Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Rheumatology > Spondyloarthritis and Psoriatic Arthritis > Flashcards

Spondyloarthritis and Psoriatic Arthritis Flashcards

1
Q

ASAS classification criteria for axial spondyloarthritis

A

≥3 months back pain and age of onset <45 years and

  • Sacroiliitis on imaging AND ≥ 1 SpA feature

OR

  • HLA-B27 positive AND ≥ 2 other SpA features

SpA Features

  • Inflammatory back pain, arthritis, enthesitis (heel), uveitis, dactylitis, psoriasis, Crohn’s/colitis, good response to NSIADs, family history of SpA, HLA-B27, elevated CRP

Sacroillitis on imaging

  • Active (acute) inflammation on MRI suggestive of sacroiliitis associated with SpA
  • Definite radiographic sacroiliitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

ASAS classification criteria for peripheral spondyloarthritis

A

Peripheral arthritis and/or enthesitis and/or dactylitis

PLUS

≥1 SpA feature (uveitis, psoriasis, Crohn’s/colitis, preceding infection, HLA-B27, sacroiliitis on imaging

OR

>2 other SpA features (arthritis, enthesitis, dactylitis, IBD, inflammatory back pain (after), family history of SpA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Spectrum of spondyloarthritides (SpA)

A
  • 40% patients with spondyloarthritis will have anterior uveitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Definition of inflammatory back pain

A
  • Age of onset < 40 years
  • Insidious onset
  • Improvement with exercise
  • No improvement with rest
  • Pain at night (improves on getting up)
  • Other features:
    • Onset <45 years of age
    • > 3 consecutive months
    • Alternating buttock pain
    • Awaken at night, particularly 2nd half of night, improve on arising
    • Responds to NSAIDs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Mechanisms of inflammatory pathways in axial spondyloarthritis (and PsA)

A

Initiating factors

  • Genes → HLA-B27, HLA-B40, cell specific SNPs, ERAP1
  • Inflammation → gut microbiome
  • Infection
  • Stress - biomechanical, infections
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Clinical features of axial spondyloarthritis

A

Axial features

  • Inflammatory back pain, buttock pain - often alternating, poorly localised
  • Restriction in spinal movements (AS)

Extra-axial MSK features

  • Most common are peripheral arthritis - usually asymmetric oligoarthritis of LL, and enthesitis (30-50%)

Extra-articular features

  • Anterior uveitis (40%), acute and limited, unilateral, may alternate sides
  • IBD, psoriasis, apical fibrosis, aortic regurgitation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Clinical differences between non-radiological axial spondyloarthritis versus ankylosing spondylitis

A
  • Spectrum of the same condition
  • Evolution of nr-axSpA to AS is time dependent
    • 10% over 2 years, 20% if high CRP and/or baseline MRI positive
    • After 20 years → 85% evolve to AS
    • 10-15% never develop x-ray changes of AS
  • Same levels of pain and disease activity irrespective of classification, impaired spinal mobility and chest expansion potentially greater in AS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Epidemiology axial spondyloarthritis

A
  • 0.5-1% population
  • Usually starts 3rd decade of life
  • AS: 3:1 male to female, Nr-axSpA = 1:1
  • Main AS prevalence determinant: frequency of HLA B27 in population
  • Age of first symptoms and diagnosis earlier in HLA-B27 positive patients
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Risk factors for radiological progression of ankylosing spondylitis

A
  1. Male gender
  2. High inflammatory markers
  3. HLA B27 positive
  4. Patients with high damage at diagnosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Investigations for axial spondyloarthritis

A
  • HLA B27 (more common North European ancestry)
  • Inflammatory markers (normal in 25%)
  • X-ray sacroiliac joint, cervical and thoraco-lumbar spines (AS)
  • MRI (AS and nr-axSpA)

Sacroiliitis on xray

  • Months to years to evolve
  • Early changes: erosions, sclerosis at joint margins
  • Later: pseudo-widening
  • Last: joint space narrowing progressing to ankylosis

MRI in Axial Spondyloarthritis

  • Active inflammation → subchondral bone marrow oedema on T2 weighted, fa suppressed (STIR) images
  • Post-inflammatory lesions - erosions, sclerosis, fatty lesion on T1 weighted images
  • Synovitis, enthesitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Non-biologic treatment of ankylosing spondylitis

A
  • Physiotherapy/exercise programme
  • NSAIDs - 80% improve, may prevent radiographic progression
  • DMARDs - only for peripheral arthritis (sulphasalazine)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Biologic treatment for axial spondyloarthritis

A
  • TNF inhibitors → adalimumab, certolizumab, etanercept, golimumab, infliximab → improve clinical, biochem and MRI, rapid and sustained. Similar improvement in non-radiological axial (Australia PBS now funds golimumab) spondyloarthritis
  • IL-17 inhibitor → secukinumab → effective in AS, trials ongoing in nr-axSpA
  • IL-12/IL 23 and IL 23 blockers ineffective for spinal

X-ray progression on biologics

  • Prevention radiographic progression not demonstrated by TNF blockers/secukinumab. Beyond 2 years of exposure - prevents radiographic changes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Diagnosis, epidemiology and pathogenesis of psoriatic arthritis

A

Epidemiology

  • 3% population psoriasis → 15% w/ psoriasis develop psoriatic arthritis
  • M:F 1:1
  • Psoriasis precedes arthritis in 70%

Pathogenesis

  • IL-23 promotes entheseal inflammation, IL-22 promotes osteoproliferation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Clinical features of psoriatic arthritis

A

5 distinct patterns

  • Asymmetric oligoarthritis/monoarthritis (<4 joints) - approx 50%
  • Polyarthritis - symmetric - approx 30%
  • Spondyloarthritis - AS like
    • Very uncommon as isolated presentation, may occur years after periphral arthritis
  • DIP joint with nail disease
  • Arthritis mutilans - uncommon but characteristic

Other features

  • Dactylitis - 40-50%
  • Enthesitis - 30-50% → most common Achilles tendon, plantar fascia
  • Skin disease
  • Nail changes common → pitting, onycholysis, nail plate crumbing (correlates better with PsA than skin disease alone)
  • Co-morbidities → increased CVS risk, higher prevalence metabolic syndrome, obesity A/W worse outcomes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Investigations for Psoriatic arthritis

A
  • Inflammatory markers (elevated in 40%)
  • Typically RF and CCP negative
  • Imaging
    • Erosion with new bone formation → pencil in cup
    • Erosions in 47% at 2 years
    • Can get ankylosis
    • Check for sacro-iliitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Treatment options for psoriatic arthritis

A
  • Smoking cessation, weight loss
  • NSAIDs - symptom relief
  • DMARDs → methotrexate, sulfasalazine, leflunomide (little data)
  • Anti-TNF → adalimumab, certolizumab, etanercept, golimumab, infliximab. TNF inhibitors only treatment demonstrated to slow radiographic changes in psoriatic arthritis
  • Anti IL 17 → secukinumab, ixekizumab
  • Anti-p40 subunit IL12/23 → ustekinumab, anti-p19 subunit IL-23 guselkumab
  • Methotrexate + etanercept → no benefit to MSK disease together
17
Q

Reactive arthritis features and investigations

A
  • Preceding infection → usually 1-4 weeks → urethritis/STI, gastro
  • Arthritis - asymmetric, oligoarticular, lower limb. Enthesitis, dactylitis, sacro-iliitis
  • Classic triad of arthritis/urethritis/conjunctivits uncommon
  • Extra-articular manifestations
    • Skin → keratoderma blennorrhagica, circinate balanitis, mouth ulcers
    • Ocular → conjunctivitis, uveitis
    • GU → aseptic urethritis, cervicitis, prostatisis
    • Constitutional symptoms

Investigations

  • Inflammatory markers
  • Preceding infections → urinary PCR for C. trachomatis
  • HLA-B27 → more severe, chronic disease (doesn’t aid diagnosis)
  • Synovial fluid analysis
  • Imaging
  • Exclude other causes
18
Q

Treatment of reactive arthritis

A
  • Treat underlying infection
  • NSAIDs - effective
  • Intra-articular glucocorticoids
  • Systemic glucocorticoids if unwell
  • DMARD → sulphasalazine for chronic disease (or methotrexate)

Natural history

  • Median disease duration 3-5 months
  • Depends on pathogen, HLA B27 status
  • 15-20% persist > 12 months
19
Q

Notes on IBD associated spondyloarthritis

A
  • 10-20% IBD patient
  • More common if: other extra-intestinal features, complications of bowel disease, large bowel involvement (for Crohn’s)
  • Two subtypes → axial (similar to AS)- asymptomatic sacro-iliitis up to 20%, peripheral
    • Usually acute, oligoarticular and lower limb
    • Deformities/erosions rare
    • Can be self-limiting and related to flares of IBD
    • Rarely progressive
    • Independent of IBD activity
    • Can see other features of SpA e.g. enthesitis

Treatment

  • NSAIDs (caution)
  • DMARDs → sulphasalazine, joints and bowel (not effective in axial disease)
  • Controlling bowel disease often helps
  • Anti-TNF for joints and bowel
  • Axial disease treat as per AS → except avoid IL-17 blockers

Rheumatology (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions