm_docs/2017/r/revised_bsr_biosimilars_position_statement_jan_2017.pdf
Accessed February 2017 BSR, The British Society for Rheumatology.
Prescription by brand name
Prescription for clinical reasons:
•Biosimilars should be included as a treatment choice for new patients
•Switching patients currently receiving a reference product to a biosimilar should be on a case-
by-case basis until further data are available to support safe switching.
Substitution only with the consent of the prescribing
clinician
Decisions made in partnership with the patients
Registration with the BSR Biologic Registers
or other appropriate UK register
1
2
3
5
4
78. The effect of biosimilars on the
treatment landscape
1. American College of Rheumatology. Drug Safety : Hotline: Biosimilar Infliximab (Inflectra):
http://www.rheumatology.org/Learning-Center/Publications-Communications/Drug-Safety/Hotline-Biosimilar-Infliximab-
Inflectra, 14.12.16, viewed March 2017
Biosimilars in biologic-naïve
patients
Biosimilar use in stable
patients: non-medical switching
Non-medical switching is defined by the American College of Rheumatology as:
“no medical indication to change drugs”1
79. Current biosimilar switching RCTs/Extension
phases: rheumatology studies
AS, axial SpA; ACR, American College of Rheumatology; ADA, anti-drug antibody; AE, adverse event; ASAS, Assessment of SpondyloArthritis international Society; CD, Crohn’s disease; CDAI, clinical disease
activity index; DAS, disease activity score; ETN, etanercept; IFX, infliximab; OLE, open-label extension; RP, reference product; SDAI, simple disease activity index; SpA, spondyloarthritis; UC, ulcerative colitis
1. Park W et al. Ann Rheum Dis 2017;76:346–354; 2. Adapted from: Goll GL et al. Presented at ACR/AHRP Annual Meeting, Washington DC, Nov 15, 2016 (Abstract 19LB); 3. Smolen JS et al. Ann Rheum Dis
2016;75(Suppl 2):488; 4. Emery P et al. Arthritis Rheumatol.2016: 68 (suppl 10). 5. Yoo DH, et al. 2017 Feb;76(2):355-363
Study Statements from the published study*
PLANETAS
Extension Study1
(IFX; Remsima/Inflectra)
NOR-SWITCH2
(IFX; Remsima/Inflectra)
Smolen et al.3
(IFX; Remsima/Inflectra)
Emery et al.4
(ETN; Benepali)
PLANETRA
Extension Study5
(IFX; Remsima/
Inflectra)
.
CT-P13, IFX biosimilar; SB2, IFX biosimilar; SB4, ETN biosimilar
Study design: OLE in patients with AS (N=174) from randomised PLANETAS study (week 62-
102). Non-randomised switch from IFX to biosimilar; comparison with biosimilar maintenance.
Single switch.1
Study design: Randomised, double-blind, non-inferiority Phase IV study in SpA, RA, PsA, CD,
UC, psoriasis (N=481). Single switch; patients on stable IFX randomised 1:1 to receive
continued IFX or biosimilar; comparison with originator. Powered for pooled data, 52-week follow
up.2
Study design: Randomised double-blind Phase III transition study. Switch from IFX to
biosimilar in patients with RA (N=396); 1:1 for SB2 or IFX to week 46. Single switch. At Week
54, IFX patients re-randomised to receive SB2 or continue IFX; 78-week follow up.3
Study design: Extension from randomised double-blind study in patients with RA (N=245).
Patients continued to receive SB4, or switched from ETN to biosimilar (non-randomised); 100-
week follow up. Single switch. Patient-reported outcome measured by HAQ-DI.4
Study design: OLE in RA (N=302) from randomised PLANETRA study (week 62-102). Non-
randomised switch from Remicade to CT-P13 (Remsima, Inflectra), comparison with biosimilar
maintenance. Single switch.5
88 patients maintained on CT-P13, 86 switched to CT-P13. ASAS20 response rates at week 102
were 80.7% and 76.9% (maintenance and switch, respectively). ASAS40 and ASAS partial
remission were also similar between groups.
241 patients continued on IFX, 240 switched to CT-P13. Disease worsening seen in 53 (26.2%)
patients maintained on IFX, 61 (29.6%) switched patients. Switching from IFX to CT-P13 was
not inferior to continued treatment with IFX.
101 patients continued on IFX, 94 switched from IFX to SB2, 201 continued on SB2. Safety,
immunogenicity and efficacy profiles remained comparable up to Week 78.
126 patients continued to receive SB4; 119 switched from ETN to SB4. ACR responses were
comparable; also sustained in the extension period. At Week 100, a similar proportion of
patients achieved low disease activity based on DAS28, SDAI, or CDAI.
158 patients maintained on CT-P13, 144 switched to CT-P13. ACR20 response rates at week
102 were 71.7% and 71.8% (maintenance and switch, respectively). ACR50 and ACR70 were
also similar between groups.
80. New classification criteria have changed the spectrum of AS
New NICE guidance on SpA will cover the whole patient journey
• Focus on EAMs and cross-disciplinary practice
• Pelvic x-rays in PsA
• New axial SpA referral guidelines
Forthcoming agents for SpA with multiple mechanisms of action
Data on switching stable patients on anti-TNF is evolving
• Biosimilars probably similar efficacy to originator biologics
• Switching studies are required
Summary
82. Thank you
Research Institute for Primary Care and
Health Sciences
David Wetherall Building
Keele University
Newcaslte-under-Lyme
ST5 5BG
Tel: 01782 733905
Fax: 01782 734719
www.keele.ac.uk/pchs
Editor's Notes
Draft for consultation by NICE, expected publication March 2017
Notes for speaker:
Recognition, referral and diagnosis:
The presence of EAMs is an indication for referral
Personal medical history and family history is important
IBD is a potential symptom in axial and peripheral SpA
History of IBD is a risk factor for SpA
People with IBD are more likely to have/develop SpA
There is an unmet need for IBD-specific referral rule(s) for SpA in people with IBD
Barriers to diagnosis
Lack of HCP awareness of complications/co-morbid manifestations
Lack of patient/HCP awareness of chronic inflammatory conditions
Pharmacological management
Treatment for axial SpA may include bDMARDs
When choosing DMARD therapy, optimal benefits in any EAMs should be considered
Biological DMARDs have been shown to have benefit in axial inflammation and in severe disease are considered a treatment mainstay
Non-pharmacological management
Referral to a specialist physiotherapist for a structured exercise program
Consider hydrotherapy as an adjunctive therapy
Consider referral to a specialist therapist for advice on physical aids
Surgical interventions
Referral for axial SpA not recommended unless spinal deformity is significantly affecting QoL and severe/progressing despite optimal non-surgical management
Organisation of long-term care and monitoring
Flares can be managed in primary or specialist care depending on patient needs
People with SpA should have access to specialist care to ensure optimal long-term disease management
Ensure effective communication and coordination between specialities
Systems that support cross-disciplinary communication should be in place (i.e. for patients with other chronic co-morbid conditions)
It is important for clinicians to know that IBD can occur in patients with SpA; its presence should be noted in people with suspected/confirmed SpA
Information for people with SpA
Tailored to patients needs and available on an ongoing basis
Advise on the possibility of flare episodes and EAMs
Consider development of a flare management plan
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016
Notes:
ID1017
Technology appraisal guidance in development
Document publication expected May 2017
ID579
Technology appraisal guidance in development
Document publication expected May 2017
Abatacept HTA – consultation took place 26 September – 24 October 2016