Ankylosing Spondylitis

Question 1

Epidemiology of AS

Answer 1

1 in 200 people
M>F 3:1
Onset 15-45yrs 
Symptoms onset to diagnosis 8yrs
History more important then examination and imaging early in disease

Question 2

Predictors of severe AS

Answer 2

Hip arthritis

Juvenile onset
Poor response to NSAIDs
Dactylitis
Oligoarthritis
Poor social supports
Smoking

Question 3

Extra Articular features

Answer 3

Eyes - Acute anterior uveitis
Dactylitis
Enthesitis
OA
IBD
Cardiac disease - aortic regurgitation, AF
Upper lobe fibrosis

Question 4

Treatment of AS

Answer 4

Non Pharm:

• Exercise
• Education

Pharmacological:

• NSAID
• Sulfasalazine
• Local corticosteroids
• TNF- alpha blockade
• IL-17 blockade

Question 5

Worst prognosis

Answer 5

Radiographic disease at onset
Smoking
High CRP

Question 6

Why use continuous NSAIDs

Answer 6

Decrease disease progression radiographically

Best used in patients most likely to progress

Question 7

Why use TNF-Alpha blockade?

Answer 7

Results in major improvements in:

• Disease activity
• Measures of spinal mobility
• Functional ability
• QOL
• Controls extra-artcular features - except etanercept

May invoke drug free remission if used early
May have disease flares on cessation

–> start early and use long term

Question 8

When are TNF-Alpha blockers not useful?

Answer 8

Patients with mature inflammatory changes
= Fatty lesions on MRI
= Don’t require TNF to drive disease progress

These patients don’t respond to TNF inhibitors

Question 9

IL-17 inhibitors

Answer 9

IL-17 A inhibitor = Secukinumab

Results in reduced inflammation, matrix destruction and cell migration

For TNF naive and TNF non responders
Similar results as TNF inhibition

No TB or MS risks

Fewer injections