Seronegative arthritis

Question 1

What is inflammatory back pain?

Answer 1

1. Onset <40-45 yo
   
   2. Insidious onset, present for 3 months
   3. Improvement with exercise, worse with rest
   4. Pain at night (particularly second half of the night)
      
      5. Response to NSAIDs

Question 2

What are the key inflammatory mediators in seronegative arthritis?

Answer 2

TNF-a
IL-17
IL-12/23
IL-22 (new bone formation)
Th1 and Th17 cells

Question 3

What are the seronegative arthridities?

Answer 3

Axial spondyloarthropathy (including ankylosing spondylitis)
Peripheral spondyloarthropathy
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis (IBD associated arthritis)

Question 4

ASAS classification criteria for axial spondyloarthitis

Answer 4

Requires: 3 months of back pain, onset <45

Imaging pathway: sacroiliitis on imaging plus 1 feature of SpA

Or

HLAB27 pathway: HLA-B27 positive plus 2 features of SpA

Question 5

What are the features of spondyloarthritis? (11)

Answer 5

inflammatory back pain
arthritis
enthesitis
dactylitis
uveitis
psoriasis
IBD
Good response to NSAIDs
Family history of SpA
HLA-B27
Elevated CRP

Question 6

ASAS classification criteria or peripheral spondyloarthritis

Answer 6

Peripheral arthritis or dactylitis or enthesitis

plus

1 key feature: uveitis, psoriasis, IBD, preceding infection, HLA B27, sacroiliitis on imaging

or

2 other features: arthritis, dactylitis, enthesitis, inflammatory back pain, family history of SpA

Question 7

How do you diagnose ankylosing spondylitis?
What is non-radiographic SpA?

Answer 7

Meet classification criteria for axial spondyloarthritis plus have sacroiliitis ON XRAY

Those that meet classification criteria for axial SpA but don’t have radiographic changes (yet)

Question 8

Axial Spondyloarthitis:
Extra-axial manifestations
Extra-articular manifestations

Answer 8

Peripheral arthritis (oligoarthritis usually), enthesitis (30-50%)
Uveitis (40%), IBD, psoriasis, apical fibrosis, aortic regurgitation

Question 9

What percentage of people with HLA-B27 have a spondyloarthropathy?
What is the average delay between onset of symptoms and diagnosis?

Answer 9

5%
7 years

Question 10

What percentage of people develop ank spon from nr-axial SpA over:
2 years
20 years

Do ank spon or nr-axial SpA have more:
- pain
- restriction of movement

Answer 10

10%
85%

same levels of pain
ank spon more restriction

Question 11

What are the XR features of sacroiliitis?
How are they graded?

Answer 11

Early: erosions, sclerosis
Late: pseudo-widening
Last: ankylosis

Graded by New York Classification from 0-4

Question 12

What XR and MRI features are seen on spinal imaging?

Answer 12

XR: squaring of vertebrae, syndesmophytes, Romanus lesions
MRI: active inflammation - oedema (T2), post-inflammatory change - sclerosis, erosions, ankylosis (T1)

Question 13

What are the goals of therapy for axial spondyloarthropathy?
What are the first and second line management strategies?
What are PBS criteria for access to biologics?
What is the only biologic available to non-radiographic axial spondyloarthritis?

Answer 13

Goals: reduce symptoms, maintain spinal flexibility, maintain function

First line: PT/exercise program and NSAIDs
Second line: TNFi or IL-17i

Must have failed 12 weeks of PT and 2 different NSAIDs

nr-axialSpA - Golimumab

Question 14

What is the role for sulfasalazine or MTX in spondyloarthopathy?

Answer 14

Only effective for peripheral arthritis
NOT effective for axial disease

Question 15

Enteropathic / IBD arthritis:
- what IBD characteristics increase likelihood of having arthritis?
- what is the typical pattern of disease (joint location, pattern, erosive / non-erosive

Answer 15

• colonic disease increases likelihood (UC or colonic Crohn’s disease)
• can be axial like AS or peripheral; usually lower limb, oligoarticular, non-erosive / non-deforming

Question 16

How do you treat IBD associated arthritis?
Axial
Peripheral

Answer 16

axial - as per AS
peripheral - sulfasalazine
avoid IL-17 inhibitors (as they are ineffective in IBD)

Question 17

Psoriatic arthritis classification criteria (CASPAR)

Answer 17

Established inflammatory arthritis (enthesitis, arthritis, axial disease) plus 3 points from the following:
1. present skin disease (2 points)
2. past or FHx of psoriasis
3. Dactylitis
4. Nail changes - pitting, onycholysis
5. RF negative
6. Juxta-articular new bone formation

Question 18

What percentage of people with psoriasis develop psoriatic arthritis?

Answer 18

15%

Question 19

What are the patterns of disease in psoriatic arthritis? (5)

Answer 19

1. asymmetric peripheral mono- / oligoarthritis (50% of cases)
2. symmetric polyarthritis
3. spondyloarthritis
4. distal interphalangeal joint disease with nail involvement
5. arthritis mutilans

Question 20

What are investigations for psoriatic arthritis?

Answer 20

1. XR - erosive disease with new juxta-articular bone formation, pencil-in-cup appearance
2. Bloods - elevated inflammatory markers, RF and CCP usually negative

Question 21

What are the treatments for psoriatic arthritis?

Answer 21

1. NSAIDs
2. csDMARDs: sulfasalazine, MTX, leflunomide
3. TNFi - adalimumab, golimumab, infloximab
4. IL17 - secukinumab
5. IL12/23 - ustekinumab
6. JAK 1/3 - tofacitinib

Question 22

What is reactive arthritis?
Typical symptoms (joints affected, duration)
Synovial fluid analysis
Treatment

Answer 22

HLA-B27 associated arthritis, following infection where organism cant be isolated from synovial fluid
Typically affects young people, lasts 3-6 months
Usually a mono- / oligoarthritis, associated with uveitis / conjunctivitis, urethritis, dactylitis.
Follows STI / GI infection
Synovial fluid: neutrophil predominant, 2000-64,000 per mm3
Treat with NSAIDs or intra-articular steroids, consider sulfasalazine for chronic or TNFi for refractory disease