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BPT Rheumatology > Axial Spondyloarthritis and Psoriatic Arthritis > Flashcards

Axial Spondyloarthritis and Psoriatic Arthritis Flashcards

1
Q

How is axial spondyloarthritis classified?

A

3/12 of inflammatory back pain with onset at age than less than 45 years plus either sacrolititis on imaging and >1 SpA feature OR HLA-B27 positive and > 2 other SpA features

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2
Q

What are the SpA features?

A 
inflammatory back pain
arthritis
enthesitis
uveitis
dactylitis
psoriasis
crohn's/colitis
good response to NSAIDs
family history
HLA-B27
elevated CRP
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3
Q

How is peripheral spondyloarthritis classified?

A

peripheral arthritis or enthesitis or dactylitis PLUS at least one of (uveitis, psoriais, colitis, preceding infection, HLA-B27, sacrolitis on imaging) OR at least two of (arthritis, enthesitis, dactylitis, inflammatory back pain, FHx)

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4
Q

What conditions are classified as spondyloarhtritides?

A

Ankylosing spondylitis, undifferentiated SpA, Juvenile SpA, arthritis associated with UC/crohn’s, reactive arthritis, acute anterior uveitis, psoriatic arthritis

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5
Q

What is inflammatory back pain?

A

Back pain that occurs at age of less than 40 with a gradual onset, improvement with exercise, pain at night that improves when getting up

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6
Q

Which genes are involved in axSpAs?

A

HLA-B27, HLA-B40, ERAP1

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7
Q

What is a characteristic feature of the spondyloarthropathies?

A

bone remodelling occurs as well as damage

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8
Q

What are the clinical features of axial spondyloarthritis?

A

inflammatory back pain, alternating buttock pain, restriction in spinal movement, extra axial MSK features, extra articular features

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9
Q

What are the extra axial MSK features of axial spondyloarthritis?

A

Peripheral arthritis - in an asymmetric oligoarthritis pattern, and enthesitis

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10
Q

What are the extra articular features of axial spondyloarthritis?

A

anterior uveitis, IBD, psoriasis, apical fibrosis, aortic regurgitation

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11
Q

How common is axial spondyloarthritis?

A

0.5-1% of population

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12
Q

When is onset of symptoms of axial spondyloarthritis?

A

3rd decade of life

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13
Q

What percentage of people with the HLA-B27 gene will develop an axial spondyloarhtitis?

A

5%

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14
Q

What investigations should be done when axial spondyloarthritis is suspected?

A

HLA-B27, inflammatory markers, XR (sacro iliac joints, cervical and thoraco-lumbar spine), MRI

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15
Q

What percentage of people with AS are positive for HLA-B27?

A

90%

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16
Q

What is the difference between non radiographic axial spondyloarthritis and ankylosing spondylitis?

A

they are a spectrum of the same disease - non radiographic patients go on to develop AS over time (after 20 years 85% will have developed AS), patients have same levels of pain however patients with AS have more imapired spinal mobility and chest expansion

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17
Q

What does sacrolitis look like on plain XR?

A

normal in early disease, early changes: erosions, sclerosis at margins, later: pseudo-widening, last: joint space narrowing progressing to ankylosis

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18
Q

What does the spine look like on plain XR in ank spond?

A

squaring of the vertebrae, romanus lesion (shiny corner), syndesmophyte. In late stages can have fractures and fusion of facet joints

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19
Q

What are the features of sacro-iliitis on MRI?

A

active inflammation (subchondral bone marrow oedema), synovitis, enthesitis, post inflammatory lesions (erosions, sclerosis, ankylosis, fatty lesions)

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20
Q

What are the features in a spine MRI in axial spondyloarthritis?

A

bone marrow oedema at vertebral corners, erosions, spondylodiscitis

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21
Q

Which MRI sequence is best for visualising subchondral bone marrow oedema?

A

STIR sequence

22
Q

What predicts radiographic progression?

A

active inflammation and smoking

23
Q

What is first line therapy for axial spondyloarhtiritis?

A

NSAIDs and non pharmacologics e.g. exercise

24
Q

Are NSAIDs disease modifying?

A

yes

25
Q

What is the indication for sulfasalazine and methotrexate?

A

peripheral manifestations (arhtritis, enthesitis, dactylitis)

26
Q

Are conventional synthetic DMARDs (sulfasalazine and methotrexate) effective for spinal inflammation?

A

no

27
Q

What is the second line therapy for axial spondyloarthritis?

A

TNF alpha blockers or IL-17 blockers

28
Q

Should NSAIDs be used continuosly or PRN?

A

depends on risk vs benefit

29
Q

Which patients are the best candidates for biologic therapies?

A

young, shorter disease duration, higher inflammatory markers, worse inflammation on MRI, less functional impairment, HLA-B27 positive

30
Q

Which patients qualify for biologic therapy in Australia?

A

patients who have failed 12 weeks of NSAIDs and exercise and still have active disease

31
Q

Which biologic therapies are beneficial in axial spondyloarthropathies?

A

all TNF inhibitors and IL-17 inhibitors

32
Q

Are IL-12 and IL-23 blockers effective?

A

no

33
Q

Which biologic is available on the PBS for non radiographic axial spondyloarthritis?

A

golimumab

34
Q

Do biologic therapies stop XR progression?

A

not within first 2 years but yes after 2 years

35
Q

What percentage of patients with psoriasis develop psoriatic arthritis?

A

15%

36
Q

What are the 5 different patterns of joint involvement in psoriatic arthritis?

A
  • asymmetric oligoarthritis (most common)
  • symmetric polyarthritis
  • axial AS like
  • distal interphalyngeal joint with nail diease
  • arthritis mutilans
37
Q

What is dactylitis?

A

swelling along the entire length of digit - tendon and joint inflammation

38
Q

What are the nail changes in psoriatic arthritis?

A

pitting, onycholysis and nail plate crumbling

39
Q

What comorbidities are commonly seen in psoriatic arthritis?

A

CV disease, depression, metabolic syndrome

40
Q

What investigations should be ordered in psoriatic arhtritis?

A

there are no biomarkers/antibodies and CRP/ESR only go up in about 40% of patients, RF and CCP are usually negative, can look at XR

41
Q

What are the characeristic XR findings of psoriatic arhtirits?

A

pencil in cup deformity, erosions, new bone formation

can also get ankylosis and sacro-iliitis

42
Q

What are the treatment options for psoriatic arthritis?

A

NSAIDs for symptom relief, methotrexate, sulfasalazine, leflunomide, biologics (anti-TNF, anti-IL17, IL12/23 blocker, JAK1/3 inhibitor)

43
Q

In which patients should IL-17 blockers be avoided?

A

patients with IBD

44
Q

What is reactive arthritis?

A

a sterile arthritis following a remote infection

45
Q

Which are the causative organisms in reactive arthritis?

A

chlamydia, shigella, salmonella, campylobacter, yersinia

46
Q

How long before the arthritis do patients have the infection in reactive arhritis

A

1-4 weeks

47
Q

How do you treat reactive arthritis?

A

treat the infection, anti inflammatories for symptom relief, consider glucocorticoid if unwell

48
Q

How long does reactive arhrtitis last?

A

3-5 months

49
Q

Which patients should you use a DMARD in for reactive arthritis?

A

If it lasts longer than 5 months

50
Q

What percentage of patients with IBD get spondyloarthritis?

A

10%

51
Q

How should IBD associated spondyloarthritis be treated?

A

NSAIDs, DMARDs, controlling bowel disease, anti-TNF

BPT Rheumatology (8 decks)

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