Musculoskeletal Flashcards
What is rheumatoid arthritis?
A chronic autoimmune condition, characterised by inflammation of the joint synovium
It is a symmetrical polyarthritis, typically affecting the small joints in a relapsing-remitting course, where disease flares can be sudden and unpredictable
Extra-articular manifestations may affect the lungs, skin, blood, eyes and other organs
The cause of RA remains unclear, however it is likely a mix of genetic, environmental and other factors
Joint structure?
The end of each bone is covered with cartilage that has a very smooth, slippery surface. The cartilage allows the ends of the bones to move against each other, almost without rubbing.
The joint is held in place by the synovium, which contains thick fluid to protect the bones and joint.
The synovium has a tough outer layer that holds the joint in place and stops the bones moving too far.
Strong cords called tendons anchor the muscles to the bones
Epidimiology of RA.
1. Prevalence
2. Gender
3. Age
- Affects around 1% of the UK population (400,000 adults aged 16 and over in the UK)
- More commion in women (female:male ratio of 2–4:1)
- Affects at any age but peak onset at 40 - 70 years
Symptoms of RA?
Main symptoms:
* Joint pain
* Joint swelling, warmth and redness
* Stiffness, especially first thing in the morning or after sitting still for a long time
Other symptoms can include:
* Fatigue
* A poor appetite
* Weight loss
* Fever
* Sweating
* Dry eyes – as a result of inflammation
* Chest pain – as a result of inflammation
* Fleshy lumps called rheumatoid nodules, which form under the skin around affected joints. They can sometimes be painful, but usually painless
Risk factors for RA?
- Age (more common in >40s)
- Being overweight
- Smoking
- Diet (some evidence that eating a lot of red meat and not consuming much vitamin C can increase risk)
- First degree relative with RA
What is the most important environmental trigger for RA?
Smoking
Increases disease susceptibility by 20- to 40-fold when associated with genetic factor
Smoking is more likely to cause the bones in the spine fuse together (for people with spondylarthritis)
Patients with RA should be counselled to reduce their risk of what other co-morbidity?
Cardiovascular disease
Advise on smoking cessation, weight loss and exercise
How is disease severity measured in people with RA?
With the 28-joint Disease Activity Score (DAS28)
A composite score calculated from the number of tender and swollen joints, erythrocyte sedimentation rate (an inflammation marker) or C-reactive protein levels, and a self-reported patient assessment of general health status according to a 100mm visual analogue scale
About half of all people with rheumatoid arthritis also have rheumatoid factor in their blood when the condition starts. However, around 1 in every 20 people without rheumatoid arthritis also test positive for rheumatoid factor
(Rheumatoid factors are proteins that the immune system produces when it attacks healthy tissue)
Patient’s with what symptoms should be referred for specialist opinion?
Suspected persistent synovitis (soft tissue joint swelling) of undetermined cause.
Refer urgently (even with a normal acute-phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if any of the following apply:
* the small joints of the hands or feet are affected
* more than one joint is affected
* there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice
What investigations should be undertaken following diagnosis of RA?
As soon as possible after establishing a diagnosis of RA:
* measure anti-CCP antibodies, unless already measured to inform diagnosis
* X-ray the hands and feet to establish whether erosions are present, unless X-rays were performed to inform diagnosis
* measure functional ability using, for example, the Health Assessment Questionnaire (HAQ), to provide a baseline for assessing the functional
response to treatment
If anti-CCP antibodies are present or there are erosions on X-ray:
* advise the person that they have an increased risk of radiological progression but not necessarily an increased risk of poor function, and
* emphasise the importance of monitoring their condition, and seeking rapid access to specialist care if disease worsens or they have a flare.
What is the aim of treatment for RA?
Remission or low disease activity if remission cannot be achieved
Consider making the target remission rather than low disease activity for people with an increased risk of radiological progression (presence of anti-CCP antibodies or erosions on X-ray at baseline assessment)
In adults with active RA, what markers should be measured until the target of remission or low disease activity is achieved?
C-reactive protein (CRP) and disease activity
(using a composite score such as DAS28) monthly in specialist care until the target of remission or low disease activity is achieved
First line pain relief medication for RA?
Regular Paracetamol +/- oral NSAID/Cox-2 inhibitor
NSAIDs are effective in reducing pain, swelling and stiffness associated with RA, but have no effect on long-term disease control
For NSAIDs, offer the lowest effective dose for the shortest possible time + PPI + review risk factors for adverse events regularly
If a patient has arthritis and is on low dose aspirin, how would their pain managment differ from a regular RA patient?
Paracetamol first, then consider opioid before starting an NSAID
First line management of patients with RA?
DMARD monotherapy e.g. MTX, leflunomide, sulfasalazine as soon as possible and ideally within 3 months of onset of persistent symptoms.
Hydroxychloroquine (weak DMARD) as alternative for for mild or palindromic disease (attacks of joint pain and inflammation that come and go)
Consider short-term bridging treatment with glucocorticoids (oral, intramuscular or intra-articular) when starting a new cDMARD
What is the ‘window of opportunity’ in RA management?
12 weeks from initial symptom onset
DMARDs should ideally be started within this timeframe
What is the ‘treat to target’ in RA management?
Core principle for RA management
The clinician and patient agree on a treatment goal, and the patient is monitored monthly, with timely treatment escalation, until the treatment target is achieved
Proven to result in improved functional and radiographic outcomes
Second line management of patients with RA?
If remission or low disease activity has not been achieved despite dose escalation:
Offer additional cDMARDs (oral methotrexate, leflunomide, sulfasalazine or hydroxychloroquine) in combination in a step-up strategy
What are DMARDs?
Disease-modifying antirheumatic drugs
Inhibit structural damage to cartilage and bone
What are the 3 types of DMARDs?
- Conventional synthetic (csDMARDs)
- Biologic (bDMARDs)
- Targeted synthetic (tsDMARDs)
What are the conventional DMARDs?
Methotrexate, leflunomide or sulfasalazine (Hydroxychloroquine can be used as an alternative for patients with mild or palindromic disease)
First line treatment for RA.
Each csDMARD has a unique mechanism of action within the inflammatory cascade
Conventional DMARDs: Methotrexate.
Generally used as a first-line csDMARD in RA
Regime
* Starting doses of 10–15mg/week, titrated up to 15–25mg/week
* Onset of action of around 4–12 weeks
* Co-administration of a minimum dose of 5mg folic acid once weekly to help reduce the risk of side effects and improve tolerability
Contraindications
* Significantly impaired hepatic function
* Alcoholism
* Pregnancy
* Known active peptic ulceration
* Immunodeficiency,
* eGFR <10 mL/min
Can be given by subcutaneous injection when patients are unable to tolerate oral doses because of gastric side effects, or to increase bioavailability and efficacy
Conventional DMARDs: Leflunomide.
Alternative in patients where methotrexate is contraindicated or there is early intolerance
Has both immunomodulatory and immunosuppressive characteristics
Regime
* Loading dose of 100mg daily for three days then maintenance dosage of 10–20mg daily
* However, many clinicians do not use this loading dose regimen because patients are unable to tolerate the associated gastrointestinal side effects
* Therapeutic effect starts after 4–6 weeks, and further improvement may be seen for up to 4–6 months.
Side effects
* Haematological ADRs
* Hepatotoxicity
* Hypertension; a patient’s blood pressure should be checked before commencing treatment and periodically thereafter
Conventional DMARDs: Sulfasalazine
Alternative to methotrexate however, methotrexate has lower rates of erosions and higher levels of drug persistence over time
Regime
* To reduce the side effect of nausea, the dose is usually titrated upwards from 500mg daily, increasing by 500mg each week to a maintenance dose of 2–3g daily, usually taken in two divided doses
* If a patient struggles with tolerance, a more gradual dose titration can be used
* Onset of action of 6–12 weeks
Side effects
* Haematological abnormalities (report unexplained bleeding, bruising, purpura, sore throat, fever or malaise)
* Can colour urine, tears and stain contact lenses yellow-orange
Conventional DMARDs: Hydroxychloroquine
May be used in milder disease, disease with palindromic onset or as an additive therapy to other csDMARDs
Although its efficacy as a DMARD or additional benefit in triple therapy regimes has been questioned in some systematic reviews
Regime
* SPC recommends a maximum dose of 6.5mg/kg/day based on ideal body weight, but the Royal College of Ophthalmologists recommends keeping the dose <5mg/kg/day based on actual body weight
* Usually given as an oral tablet, typically in one to two divided doses per day
Side effects
* Retinopathy
Refer patients to a secondary care ophthalmologist after five years of treatment for ongoing annual retinopathy screening, or after a year if risk factors for retinopathy are present, such as
* Concomitant tamoxifen use
* Impaired renal function (eGFR <60mL/min/1.73m2)
* Hydroxychloroquine dose >5mg/kg/day
How long can conventional DMARDS take to be effective?
2-3 months
How are csDMARDs monitored?
All subject to standard tests:
* FBC
* creatinine/calculated GFR
* Alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST)
* Albumin
With some requiring additional monitoring (see table)
CRP or ESR is also typically monitored for DAS-28 calculation to assess efficacy
Tests are completed at initiation, then every 2 weeks for 6 weeks
Once the patient is stable
* Test monthly for 3 months, then at least every 12 weeks thereafter (more frequent monitoring is appropriate in patients at higher risk of toxicity)
Following a dose increase
* Monitoring is required every 2 weeks for 6 weeks, and then reverts to the previous schedule
What can DMARDS be bridged with to give a more rapid effect of symptomatic control?
Glucocorticoids
Act by inhibiting cytokine release and are effective at reducing inflammation and suppressing the immune system to give rapid relief of symptoms
Depending on the number of affected joints, they may be administered as an intra-articular injection for local action or as an intramuscular depot injection, intravenous infusion or short-term oral therapy for systemic effects
In patients with severe or moderate disease activity (measured by DAS28) despite having tried at least two csDMARDs (including methotrexate), what else can be offered?
Biological DMARDs or Targeted synthetic DMARDs
NICE stipulates that should be used in combination with methotrexate but local agreements may vary
Combination therapy using a b/tsDMARD and methotrexate (‘anchor therapy’) is advocated because of superior efficacy and reduced risk of b/tsDMARD immunogenicity
Example of TNF alpha inhibitors
Infliximab, adalimumab, golimumab, etanercept, certolizumab pegol
Mechanism of action of bDMARDs?
TNF-alpha inhibitors
* Adalimumab, certolizumab, etanercept, golimumab and infliximab
* Block TNF-α, resulting in dampening of the inflammatory cascade and blocking IL-1 activity
Monoclonal antibody
* Rituximab, tocilizumab, sarilumab
* Rituximab - binds specifically to the transmembrane antigen CD20, depleting B-cells, affecting B- and T-cell interaction, antigen presentation and cytokine production
* Tocilizumab and sarilumab — block the actions of interleukin-6 (IL-6), a multifunction cytokine which regulates immune responses. IL-6 blockade is associated with reduced production of acute-phase proteins and auto-immune antibodies
CTLA-4 inhibitor
* Abatacept
* Cytotoxic T-lymphocyte associated antigen-4 inhibitor
* Causes attenuation of T-cell activity by blocking a co-stimulatory signal, thereby reducing expression of activation markers, secretion of cytokines and stimulation of macrophages to reduce inflammation
IL-17 inhibitor
* Secukinumab
If someone with severe active rheumatoid arthritis has had an inadequate response to or is intolerant of other DMARDs (including at least one TNF alpha inhibitor) What can be tried?
RTX in combination with MTX
What are targeted synthetic (tsDMARDs)?
Janus kinase inhibitors (JAKis)
* Inhibit the activity of one or more of the janus kinase family of enzymes
* Tofacitinib and baricitinib (active on the majority of the four JAK family members (JAK1, JAK2, JAK3 and TYK2))
* Filgotinib and upadacitinib (JAK-1 selectivity)
Subject of a Pharmacovigilance Risk Assessment Committee (PRAC) investigation owing to safety concerns (CVD, VTE, malignancy, infection)
Treatment with a b/tsDMARD therapy should only be continued if what response is achieved?
Only if there is a moderate response measured using EULAR criteria at six months after starting therapy
Monitoring requirements for b/tsDMARDs?
(Pre-screening, frequency etc.)
Standard tests:
* FBC
* Creatinine/calculated GFR
* ALT and/or AST
* Albumin blood
* Chest radiograph
* Tuberculin skin test (TST) or IFN-γ release assay (IGRA) or both as appropriate
* Serology for hepatitis B and C
* HIV serology if risk factors for HIV infection
First 4 tested every 3–6 months (in practice this could be 3-monthly for the first 12 months and then 6-monthly)
The following should also be considered:
* Varicella zoster virus antibody test if no positive history of previous varicella infection and, if negative, consider varicella zoster vaccination if no contraindications
* Herpes zoster (Shingles) vaccination if patient >50 years and no contraindications
* Hepatitis B vaccination for at-risk patients
Factors that influence b/tsDMARD selection?
On the balance of its clinical benefits and cost effectiveness, anakinra is not recommended for the treatment of RA, except in the context of a controlled,
long-term clinical study.
True or False?
True
If already taking anakinra, patients should continue therapy with anakinra until they and their consultant consider it is appropriate to stop
Short-term treatment with glucocorticoids is used for managing RA flares.
When can they be used for long-term treatment?
When the long-term complications of glucocorticoid therapy have been fully discussed and all other treatment options (including biological and targeted synthetic DMARDs) have been offered
What needs to be monitored with patients on hydroxychloroquine / chloroquine?
Ocular function - risk of retinopathy
Non-pharmacological treatment of RA?
Physiotherapy
* Access to specialist PT
* Learn about the short-term pain relief provided by methods such as transcutaneous electrical nerve stimulators (TENS) and wax baths
Occupational therapy
Access to specialist OT
Hand exercise programmes
Consider a tailored strengthening and stretching hand exercise programme for adults with RA with pain and dysfunction of the hands or wrists if:
* they are not on a drug regimen for RA, or
* they have been on a stable drug regimen for RA for at least 3 months.
Podiatry
* All adults with RA and foot problems should have access to a podiatrist
* Functional insoles and therapeutic footwear should be available for all adults with RA if indicated
Psychological therapy
Offer psychological interventions (for example, relaxation, stress management and cognitive coping skills [such as managing negative thinking])
Self-care advice for patients during RA flare ups
- Increasing or starting “when required” analgesics
- Using cold therapy (ice packs wrapped up or cold water for max. 30 minutes) to soothe hot, red, swollen joints, or using warm therapy (warm water, warm bath, heat pads, hot water bottle or heat bags) to relieve stiff joints
- Using gentle stretching and a range of motion exercises to help improve joint function. Movement can help keep joints flexible, reduce pain, and improve balance and strength
- Balancing activities with plenty of rest during a flare-up (pacing)
- Using temporary aids e.g. a walking stick or accessing aids up to £1000
- Considering stress-relieving activities (e.g. yoga, deep breathing, meditation)
- Letting friends, family and colleagues know, so they are aware and can help if needed
- Speaking to their GP or specialist rheumatology team if the flare-up is severe or does not resolve
- Identifying and avoiding potential triggers for a flare-up
- Assessing the frequency and severity of flare-ups and, if happening regularly, speaking to their GP or specialist rheumatology team
- Establishing how the flare-up is impacting their daily life and activities, and seeking help from a support network
- Accessing supportive websites from the secondary care provider or patient charities
Changes in diet can reduce inflammation in RA.
True or False?
False
There is no strong evidence that their arthritis will benefit from diet changes
However, patients could be encouraged to follow the principles of a Mediterranean diet (more bread, fruit,
vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils) and to take daily vitamin D containing 10 micrograms in autumn and winter
How often should RA patients be reviewed?
Consider a review appointment to take place 6 months after achieving treatment target (remission or low disease activity) to ensure that the target has been maintained
Then annual reviews to assess:
* Disease activity and damage, and measure functional ability (using, for example, the Health Assessment Questionnaire [HAQ])
* The development of comorbidities (e.g. HTN, IHD, osteoporosis and depression)
* Symptoms that suggest complications (e.g. vasculitis and disease of the cervical spine, lung or eyes)
* The need for referral for surgery
* The effect the disease is having on a person’s life
Reducing drug doses or stopping drugs should be considered when?
For adults who have maintained the treatment target (remission or low disease activity) for at least 1 year without glucocorticoids
Return promptly to the previous DMARD regimen if the treatment target is no longer met
Ultrasound should not be used for routine monitoring of disease activity in adults with RA.
True or False?
True
Patients with what symptoms should be referred for surgery? What is the benefit?
If any of the following do not respond to optimal non-surgical management:
* persistent pain due to joint damage or other identifiable soft tissue cause
* worsening joint function
* progressive deformity
* persistent localised synovitis
or presence of the following:
* imminent or actual tendon rupture
* nerve compression (for example, carpal tunnel syndrome)
* stress fracture
When surgery is offered to adults with RA, explain that the main expected benefits are:
* pain relief
* improvement, or prevention of further deterioration, of joint function, and
* prevention of deformity
Cosmetic improvements should not be the dominant concern
What are the symptoms of cervical myelopathy?
Paraesthesia (pins and needles), weakness, unsteadiness, reduced power, extensor plantars (reflex elicited when the sole of the foot is stimulated, an upwards response indicates neurological damage)
Need to request an urgent MRI scan, and refer for a specialist surgical opinion
Concerns about the long-term durability of prosthetic joints should influence decisions to offer joint replacements to younger adults with RA.
True or False?
False
What organ needs to be monitored in patients using Toculizumab?
Hepatic function
Acute low back pain should be treated with which analgesics?
NSAIDS
Is paracetamol alone effective for treating lower back pain?
No - if intolerate to NSAID add in opioid
What enzyme do NSAIDS inhibit?
COX enzyme thereby inhibiting prostagladin production
Which COX enzyme is associated with less GI intolerance
COX 2
If a patient is on Mercaptopurine or Azathioprine and is due to start Allopurinol what dose alteraction is required?
Reduce dose by 1/4 to 1/2 with allopurinol
Celecoxib, etorocoxib and parecoxib are examples of what type of NSAID
COX 2 selective
Ketoprofen, piroxicam and ketolorac are the highest risk of what side effect
GI toxicity
Lowest risk NSAIDS of GI toxicity
COX 2 selective (COXIBS)
What NSAIDS are at high risk of CV events
Cox 2 selectives (coxibs), High dose ibuprofen (>2.4g), Diclofenac
Can NSAIDS be given in severe heart failure?
No - always contraindicated
Are NSAIDS safe in pregancy?
No - they delay labour, cause pulmonary hypertension and premature closure of ductus arteriosus
If a patient is taking an ACEi / Ciclosporin / Tacrolimus / Diuretics with an NSAID - what is the risk
risk of AKI
Potassium sparring diuretic + NSAID interaction
Hyperkalaemia
Quinolones + NSAID interaction
Risk of convulsions
Methotrexate / Lithium + NSAID interaction
Risk of toxicity
What is Spondyloarthritis?
A group of inflammatory conditions that have a range of manifestations. Can be:
Axial
* radiographic axial spondyloarthritis (ankylosing spondylitis)
* non-radiographic axial spondyloarthritis (same as radiographic but physical changes to the back cannot be seen on an x-ray)
Peripheral
* psoriatic arthritis
* reactive arthritis
* enteropathic spondyloarthritis (spondyloarthritis associated with inflammatory bowel disease)
People with predominantly axial spondyloarthritis may have additional peripheral symptoms, and vice versa
What is ankylosing spondylitis?
Radiographic axial spondyloarthritis that mainly affects the back, by causing inflammation in the spine
- Results in a painful back and rib cage; and neck stiffness
- While it mainly affects the neck and back, it can also cause pain and stiffness elsewhere in the body
In response to the inflammation, the body produces extra calcium around the bones of the spine. This can make extra bits of bone grow and cause stiffness
In rare cases some of the bones of the spine may link up, or fuse together because of the extra calcium. In serious cases this can make the spine curve forward more
It often starts in people who are in their late teens or 20s
What are the symptoms of spondyloarthritis?
Signs and symptoms may be:
Musculoskeletal
* Inflammatory back pain
* Stiff lower back in the early morning that lasts at least 30 minutes and then eases through the day or with activity
* Pain that wakes at night
* Pain in one or both buttocks and sometimes the backs of the thighs
* Enthesitis (inflammation at tendon, ligament or joint)
* Dactylitis (inflammation of an entire digit)
Extra-articular
* Uveitis (inflammation of the middle layer of the eye)
* Psoriasis (dry, scaly and sometimes itchy or sore patches on the skin; including psoriatic nail symptoms)
* Inflammatory bowel disease
Can have diverse symptoms and be difficult to identify
What are risk factors for spondyloarthritis?
- Recent genitourinary infection
- Family history of spondyloarthritis or psoriasis
What are the criteria for diagnosis of axial spondyloarthritis?
If a person has low back pain that started before the age of 45 years and has
lasted for longer than 3 months, refer the person to a rheumatologist for a spondyloarthritis assessment if 4 or more of the following are present:
1. Low back pain that started before the age of 35 years
2. Waking during the second half of the night because of symptoms
3. Buttock pain
4. Improvement with movement
5. Improvement within 48 hours of taking NSAIDs
6. A first-degree relative with spondyloarthritis
7. Current or past arthritis
8. Current or past enthesitis
9. Current or past psoriasis
If exactly 3 of the additional criteria are present
* Perform an HLA-B27 test. If the test is positive, refer the person to a rheumatologist
If the person does not meet the criteria but clinical suspicion remains
* Advise the person to seek repeat assessment if experiences new signs and symptoms
People with dactylitis (digit inflammation) should always be referred to a rheumatologist for a spondyloarthritis assessment.
True or False?
True
People with enthesitis (joint inflammation) should always be referred to a rheumatologist for a spondyloarthritis assessment.
True or False?
False
Only refer if excluded mechanical causes and they have any of the following:
* It is persistent
* It is in multiple sites
* Any of the following are also present
－ back pain without apparent mechanical cause
－ current or past uveitis
－ current or past psoriasis
－ gastrointestinal or genitourinary infection
－ inflammatory bowel disease (Crohn’s disease or ulcerative colitis)
－ a first-degree relative with spondyloarthritis or psoriasis
People with acute anterior uveitis (eye inflammation) should be referred to a same-day ophthalmological assessment.
True or False?
True
Symptoms include eye pain, eye redness, sensitivity to light and blurred vision
Axial spondyloarthritis:
* Affects a similar number of women as men
* Can occur in people who are human leukocyte antigen B27 (HLA-B27) negative
* May be present despite no evidence of sacroiliitis on a plain film X-ray
True or False?
True
Diagnosis of spondyloarthritis should not be ruled out solely on the basis of a negative HLA-B27 result.
True or False?
True
Most people with ankylosing spondylitis test positive for HLA-B27, but so do many people who don’t have the condition (it is found in 90% of people with AS)
It’s thought that HLA-B27 proteins tend to fold incorrectly inside cells, which may lead to the immune system releasing chemicals that cause inflammation
Diagnosis of spondyloarthritis should not be ruled out if a person’s C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are normal.
True or False?
True
You should not routinely test for infective antibody status to diagnose reactive arthritis in people with a history of gastrointestinal infection.
True or False?
True
People with spondyloarthritis can experience flares and extra-articular symptoms.
What should be part of their flare management plan?
- Access to care during flares (including details of a named person to contact e.g. a specialist rheumatology nurse)
- Self-care (for example, exercises, stretching and joint protection)
- Pain and fatigue management
- Potential changes to medicines
- Managing the impact on daily life and ability to work
What analgesic should be offered to people with axial spondyloarthritis?
Offer NSAIDs at the lowest effective dose to people with pain associated with axial spondyloarthritis
If an NSAID taken at the maximum tolerated dose for 2–4 weeks does not provide adequate pain relief, consider switching to another NSAID
Ankylosing spondylitis management
- NSAIDs (paracetamol +/- codeine if NSAID not tolerated)
- Biologic DMARD (or conventional DMARD if there is pain and inflammation in peripheral joints such as the hands, knees, feet. Ineffective on the spine)
Corticosteroids for flare-ups
Biological DMARDs are used in severe active ankylosing spondylitis and non-radiographic axial spondyloarthritis in adults whose disease has responded inadequately to, or who cannot tolerate, NSAIDs.
Which ones are used?
TNF-alpha inhibitors
* Adalimumab
* Certolizumab pegol
* Etanercept
* Golimumab
* Infliximab
Biological DMARDs in spondyloarthritis should only be continued if there is clear evidence of response. How is this defined?
- A reduction in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score to 50% of the pre-treatment value or by 2 or more units and
- A reduction in the spinal pain visual analogue scale (VAS) by 2 cm or more
Response should be assessed 12 weeks after the start of treatment
Trial another TNF-alpha inhibitor if the first is not tolerated or response is inadequate or if the disease has stopped responding after an initial response
When is secukinumab recommended for the treatment of ankylosing spondylitis?
For treating active ankylosing spondylitis in adults whose disease has responded inadequately to conventional therapy (NSAIDs or TNF-alpha inhibitors)
The drug is recommended only if the company provides it with the discount agreed in the patient access scheme
Assess the response to secukinumab after 16 weeks
Only continue if:
* A reduction in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score to 50% of the pre-treatment value or by 2 or more units and
* A reduction in the spinal pain visual analogue scale (VAS) by 2 cm or more
Non-biological management of peripheral spondyloarthritis? (e.g. psoriatic arthritis)
Consider local corticosteroid injections as monotherapy for non-progressive monoarthritis
Offer standard DMARDs to people with:
- peripheral polyarthritis
- oligoarthritis (arthritis affecting less than four joints)
- persistent or progressive monoarthritis associated with peripheral spondyloarthritis
If a standard DMARD taken at the maximum tolerated dose for at least 3 months does not provide adequate relief from symptoms, consider switching to or adding
another standard DMARD
What can be used as adjuncts to biological or standard DMARDs in peripheral spondyloarthritis?
NSAIDs
If NSAIDs do not provide adequate relief from symptoms, consider steroid injections (local or intramuscular) or short-term oral steroid therapy
Etanercept, infliximab and adalimumab are recommended for the treatment of adults with active and progressive psoriatic arthritis under what criteria?
- The person has peripheral arthritis with 3 or more tender joints and 3 or more swollen joints, and
- The psoriatic arthritis has not responded to adequate trials of at least 2 standard DMARDs (either separately or in combination)
Treatment should be discontinued in people without an adequate response at 12 weeks, defined as:
* An improvement in at least 2 of the 4 Psoriatic Arthritis Response Criteria (PsARC) [1 of which has to be joint tenderness or swelling score]
* With no worsening in any of the 4 criteria.
Golimumab is only used for psoriatic arthritis if what cost condition is satisfied?
Only if the manufacturer provides the 100 mg dose of golimumab at the same cost as the 50 mg dose
Ustekinumab is recommended as an option, alone or in combination with methotrexate, for treating active psoriatic arthritis in adults under what conditions?
- Treatment with TNF-alpha inhibitors is contraindicated but would otherwise be considered or
- The person has had treatment with 1 or more TNF-alpha inhibitors
Only if the company provides the 90 mg dose of ustekinumab for people who weigh more than 100 kg at the same cost as the 45 mg dose, as agreed in the patient access scheme
Treatment should be discontinued in people without an adequate response at 24 weeks, defined as:
* An improvement in at least 2 of the 4 Psoriatic Arthritis Response Criteria (PsARC) [1 of which has to be joint tenderness or swelling score]
* With no worsening in any of the 4 criteria.
What is reactive arthritis?
Should antibiotics be used long term for it?
Inflammatory arthritis that develops in response to a gastrointestinal or genitourinary infection
After treating the initial infection, antibiotics should not be offered long-term (4 weeks or longer)
Non-pharmacological management of
spondyloarthritis?
- Physiotherapy (stretching, strengthening, deep breathing, spinal extension, aerobic exercise)
- Exercise (pilates, yoga and t’ai chi may be useful as these can help with posture, strength and flexibility)
- Swimming and hydrotherapy (uses lots of muscles and joints without jarring them)
- Referral to a specialist therapist (occupational therapist, hand therapist, orthotist or podiatrist)
Spinal manipulation is not helpful or safe for people with ankylosing spondylitis as it could result in permanent damage to the spine
Ankylosing spondylitis is automatically covered by the Equality Act.
True or False?
False
Ankylosing spondylitis isn’t automatically covered under the Equality Act (2010) but it is if it affects ability to carry out every-day tasks. This is based on how someone would manage if they weren’t taking any medication.
Spondyloarthritis and pregnancy
- Methotrexate should be stopped several months before a woman tries to get pregnant
- Latest research suggests it’s safe for men to take methotrexate when trying for a baby with their partner
- Biological therapies seem to be safe in the earlier stages of pregnancy but are then stopped later in pregnancy
Usually, pregnancy doesn’t cause any special problems for the mother or baby. If the spine is very stiff, it may not be possible for the mother to have an epidural during childbirth
Testing children for HLA-B27 gene isn’t recommended because there’s no way of knowing whether a child will develop ankylosing spondylitis even if they do have the gene
Sleep hygeine advice for people who struggle with night time back pain?
- Establish ood a of going to bed at the same time each evening, and getting up at the same time each morning
- Keep your bedroom clean and tidy to aid relaxation
- Avoid watching TV, or looking at electrical screens for at least one hour before bed
- Avoid having a big meal in the two hours before bed
- Do regular exercise, especially exercise that gets you at least a bit out of breath. However, it’s best not to exercise within two hours of going to bed
- Your head and neck should stay in line with the rest of your body when you’re in bed. Too many or not enough pillows could strain your neck
- A hot water bottle or an electric blanket could also be soothing
A medium-firm bed will be more comfortable than one that’s too soft, although the mattress should have some give in it so that it moulds to the shape of your spine.
Memory foam mattresses may be helpful to support the spine
When is surgery indicated for spondyloarthritis?
Should not be routinely offered
Only offer if spinal deformity is:
* significantly affecting their quality of life and
* severe or progressing despite optimal non-surgical management (including physiotherapy)
Flares can be managed in either specialist care or primary care.
True or False?
True
Depending on the person’s needs
When managing flares in primary care, seek advice from specialist care for people who:
* have recurrent or persistent flares
* are taking biological DMARDs
* have comorbidities that may affect treatment or management of flares
Patients should be advised that there may be a greater risk of skin cancer with TNF-alpha inhibitors.
True or False.
True
People with axial spondyloarthritis should be assessed for what other bone disease?
Osteoporosis
Consider regular assessments (every 2 years)
Be aware that bone mineral density measures may be elevated on DEXA scans due to the presence of syndesmophytes and ligamentous calcification, whereas hip measurements may be more reliable
In serious cases ankylosing spondylitis can affect your posture, or the position in which you hold your body
Patient advice on maintaining good posture?
- Relax your shoulders and keep them back, rather than hunched forward
- Keep your chin up
When sitting down:
* Don’t lean on your elbows
* Hardback, upright chairs or straight-backed rocking chairs are better for posture. Your buttocks should touch the back of your chair
* Try using a cushion behind your lower back to give extra support or a custom-made lumbar support
* When working at a computer desk or workstation, don’t stoop or stretch to reach things
* Make sure your seat is at the correct height
* Keep your knees at right angles – get a foot rest if you need one
* Don’t sit in one position for too long without moving your back
Try to lie on your back on the floor sometime during the day. This will help stretch out the front of your hips and improve your posture. Don’t place a pillow under your knees – stretching your knees out fully helps to maintain flexibility.
Driving advice for people with spondyloarthritis?
- On a long journey, stop from time to time at a safe place for five minutes and get out of the car for a stretch and quick walk around.
- Special mirrors and parking sensors can be fitted to help with parking. You should inform the Driver & Vehicle Licensing Agency (DVLA) of your condition if you use fitted adaptations.
- If your neck is stiff, it will be more prone to injury. Make sure your headrest is correctly adjusted and that you keep your head back against it.
Having ankylosing spondylitis, or any kind of spondyloarthritis, can make you more at risk of having a heart attack or stroke.
True or False?
True
It can also cause problems with the lungs, as it can reduce movement of the joints in the chest.
Depression is the most common condition among people with rheumatoid arthritis, affecting one in six people.
True or False?
True
