ankylosing spondylitis

Question 1

definition of AS

Answer 1

Ankylosing spondylitis (AS) is a chronic progressive inflammatory arthropathy. Patients present with severe pain and spinal stiffness, which ultimately may lead to spinal fusion

Question 2

symptoms

Answer 2

symptoms of inflammatory back pain:
(need at least 2 to consider it inflammatory back pain)
Early morning back stiffness
Improvement of stiffness with exercise
Resolution of symptoms using non-steroidal anti-inflammatory drugs (NSAIDs)
Alternating buttock pain
Waking in the second half of the night with back pain.
++ <40y/o, insidious onset, pain >3 months

Obtain further history to establish the presence of disease-associated features such as:
Iritis
Enthesitis (affecting tendon or ligament attachments to bone)
Family history of spondyloarthropathy
Psoriasis
Uveitis
Inflammatory bowel disease
Dyspnoea
Fatigue
Sleep disturbance.

Question 3

risk factors

Answer 3

• positive family history of AS
• HLA-B27-positive
• IL23R and ERAP1 genes

(weak) - klebsiella pneumoniae

Question 4

investigations

Answer 4

1st: pelvic x ray

• HLA-B27
• MRI
• cervical spine x ray (lateral)
• lumbar spine x ray (lateral)
• thoracic spine x ray (lateral)
• ultrasound
• ESR, CRP (to keep tract of baseline too)

Question 5

treatment

Answer 5

acute:
NSAIDS (naproxen, ibuprofen etc.) + physio
++ analgesics
++ Intra-articular corticosteroid injections (with local intra-articular inflammation or enthesitis)
++ sulfasalazine (with peripheral joint involvement)

ongoing:
(pain and stiffness refractory to NSAIDs + physio)
1st line => TNF-alpha inhibitor + physio OR secukinumab
++ NSAIDs
2nd line => IV pamidronate + physio
++ NSAIDs