Axial spondyloarthritis

Question 1

?What must you have to be dx

Answer 1

> 3 months of inflammatory back pain and age <45

Question 2

What are the SpA features in the criteria?

Answer 2

Inflammatory back pain
Arthritis
Enthesitis
Uveitis
Dactylitis
Psoriasis
Crohn's / colitis
Good response to NSAID
Family Hx of SpA
HLA-B27
Elevated CRP

Question 3

What is required for ank spond dx?

Answer 3

Sacroiliitis on plain x-ray

Question 4

What is peripheral spondyloarthritis?

Answer 4

Peripheral arthritis and/or enthesitis and/or dactylitis

Plus either one of the extra-articular, extra-spinal SpA features
Or >2 of the artricular manifestations

Question 5

What conditions fall over the umbrella of spondyloarthritis (SpA)?

Answer 5

Ank spond
Juvenile SpA
Arthritis associated with UC or Crohn's
Reactive arthritis
Acute anterior uveitis
Psoriatic arthritis
Undifferentiated SpA

Question 6

What are the features inflammatory back pain?

Answer 6

Aged at onset <40
Insidious onset
Improves with exercise
No improvement with rest
Pain at night (with improvement upon getting up)

Question 7

What is the pathogenesis of axSpA and PsA?

Answer 7

HLA-B27 allele + environmental factors
> IL-23 production 
> Th-17 cells activated by IL-23
> STAT3 planway > IL-17 produced
> NFKB
> Proinflammatory cytokines - IL-6, TNF, endothelial activation + osteoclast + osteoblasts activation (bone remodelling)

Question 8

What environment features play a roll?

Answer 8

Mechanical stress

Inflammation in gut - microbiome

Question 9

What are some clinical features of Axial SpA?

Answer 9

Inflam back pain, buttock pain
Restriction of spinal movement (later)
Extra-axial - asymmetric oligoarthritis of lower limb, enthesitis
Extra-articular - anterior uveitis, IBD, psoriasis, apical fibrosis, AR

Question 10

What percentage of HLA-B27+ people will develop AS

Answer 10

5%

Question 11

What percentage of patients with AS are HLA-B27 positive?

Answer 11

90%

Question 12

What percentage of people with AS have normal inflammatory markers?

Answer 12

25%

Question 13

What percentage of non-radiographic ank spond don’t go onto develop AS?

Answer 13

10-15%

Question 14

What are the x-ray signs of sacroiliitis?

Answer 14

Erosions and sclerosis at joint margins
Pseudo-widening
Joint space narrowing and ankylosis

Question 15

What are the x-ray signs in the spine?

Answer 15

Squaring of vertebral
Romanus lesion - “Shiny corner”
Syndesmophyte

Question 16

What are the MRI signs of sacroiliitis?

Answer 16

Sub-chondral bone marrow oedema - T2 weighted
Fatty lesions, erosions, sclerosis, ankylosis - T1 weighted
Synovitis enthesitis

Question 17

What is the first line Rx?

Answer 17

NSAIDs - symptomatic +/- disease modifying effect

Question 18

When are conventional DMARDs effective?

Answer 18

Peripheral arthritis only

Question 19

What factors predict response to biologic?

Answer 19

Younger
Higher baseline inflam markers
Worse inflammation on baseline MRI 
Less functional impairment
HLA-B27 positive

Question 20

How do you qualify for biologics in Australia?

Answer 20

Failed 12 weeks of NSAIDs and exercise and still have active disease

Question 21

Which biologics are useful in Ax SpA?

Answer 21

TNF-inhibitors - adalimumab, certolizumab, etanercept, golimumab, infliximab

IL-17A inhibitor - secukinumab

Question 22

Which biologic is available for nr-axSpA?

Answer 22

Golimumab

Question 23

How long do you need to be on biologics to get limitation of radiographic progression?

Answer 23

2 years