ESPONDILOARTRITE AXIAL Flashcards
O QUE É ESPONDILOARTRITE AXIAL
D. INFLAMATORIA AFETA COLUNA VERTEBRAL
QUAL SUA PREVALENCIA MUNDIAL
0,5-1% (INCLUINDO ESTAGIOS INICIAIS)
QUAL A DOENÇA PROTOTIPO DE ESPONDILOARTRITE AXIAL
ESPONDILITE ANQUILOSANTE
FATO CONHECIDO SOBRE ELAS
INICIO INSIDIOSO / >40a IDADE / DOR CRONICA (>3meses)
POSSUI FORMAS NÃO RADIOGRÁFICAS?
SIM, até mesmo além do RX inalterado a RNM TB INALTERADA.
AS VEZES AQUELE ESPECTRO DE DOENÇA NÃO CHEGA PRODUZIR ALTERAÇÃO RADIOGRÁFICA
TEMPO MÉDIO DIAGNÓSTICO DEMORADA
7-13 ANOS DESDE INICIO SINTOMAS (PREJÚIZO PQ ATRADA QUALIDADE DE VIDA ATINGIDA PELOS TRATAMENTOS ATUAIS)
QUANDO PENSAR NESSE DIAGNÓSTICO
- LOMBALGIA INFLAMATÓRIA DE INICIO <40-45 ANOS
- MANIFESTAÇÃO EXTRA ARTICULAR (D. Inflatória Intestinal, UVEITE, ENTESITES calcaneo/fascia plantar por ex, DACTILITE dedo em salsicha que é uma artrite mais entesite)
- HISTÓRIA FAMILIAR (ESPONDILITE ANQUILOSANTE, PSORIASE que pode da acometimento axial, D. Inflatória Intestinal, UVEITE, ENTESITES calcaneo/fascia plantar por ex, DACTILITE dedo em salsicha que é uma artrite mais entesite)
PREDOMINÂNCIA POR GENERO
MASCULINO 3:1
EXÂMES A SEREM PEDIDOS INICIALMENTE
PCR VHS
HLA B27
SACROILEÍTE NA IMAGEM (RX RNM)
As incidências mais usadas no nosso meio são a ântero-posterior com angulação caudal do raio de 25-30° e oblíquas, na tentativa de minimizar a sobreposição de estruturas, facilitando assim a interpretação do exame
CRITÉRIOS DOR LOMBAR INFLAMATÓRIA (4/critérios)
- INICIO <40a
- DURAÇÃO >3meses (CRÔNICA)
- INSIDIOSA
- RIGIDEZ MATINAL
- MELHORA COM EXERCÍCIOS E NAO COM REPOUSO
- DESPERTA A NOITE PELA DOR
- DOR EM NADEGAS ALTERNANTES
SACROILEITE GRAUS 1-4
UNI OU BILATERAL
grau 0 normal; grau 1 alterações suspeitas, porém não claras; grau 2 pequenas erosões e esclerose, porém sem alteração no espaço articular; grau 3 erosões e esclerose, com alargamento ou redução do espaço articular; grau 4 anquilose
QUADRATURA (RX)
CALCIFICAÇÃO (RX)
Retificação lombar com quadratura das vértebras
Calcificação do ligamento longitudinal anterior em região cervical, toracolombar e lombar
ATENTAR PARA ENTESISTES TORÁCICAS SINTOMÁTICAS
DIMINUIÇÃO DA EXPANSÃO TORÁCICA
CRITERIOS MODERDOS para diagnostico
DE ASAS classification criteria for axial espondyloarthritis
EM PACIENTES COM LOMBALGIA CRÔNICA (>3m) + INICIO <45 ANOS:
- SACROILEITE EM IMAGEM (RX ou RMN) + 1 ou > SINTOMAS de Espondiloartrite axial
- HLA B27 positivo + 2 ou > SINTOMAS de Espondiloartrite axial
sintomas de Espondiloartrite axial:
-dorsalgia inflamatoria
-artrite
-entesite
-uveite
-psoriase
-doença inflamatoria intestinal
-dactilite
-otima resposta aos AINE´s
-HLA B27
-PCR elevado
-historia familiar de Espondiloartrite axial
AMPLITUDE MOVIMENTO teste fisico
teste de schober 10»_space;> 15cm lombar
expansao toracica (medir circurnferencia 4 eic e depois medir apos expansao normal acima 5cm)
avaliaçao sacroiliaca
teste Gaenslen: flexao maxima quadril sobre a mesa e extensão maxima com quadril suspenso da mesa
teste de Patrick (F-Ab-Re)
Diagnóstico pelo Reumatologista
The 2009 ASAS criteria should be used to classify patients with axial spondyloarthritis. The diagnosis should be performed by an experienced physician or rheumatologist. Level of evidence: 1B; strength of recommendation: A (strong); Degree of agreement: 9.2.
The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis – 2019
What is the role of magnetic resonance imaging (MRI) for the initial evaluation of axial SpA?
In patients with clinically suspected axial SpA, in which sacroiliac radiography is not conclusive, sacroiliac joints (SIJ) MRI is recommended. Level of evidence: 1A; Strength of recommendation: A (strong); Degree of agreement: 9.0.
SIJ MRI scans should be acquired in T1W and STIR and/or T2 fat saturation (FATSAT) sequences. Intravenous MRI contrast (gadolinium) is not recommended routinely. Level of evidence: 2B; Strength of recommendation: B (moderate); Degree of agreement: 9.5.
Spine MRI scans are not recommended on a routine basis for the diagnosis of patients with suspected axial SpA and no sacroiliitis on images. Level of evidence: 1B; Strength of recommendation: A (strong); Degree of agreement: 8.5.
The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis – 2019
What is the role of HLA-B27 in axial spondyloarthritis? Diagnosis
HLA-B27 test is recommended for patients with clinically suspected axial SpA for prognostic reasons (more severe axial involvement, higher risk of anterior uveitis and family history of axial SpA). Although it is frequently used as a diagnostic tool in our population, there is very limited evidence of its value. Level of evidence: 2A; Strength of recommendation: B (moderate); Degree of agreement: 9.2.
The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis – 2019
- What is the evidence for the use of physical rehabilitation in patients with axial SpA?
Physical rehabilitation programs should be indicated for and offered to all patients diagnosed with axial spondyloarthritis during all stages of the disease. Level of evidence: 1A; Strength of recommendation: A (strong); Degree of agreement: 9.8.
Programs specifically focused on improving mobility are primarily recommended, although programs focused on improving endurance and cardiorespiratory fitness are also beneficial. Level of evidence: 2A; Strength of recommendation: B (moderate); Degree of agreement: 9.6.
The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis – 2019
- What is the evidence for the use of glucocorticoids in patients with axial SpA?
Long-term use of systemic glucocorticoids to treat axial spondyloarthritis is not recommended. Level of evidence: 5; Strength of recommendation: D (very weak); Degree of agreement: 9.6.
Patients with symptomatic peripheral enthesitis can undergo peritendinous glucocorticoid injections. Caution is advised because the procedure may increase the risk of rupture, particularly in the Achilles tendon. Level of evidence: 2A; Strength of recommendation: B (moderate); Degree of agreement: 9.2.
Patients with isolated buttock pain who are unresponsive to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) may experience short-term benefits from an intraarticular injection of triamcinolone acetate in the sacroiliac joints. Level of evidence: 2C; Strength of recommendation: B (moderate); Degree of agreement: 8.5.
The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis – 2019
In which situations is the continuous use of NSAIDs recommended for patients with axial SpA?
NSAIDs should be indicated as the first-line treatment for active and symptomatic axial SpA. Level of evidence: 1A; Strength of recommendation: A (strong); Degree of agreement: 9.8.
There is no evidence that a specific NSAID can be considered superior to the other NSAIDs. Level of evidence: 1A; Strength of recommendation: A (strong); Degree of agreement: 9.3.
Evidence on the effect of NSAIDs on reducing radiographic progression in patients with axial SpA is conflicting. Level of evidence: 1B; Strength of recommendation: B (moderate); Degree of agreement: 9.3.
The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis – 2019
What is theevidencefor theuseof syntheticdisease-modifying antirheumatic drugs (methotrexate, sulfasalazine and leflunomide) in patients with axial SpA?
The use of methotrexate and sulfasalazine is recommended for the treatment of patients with axial SpA when peripheral arthritis is present or in the absence of another pharmacological treatment option due to toxicity, intolerance or contraindications. Level of evidence: 2A; Strength of recommendation: B (moderate); Degree of agreement: 8.4.
The routine use of methotrexate or sulfasalazine as a co-medication in patients with axial SpA who are using biologics is not recommended. Level of evidence: 2B; Strength of recommendation: B (moderate); Degree of agreement: 9.6.
The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis – 2019
What evidence of efficacy supports indications for the use of biologics in patients with axial SpA?
The TNFα inhibitors and the IL17A inhibitors exhibit similar effect sizes for controlling inflammatory activity in patients with axial SpA. Level of evidence: 1A; Strength of recommendation: A (strong); Degree of agreement: 8.9.
The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis – 2019
